Clinical Review

2019 Update on minimally invasive gynecologic surgery

Arnold P. Advincula, MD

Dr. Advincula is Levine Family Professor of Women's Health, Vice-Chair, Department of Obstetrics and Gynecology, Chief of Gynecologic Specialty Surgery, Sloane Hospital for Women; Medical Director, Mary and Michael Jaharis Simulation Center, Columbia University Medical Center/New York-Presbyterian Hospital. He serves on the OBG Management Board of Editors.

Tamisa Koythong, MD

Dr. Koythong is Minimally Invasive Gynecologic Surgery Fellow, Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas.

Juan Liu, MD, PhD

Dr. Liu is Chief of Minimally Invasive Gynecologic Surgery, Professor, Department of Obstetrics and Gynecology, Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.

Xiaoming Guan, MD, PhD

Dr. Guan is Chief of Minimally Invasive Gynecologic Surgery, Texas Children's Hospital, Professor, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston.

Dr. Advincula reports serving as a consultant to AbbVie, ConMed, CooperSurgical, Eximis Surgical, Intuitive Surgical, and Titan Medical and receiving royalties from CooperSurgical. Dr. Guan reports that he is a speaker for Applied Medical. The other authors report no financial relationships relevant to this article.

Requiring a very particular set of surgical skills, the cutting edge vNOTES technique for hysterectomy incorporates conventional laparoscopic instrumentation in a vaginal approach. Here, its pioneers describe how it’s done.



Through the years, the surgical approach to hysterectomy has expanded from its early beginnings of being performed only through an abdominal or transvaginal route with traditional surgical clamps and suture. The late 1980s saw the advent of the laparoscopic-assisted vaginal hysterectomy (LAVH), and from that point forward several additional hysterectomy methods evolved, including today’s robotic approaches.

Although clinical evidence and societal endorsements support vaginal hysterectomy as a superior high-value modality, it remains one of the least performed among all available routes.1-3 In an analysis of inpatient hysterectomies published by Wright and colleagues in 2013, 16.7% of hysterectomies were performed vaginally, a number that essentially has remained steady throughout the ensuing years.4

Attempts to improve the application of vaginal hysterectomy have been made.5 These include the development of various curriculum and simulation-based medical education programs on vaginal surgical skills training and acquisition in the hopes of improving utilization.6 An interesting recent development is the rethinking of vaginal hysterectomy by several surgeons globally who are applying facets of the various hysterectomy methods to a transvaginal approach known as vaginal natural orifice transluminal endoscopic surgery (vNOTES).7,8 Unique to this thinking is the incorporation of conventional laparoscopic instrumentation.

Although I have not yet incorporated this approach in my surgical armamentarium at Columbia University Medical Center/New York–Presbyterian Hospital, I am intrigued by the possibility that this technique may serve as a rescue for vaginal hysterectomies that are at risk of conversion or of not being performed at all.9

At this time, vNOTES is not a standard of care and should be performed only by highly specialized surgeons. However, in the spirit of this Update on minimally invasive surgery and to keep our readers abreast of burgeoning techniques, I am delighted to bring you this overview by Dr. Xiaoming Guan, one of the pioneers of this surgical approach, and Dr. Tamisa Koythong and Dr. Juan Liu. I hope you find this recent development in hysterectomy of interest.

—Arnold P. Advincula, MD

Continue to: Development and evolution of NOTES...


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