AFJOG

REVIEW African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 3 | 2025 | Review of Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) Figure 3: GelPOINT" V-Path kit Yoong Wai, Baekelandt Jan. vNOTES (vaginal Natural Orifice Transluminal Endoscopic Surgery): is this the future of gynaecological surgery? The Obstetrician & Gynaecologist, 2023) SURGICALAPPLICATIONOFVNOTES Surgical innovations, aimed at safely and successfully applying NOTES, followed the initial preclinical trial by Kalloo et al [8] . This resulted in increasing interest in vNOTES utilization in the field of gynaecological surgery including for adnexectomy, hysterectomy, myomectomy, cancers and sacro-colpopexy. Jung Chul Kim et al reported that already in 2012 Lee and Ahn described the first adnexal procedures using vNOTES [9] , with Lee et al performing tubal sterilisation, salpingectomy and ovarian cyst enucleation. Ahn reported performing similar procedures including oophorectomy, without any complications. Wang’s case series involving few cases appeared feasible due to absence of complications and a high level of cosmetic satisfaction [10]. Wang also provided evidence that vNOTES is similar in outcome regarding feasibility and safety when compared to conventional laparoscopy for ovarian cystectomy [10]. In the NOTABLE trial, Baekelandt et al. showed that for benign adnexectomy, vNOTES had a shorter operating time, lower pain scores and lower use of postoperative analgesics, compared to conventional laparoscopy [11] . Despite the non-inferiority to conventional laparoscopy, limitations of use of vNOTES in this study include intraperitoneal spillage and dissecting of adhesions, as noted in previous studies, and must be further analysed. vNOTES hysterectomy was suggested to overcome the limitations of vaginal hysterectomy such as to poor visualization, limited surgical space, and the need for extensive surgical training. Lee et al stressed the importance of transvaginal posterior colpotomy to implement vNOTES successfully while Wang compared the surgical outcomes of vNOTES with those of conventional laparoscopic hysterectomy in a large cohort [9] . Wang’s study showed vNOTES for vaginal hysterectomy was associated with significantly less blood loss, shorter operative times, and shorter hospital stays. The results of five retrospective cohort trials and one RCT showed that vNOTES was equally effective for hysterectomy as conventional laparoscopy, while vNOTES was associated with a significantly shorter operative time, blood loss, and length of stay. Intra- and postoperative complications, readmission rates, and pain scores at 24 hours post-surgery did not significantly differ between the two surgical methods [11] . In the same meta-analysis, Baekelandt et al showed there were no differences between the vNOTES and laparoscopic hysterectomy arms regarding the severity of dyspareunia, sexual well-being, or health-related QOL at 3 and 6 months postoperatively. While transvaginal myomectomy may be technically challenging compared with other modes of surgery owing to the restricted operative field, Baekelandt suggested that the vNOTES technique could be applied to the International Federation of Gynaecology and Obstetrics type 3–7 myomas [12] . Liu et al [13] described the removal of a 6-cm anterior myoma with anterior colpotomy, suggesting that in their experience, the vNOTES approach was more advantageous for larger uteri as the flexibility of the vaginal canal provided an enhanced extension of the colpotomy incision and subsequently allowed the laparoscopic instruments to reach the deeper pelvic area . Sacro-colpopexy and uterosacral ligament suspension using vNOTES appears feasible and safe according to a few retrospective and prospective studies [ 9] , especially for patients who desire excellent cosmetic results through a minimally invasive approach. The rationale for safer access to the sacrum via the vaginal route is that extraperitoneal access to the sacrum can be achieved through the vNOTES route so that the mesh goes along the access to the presacral region without affecting the intraperitoneal organs and in addition, sacro-colpopexy via NOTES allowed improved visualization, leading to safe access to the sacrum and decreases the risk of ureteral injury owing to adequate ureteral exposure and safe stitch placement [9] . However, the vNOTES approach for vault suspension procedures requires training, although surgical performance can reportedly be achieved over a short period. Data concerning vNOTES in gynaecologic malignancies are generally scarce compared with those concerning benign surgical indications. Lee et al. [14] described surgical staging in patients with early-stage endometrial cancer by performing lymphadenectomy, hysterectomy and bilateral salpingo- oophorectomy, which has broadened the indications for vNOTES in oncology in 2014. They demonstrated the feasibility of dissecting lymph nodes around the external iliac vessels, hypogastric vessels, and obturator nerves and published an update on patients with stage 1, grade 1–2 endometrial cancer in 2022. Despite the feasibility of vNOTES for early endometrial cancer staging, the authors described the limitations of this new approach including difficulty in identifying the paravesical and pararectal spaces, making lymph node assessment challenging in vNOTES. Visualization and approach to the para-aortic space above the inferior mesenteric artery will be incredibly challenging with the current vNOTES approach, unless a retroperitoneal approach through a paracervical incision in the vaginal lateral fornix is used [15] . The need for radical hysterectomy for cervical cancer limits the completion of pure vNOTES. Therefore, retroperitoneal vNOTES for cervical cancer could be a valuable tool for integrating a two-step approach to cervical cancer treatment with reduced surgical morbidity. African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 2 | 2025 | 09