Initiating robotic vaginal natural orifice transluminal endoscopic surgery: a Beginner's guide.

Vaginal natural orifice transluminal endoscopic surgery (vNOTES) is an emerging field in minimally invasive surgery [ 1 ]. By incorporating the advantages of endoscopic surgery, the vNOTES approach avoids abdominal wall wounds and trocar-related complications [ 2 ], and is associated with reduced pain and faster recovery compared with conventional laparoscopy [ 3 ]. However, it has limitations including challenging triangulation, a caudal-to-cephalic view requiring a learning curve, and restricted instrumental length for challenging pathologies [ 4 ]. The robotic approach, which provides three-dimensional visualization, greater wristed instrumentation freedom, and surgeon-controlled camera movement, can help overcome these challenges and may expand the use of minimally invasive vaginal surgery to more complex cases [ 5 ]. The combination of robotic surgery and vNOTES is novel and has been reported for various complex gynecologic procedures, including hysterectomy, sacrocolpopexy, and the resection of endometriosis, with favorable outcomes [ 6 – 8 ]. A recent study comparing traditional and robotic vNOTES demonstrated similar operative time, length of hospital stay, postoperative pain levels, and conversions [ 6 , 9 ]. Despite its advantages, robotic vNOTES remains limited to specialized centers.

The second part of the video features a 43-year-old woman with a history of one cesarean delivery and one vaginal delivery who reported heavy menstrual bleeding due to multiple fibroids. Preoperative ultrasound demonstrated a uterus enlarged to approximately 14 weeks’ size, with fibroids measuring up to 5 cm and a 4.3-cm simple right ovarian cyst. The patient underwent robotic vNOTES hysterectomy, bilateral salpingectomy, and right ovarian cystectomy. After colpotomy and uterosacral ligament detachment, the Alexis ring (Applied Medical) and GelSeal (Applied Medical) were placed with diamond-configured trocars. Pneumoperitoneum was established and the robot was docked as described. The central trocar and 30-degree upward camera were introduced first, followed by targeting to the cervix and placement of two additional trocars. A vessel sealer was inserted in the right arm and a bipolar grasper in the left. After separation of the uterus and fallopian tubes, a broad ligament fibroid was identified and removed while protecting the ureter. The enhanced visualization and instrument articulation facilitated precise dissection compared with conventional laparoscopy. Following right ovarian cyst removal, hemostasis was confirmed. If needed, bleeding could have been readily controlled using standard robotic techniques such as suturing or use of hemostatic agents. The robotic instruments were withdrawn, and the arms were detached. All specimens were removed vaginally and sent for pathological examination. The robot was undocked, the Alexis ring (Applied Medical) removed, and the vaginal cuff closed with a running vertical 0 V-Loc suture. Cystoscopy confirmed bladder integrity and bilateral ureteral efflux. The patient tolerated the procedure well and was transferred to the recovery unit in stable condition. She was discharged 4 hours later as part of the enhanced recovery after surgery protocol. On a follow-up phone call the next day, she reported minimal pain (2–3 on the visual analog scale) and a high level of satisfaction.

Robotic vNOTES represents an emerging evolution in minimally invasive gynecologic surgery [ 10 ]. While conventional vNOTES has gained increasing acceptance and demonstrated safety and feasibility in several gynecologic procedures, the integration of robotic technology into this approach remains relatively novel, and the available evidence is still limited [ 8 , 9 , 11 – 13 ]. This video provides practical insights and technical nuances derived from our experience to assist surgeons adopting this technique and help overcome the initial learning curve. The integration of robotic assistance improves triangulation, visualization, and instrument dexterity, addressing traditional vNOTES limitations such as restricted instrument length and challenging angles. This may broaden the applicability of minimally invasive vaginal surgery, even for surgeons with limited single-site laparoscopy experience. For patients, expanded adoption may translate into shorter recovery, reduced postoperative pain, and avoidance of abdominal incisions. The approach may also expand indications for vaginal surgery in complex cases. Economic considerations remain a significant limitation. Robotic platforms require substantial investment, training, and maintenance, making them more expensive than conventional laparoscopy or standard vNOTES. These costs may limit broader implementation, particularly in smaller institutions. Cost-benefit analyses and reimbursement considerations will be essential to support sustainable integration. With appropriate patient selection, robotic vNOTES is a feasible approach that combines the benefits of vaginal natural orifice surgery with robotic visualization and precision. Although challenges remain, continued experience, technological refinement, and structured training may improve efficiency and cost-effectiveness, supporting broader adoption in gynecologic surgery.

We present a video demonstrating essential steps and practical tips for beginner surgeons performing robotic vNOTES hysterectomy using the da Vinci Xi robotic system (Intuitive Surgical, Sunnyvale, CA, USA). The first part of the video includes a simulation model. The surgical bed is aligned diagonally to allow optimal robotic access, with system settings oriented to upper abdominal anatomy. After anterior and posterior colpotomy and bilateral uterosacral ligament detachment, an Alexis ring (Applied Medical, Rancho Santa Margarita, CA, USA) is inserted as in conventional vNOTES. The GelSeal cap (Applied Medical) is attached and pneumoperitoneum is established at 15 mmHg. The diamond configuration of trocars on the GelSeal cap (Applied Medical), with a central camera port and lateral ports spaced 6–8 cm apart, was intentionally standardized based on prior experience to optimize triangulation, instrument range of motion, and reproducibility while minimizing robotic arm collisions. The patient is placed in a 20-degree Trendelenburg position with legs lowered to maximize docking space. The robot is advanced from the side of the bed, targeting the mons pubis to optimize alignment. The robotic arms are positioned between the patient’s legs ( Fig. 1 ). The central camera trocar is inserted first directly to the Gelseal (Applied Medical) or to the Gelpoint (Applied Medical) trocar, to the level of the thin line ( Fig. 2 ). A 30-degree camera is introduced in the “upward” position to enhance visualization of the cervix and pelvic structures. The camera can later be rotated to the “downward” orientation, as needed. After targeting the cervix, two additional trocars are placed under visualization, maintaining adequate spacing to prevent arm collisions. Adjusting trocar depth within the GelSeal (Applied Medical) further optimizes maneuverability ( Fig. 3 ). Instruments are then introduced under direct vision. The primary surgeon operates from the console, while the assistant works between the legs using the lower trocar ( Fig. 4 ).