In this episode, Dr. Mark Hoffman hosts Dr. Jan Baekelandt, a gynecologic surgeon from Mechelen, Belgium, to discuss a novel gynecologic surgery approach known as vaginal natural orifice transluminal endoscopic surgery (vNOTES). --- SHOW NOTES This technique involves entering the pelvic cavity through the vaginal lumen, eliminating the need for abdominal incisions and promoting a less invasive procedure. Dr. Jan Baekelandt explains that during his career this approach originated from the single-side surgery technique, gradually evolving into a fully transvaginal procedure. He highlights that the advanced tools required for vaginal surgeries now offer equivalent visualization and hemostatic control as laparoscopic techniques, while providing the added benefit of reduced invasiveness. The benefits of vNOTES for patients are discussed, including findings from two randomized control trials comparing vNOTES hysterectomy and adnexectomy to laparoscopic approaches. The results indicate non-inferiority, reduced postoperative pain, decreased analgesic use, and shorter hospital stays for vNOTES. Complications were also lower in the hysterectomy trial. Notably, the vNOTES technique especially benefited patients who were obese, had undergone prior abdominal surgeries, or had large uteruses. Jan underscores the significance of technique standardization to facilitate teaching and complication avoidance. He acknowledges vNOTES-specific complications, such as a higher cystotomy rate, but notes a lower ureter damage rate. However, he cautions that vNOTES might not be suitable for certain patients, like those with endometriosis, prior pelvic inflammatory disease or pelvic abscesses. The potential impact of vNOTES on non-hysterectomy surgeries, future deliveries, and sexual function is briefly discussed, though data in these areas remain limited. Dr. Jan Baekelandt is hopeful that more evidence will emerge to guide physicians. He shares that, based on available data and his own experience, vaginal deliveries following vNOTES have generally proceeded without complications, without a notable increase in cesarean sections or vaginal tears. He notes that to protect sexual function, surgeons should take care to make incisions away from the posterior cervical fornix to avoid subsequent dyspareunia for their patients. The episode concludes with Jan emphasizing the importance of formal training and starting with simpler cases to build proficiency and confidence. He asserts that the best technique for a surgeon is the one that instills confidence in keeping patients safe. --- RESOURCES Baekelandt J, De Mulder PA, Le Roy I, Mathieu C, Laenen A, Enzlin P, Weyers S, Mol BW, Bosteels JJ. HALON-hysterectomy by transabdominal laparoscopy or natural orifice transluminal endoscopic surgery: a randomised controlled trial (study protocol). BMJ Open. 2016 Aug 12;6(8):e011546. doi: 10.1136/bmjopen-2016-011546. PMID: 27519922; PMCID: PMC4985989. Baekelandt JF, De Mulder PA, Le Roy I, Mathieu C, Laenen A, Enzlin P, Weyers S, Mol BWJ, Bosteels JJA. Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) adnexectomy for benign pathology compared with laparoscopic excision (NOTABLE): a protocol for a randomised controlled trial. BMJ Open. 2018 Jan 10;8(1):e018059. doi: 10.1136/bmjopen-2017-018059. PMID: 29326183; PMCID: PMC5780723.