AFJOG

REVIEW African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 3 | 2025 | Review of Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) INTRODUCTION Laparo-endoscopic single site surgery (LESS) emerged as a result of surgeons looking for new innovations as multiport laparoscopy and robotics began to replace open surgery [1] . Natural orifice transluminal endoscopic surgery (NOTES), which emerged as an extension of LESS, is a minimally invasive procedure that uses the natural orifices of the human body to access the abdominal cavity. Utilizing natural orifices such as the stomach, oesophagus, rectum, bladder, and vagina, spares the abdominal wall from incisions [2] . Transvaginal vNOTES emerged as the preferred approach due to the lowest risk of contamination and improved visualization, closure, and healing [3] . Tolcher et al reported that among the several entry sites for NOTES, the vaginal approach through the vaginal fornix has gained special interest because colpotomy has been used widely in gynaecologic surgery and has proven to be a safe and feasible entry port [4] . Vaginal natural orifice transluminal endoscopic surgery (V-NOTES) which combines the advantages of endoscopic surgery with those of the vaginal approach, has emerged as an innovative surgical approach that is on the rise within gynaecology [5] . The unique natural cavity of the vagina has facilitated the rapid development of vNOTES in minimally invasive gynaecologic surgery techniques, offering superior clinical outcomes [6] with an increasing focus on treatment efficacy, safety, postoperative recovery speed, quality of life, and cosmetic outcomes. Figure 1: Vaginal natural orifice transluminal endoscopic surgery (vNOTES) with the patient in the Trendelenburg position (Yoong Wai, Baekelandt Jan. vNOTES (vaginal Natural Orifice Transluminal Endoscopic Surgery): is this the future of gynaecological surgery? The Obstetrician & Gynaecologist, 2023) TECHNIQUE INBRIEF vNOTES procedures are typically performed under general anaesthesiawith thepatient placed in theTrendelenburgposition [7] . The vaginal mucosa is initially circumscribed around the cervix and mobilised from the uterus – similar to the first steps of a vaginal hysterectomy. An O-Retractor is introduced behind the colpotomy incision and pneumoperitoneum then created with an insufflation pressure of 10mm Hg, allowing good visual and operative access. Su and colleagues first described the concept of attaching a surgical glove onto the rim of an O-Retractor and incising the finger ends to admit a standard 10-mm trocar (which is used for CO2 insufflation and laparoscope insertion) and various endoscopic instruments (Figure 2). The current practice is to use specially designed airtight access platforms such as GelPOINT" V-Path (Applied Medical, Figures 1 and 3) in order to provide a seal around the vaginal cuff to maintain insufflation pressure and allow introduction of instruments. Following surgery, specimens are retrieved through the vagina and the colpotomy incision closed with absorbable sutures. Compared with traditional laparoscopy, the low- pressure maintenance pneumoperitoneumused in vNOTES (6–10mmHg versus 12–16 mmHg, respectively) means that less anaesthetic ventilation is required, and there is a lower risk of insufflation- induced bradycardia and carbon dioxide resorption. The lower insufflation pressure and less invasive approach have resulted in the reporting of less severe postoperative visual analogue pain scores, and most patients are comfortable with paracetamol and non- steroidal anti-inflammatory drugs. Figure 2: Early modification using a surgical glove attached to an O-Retractor Yoong Wai, Baekelandt Jan. vNOTES (vaginal Natural Orifice Transluminal Endoscopic Surgery): is this the future of gynaecological surgery? The Obstetrician & Gynaecologist, 2023) Dr Quinton Blignaut Department of Obstetrics & Gynaecology, Walter Sisulu University, Mthatha, Eastern Cape, South Africa CORRESPONDENCE: Q Blignaut | Email: qblignaut@gmail.com Review of Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 3 | 2025 | 08