**2. History of the technique**

The use of endoscopic procedures to visualize the abdomen is over 100 years old. Visualization of the pelvis through the vagina was developed by Decker who first reported the procedure in 1944 [1]. The term culdoscopy was used to describe placement of a scope into the posterior cul-de-sac with the patient in knee-chest position. This was originally used for diagnostic purposes but later modified for treatment of ovarian conditions, ectopic pregnancy and tubal ligation. However, the technique was never utilized by a wide audience of gynecologists, and abdominal and traditional transvaginal procedures continued to dominate the field. In the 1990s as fiber-optic cameras and improved instrumentation developed, abdominal laparoscopy came into vogue and has since exploded as a dominant method of performing gynecologic surgery along with its more recent counterpart, robotic surgery. Laparoscopy has replaced a large percentage of abdominal procedures permitting faster recovery, less pain, and better cosmetics for our patients. Unfortunately, as laparoscopic techniques and instrumentation continued to improve, the percent of hysterectomies performed transvaginally diminished. For example, the percent of hysterectomies performed vaginally dropped from 25% in 1998 to 17% in 2010 and continues to fall [2]. This despite the recommendation by the American College of Obstetricians and Gynecologists [3] and the AAGL [4] that transvaginal hysterectomy is the preferred method for benign gynecological disease as the optimum approach for patient safety and recovery. Younger gynecologists in academic and community settings are performing fewer transvaginal techniques. As a consequence, they are less likely to train resident physicians in transvaginal surgery.

The earliest utilization of a vNOTES approach was for general surgery procedures such as cholecystectomy and appendectomy [5]. In Asia in 2012, Ahn reported on the use of the single-port placed into the posterior vagina to remove the adnexa [6]. At the same time, the first series of vNOTES hysterectomies was published [7]. These authors utilized an Alexis retractor (Applied Medical, Rancho Santa Margarita, CA) placed into the anterior and posterior cul-de-sac with a surgical glove attached on the outer ring through which the glove fingers were used as laparoscopic ports. In Europe in 2013 Jan Baekelandt adapted the GelPoint device (Applied Medical, Rancho Santa Margarita, CA) to the transvaginal approach and has been the major developer and promoter of vNOTES surgery in the West [8, 9]. The GelPoint has the advantage of ease of set up, better ergonomics, and simplicity in specimen removal over a glove fastened to an Alexis. A group of American gynecologists (including the author of this chapter) trained with Dr. Baekelandt beginning in 2017 and brought the technique to the United States. To date, this core of vNOTES surgeons has trained approximately 100 gynecologists in this country. In 2019, a port specifically created for vNOTES (VPath, Applied Medical, Rancho Santa Margarita, CA) was developed and approved by the FDA.
