A Review of Robotic vNOTES Surgery: Current Applications, Advantages, and Future Directions

There is a clear interest in minimally invasive and single-site surgery as robotic platforms evolve to meet this demand. With the introduction of the da Vinci SP, Jingfeng, and Shurui robotic systems, this technology is already being applied. These robots represent the present. What does the future hold? At Vanderbilt University School of Engineering, three trends have been identified. The first trend is miniaturization and micro-robotics. This development is underway – not only for surgery, but also for drug delivery and cancer treatment. The second trend is artificial intelligence and machine learning, which are gaining momentum. These technologies are expected to assist in real-time decision-making, improve surgical planning, and enhance precision. The third trend is telepresence and global translation. This concept is not new; the first procedure was performed between New York and Strasbourg in 2002. However, it is not yet commonplace. The exciting application of this technology is the potential to perform robot-assisted procedures in remote areas, offering benefits such as lower infection rates, same-day discharge, and quicker return to baseline quality of life. In the past, the concept of conventional laparoscopy and those who recognized its potential in its early stages were met with skepticism. The art of vaginal surgery in the United States is being replaced by laparoscopy. In 2008, only 21% of graduating residents believed they could perform a vaginal hysterectomy. However, vNOTES may allow for a resurgence in vaginal surgery. This is becoming a reality, as the implementation of vNOTES in academic settings has led to more residents performing vaginal surgeries. This increase is attributed to the fact that vNOTES broadens the indications for vaginal surgeries. If there is ever a time to promote a procedure, it is during training. The same applies to RA-vNOTES – with the rise of single-site robotic technology, it could one day become the standard of care for pelvic surgeries. To better define the role of RA-vNOTES in clinical practice, future studies should include well-designed randomized controlled trials with standardized outcome measurements (including cost, pain, and ergonomics) and stratification by surgeon experience to provide robust, generalizable evidence. Additionally, further research should explore training pathways and learning curves for RA-vNOTES to promote its safe integration into broader surgical practice. In conclusion, robot-assisted vNOTES has advanced over the last decade, providing improved visualization and maneuverability in the pelvis, which has benefited both surgeons and patients. *　　　　*　　　　*

Substantial evidence demonstrates the benefits of conventional vNOTES and robotic assistance in surgery. However, there is currently a lack of long-term data on RA-vNOTES, with much of the available information extrapolated from conventional vNOTES studies. Additionally, research on RA-vNOTES is limited to a few groups and, consequently, a small number of publications. When comparing conventional vNOTES and RA-vNOTES, outcomes were similar, demonstrating non-inferiority [ 37 ] . Without increased risks associated with RA-vNOTES, robotic assistance can help overcome the limitations of traditional vNOTES, allowing for broader application. Incisionless surgery with improved cosmesis and reduced infection risk are compelling reasons patients may prefer or seek a vNOTES procedure. In a study evaluating quality of life (QOL) in patients undergoing RA-vNOTES compared to robot-assisted abdominal laparoscopic surgery, patients experienced improved QOL by postoperative day 28. Using the EQ-5D-5L questionnaire, the study found that 90% of patients in the RA-vNOTES group achieved complete QOL by postoperative day 14, and 100% by postoperative day 28. In another trial measuring time to full return to work (RTW), the timeframe for laparoscopic hysterectomy ranged from three to 45 weeks. Although these are just numbers, they have real implications for patients' lives, particularly regarding return to work, which can be a significant source of stress [ 54 ] .

The literature search was conducted in PubMed, Medline, and the Cochrane Library using the following keywords: robotic natural orifice transluminal endoscopic surgery, robot-assisted vaginal natural orifice transluminal endoscopic surgery (RA-vNOTES), single-port RA-vNOTES, and single-port robot-assisted natural orifice transluminal endoscopic surgery. The searches were limited to gynecologic surgery, yielding 66 publications in PubMed, 0 in Medline, and 1 in the Cochrane Library. The search included all studies from each database's inception through July 7, 2025. Inclusion criteria were publications focusing on the gynecologic application of the RA-vNOTES approach. No exclusion criteria were defined. This publication is not a systematic review; the search criteria are outlined to demonstrate the limited number of publications on these keywords. Descriptions of the technical aspects of the procedures are based primarily on the methodology used by a single fellowship-trained minimally invasive gynecologic surgeon at one academic center. Methodological deviations from these procedural steps are cited as appropriate.

For vNOTES, the procedure begins with cystoscopy to place ureteral stents and inject ICG. This approach has been shown to save time when there is concern for endometriosis or adhesions [ 9 ] . After ICG stent placement, vaginal hysterectomy is initiated in the standard manner with the goal of completing the total hysterectomy. However, when the size of the uterus or adhesions prevents completion of the hysterectomy, the robot must be docked before the procedure can be finished. In these cases, the cervicovaginal junction is scored, and the robotic port is sutured to the vaginal mucosa using the 4-P port anchoring technique [ 10 ] . The peritoneal ring is then rolled down to the peritoneum, and the robot is docked. Table 3 outlines the early evolution and application of RA-vNOTES. GUAN et al ., 2023 SP Technique Paper Hysterectomy － － 0 Stepwise RSP-vNOTES protocol ensures safety GUAN et al ., 2024 SP 28 CPP, endometriosis 188.7 32.1 1 High feasible with severe endo; excellent visualization KANNO et al ., 2025 SP 1 Large uterus (970 g) 102 50 0 SP-VANH is feasible and offers enhanced dexterity in large uteri LEE et al ., 2015 Early robot-assisted NOTES 4 Adenomyosis, leiomyoma 198.8 180 0 High docking time; good access, limited by instruments LIU et al ., 2023 Xi 1 BMI 70, 16-week uterus － － 0 Tailored exposure allows safe hysterectomy in extreme obesity MEI et al ., 2023 Xi (Gasless) 14 Hysterectomy Similar Minimal 0 GR-vNOTES is comparable to traditional methods; safe, minimal fever YANG et al ., 2020 RGPT (rigid wristed via glove port) 13/35 Myoma, cyst, hysterectomy 160 － 0 Parallel setup improves triangulation, no complications YANG et al ., 2024 Xi 286/298 Endometriosis, AUB, CPP 138 50 1% High feasibility even in complex cases; 64% endo resection Table 3 demonstrates the feasibility of the da Vinci Xi and SP platforms for vNOTES hysterectomy, even in technically challenging cases such as obesity, large uterus, or deep endometriosis. Complication and conversion rates are low in the cited studies. The da Vinci SP provides better ergonomics and instrument articulation, while the da Vinci Xi demonstrates strong adaptability in patients with high BMI. RA-vNOTES with the da Vinci Xi system is ideal for institutions with existing Xi systems, offering benefits such as wristed instruments, versatile docking, and adaptability. The da Vinci SP surpasses the Xi with superior triangulation, reduced instrument clutter, single-arm docking, and shorter docking time. These advantages are especially beneficial in confined vaginal spaces. To optimize the use of the da Vinci Xi and SP platforms, specific training is recommended. Performing a myomectomy using the RA-vNOTES approach presents challenges distinct from those encountered during a hysterectomy. In some cases, myomectomy can be more difficult because the uterus itself becomes an additional obstacle in the surgical field. Type 6 or type 7 leiomyomas, located mainly on the posterior or anterior aspect of the uterus, allow for easier surgery, as they are accessible through an anterior or posterior colpotomy [ 24 ] . However, more complex procedures have also been performed, including myomectomies for type 3-7 leiomyomas [ 25 ] . Leiomyomas up to 8 cm in size have been removed via RA-vNOTES [ 26 ] . In a case series of 17 patients, myomectomy was performed via laparoscopic vNOTES with the patient in the prone position, allowing removal of leiomyomas weighing up to 519 grams [ 27 ] . The various myomectomy techniques are summarized in Table 4 . BAEKELANDT, 2017 Traditional vNOTES 8 Types 3-7, anterior/posterior Anterior/posterior colpotomy, glove port or commercial port, laparoscopic instruments All cases successful, no complications, < 24 h discharge No scars, cost-effective, adaptable to low-resource settings LIU et al ., 2018 Single-site vNOTES 1 6 cm anterior Combines vaginal + single-site lap skills, anterior colpotomy, barbed suture closure Minimal blood loss, full recovery Expands vaginal access, improves visibility compared to traditional vaginal SUNKARA, GUAN, 2022 Robotic vNOTES (Xi or SP) 1 8 cm posterior Robotic port, posterior colpotomy, Extracorporeal C-incision morcellation, wristed suturing Minimal blood loss, day surgery, V-Loc closure Precision in suturing, deep fibroid access, fertility-sparing Depending on the location of the leiomyoma, a colpotomy is performed. In our practice, the cervicovaginal junction is infiltrated with dilute vasopressin, and the mucosa is incised with an angled electrosurgery device 5 mm from the cervix. This distance is selected to provide adequate tissue for closing the colpotomy at the end of the procedure. The posterior cul-de-sac is entered with cold Mayo scissors and extended laterally. The apices are sutured with 0-polyglactin suture in a figure-of-eight pattern to prevent lateral extension. The peritoneum is then sutured to the mucosa at the 6 and 12 o'clock positions. A self-retaining ring is placed, serving as a portal to the peritoneum and as a retractor when positioned in the posterior colpotomy to keep the uterus elevated and out of the surgical field. The robot is then docked. Entry for adnexal surgery is performed similarly to peritoneal entry for myomectomy. Typically, a posterior colpotomy is used, as the adnexa are likely to be resting in the posterior cul-de-sac. In addition to the ring retractor used for peritoneal entry, some groups have used a uterine manipulator to elevate the uterus. Emergent cases have also been performed via vNOTES. A small case series by CHEN in 2020 reviewed 12 patients who underwent management of ectopic pregnancies. In a morbidly obese patient with ovarian torsion, the vaginal approach may be safer, even in an emergency setting. The video case report demonstrated the key surgical steps, including detorsion, paratubal cystectomy, and salpingectomy via a posterior colpotomy. The video highlights technical tips, particularly for obese patients, while emphasizing that similar outcomes can be achieved laparoscopically if robotic access is unavailable [ 28 ] . Oncologic applications for RA-vNOTES can be limited, as tumor metastasis can occur throughout the entire abdominopelvic space. This is also true for benign pathologies such as endometriosis. This limitation restricts the use of vNOTES because access to the upper abdomen is reduced ( Table 5 ). BAEKELANDT et al ., 2024 Prospective multicenter series (64 patients) Conventional laparoscopic retroperitoneal vNOTES SLN dissection + hysterectomy Median operative time was 126 min; estimated blood loss was 80 mL; bilateral SLN identification occurred in 97%; only one macrometastasis was found, with no significant complications. COMBA et al ., 2024 Comparative cohort (19 vNOTES vs. 38 laparoscopy) Retroperitoneal vNOTES SLN biopsy vs. conventional laparoscopy Operative time, blood loss, and SLN counts were similar; the vNOTES group experienced lower pain and a shorter hospital stay; no recurrences have been reported. LIU et al ., 2022 Case report 1 patient (32 years old, early-stage endometrial carcinoma) Robot-assisted vNOTES hysterectomy + staging The procedure was successful with disease confined to the uterus; no complications were reported. The video demonstrates the robotic technique via natural orifice. WANG et al ., 2021 Single-center cohort (23 vNOTES; 51 laparoscopy) Transperitoneal vNOTES + SLN mapping vs. laparoscopic control SLN detection rates were approximately 96% vs. 92%; estimated blood loss and operative time were comparable. The vNOTES group had fewer complications (4.3% vs. 7.9%, P = 0.029) and a shorter hospital stay (3 d vs. 4 d, P = 0.003) However, applications within the pelvis can make vNOTES an appealing approach. In cases such as early endometrial cancer, surgical evaluation includes sentinel lymph node sampling, which can be challenging due to its location. Multiple case reports have described techniques for retroperitoneal sentinel lymph node biopsies and mapping [ 29 - 32 ] . In this context, it is not the visualization and dissection of the cephalad portions of the pelvis that are limited, but rather the caudal portions due to camera angling. To address this, a retroperitoneal approach was developed to improve visualization of this space. An additional benefit of this approach is the ability to perform the procedure without Trendelenburg positioning [ 33 ] . There is ongoing debate regarding the use of minimally invasive surgery in the treatment of cervical cancer, mainly due to the results from the Laparoscopic Approach to Cervical Cancer (LACC) trial. This study showed decreased overall survival at 4.5 years: 90.6% in the minimally invasive group versus 96.2% in the open surgery group. The LACC trial concluded by recommending open surgery, with minimally invasive surgery reserved for research purposes [ 34 ] . At this time, there do not appear to be any publications on RA-vNOTES for the treatment of cervical cancer; however, there are case reports for conventional vNOTES [ 35 - 36 ] . It has been suggested that limitations in laparoscopic training may have contributed to the results of the LACC trial [ 37 ] . Could RA-vNOTES serve as an aid for minimally invasive surgical treatment of cervical cancer? No case reports exist for RA-vNOTES in the treatment of ovarian cancer, and there are only a few case reports for conventional vNOTES. These have mostly involved patients with borderline disease, where full staging was feasible transvaginally [ 38 - 39 ] . One contraindication to vaginal surgery is suspicion of an obliterated posterior cul-de-sac. However, in a case review of 23 patients with an obliterated posterior cul-de-sac, the procedure was found to be safe and feasible when performed by an experienced surgeon [ 40 ] . The benefits of the robotic platform include controlled dissection and cautery for establishing tissue planes. This is especially useful not only in cases with an obliterated posterior cul-de-sac but also in patients with a frozen pelvis. These advantages also apply to procedures where an abdominal approach would be more complex, such as cases involving abdominal mesh, multiple prior abdominal surgeries, or complex urologic procedures like a Mitrofanoff. The advantages of RA-vNOTES were demonstrated in a patient with a history of ruptured tubo-ovarian abscess, which caused severe, dense adhesions throughout the pelvis and abdomen. Performing RA-vNOTES allowed the hysterectomy to be completed without significant intestinal adhesiolysis. At our institution, we conducted a retrospective case series of 274 patients undergoing RA-vNOTES hysterectomy on the da Vinci Xi and SP platforms, with additional endometriosis resection across all disease stages. The study found that while RA-vNOTES is a safe and effective approach regardless of stage, advanced endometriosis was significantly associated with longer operative times (median 222 min in stage Ⅳ vs. 138 min in stage Ⅰ, P < 0.001), increased hysterectomy time (median 51 min in stage Ⅳ vs. 38 min in stage Ⅰ, P < 0.001), greater blood loss (median 50 mL in stage Ⅲ/Ⅳ vs. 25-30 mL in stage Ⅰ/Ⅱ, P < 0.001), and higher conversion rates (3 conversions, all in stage Ⅲ/Ⅳ, P = 0.03). Despite these differences, complication rates, same-day discharge, and postoperative pain scores were comparable across all stages. Selecting urogynecology cases for uterine prolapse is feasible with RA-vNOTES. Several case reports ( Table 6 ) demonstrate sacrocolpopexy performed using the RA-vNOTES approach, with LUI et al . describing the learning curve [ 41 ] . Both abdominal and vaginal approaches can be used for uterine suspension procedures. In vaginal surgery, the enhanced visualization and dexterity provided by robotic assistance allow precise identification of surrounding structures, such as the ureters, to ensure safe placement of suspension sutures. GUAN et al ., JMIG 2020 1 Robot-assisted transvaginal single-site 227 min POP-Q 0 postoperatively; vaginal length preserved Detailed technique highlights include wristed instruments, a 30° scope, and 3D vision GUAN et al ., Urology 2021 2 Robotic vNOTES (Xi) Not explicitly stated Both patients were discharged on postoperative day 1 with no complications; POP-Q 0 at 3 weeks This is the first report of using the robotic Xi platform for vNOTES sacrocolpopexy, emphasizing simplified suturing MEI et al ., HELIYON 2023 Mixed (TV-NOTES and RV-NOTES) There was no mesh exposure or recurrence; procedures performed by beginners were successful This highlights the training feasibility and potential for expanding cases to early learners All three studies in Table 6 support the technical feasibility of robotic vNOTES for sacrocolpopexy using the da Vinci Xi system, with no major perioperative complications or recurrences reported during follow-up. Robotic platforms address key limitations of standard vNOTES and single-site laparoscopy, particularly challenges in suturing, triangulation, and deep pelvic dissection. Guan et al . highlighted the ergonomic and technical advantages of wristed robotic instruments and 3D visualization. Operative times in RA-vNOTES cases varied significantly (132-275 min), reflecting differences in surgeon experience, patient complexity, and case setup [ 42 - 43 ] . Regarding expandability, the learning curve potential is evident, as MEI et al . reported successful implementation even by beginners. The inclusion of beginners in the MEI study is encouraging and suggests scalability of RA-vNOTES in training environments [ 41 , 44 ] . However, most reports are small, single-surgeon case series, limiting broader generalizability. To validate these findings, prospective, multi-institutional studies comparing RA-vNOTES to both laparoscopic sacrocolpopexy and conventional transvaginal approaches with long-term follow-up are needed. Additionally, procedures should be incorporated into residency training by creating stepwise pathways or simulation-based models for robotic Xi vNOTES sacrocolpopexy to ensure reproducibility, especially for early adopters and residents or fellows. As mentioned earlier, vNOTES offers specific advantages when bypassing abdominal pathology. The increasing BMI in the United States has resulted in a growing number of overweight and obese patients. Table 7 presents current cases that highlight the benefits of the vNOTES approach. LIU et al ., 2023 (PMID 37328095) Case report ( n = 1) BMI 70 kg/m 2 , 16-week-sized uterus Robotic vNOTES hysterectomy + bilateral salpingo-oophorectomy Feasible and safe in extreme obesity using an air seal for exposure, lap pads, ureter identification, vessel sealing, and contained tissue extraction. MATAK et al ., 2024 (PMID 38557832) Retrospective cohort ( n = 24) BMI > 30 kg/m 2 , benign indications Conventional laparoscopic vNOTES vs. total laparoscopic hysterectomy (TLH) vNOTES had a significantly shorter median operative time (35 min vs. 125 min, P < 0.05), similar conversion and complication rates, demonstrating feasibility in the obese population. SENDUKAS and GUAN, 2025 Case report ( n = 1) Morbid obesity, emergency torsion Robotic vNOTES emergency detorsion Demonstrated safe emergency use in obese patients, avoiding abdominal incisions; no complications SUNKARA and GUAN, 2022 Case report ( n = 1) BMI > 70 kg/m 2 , sterilization patient Robotic vNOTES bilateral salpingectomy The technique enabled precise, fine robotic handling in super-obese patients; successfully completed with no reported complications. Conventional and RA-vNOTES have been successfully performed in patients with a BMI up to and above 70 kg/m 2 . In obese patients, vNOTES significantly reduced operative times compared to traditional abdominal laparoscopic approaches (median, 35 min vs. 125 min) [ 45 ] . Across all cases, including complex scenarios, there were no major intraoperative complications, conversions were rare, and tissue extraction techniques ensured oncologic safety. These procedures included planned hysterectomy, sterilization, and emergency adnexal detorsion in morbidly obese patients [ 28 , 46 ] . Certain strategies, such as adjusting air-seal insufflation pressures, strategic use of laparotomy sponges, contained tissue extraction, and robotic instrumentation adjustments, are integral considerations in obese patients [ 47 ] . A retrospective cohort study of 287 patients found that RA-vNOTES hysterectomy is a safe and effective approach for both obese and non-obese patients, with comparable outcomes in operative time, blood loss, hospital stay, and complication rates. Although hysterectomy time was significantly longer in the obese group (42 min vs. 38 min, P = 0.003), overall surgical performance remained consistent, and conversion to conventional laparoscopy was rare (1.5%) [ 48 ] .

For all RA-vNOTES procedures, indocyanine green (ICG) is injected into both ureters before the procedure. In our practice, this approach is chosen because it takes approximately four minutes to place stents and inject ICG before robot docking, compared to the inefficiency of undocking the robot mid-procedure to place stents. As most of our cases involve endometriosis excisions, ICG assists with ureteral identification [ 9 ] . After ICG stent placement, the peritoneum is entered in the standard manner for vaginal hysterectomy using the conventional clamp-cut-tie method. This continues until the total hysterectomy is complete or until pelvic pathology prevents safe continuation. At that point, the robot is docked. Once the peritoneum is entered, regardless of hysterectomy completion, a self-retracting ring is sutured at the 5, 7, 10, and 2 o'clock positions using the 4-P port anchoring technique [ 10 ] . The appropriate port is then attached to the ring, and pneumoperitoneum is established. An intra-abdominal and pelvic survey is performed with a laparoscopic camera to ensure there is no endometriosis in the upper abdomen. After confirming that the pathology is confined to the pelvis, the robot is docked. At the end of the procedure, the steps are reversed to close the vaginal cuff. Two direct comparisons have been made between the da Vinci robotic Xi RA-vNOTES and traditional laparoscopic vNOTES (T-vNOTES) for hysterectomy in benign cases. KOYTHONG et al . compared RA-vNOTES ( n = 35) and T-vNOTES ( n = 79), finding similar operative times, estimated blood loss, hospital stays, and pain scores over three weeks [ 11 ] . Similarly, ZHANG et al . compared RA-vNOTES ( n = 8) and T-vNOTES ( n = 17), reporting similar safety and feasibility, with no significant differences in operative time, hospital stay, blood loss, or postoperative complications. Notably, ZHANG et al . found significantly less pain on postoperative days 1 and 3 in the RA-vNOTES group ( n = 8) [ 12 ] . Both studies support the safety and feasibility of RA-vNOTES. KOYTHONG et al .reported six conversions in the T-vNOTES group and none in the RA-vNOTES group. These six conversions in the T-vNOTES group suggest that the robotic platform may reduce the likelihood of intraoperative complications, especially in patients with challenging pelvic anatomy. Additionally, in the ZHANG et al . study, the reduced pain in the RA-vNOTES group may be due to more precise dissection and less tissue trauma with the robotic platform. This finding suggests a potential patient-centered benefit of RA-vNOTES. Table 1 summarizes the main differences between the studies, primarily the increased statistical power from the 114 patients in Koythong's work. However, both studies are single-surgeon, single-center studies, which limits the generalizability of their findings. Neither study evaluates long-term outcomes such as vaginal cuff healing, sexual function, or symptom recurrence, limiting the ability to fully compare surgical efficacy beyond the immediate postoperative period [ 11 - 12 ] . THIGPEN et al . conducted a large retrospective study comparing surgical outcomes of RA-vNOTES ( n = 159) and robotic-assisted single-site port (RSSP) ( n = 269) in 428 patients who underwent hysterectomy for benign indications by a single surgeon from 2015 to 2022. The RA-vNOTES group had significantly shorter operative times (132 min vs. 146 min, P = 0.0001), lower postoperative pain scores at weeks 1 and 3, and fewer superficial surgical site infections (0.6% vs. 4.5%, P = 0.03). This study strongly supports the efficacy and enhanced recovery profile of RA-vNOTES compared to RSSP hysterectomy, likely due to intraperitoneal access via a natural orifice [ 8 ] . Additionally, the benefits of vNOTES compared to abdominal laparoscopy include decreased postoperative pain, faster recovery, improved cosmesis, shorter operative time, reduced hospital stay, and less estimated blood loss. These advantages were achieved without increasing intraoperative or postoperative complications, readmissions, 24-hour pain scores, or hemoglobin changes between the abdominal laparoscopic and vNOTES hysterectomy groups [ 13 ] . Expected patient concerns regarding procedures performed solely through the vagina, such as dyspareunia, pelvic pain, and quality of life, have not been substantiated, as current data do not show significant differences compared to laparoscopy [ 8 , 14 ] . The vNOTES approach is highly versatile and has been successfully used for hysterectomy, adnexal surgery, myomectomy, sacrocolpopexy, isthmocele repair, and lymphadenectomy [ 15 ] . Despite its benefits, vNOTES has limitations. The use of straight laparoscopic instruments in a confined orifice restricts maneuverability and triangulation. This challenge is compounded by the need for at least two surgeons or a surgeon with an appropriate assistant. Many of these limitations are addressed with the assistance of a robotic platform [ 16 ] . The da Vinci Xi system was first used for vNOTES in four cases in 2014 by CHYI-LONG LEE. At that time, several limitations were noted, mainly related to instrumentation, and patient selection was considered very important [ 7 ] . Ten years later, a case series of 298 patients demonstrated the versatility of RA-vNOTES. The robotic system provided three-dimensional visualization, articulating instruments, reduced surgeon tremor, and decreased surgeon fatigue due to improved ergonomics. The wristed robotic instruments, in particular, facilitated dissection and suturing [ 17 ] . Though an improvement, the da Vinci Xi remained a platform based on a multi-port design. In 2014, the United States Food and Drug Administration (FDA) approved the da Vinci SP (Single Port) robotic platform, with its first use in 2018 [ 18 ] . The SP was first used for gynecology in 2023, both transumbilically and transvaginally [ 19 ] . Colleagues in China also recognized the potential of single-incision surgery, developing the Jingfeng SP1000 and showcasing its performance through the vNOTES approach on 20 patients in 2024 [ 20 - 21 ] . In parallel, the Shurui, another Chinese SP platform, was presented at the first Gynecological Minimally Invasive Oncology and Artificial Intelligence Conference. When compared transumbilically, the Shurui had outcomes comparable to the da Vinci robotic platform, but further data regarding the vNOTES approach are limited [ 22 ] . While the aforementioned platforms offer similar designs, the Hominis system by Memic Innovative Surgery Ltd. (Yehuda, Israel) was intended to mimic the surgeon's upper extremities. LOWERSTEIN et al . described a prospective study on the use of the Hominis system in women undergoing bilateral salpingo-oophorectomy. Although the instruments are placed vaginally, a camera must be placed transumbilically for visualization throughout the surgery [ 23 ] . Comparisons of the robotic systems are shown in Table 2 . da Vinci Xi (intuitive surgical) Multiport Conventional robotic arms; 8 mm ports Moderate Widely available-excellent visualization-wristed instruments Bulky for vaginal access-requires workarounds (GelPOINT + retroflexion)-not optimized for natural orifice access da Vinci SP (single port) (intuitive surgical) Single port (25 mm cannula) 3 multijointed instruments + flexible camera-ideal for confined spaces-entry through posterior colpotomy High Purpose-built for narrow access-natural fit for vNOTES-minimal collision Costly-limited availability-no energy devices on some instruments (in early generations) Shurui SR-01 (China) Single port, multi-arm adaptable Emerging domestic Chinese system-SP-compatible- instruments allow endowrist-like motion Emerging potential Designed for cost-effective robotic MIS-local integration in Chinese hospitals Limited international experience-lack of published clinical vNOTES trials Jingfeng (Jingfeng medical technology) (China) Flexible port platform Robotic SP with optional flexible arms-modular design Emerging Designed for hybrid orifices (rectum, vagina)-early flexibility for NOTES Clinical data limited-needs validation in gynecology Memic Hominis (Israel/USA) Transvaginal or mixed (camera via umbilicus) Miniature robotic arms introduced vaginally-camera inserted through umbilicus (hybrid-NOTES) Hybrid True NOTES entry for instruments-designed specifically for gynecology-ergonomic and compact Not true “pure vNOTES”- Umbilical camera limits cosmesis-FDA approval is restricted; still emerging

VNOTES hysterectomy has been validated by studies demonstrating shorter operative times and hospital stay with no significant differences in intraoperative or postoperative complications [ 13 ] . Additionally, patients undergoing vNOTES are typically discharged within 12 hours (77% vs. 43%), report lower visual analog scale (VAS) pain scores, require less analgesia in the first seven days after surgery, have shorter operative times (39-99 min for vNOTES vs. 72-171 min), and, if needed, spend fewer nights in the hospital (0.5 night vs. 2 nights) compared with conventional laparoscopy [ 49 ] . For adnexal cystectomies, the vNOTES approach results in less pain, shorter postoperative stays, and improved cosmesis compared with conventional laparoscopy [ 50 ] . When comparing robot-assisted single-incision laparoscopic surgery (RA-SILS) with RA-vNOTES, the vaginal approach shows a significant reduction in surgical site infections [ 8 ] . In RA-vNOTES, 84.5% of patients had no complications, and an additional 13.1% experienced Clavien-Dindo Ⅰ–Ⅱ complications, compared to complication rates of 11.68%-27.84% in the traditional vNOTES group (63a). These are some of the benefits observed in patients. Using a robotic platform also offers benefits for the surgeon, including 3D visualization, jointed instruments, tremor control, 10 × magnification, and ergonomic positioning [ 51 ] . Currently, surgical robot platforms are being developed specifically for single-port use. The da Vinci SP, Jingfeng, and Shurui robotic platforms are designed as single arms with outlets for advancing elbowed and wristed instruments, allowing triangulation in confined spaces. Additionally, the robotic camera can articulate away from the operating field to provide a vantage point distant from the robotic instruments [ 19 ] . These benefits also apply to the transabdominal approach.

With increased use of the robotic platform, there is growing interest in understanding the learning curves required to achieve proficiency, particularly in gynecology and urology. Meta-analyses and literature on this topic are difficult to interpret regarding the specific requirements for proficiency, aside from the general principle that more prior experience leads to a shorter learning curve: “Those with greater experience required fewer procedures to overcome their learning curve” [ 52 ] . For new learners, such as residents, simulator robotic consoles provide opportunities for practice and assessment ex vivo , allowing a certain level of proficiency to be achieved before operating on patients [ 53 ] . RA-vNOTES faces several limitations, including the need for a dedicated robotics program, access to a robotic simulator, and the availability of preceptors or surgeons who are comfortable with vNOTES and, separately, with RA-vNOTES. Achieving proficiency in RA-vNOTES is challenging. A high level of skill is required in single-incision procedures, robotic surgery, and vaginal surgery before attempting RA-vNOTES. After reaching baseline proficiency, additional challenges arise due to changes in the anatomical perspective when viewing the surgical field cephalad, which may obscure anatomical relationships. Complexity increases further when significant pelvic pathology is present. A case series of 84 patients demonstrated that 10 cases of RA-vNOTES were needed to achieve surgical proficiency in performing a hysterectomy, and 10-20 cases were required for port placement and robot docking. This series clearly stated that the surgeon needed experience in single-incision laparoscopic surgery as well as robotic surgery to qualify for this learning curve [ 53 ] . One of the major factors in RA-vNOTES is the upfront cost of the robot, along with annual maintenance within the context of operative expenses. Compared with conventional laparoscopy, RA-vNOTES cases cost $ 2 189 to $ 6 685 more per case. Cost is an important factor, but it should be considered alongside multiple other factors [ 17 ] . This is one example of a cost breakdown, but caution is warranted as this factor may have limited generalizability.