The evolution from traditional open surgery to laparoscopic surgery has led to a significant
reduction of morbidity and mortality. Newer advances such as development of single port
laparoscopic surgery and scarless Natural Orifice Transluminal Endoscopic Surgery (NOTES)
with or without robot assistance have moved forward the practice in "Minimally Invasive
Surgery".
Described for the first time in 2004 at John Hopkins University in an experimental porcine
model, NOTES is a surgical technique in which the natural orifices (mouth, vagina, urethra
and rectum) are used as access routes to the peritoneal cavity for endoscopic surgery with no
abdominal incisions.
Clinical application of NOTES has been initially reported in general surgical procedures
where Trans-gastric Appendectomy and Cholecystectomy have been performed using the mouth and
the stomach as the access route.
The technique seems to be feasible and safe when performed by experienced surgeons.
Favourable outcomes such as reduced post-operative pain, a shorter length of hospital stay,
improved cosmetic results due to scar-free surgery and reduced wound complications at trocar
insertion sites, promote the increasing use of this new surgical technique.
Although NOTES may be performed through various entries including the stomach, oesophagus,
bladder and rectum, NOTES procedures in women have been commonly performed through the vagina
as this allows direct access to the abdominal cavity. Therefore, trans-vaginal NOTES (vNOTES)
has gained popularity among general surgeons, urologists and gastroenterologists over the
past decade and was adopted in various surgical procedures, varying from cholecystectomy,
appendectomy, sigmoidectomy, nephrectomy, splenectomy, liver resection and sleeve
gastrectomy.
Recently, clinical application of vNOTES has broadened significantly in the field of
gynaecological surgery. The feasibility and safety of vNOTES in this specialty was firstly
demonstrated in 2012. This event represented the key milestone in the evolution of vNOTES for
gynaecologic procedures. Based on the current reports, we know that many of these procedures,
such as oophorectomy, salpingectomy, adnexectomy, hysterectomy and many other more complex
surgeries can be performed using vNOTES by the majority of surgeons who have adequate skills
in performing laparoscopy.
As the application of vNOTES is increasing, it is deemed mandatory to assess the learning
curve (LC) of this novel technique. This is particularly important in surgery where new
skills must be acquired constantly, safely and proficiently. It would be useful to know how
many vNOTES procedures a surgeon may have to carry out before reaching an adequate level of
safety and efficiency. Furthermore, a correct understanding of the LC is essential in
randomised control trials comparing vNOTES with alternative types of surgery in order to
reach valid conclusions.
There is a paucity of reports in the literature analysing the LC of vNOTES. The "learning
curves" for performing vNOTES hysterectomy and adnexal surgery have been previously assessed
by retrospective studies, each conducted on a single surgeon basis and in a single
institution (19-21). In a report published in June 2020, Lowenstein et al were among the
first researchers that evaluated prospectively the learning curve of mastering the skills to
perform vNOTES hysterectomy and uterosacral ligament suspension in two different centres.
To the investigators knowledge, there is no published prospective multicentre study that aims
to evaluate the feasibility, the LC, the peri- and postoperative outcomes of salpingectomy
for tubal sterilization by the technique of vNOTES.