Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) Procedure

After administration of general anesthesia and endotracheal intubation, patients were placed in the Trendelenburg position;

Each vNOTES operation started with conventional vaginal surgery by creating a 2 cm posterior colpotomy;

A small wound retractor (HTKD-Med, HK-120/100-60/70D, Beijing, China) was inserted and fixed from behind the colpotomy to the vaginal introitus to maximize and protect the incision area (Figure 1A). Then, a port was established in the vagina using two 3–5 mm and two 5–12 mm cannulas, as used in transumbilical single-port laparoscopy (Figure 1B);

Instruments used in all vNOTES procedures included a 30° endoscope (KARL STORZ GmbH & Co., KG., Tuttlingen Germany), conventional rigid laparoscopic instruments, and a 6.5 mm, 22° endoscope (HAWK GMBH, W5050, Hangzhou, China) (Figure 1C,D).