March 4, 2019

Over the past century, medical advances and cutting-edge technology have enabled surgeons to move from traditional surgeries that required large incisions and lengthy recovery periods to minimally-invasive techniques with much smaller incisions and quicker recovery times. That evolution continues at CAMC with an innovative, non-invasive procedure to remove the uterus, ovaries and fallopian tubes called the vaginal NOTES technique.


Vaginal natural orifice transluminal endoscopic surgery (or NOTES) is a new procedure being offered by the surgical experts at CAMC that requires no incision in the abdomen to perform a total hysterectomy (removal of the uterus, both ovaries and the fallopian tubes). CAMC is the only hospital in the region offering the procedure.

This new method is essentially the combination of two procedures. Surgeons perform a vaginal hysterectomy (removing the uterus through the vagina) and then use a laparoscope (small camera) to visualize and remove the ovaries and tubes also through the vagina – without having to make any incisions in the abdomen.

When it comes to having a total hysterectomy, patients typically have three options: abdominal, vaginal or laparoscopic hysterectomy. Determining the best surgical option usually involves a number of factors including the size and shape of the uterus, the presence of descent or sagging of the uterus and the overall health of the patient. When possible, many physicians recommend having a vaginal hysterectomy to avoid incisions in the abdomen.

“We have longstanding data that of all the different routes of hysterectomy vaginal surgery is the safest and most cost-effective with patients having the shortest length of stay. If we can increase the number of patients that we can offer a vaginal approach to, the more we can improve their outcomes,” said Stephen Bush II, MD.

This same rationale can be applied to removal of the fallopian tubes and ovaries. However, previously, physicians often had trouble visualizing them through the vagina to safely remove them. This required them to perform a laparoscopic surgery, inserting a camera into the belly through small incisions in the abdomen.

WATCH: Dr. Stephen Bush and Dr. Stephen Bush II explain the procedure.

“Typically, when someone is doing a vaginal hysterectomy and you want to remove the tubes and ovaries, sometimes it’s very difficult to get to the tubes and ovaries vaginally because you can’t really see that well. If the tubes and ovaries had to be removed, typically we would have to move to a laparoscopy following the vaginal hysterectomy so they would’ve ended up with an incision,” said Stephen Bush, MD.

This all has changed with the introduction of the NOTES procedure. During this surgery, the surgeon performs a vaginal hysterectomy as normal to remove the uterus, and then uses the same equipment used for laparoscopic surgery, but instead of going through incisions in the belly, takes the camera through the vagina to visualize the ovaries and fallopian tubes. The patient’s belly is expanded with gas to help the surgeon see the area, and then long instruments are used to clamp the blood vessels and separate the organs from their connective tissue. The uterus, ovaries and tubes are all removed through the vagina, and there is no incision in the abdomen.

According to medical research, the NOTES procedure originated with a surgeon in Belgium, and has been performed in a few hospitals across the United States. Surgeons at CAMC researched the procedure, patient outcomes and other data and began performing it last year.

“We have multiple gynecologic surgeons performing minimally-invasive hysterectomies using all the different technologies available including robotic surgery, laparoscopic surgery, single-incision laparoscopic surgery, laparoscopically-assisted vaginal hysterectomies, vaginal hysterectomies and now this new approach,” Bush II said.

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