AFJOG

REVIEW African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 3 | 2025 | Review of Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) According to a feasibility study by Nulens et al, the surgical technique of vNOTES hysterectomy in virgin patients was not different from that of sexually active patients, while Kale et al demonstrated that postoperative pain was well tolerated, and conversion to conventional laparoscopy or open surgery was not required in obese patients [9] . In cases of repeat vNOTES procedures, there were no serious complications or conversions to other surgical methods, while a previous colpotomy does not seem to increase complications related to adhesions or scar formation during repeat surgeries [16] . Tavano et al showed that vNOTES had no adverse effects in women of reproductive age and that posterior colpotomy itself was not an indication for surgical delivery as no pregnancy-related complications related to the mode of delivery or perineal rupture were observed [9] . BENEFITSOFVNOTES The potential for less pain, decreased operative time, improved cosmesis, anddecreasedrisks related toabdominal entryandport placement, especially in patients with multiple prior abdominal surgeries, such as visceral and abdominal wall injuries, port site hernias, and nerve entrapments are all potential advantages of vNOTES compared to open and transabdominal multiport and LESS laparoscopic and robotic approaches [17] . Technically vNOTES colpotomy have a larger and less rigid opening compared to transabdominal LESS and mini- laparotomy or transabdominal incisions, while the target tissue is closer to the port, decreasing restricted movements. Furthermore, the smoke plume is less likely to obstruct the view, and the camera and instruments are less likely to collide. Lower insufflation pressures and shorter operative times are possible with vNOTES for obese patients as it allows significantly less Trendelenburg. With better “bottom-up” compared to the “top-down” camera visualisation, fewer surgical assistants are required. Procedural advantages include elimination of need for extensive adhesiolysis in certain cases like bladder adhesions, and creating more space to operate and controlling the uterine blood supply due to cephalad movement of the uterus in cases of hysterectomies for enlarged uteri (large fibroids, adenomyosis). The potential for improved visualization and more precise apical suture placement reduce the risk of ureteral kinking with vNOTES when doing apical suspension, while the lack of visible laparoscopy scars is an important cosmetic advantage. The vNOTES surgeon could likely operate in a neutral and non static position, seated or standing, compared to laparoscopy, vaginal surgery, and robotics. The mechanics and ergonomics of vNOTES are potentially more favourable compared to unassisted transvaginal surgery [17] . More studies are needed to assess cost and efficiency but the vNOTES setup compared to laparoscopy has the potential for cost savings due to decreased need for skilled bedside assistants and the fewer less expensive equipment and accessories. ADVERSEEFFECTS ANDCHALLENGESOFVNOTES Several potential adverse effects of vNOTES must be considered despite the many advantages thereof. These include infections, pain, and sexual dysfunction. As reported by Tolcher [4] and Lee [14], cellulitis, vaginosis, vaginitis, pyrexia and urinary tract infection can result due to the non-sterile vaginal entry. vNOTES, however, does not seem to significantly increase postoperative wound infection, according to the current literature. While Baekelandt [15] confirmed a significantly lower visual analog scale (VAS) score in vNOTES compared to a total laparoscopic hysterectomy group, Park et al [18] in a RCT reported significantly higher vaginal pain intensity in a vNOTES group compared to a laparoendoscopic single-site (LESS) hysterectomy group. Therefore more research is needed on pain intensity according to the surgical entry route. Changes in sexual functioning such as libido issues is a concern for many patients post operatively. Using the female sexual function index (FSFI), Xu et al compared patients who underwent vNOTES or transabdominal laparoscopy respectively and reported no statistically significant difference in the total FSFI scores before or at 3 and 6 months postoperatively between the two groups [19] . In terms of some of the challenges, the surgeon must be able to perform the rate-limiting anterior and posterior colpotomy can be difficult in complex cases such as a narrowed introitus and vaginal canal, limited descent, narrow pubic arch, and postmenopausal atrophy. With the “bottom-up view” it can also be limiting because the surgeon may not be able to see potential pathology such as upper abdominal bowel adhesions converting from vNOTES to a laparoscopic route is generally considered a reversion to a default approach. Several publications describe the initial experiences with hysterectomies performed via V-NOTES. Compared to complication rates during the learning process of performing laparoscopic hysterectomy, some studies report similar or even lower rates of perioperative complications (2.99%), postoperative complications (7.61%), and overall complications (6.2%) for vNOTES [20] . Notably, these studies describe the occurrence of ureteral and digestive injuries in laparoscopic hysterectomies, which were not observed in this study. DISCUSSION Based on available randomized and observational data, the innovative vNotes technique appears to be safe and effective for specific indications where women are eligible for endoscopic surgery. The many benefits of vNotes have been extensively researched and include less postoperative pain and discomfort, quicker recovery times, reduced incidence of postoperative wound infections with better and more acceptable aesthetic outcomes. The successful application of vNOTES to a wide variety of gynaecological operations has been demonstrated and these include hysterectomy, cystectomy, myomectomy, lymphadenectomy as well as sacro-colpopexy. Considering the recent extensivelypromoted same-day surgery option with its substantially lower cost, and the application of the popular enhanced recovery after surgery (ERAS) principles, there is a well established foundation for the broader application of vNOTES where same-day discharge is desired. Patient selection should include a thorough preoperative assessment to determine potential difficulties such as severe pelvic adhesions where a vaginal natural orifice approach is not advised. Safety, technical limitations and non-inferiority of vNOTES to conventional laparoscopy still needs to be accurately determined and resolved before widespread use is implemented. Larger multi-centre randomized trials would aid in further establishing the safety and efficacy of vNOTES. This can facilitate its wider application, particularly in day surgery settings. Recently there has been a decline in vaginal surgical approaches in favour of emerging laparoscopy and robotics. While more experienced and older surgeons who already have good vaginal surgical skills can learn additional new laparoscopic skills using vNOTES, a new generation of surgeons who possess laparoscopic skills can easily adopt the vNOTES technique in their practice. African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 3 | 2025 | 10