vNOTES Hysterectomy: How It Works, Who It Suits and What the Evidence Shows

vNOTES is a way of doing a hysterectomy entirely through the vagina, but with the camera and long, thin instruments used in keyhole surgery. Because nothing is cut on the belly, it is sometimes described as “scarless” hysterectomy. It is newer than the other routes, the first vNOTES hysterectomy was reported in 2012, and it is offered at a growing number of hospitals, but not everywhere.^[4] This guide explains how vNOTES works, who it may suit, what the research does and does not show so far, and what to ask if your surgeon suggests it.

The short answer

• What it is: the uterus is removed through a cut at the top of the vagina, around the cervix. A port placed in that opening lets the surgeon use a camera and laparoscopic instruments from below, so there are no cuts on the abdomen.^[6]
• What it is for: non-cancerous conditions such as fibroids, heavy bleeding, adenomyosis or prolapse. The ovaries and fallopian tubes can also be removed this way.^[6][7]
• What studies show so far: in the only randomized trial against laparoscopic hysterectomy, vNOTES worked just as well and more women went home within 12 hours.^[2] Reviews of mostly smaller studies found similar complication rates to laparoscopic and vaginal hysterectomy.^[3][4]
• What is still uncertain: the evidence is small and short-term. A 2023 Cochrane review and the UK’s NICE both say vNOTES needs more research, especially on long-term results.^[5][6]
• Not for everyone: it is usually not offered if there may be scar tissue behind the uterus, for example from deep endometriosis, pelvic infection or earlier rectal surgery, or if cancer is suspected.^[6][7][8]
• The surgeon matters: NICE advises that vNOTES should only be done by surgeons and teams with specific training who can switch to another method if needed.^[6]

What does vNOTES stand for?

vNOTES means vaginal Natural Orifice Transluminal Endoscopic Surgery. In plain words:

• Natural orifice: the surgeon goes in through an opening the body already has, here the vagina, instead of cutting the skin.
• Transluminal: the instruments pass through the wall at the top of the vagina into the pelvis.
• Endoscopic: the surgeon works while watching a camera image on a screen, as in keyhole (laparoscopic) surgery.

Surgeons who use it describe vNOTES as a blend of a vaginal hysterectomy and a laparoscopic hysterectomy: it uses the vaginal route, with the view and tools of keyhole surgery. Rather than a completely new operation, they see it as another tool for minimally invasive surgery.^[8]

How a vNOTES hysterectomy is done

Details vary between surgeons and the devices they use, but the main steps described by NICE are these:^[6]

1. You have a general anesthetic and lie on your back with your legs in supports, as for a vaginal hysterectomy.
2. The surgeon makes a circular cut in the vagina around the cervix and opens into the pelvis in front of and behind the uterus.
3. A soft port is fitted into this opening. Gas is used to gently inflate the abdomen, and the operating table is tilted head down so the bowel moves out of the way.
4. A camera and laparoscopic instruments go in through the port. The surgeon seals and divides the blood vessels and ligaments that hold the uterus, working upward from below. The tubes and ovaries can be removed at the same time if that was planned.
5. The uterus is taken out through the vagina, the port is removed and the gas is let out.
6. The top of the vagina is closed with dissolvable stitches. This closure is called the vaginal cuff.

Like other total hysterectomies, a vNOTES hysterectomy normally removes the uterus and cervix together. If you want to compare the terms, see our guide to partial vs total hysterectomy.

A common mix-up: vNOTES is not the same as single-port (single-incision) laparoscopy, where the instruments go through one cut in the belly button. With vNOTES there is no cut on the abdomen at all.

How vNOTES compares with other types of hysterectomy

For non-cancerous conditions, the American College of Obstetricians and Gynecologists (ACOG) recommends a minimally invasive route whenever possible, with vaginal hysterectomy as the preferred approach when it is feasible and laparoscopic hysterectomy as the alternative when it is not.^[1] vNOTES aims to keep the advantages of the vaginal route while giving the surgeon a better view of the upper pelvis, which can help when the uterus is less easy to reach from below or when the ovaries also need to be removed.^[8]

Route	Cuts on the abdomen	How the uterus comes out
Abdominal (open)	One larger cut, usually across the bikini line	Through the abdominal cut
Laparoscopic or robotic	Usually 3 to 5 small cuts	Usually through the vagina
Vaginal	None	Through the vagina
vNOTES	None	Through the vagina, with keyhole camera and instruments

You can see what each type of incision looks like after healing in our article on hysterectomy scars.

What the research shows

vNOTES vs laparoscopic hysterectomy

The first randomized trial, called HALON, took place in a Belgian teaching hospital and included 70 women having a hysterectomy for non-cancerous reasons. Half had vNOTES and half had a total laparoscopic hysterectomy:^[2]

• Every operation in both groups was completed as planned, with no switch to another method.
• 77% of women in the vNOTES group left hospital within 12 hours, compared with 43% after laparoscopy.
• The average hospital stay was 0.8 days after vNOTES and 1.3 days after laparoscopy.

A 2020 review that pooled this trial with five retrospective studies found shorter operating time, shorter hospital stay and less blood loss with vNOTES, and no significant difference in complications, readmissions or pain 24 hours after surgery.^[3]

vNOTES vs vaginal hysterectomy

A 2024 review found only four studies comparing vNOTES with a standard vaginal hysterectomy. It found no significant differences in blood loss, operating time, hospital stay, pain the day after surgery or complications.^[4] In other words, there is no proof yet that vNOTES is better than a well-done vaginal hysterectomy when that is possible.

What the big reviews conclude

The 2023 Cochrane review of all hysterectomy routes included only two small randomized trials of vNOTES, with 96 women in total. Its authors concluded that robotic hysterectomy and vNOTES “require further evaluation” because there is not yet evidence of a patient benefit over conventional laparoscopic hysterectomy.^[5]

In 2023, NICE in the UK reviewed the evidence and advised that vNOTES hysterectomy and ovary or tube surgery should only be done with special arrangements for consent and audit or research. Its reasons: apart from one good trial for hysterectomy and one for ovary removal, most studies are retrospective, all report only short-term results, and results from high-volume expert centers may not carry over to smaller hospitals. NICE asked for more information on long-term outcomes, particularly vaginal prolapse.^[6] This does not mean vNOTES is unsafe. It means that the long-term picture is not yet known, and that you should be told about these uncertainties before you agree to it.

Removing the ovaries or tubes

A second randomized trial from the same Belgian team, NOTABLE, compared vNOTES with laparoscopy for removing an ovary and tube with a non-cancerous mass. vNOTES was as successful, with shorter operations, less pain and fewer painkillers, but there was a trend toward more adverse events in the vNOTES group.^[7] Ovaries are not always removed during a hysterectomy. If you are unsure about yours, read about surgical menopause before deciding.

Possible benefits

• No scars on the abdomen and no risk of infection or hernia at abdominal cuts, because there are none.
• Earlier discharge: in the HALON trial, three in four women went home within 12 hours.^[2]
• A good view of the pelvis from below, which makes it easier than a standard vaginal hysterectomy to see and remove the tubes and ovaries.^[8]
• A possible option when belly surgery is harder: NICE was told by experts that vNOTES may particularly help people with a high BMI or a history of bowel surgery, though this has not been tested in trials.^[6] Read more in our guide to obesity and hysterectomy.

Risks and limits

vNOTES shares the general risks of any hysterectomy: bleeding, infection, blood clots, injury to the bladder, bowel or ureters, and problems with the anesthetic.^[10] In the studies so far, these complications have been uncommon and similar to laparoscopic and vaginal hysterectomy, but the studies are small.^[3][4][5] Points specific to vNOTES:

• Entering the pelvis from below is done close to the rectum and bladder. If scar tissue has stuck the bowel to the back of the uterus, the surgeon cannot see this before opening, which is why vNOTES is avoided when such scarring is likely.^[8]
• Conversion: if the surgeon cannot safely finish by vNOTES, they may switch to a laparoscopic or open operation. Ask your surgeon how often this happens in their hands.
• Long-term effects such as vaginal prolapse and pain with sex have not been studied for long enough. NICE lists both among the key safety questions.^[6]
• Experience: fewer surgeons are trained in vNOTES than in laparoscopic surgery, and outcomes in expert centers may not reflect every hospital.^[6]

Who may and may not be a candidate

vNOTES is used for non-cancerous conditions such as fibroids, heavy or irregular bleeding, adenomyosis, prolapse or ovarian cysts. Your surgeon will look at the size and mobility of your uterus, your past surgery and a pelvic exam, which includes checking behind the uterus for nodules or scarring.^[8] If you are still weighing whether surgery is right for you, see our overview of the reasons for a hysterectomy.

It is usually not offered, or is approached with great caution, if you have:^[6][7][8]

• suspected or known deep endometriosis between the vagina and rectum, or a pelvis “frozen” by scar tissue (see hysterectomy for endometriosis)
• a history of pelvic inflammatory disease or a current vaginal or pelvic infection
• previous rectal surgery or pelvic radiotherapy
• suspected cancer of the uterus, cervix or ovaries
• a very narrow vagina, or no previous vaginal intercourse
• pregnancy

Other factors, such as a very large uterus or past cesarean sections, can make any vaginal approach more difficult. Your surgeon can explain how they apply to you.

Recovery after vNOTES

Many people go home within a day, and in the HALON trial three in four left hospital within 12 hours.^[2] Even without cuts on the belly, the uterus has been removed and there is a healing wound at the top of the vagina, so recovery follows the general pattern of a vaginal or laparoscopic hysterectomy rather than that of a minor procedure. Our week-by-week recovery guide covers what to expect in more detail.

• Pain: expect cramping and soreness in the lower belly and pelvis. Some people also feel shoulder-tip pain for a day or two from the gas used during surgery.
• Bleeding: light bleeding or discharge for a few weeks is common while the vaginal cuff heals.
• Sex and tampons: the NHS advises waiting until the wound has healed and any discharge has stopped, usually at least 4 to 6 weeks. Follow your own surgeon’s advice.^[9]
• Driving: when you can wear a seatbelt comfortably and make an emergency stop, often 2 to 6 weeks after surgery.^[9]

Two small studies so far suggest that sexual function a few months after vNOTES is similar to that after other keyhole methods, and possibly with an earlier return to sex, but they were retrospective and short-term.^[11][12]

Contact your surgeon or seek urgent care if you have: heavy vaginal bleeding or clots, a fever or a strong-smelling discharge, pain that gets worse instead of better, trouble passing urine, or a swollen, painful leg. Call 911 for chest pain or sudden shortness of breath.^[9][10]

Questions to ask your surgeon

• Why do you recommend vNOTES for me rather than a vaginal or laparoscopic hysterectomy?
• How many vNOTES hysterectomies have you done, and how often do you need to switch to another method?
• Is there anything in my history (endometriosis, infections, past surgery) that makes vNOTES riskier for me?
• Will my cervix, tubes or ovaries be removed?
• Do you expect me to go home the same day?
• If vNOTES is not available here, what would you recommend instead?

For more on getting ready, see our tips before your hysterectomy.

Frequently asked questions

Is vNOTES really scarless?

There are no scars on the skin. There is still an internal scar at the top of the vagina, as there is after any total hysterectomy done through the vagina or by keyhole surgery.

Is vNOTES better than laparoscopic hysterectomy?

It appears to be as effective and may allow more same-day discharge, but there is not enough evidence to say it is better overall.^[2][5] The best route for you depends on your anatomy, your history and your surgeon’s experience.

Can vNOTES be done if I have fibroids?

Often, yes. Fibroids are one of the common reasons for vNOTES, but a very large uterus can make it harder. Your surgeon will judge this from your exam and scans. You may also want to read about alternatives to hysterectomy for fibroids.

Is vNOTES available everywhere in the US?

No. It requires specific training and equipment, so it is offered mainly by surgeons with a special interest in minimally invasive gynecology. If you are interested, ask your gynecologist whether they or a colleague perform it.

Sources

1. American College of Obstetricians and Gynecologists. Committee Opinion No. 701: Choosing the route of hysterectomy for benign disease. Obstetrics & Gynecology. 2017;129(6):e155-e159.
2. Baekelandt JF, De Mulder PA, Le Roy I, et al. Hysterectomy by transvaginal natural orifice transluminal endoscopic surgery versus laparoscopy as a day-care procedure: a randomised controlled trial. BJOG. 2019;126(1):105-113.
3. Housmans S, Noori N, Kapurubandara S, et al. Systematic review and meta-analysis on hysterectomy by vaginal natural orifice transluminal endoscopic surgery (vNOTES) compared to laparoscopic hysterectomy for benign indications. Journal of Clinical Medicine. 2020;9(12):3959.
4. Marchand GJ, Ulibarri H, Arroyo A, et al. Systematic review and meta-analysis of vaginal natural orifice transluminal endoscopic surgery hysterectomy versus vaginal hysterectomy for benign indications. AJOG Global Reports. 2024;4(2):100355.
5. Pickett CM, Seeratan DD, Mol BWJ, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews. 2023;8:CD003677.
6. National Institute for Health and Care Excellence (NICE). Vaginal transluminal endoscopic hysterectomy and adnexal surgery for benign gynaecological conditions (published October 2023 as IPG774; now HTG699).
7. Baekelandt J, De Mulder PA, Le Roy I, et al. Adnexectomy by vaginal natural orifice transluminal endoscopic surgery versus laparoscopy: results of a first randomised controlled trial (NOTABLE trial). BJOG. 2021;128(11):1782-1791.
8. Lerner V, Stuart AE, Baekelandt J. Vaginal natural orifice transluminal endoscopic surgery hysterectomy deconstructed: expanding minimally invasive gynecologic surgeons’ toolbox. Journal of Gynecologic Surgery. 2024;40(2):78-99.
9. NHS. Hysterectomy: recovery.
10. NHS. Hysterectomy: risks.
11. Timmermans M, Hovsepyan H, Tanos P, Nisolle M, Karampelas S. Sexual quality of life after hysterectomy performed by conventional laparoscopy versus vaginal natural orifice transluminal endoscopic surgery (vNOTES) in benign gynaecology. Facts, Views & Vision in ObGyn. 2025;17(1):68-74.
12. Ayçiçek S, Halisçelik MA, Ayçiçek PD, Sengi A, Değirmenci A. Short-term sexual function after vNOTES vs. transumbilical single-port laparoscopic hysterectomy for benign indications: a retrospective cohort study. Frontiers in Surgery. 2026;13:1869063.

This article is for general information and is not a substitute for medical advice. Always discuss which type of hysterectomy is safest for you, and your surgeon’s experience with it, with your gynecologist, and contact them or emergency services if you are worried about any symptom after surgery.