**4. Vaginal natural orifice transluminal endoscopic surgery (vNOTES)**

Natural orifice surgery (NOTES) originated in Gastroenterology/General Surgery circa 2004, utilizing rectal and oral endoscopy to visualize the peritoneum through specific visceral organ sites, such as the fundus of the stomach [11]. NOTES was heralded as a novel method of peritoneal access, subverting the need for skin incisions.

Approximately 10 years later, NOTES has been applied to gynecology by several authors. It was piloted first by Dr. Baekenlandt in the setting of hysterectomy, demonstrating feasibility and safety [12, 13] of the technique. It was developed further for other applications, predominately adnexal surgery via posterior colpotomy while maintaining the uterus. Although there has been limited adoption in the US, this technique has reached faster acceptance internationally, with a high percentage of laparoscopic procedures currently being completed using this method in Taiwan [14–16]. Preliminarily, many early studies have found lower blood loss, shorter hospital stay, and less postoperative pain with vNOTES procedures compared to other accepted modalities [17, 18].

For Gynecologists, it is well known that the vaginal epithelium rapidly heals. Vaginal surgery has been performed safely for generations from vaginal hysterectomies to the historic culdocentesis. In many ways, vaginal surgery has been the conventional "natural orifice" surgery. NOTES, therefore, naturally lent itself to gynecologic surgery. vNOTES is particularly useful for adnexal surgery at the time of vaginal hysterectomy, which offers safe, direct visualization of adjacent anatomy. This is particularly useful in light of the growing evidence suggesting that opportunistic salpingectomy may reduce the risk of epithelial ovarian cancers [17].

While this field is in its infancy in the United States, the technique has great potential to meaningfully impact the field of Gynecology. It combines the techniques of our predecessors with novel technology. In the opinion of some authors, this comes at a critically important time, as the classical vaginal surgical skills in Gynecology are at risk of being lost in many academic settings. Vaginal hysterectomies in general practice and in OB/GYN residencies are decreasing [15, 16] in favor of laparoscopic procedures. This is an unsettling trend, where a procedure that was once the hallmark of gynecologic surgery appears to be phasing out slowly. Many authors suggest that a strong benefit of full acceptance of vNOTES techniques in

gynecology will be the maintenance of the vaginal surgery skills. Many consider these skills and techniques of vaginal surgery to be the original first steps towards a minimally invasive culture in gynecology, and that they were seen as the original "calling card" of our field for much of the specialty's existence.
