Greater Boston Urology Blog

Say Hello to vNOTES: Minimally Invasive Gynecologic Surgery

Greater Boston Urology is proud to offer patients the latest surgical innovations like vNOTES, which stands for vaginal natural orifice transluminal endoscopic surgery.

Dr. Angel Marie Johnson, director of our Women's Health Centers, is trained in vNOTES.

Below, you can learn more about what vNOTES is, including its benefits. Keep in mind that the following is meant to be educational in nature, not medical advice.

What is vNOTES?

vNOTES is a minimally invasive gynecologic approach using the vagina as a surgical access route. Hysterectomy is the most common procedure performed via the vNOTES technique and the second most common surgery performed in the United States.

Both the American College of Obstetricians and Gynecologists (ACOG) and American Association of Gynecologic Laparoscopists (AAGL) have recommended vaginal hysterectomy, whenever feasible, as the approach of choice for hysterectomy.[1][2]

Dr. Johnson currently performs approximately 50% of her hysterectomies vaginally. Historically, she performed laparoscopic surgery or surgery through small abdominal incisions when the removal of tubes and ovaries were necessary; however, with the advent of vNOTES, this has started to change.

Dr. Johnson uses this technique primarily to help remove tubes and ovaries at the time of hysterectomy and to make vaginal hysterectomies safer for women with larger uteri due to fibroids. This technique enables Dr. Johnson to visualize the upper abdomen through the vagina.

The use of the vNOTES technique results in lower blood loss and shorter operative time with less post-procedure pain than traditional vaginal surgery. Due to increased visualization, Dr. Johnson is able to provide additional support to the vagina and is hopeful this technique will result in less prolapse recurrence.

 vNOTES allows the entire surgery to be completed vaginally without any abdominal incisions thus making it scar-free surgery.

Can vNOTES be used in other procedures besides hysterectomies?

Yes. However, Dr. Johnson is a urogynecologist. She uses vNOTES primarily at the time of vaginal hysterectomy. General gynecologists can employ this technique to assist in other procedures listed below.

  •  Salpingectomy
  • Oophorectomy
  • Salpingo-oophorectomy
  • Cystectomy
  • Uterosacral ligament suspension

Conditions treated include the following:

  • Adnexal pathology
  • Abnormal uterine bleeding
  • Chronic pelvic pain
  • Fibroids
  • Prolapse of the uterus

What happens during the vNOTES procedure?

In the vNOTES procedure, your doctor uses specialized instruments inserted through the vagina instead of creating visible abdominal incisions in the body. This allows your doctor to gain access to the uterus and/or fallopian tubes and ovaries without any visible scarring.

Why should patients consider vNOTES?

vNOTES has been shown to provide the following benefits to patients compared to the laparoscopic approach[3]:

  • Shorter hospital stay
  • Less post-operative pain
  • Less pain medication
  • Faster recovery time

What can patients expect before, during, and after the vNOTES procedure?

Prior to the procedure, your doctor will advise you on any pre-surgical tests and give you guidelines for eating, drinking, and taking medications.

vNOTES is performed under general anesthesia, so you will be asleep throughout the procedure.

During the vNOTES procedure, the following will happen:

  • An incision is made in the vagina, and a specialized vNOTES device is placed to provide your doctor access to the uterus and/or fallopian tubes and ovaries.
  • The abdomen is inflated with carbon dioxide gas (similar to traditional laparoscopic surgery) to give your doctor the necessary space to see and operate.
  • A high-definition camera and specialized instruments are inserted through the vNOTES device, allowing your doctor to operate with the utmost precision and visualization.
  • Once the surgery is complete, the vNOTES device is removed, the gas is evacuated, and all internal incisions are closed.

You may be discharged the same day as your procedure. Your doctor will advise you on your recovery and schedule a follow-up appointment.

What should you do if you'd like to know more about vNOTES and whether you're a good candidate?

Only a trained doctor can determine whether you are eligible for a vNOTES procedure. At Greater Boston Urology, we’re proud of Dr. Angel Marie Johnson for successfully completing the vNOTES Workshop and for being among the first surgeons in Massachusetts to offer this procedure to patients. Click here to schedule an appointment with Dr. Johnson.

[1] Choosing the route of hysterectomy for benign disease. Committee Opinion No.701. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017:129:e155-9.

[2] AAGL Position Statement: Route of Hysterectomy to Treat Benign Uterine Disease. JMIG 2011 Jan;18(1):P1-3.

[3] Baekelandt J, et al. Hysterectomy by Transvaginal Natural Orifice Transluminal Endoscopic Surgery versus laparoscopy as a day-care procedure: a randomized controlled trial. BJOG 2019 Jan;126(1):105-113.

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