The most natural and least invasive approach to gynecologic surgery — no visible abdominal incisions. Vaginal surgery is the gold standard for numerous gynecologic procedures thanks to its reduced invasiveness, absence of abdominal scarring, and rapid postoperative recovery. The vNOTES technique (vaginal Natural Orifice Transluminal Endoscopic Surgery) combines the benefits of vaginal access with full endoscopic vision, representing one of the most advanced evolutions of minimally invasive vaginal gynecologic surgery.
[Image placeholder — vNOTES setup / scarless surgery concept]
Suggested: infographic or clinical photo illustrating no abdominal scars
1 · What It Is
Scarless Gynecologic Surgery
The Scarless Surgery Principle
The vagina is a natural anatomical access to the pelvic organs — a biological "highway" that surgeons have used for centuries for the safest and least invasive approach to the uterus, adnexa, and pelvic floor. The modern evolution of this principle, combined with endoscopic technology, allows complex gynecologic procedures to be performed with no visible abdominal scars at all.
Vaginal surgery refers to gynecologic procedures performed entirely through the vaginal canal, using conventional surgical instruments. It has been the reference technique for hysterectomy and pelvic-floor surgery for over a century, and international guidelines (ACOG, AAGL, ESGE) continue to recommend it as the first-choice approach for benign hysterectomy whenever technically feasible.
vNOTES (vaginal Natural Orifice Transluminal Endoscopic Surgery) is a modern evolution that uses the transvaginal route as a natural surgical access while introducing a single-port device to insufflate the pelvis with CO₂ and allow endoscopic vision. This combines the scarless advantage of vaginal surgery with the visibility and operative capability previously offered only by laparoscopy.
Key technical features that distinguish vaginal and vNOTES surgery:
No abdominal incisions — the entire procedure is performed through the vaginal natural orifice, leaving no visible external scars.
Reduced parietal trauma — no damage to abdominal wall muscles, fascia, or nerves; negligible risk of incisional hernia or wound complications.
Direct anatomical access — the vaginal route provides immediate access to the uterus, adnexa and Douglas pouch without needing to traverse the peritoneal cavity from above.
Endoscopic vision (vNOTES) — when vNOTES technique is used, a single-port platform provides 360° endoscopic visualization of the pelvis through the vaginal route.
2 · Indications
When Vaginal or vNOTES Surgery Is Indicated
Vaginal and vNOTES surgery are indicated in a wide range of gynecologic conditions, primarily benign, with selected applications in early oncologic disease in specific clinical scenarios.
Hysterectomy & Adnexal Surgery
Vaginal hysterectomy — with or without endoscopic assistance (vNOTES). First-line approach for benign hysterectomy when technically feasible, per international guidelines.
Transvaginal adnexectomy and salpingectomy — including risk-reducing bilateral salpingectomy, particularly suited for patients undergoing concomitant hysterectomy.
Surgery for benign adnexal masses — selected patients with simple ovarian cysts or benign adnexal pathology suitable for transvaginal access.
Vaginal Myomectomy
Vaginal myomectomy is a minimally invasive option for fibroids accessible through the cervical canal or vagina. Main indications:
FIGO 0–1 submucosal fibroids with predominant intracavitary component
Pedunculated submucosal fibroids protruding into the cervical canal or vagina
Accessible cervical fibroids
Myomas in expulsion (prolapsing myoma)
Symptomatic myomas with technically favorable vaginal access
Selected Oncologic Indications
Early endometrial carcinoma in fragile patients — in patients with severe obesity or significant comorbidities, when transabdominal approaches are technically risky or contraindicated, the vaginal route can represent a surgical alternative for the treatment of early endometrial tumors in carefully selected cases. This is a highly specialized indication that requires rigorous multidisciplinary evaluation.
Pelvic Floor Surgery
Vaginal prolapse repair (native tissue or mesh-augmented)
Vaginal correction of cystocele, rectocele and enterocele
3 · How It Works
The Procedure — Step by Step
The exact technical sequence varies between pure vaginal surgery and vNOTES, but the underlying principle is the same: accessing the pelvic organs through the vaginal natural orifice. Below is a typical sequence for vaginal hysterectomy with vNOTES-assisted adnexectomy, one of the most common applications.
01
Anesthesia & Positioning
General or regional anesthesia. The patient is placed in lithotomy position with adequate exposure of the vaginal field. No abdominal preparation is needed.
02
Vaginal Access
A circumferential incision is made around the cervix (colpotomy), gaining access to the anterior and posterior vaginal fornices and to the Douglas pouch. The bladder and rectum are carefully dissected off the uterus.
03
Uterine Ligament Section
The uterosacral, cardinal, and broad ligaments are sequentially clamped, divided and ligated — from lower to upper pedicles — using conventional surgical instruments.
04
vNOTES Port Placement (if indicated)
When vNOTES is used, a single-port device is positioned in the vaginal cuff. CO₂ insufflation creates working space; endoscopic vision is achieved through the same port.
05
Adnexal & Upper Pedicle Management
Through the vNOTES port — or conventional vaginal access — the adnexa are inspected, dissected and removed if indicated. Upper uterine pedicles and ovarian vessels are safely controlled under endoscopic vision.
06
Specimen Extraction & Closure
The uterus and adnexa are extracted through the vaginal route. In-bag extraction may be used for added safety. The vaginal cuff is closed with absorbable sutures. No external sutures or dressings are needed.
4 · Advantages
Evidence-Based Advantages
The benefits of vaginal and vNOTES surgery, compared to abdominal and laparoscopic approaches in appropriate indications, are well documented in the literature and endorsed by international guidelines.
No Visible Scars
The defining advantage: the absence of abdominal incisions leaves no visible external scarring, an important factor for many patients' quality of life and body image.
Less Postoperative Pain
Studies consistently show lower postoperative pain scores and reduced opioid requirements compared to laparoscopic and open approaches, due to absent abdominal-wall trauma.
Faster Recovery
Return to normal activities typically within 2–3 weeks. Many patients describe the recovery as the easiest of all minimally invasive options.
No Abdominal Wall Complications
Absent risk of port-site hernia, wound infection, or incisional hernia — complications that, while rare, remain possible with any transabdominal approach.
First-Choice Guideline Status
International guidelines (ACOG Committee Opinion 701, AAGL, ESGE) recommend the vaginal approach as first-line for benign hysterectomy when technically feasible.
Cost-Effectiveness
Pure vaginal surgery requires no specialized technology beyond standard instruments; even vNOTES uses a single disposable port. Lower overall cost compared to robotic surgery.
5 · Patient Selection
Who Is a Candidate
Vaginal and vNOTES surgery require careful preoperative assessment to confirm technical feasibility. Not every gynecologic condition is amenable to this approach, but when it is, it often represents the least invasive option available.
Typical candidates for vaginal or vNOTES surgery include:
Women requiring hysterectomy for benign conditions with a mobile uterus of normal or moderately enlarged size
Patients who have had vaginal deliveries and have adequate vaginal access
Women needing risk-reducing salpingectomy (alone or concomitant to hysterectomy)
Patients with FIGO 0–1 submucosal fibroids or prolapsing cervical myomas
Women with early endometrial cancer and severe comorbidities contraindicating laparoscopy or robotic surgery
Patients requiring pelvic-floor reconstructive surgery for prolapse
Patients who prioritize absence of abdominal scarring and fastest recovery
Vaginal or vNOTES may not be the first choice when: the uterus is very large or immobile (significantly enlarged fibromatous uterus), there is a history of multiple pelvic surgeries with expected severe adhesions, the patient is nulliparous with very narrow vaginal access, advanced oncologic disease requires extensive pelvic and para-aortic lymphadenectomy, or deep infiltrating endometriosis requires multi-compartmental abdominal resection.
A note on expertise. Vaginal surgery is a technically demanding discipline that has declined in younger surgical generations worldwide, despite being the most advantageous approach for many benign conditions. Proper case selection and surgical expertise are essential to achieving the best outcomes. Every indication is individually assessed to identify the optimal approach.
6 · Recovery
Recovery & Outcomes
Postoperative recovery after vaginal or vNOTES surgery is typically the fastest and easiest among all minimally invasive gynecologic approaches. The absence of abdominal-wall trauma, combined with the natural healing of the vaginal cuff, contributes to an early return to normal life.
D0
Day of Surgery
Transfer to ward within 2–3 hours. Liquid diet restarted the same evening. Early mobilization encouraged — the absence of abdominal incisions makes movement particularly comfortable.
D1
Early Discharge
Most patients are discharged within 24 hours — often the quickest of all minimally invasive approaches. Solid diet resumed, independent walking, oral analgesia only.
W1
First Week
Return to light daily activities already within the first week. Vaginal spotting or light discharge is normal as the vaginal cuff heals. Avoid penetrative sexual activity, tampons, and swimming for 4–6 weeks.
W2–3
Full Recovery
Gradual return to full physical activity including exercise, driving, and work. Complete vaginal cuff healing around week 6. Follow-up visit typically scheduled around day 10–14.
7 · Research & Evidence
The Evidence Base
Vaginal surgery has over a century of documented outcomes, making it one of the most evidence-rich techniques in gynecologic surgery. vNOTES, while more recent, has accumulated substantial supporting evidence in the past decade. Below are the key references informing current practice.
ACOG Committee Opinion 701 (2017) — Choosing the Route of Hysterectomy
The American College of Obstetricians and Gynecologists explicitly recommends the vaginal approach as the first choice for benign hysterectomy when technically feasible, based on consistent evidence of equivalent or superior outcomes compared to other routes, with the lowest complication rate.
AAGL Position Statement on Vaginal Hysterectomy
The American Association of Gynecologic Laparoscopists endorses vaginal hysterectomy as the preferred approach for benign disease, citing data on reduced operative time, shorter hospital stay, faster recovery and lower cost compared to laparoscopic or robotic approaches.
HALON Trial (2021) — vNOTES vs Laparoscopic Hysterectomy
Randomized controlled trial comparing vNOTES hysterectomy to standard laparoscopic hysterectomy for benign indications. Results demonstrated non-inferiority of vNOTES, with shorter operative time, faster recovery and equivalent safety, supporting the adoption of vNOTES as a viable alternative.
Cochrane Review on Hysterectomy Approaches
Systematic reviews consistently confirm that vaginal hysterectomy should be the preferred approach when feasible, offering the best balance of safety, recovery, cost and patient satisfaction compared to abdominal, laparoscopic and robotic routes.
NOTES International Registries
International registries tracking vNOTES outcomes across multiple European and North American centers have documented consistent safety and efficacy profiles, with expanding indications including adnexal surgery and selected oncologic applications.
Prof. Di Donato's own research contribution: author of over 266 peer-reviewed publications on Scopus, with active research in vaginal and minimally invasive gynecologic surgery. View full publication list →
8 · Frequently Asked Questions
FAQ — Vaginal Surgery & vNOTES
What is the difference between vaginal surgery and vNOTES?
Both approaches use the vaginal natural orifice as the surgical access route, avoiding abdominal incisions. Conventional vaginal surgery uses standard surgical instruments and direct vision. vNOTES adds a single-port device that allows CO₂ insufflation and endoscopic vision, expanding the range of procedures that can be safely performed through the vaginal route — particularly upper pedicles, adnexal surgery, and cases with partially limited direct visibility.
Will I really have no scars at all?
Yes. With vaginal or vNOTES surgery there are no external abdominal incisions, therefore no visible external scars. The vaginal cuff heals internally within 4–6 weeks and is not visible. This is the defining advantage of these techniques and an important factor for many patients.
Does this technique affect my sexual life afterwards?
After a standard healing period of 4–6 weeks (avoiding penetrative intercourse, tampons and vaginal douching during this window), sexual activity can normally be resumed. Long-term studies show no negative impact on sexual function compared to other hysterectomy approaches; some data even suggest better outcomes in terms of vaginal sensation and elasticity.
Am I a candidate if I've never had a vaginal delivery?
Nulliparity (never having given birth vaginally) is not an absolute contraindication, but it may make vaginal access more technically challenging. A careful preoperative gynecologic examination assesses vaginal capacity and uterine mobility. In some nulliparous patients vNOTES can overcome limitations of pure vaginal surgery. In other cases laparoscopic or robotic surgery may be preferred.
I'm traveling from abroad for vaginal surgery. How does it work?
Prof. Di Donato regularly treats international patients for vaginal and vNOTES surgery. The typical pathway includes: (1) remote Second Opinion review of your records and imaging; (2) in-person consultation in Rome with preoperative pelvic examination and assessment of technical feasibility; (3) surgery at an accredited Rome facility; (4) 1-day hospital stay (often the quickest of all approaches); (5) recovery in Rome for 5–7 days before return travel; (6) long-distance follow-up coordination. English-speaking support throughout.
Discuss Your Case with Prof. Di Donato
Request a personalized consultation or submit your records for a Second Opinion review. International patients are welcome.