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

Vaginal natural orifice transluminal endoscopic surgery (vNOTES) is associated with reduced postoperative pain and faster recovery compared with conventional laparoscopy. However, its adoption is limited by challenging triangulation, caudal-to-cephalic visualization requiring a learning curve, and restricted instrument length when managing complex pathology. Robotic assistance provides three-dimensional visualization, wristed instrumentation with enhanced dexterity, and surgeon-controlled camera movement, which may help overcome these limitations and expand the role of minimally invasive vaginal surgery. This video aims to demonstrate essential procedural steps and practical tips for surgeons beginning robotic vNOTES hysterectomy.

The first part of the video demonstrates key procedural steps using a simulation model. Following anterior and posterior colpotomy and bilateral detachment of the uterosacral ligaments, an Alexis ring (Applied Medical, Rancho Santa Margarita, CA, USA) is inserted, as in conventional vNOTES. GelPoint (Applied Medical) trocars are arranged in a diamond configuration on the GelSeal cap (Applied Medical) and secured to the ring to establish pneumoperitoneum. The patient is placed in Trendelenburg position, the robot is docked, and the camera trocar is inserted first, followed by two additional trocars with appropriate spacing to avoid arm collision. The second part of the video demonstrates application of the technique in a 43-year-old woman who presented with heavy uterine bleeding secondary to multiple fibroids.

The patient successfully underwent robotic vNOTES hysterectomy, bilateral salpingectomy, and right ovarian cystectomy, demonstrating translation of simulation-based principles into clinical practice.

Robotic vNOTES is a feasible approach that combines robotic advantages with vaginal access, enabling minimally invasive management of complex gynecologic pathology under direct visualization.