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A Guide to Hysterectomy and vNOTES for Arizona Patients

A New Minimally Invasive Hysterectomy Procedure

A Guide to Hysterectomy and vNOTES for Arizona Patients

Each year, nearly 500,000 women face the prospect of undergoing a hysterectomy—the surgical removal of the uterus. In some cases, women may also experience the removal of the cervix, ovaries, Fallopian tubes, or other elements of the female reproductive system and its support structures. In the past, this procedure involved the use of either open abdominal surgery or laparoscopic surgery, leaving many women anxious about potential scarring, lengthy recovery times, and other common side effects of traditional hysterectomy surgery.

Now, Arizona Gynecological Consultants is proud to announce the availability of a new, minimally invasive hysterectomy procedure—vaginal natural orifice transluminal endoscopic surgery, or vNOTES. Our own Dr. Heather Zechman has completed advanced training on this highly specialized approach, and since Arizona Gynecological Consultants began offering the procedure in July of 2020, she has performed more vNOTES surgeries than any other surgeon in the state. In addition, Dr. Zechman is one of a select few surgeons in Maricopa County who are highly qualified to perform vNOTES. What is vNOTES? What advantages does vNOTES offer over traditional hysterectomy procedures? Read on to learn more about vNOTES and why it is such a significant advancement in women’s health.

Dr. Heather Zechman

What Is Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES)?


Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) is an advanced gynecological technique first developed in 2012. While the traditional approaches to hysterectomy—open abdominal surgery and laparoscopic surgery—rely on making one large or

four small incisions into the abdominal cavity, vNOTES avoids abdominal skin incisions altogether. Instead, vNOTES utilizes the vagina as an access path to the uterus and other female reproductive organs and employs innovative technology to improve surgical outcomes. During a vNOTES procedure, the surgeon inserts a vNOTES device known as the GelPOINT® V-Path transvaginal access platform through the vagina and into the pelvic cavity. Then, the vNOTES device inflates the patient’s abdomen with carbon dioxide, giving the surgeon access to the uterus, fallopian tubes, ovaries, and the remainder of the pelvic cavity. The space provided by the device allows the surgeon to both see and operate on the organs inside.

The vNOTES device contains numerous, special openings through which the surgeon can insert the long, thin, surgical tools necessary for a hysterectomy procedure. Also, the surgeon employs the use of a specialized, high-definition camera, which can be inserted through the same access points; the camera allows extensive visualization into the area and allows the utmost precision. Once removal of the uterus is completed, the vNOTES device is removed, and the excess carbon dioxide can escape.

What Advantages Does vNOTES Offer Over Other Types of Hysterectomy Surgery?

As mentioned, the vNOTES procedure does not require any incisions into the patient’s abdominal cavity, instead using the vaginal opening to access the uterus or other reproductive organs.

As a result, vNOTES offers multiple advantages over open abdominal or laparoscopic hysterectomy, including:

  • No visible scarring. Since there are no abdominal skin incisions, vNOTES allows the patient to completely avoid the abdominal scarring caused by traditional hysterectomy procedures.
  • Shorter operating times. As this efficient procedure does not require creating or closing skin incisions, it takes less time in the operating room than other types of hysterectomy surgery. Traditional hysterectomy surgery can take over three hours, with the average lengths of laparoscopic, other vaginal surgery, and vNOTES requiring much closer to 1 to 2 hours. ? Reduced postoperative pain. Skin incisions and high abdominal pressure are major sources of postoperative pain regardless of the surgery involved. By eliminating skin incisions entirely and reducing the necessary abdominal pressure, vNOTES effectively minimizes the amount of postoperative pain experienced by most women.
  • Reduced need for pain relievers. As a direct result of decreased postoperative pain, vNOTES helps to reduce the dosage of pain relievers needed after surgery and can help shorten the length of time they are needed.
  • Shorter hospital stays. Unlike other hysterectomy procedures, vNOTES can be performed on an outpatient basis. Research revealed that more vNOTES patients leave the hospital within 12 hours as compared to laparoscopic patients, data that echoes Dr. Zechman’s working experiences. “The vast majority of my patients are able to go home on the same day they were admitted for their vNOTES hysterectomy procedure,” she noted.
  • Reduced recovery time. Reduced pain, fewer pain relievers, and shorter hospital stays, coupled with minimal bleeding, mean that vNOTES patients can return to their regular activities much more quickly than either laparoscopic or open surgery patients.

The HALON Study—published in 2019 in BJOG: an International Journal of Obstetrics and Gynecology—affirmed the above advantages of vNOTES. Conducted over two years between 2015 and 2017, this study consisted of a randomized and controlled clinical trial of 70 women, aged 18 to 70, at Imelda Hospital in Bonheiden, Belgium. All were set to undergo hysterectomy for non-cancerous conditions and randomly assigned either vNOTES or laparoscopic procedures. As a result of this study, both the American Association of Gynecologic Laparoscopists (AAGL) and American College of Obstetricians and Gynecologists (ACOG) recommend vNOTES over other procedures whenever possible.

Uses of vNOTES

As vNOTES is a transvaginal procedure—a procedure that takes place via the vaginal opening—it allows surgical access to many of the primary and secondary organs of the female reproductive system. As a result, vNOTES can give surgeons and patients a non-invasive hysterectomy option for the treatment of uterine conditions like uterine prolapse. However, vNOTES provides a non-invasive path for use in other circumstances, as well, including the treatment and removal of uterine fibroids, abnormal bleeding, chronic pain, the removal of adnexal masses, prophylactic ovarian surgery, sterilization, cancer prevention, and more. vNOTES has been successfully employed to perform the following Ob/Gyn surgeries:

  • Cystectomy – removal of an abnormal growth or cyst from any of the female reproductive organs
  • Salpingectomy – removal of the Fallopian tubes
  • Oophorectomy – removal of the ovaries
  • Salpingo-oophorectomy – removal of both the Fallopian tubes and ovaries

However, hysterectomy is by far the most common surgery performed using vNOTES, and is one of the most common surgeries experienced by women. Learn more about hysterectomy surgery and what you can expect from the vNOTES procedure in our guide below.

About Hysterectomy Surgery

One out of every nine women will undergo a hysterectomy at some point in her life, making the procedure the second most common type of surgery in women (only cesareans occur moreoften). As a result, obstetrician-gynecologists (Ob/Gyns), gynecologic surgeons, gynecologic oncologists, and general surgeons have dedicated a great deal of research to develop the safest, least-invasive surgical options. Your gynecologist and your gynecologic surgeon can help you determine which option may be best for your situation.

While the average age of a woman undergoing hysterectomy falls between 40 and 45, all women can benefit from reducing the invasiveness of the procedure. As a result, as proven by the HALON study, the least invasive hysterectomy procedure proves to be the best option. Here at Arizona Gynecology Consultants, Dr. Zechman firmly believes in the use of transvaginal natural orifice transluminal endoscopic surgery (vNOTES).

What Conditions Lead to a Hysterectomy?

In part, hysterectomies are so common because they are a practical solution for many gynecological issues after more conservative treatments have failed. Women undergo hysterectomies to treat a variety of conditions, including (but not limited to):

Uterine Fibroids

Uterine fibroids are noncancerous muscular and fibrous tissue growths that protrude from the areas in and around the uterus. Fibroid growths vary in size and typically appear during a woman’s childbearing years; some fibroids may shrink during or shortly after menopause. The cause of fibroids isn’t well understood, though they can sometimes be successfully treated with medications.

Severe fibroids can cause:

  • Pain during and after sex
  • Painful menstruation
  • Excessive menstrual bleeding
  • Excessive urination or constipation

In many cases, physicians recommend a hysterectomy to treat severe fibroids that produce heavy, painful bleeding.

Uterine Fibroids

Uterine Prolapse

Uterine prolapse occurs when the muscles and ligaments of the pelvic floor are so weakened that the uterus is no longer held in place. In some cases, the uterus slips so severely out of place that it begins to protrude into the vagina.

Most cases of prolapsed uterus are caused by childbirth and can lead to:

  • Difficult, painful sex
  • Incontinence
  • Back pain

If you don’t desire to have any more children, your Ob/Gyn may recommend a hysterectomy to treat a prolapsed uterus.

Pelvic Inflammatory Disease (PID)

Pelvic Inflammatory Disease, or PID, is a bacterial infection of the reproductive system. In most cases, antibiotics are all that’s needed to address the infection; however, if the disease is not discovered early enough, antibiotics may not be sufficient. In these cases, PID can cause extensive damage to the uterus, fallopian tubes, and other reproductive organs and cause additional, prolonged pain. If your PID is causing you severe pain and you no longer wish to have children, hysterectomy may be an option for you.


uterine cancer

One of the most common reasons for hysterectomy is a cancer of one of the elements of the reproductive system. If you have uterine cancer, cervical cancer, ovarian cancer, or cancer of the fallopian tubes, your oncologist may recommend a hysterectomy. In most cases, hysterectomy becomes an option if cancer is not well-controlled through other methods or if cancer has spread.

Is Hysterectomy an Option for You?

For many women with cancer—especially advanced cancers of the uterus or cervix—a hysterectomy is one of the only options to prevent its further spread. For women experiencing other conditions, however, it is crucial first to determine whether a hysterectomy is the best treatment option.

Discuss the following questions with your physician:

  • Are you finished having children, or are you satisfied remaining child-free?
  • Are you prepared for the possibility of early-onset menopause?
  • Have you attempted other, less-invasive treatment options for your condition?
  • Are your symptoms continuing to affect your quality of life negatively?

If you answered yes, hysterectomy is likely a potential solution to your gynecological health issue. However, it’s crucial to note that each case is different and should be evaluated separately. For that reason, it’s important to thoroughly discuss all treatment options with your doctor before deciding on a hysterectomy.

Different Types of Hysterectomy

Different Types of Hysterectomy

Many conditions may lead to a hysterectomy, and there are multiple types of hysterectomy your physician may recommend. For instance, your physician may recommend the removal of other organs in addition to the uterus—or may want to leave a portion of your uterus as is.

The types of hysterectomy can be broken down into four common categories:

  • Complete hysterectomy – this is the type of hysterectomy most people think of when referring to the procedure. In a complete hysterectomy, the surgeon will remove the entirety of the uterus as well as the cervix.
  • Partial hysterectomy – in a partial (supracervical) hysterectomy, the surgeon only removes the upper portion of the uterus, leaving the cervix intact.
  • Radical hysterectomy – this hysterectomy is the most complete and is usually performed in cases of uterine, cervical, or other cancer. All portions of the female reproductive system are removed, including the uterus, cervix, ovaries, fallopian tubes, upper vagina, and nearby lymph nodes.
  • Hysterectomy with bilateral salpingo-oophorectomy – this is the removal of the uterus and both ovaries and fallopian tubes.

Methods of Hysterectomy Surgery

As with most surgical procedures—especially procedures as common as hysterectomy—there are multiple approaches surgeons can take. The type of procedure your surgeon will select depends on his or her skill level, comfort with the procedure, as well as other extenuating circumstances like insurance requirements, hospital scheduling, caseload, available technology, and more. In addition, your surgeon may choose a procedure based on other concurrent procedures you require.

The procedure selected also depends on factors related to your case, such as the condition necessitating the hysterectomy, your symptom severity, and the type of hysterectomy recommended. Factors like the shape of your uterus, the presence of pelvic adhesions, and whether your case is considered emergent can also determine which surgical method is used. Currently, most surgeons in the US rely on one of three surgical methods for hysterectomies.

Traditional Hysterectomy

A traditional hysterectomy—known as an open hysterectomy—requires the surgeon to make a large incision into the abdomen. Typically about five inches, though the size can vary depending on multiple factors, this incision can be placed either vertically or horizontally along the bikini line to minimize scarring on the most visible parts of the abdomen. After incision, the surgeon can view the uterus and the surrounding tissues and remove the uterus and other necessary organs. For particularly large fibroids or a radical hysterectomy, the traditional approach may be necessary for adequate visibility and removal of all the necessary tissue.

Laparoscopic Hysterectomy

As with many modern surgical procedures, surgeons can benefit from the aid of a small camera (or laparoscope) situated at the end of a narrow tool. This camera allows the surgeon to view the interior of the abdomen without making a large incision to expose it. Instead, the surgeon makes multiple, small incisions for the camera and tools and removes the necessary portions of the uterus piece by piece. As the incisions are much smaller, the recovery time is much shorter than from a traditional hysterectomy.

Vaginal Hysterectomy

In a vaginal hysterectomy, the surgeon can avoid making an external incision altogether; instead, a tiny, internal incision is made at the top of the vagina. Using long-handled tools, the surgeon can separate the uterus from its connecting blood vessels and repair any damage. Then, the

uterus (as well as the cervix, fallopian tubes, or ovaries, in some cases) can be removed, piece by piece, through the vaginal canal. This type of hysterectomy makes use of the body’s natural openings and is by far the least invasive type of hysterectomy.

What Is the Best Type of Hysterectomy?

Best Type of Hysterectomy

As mentioned, much goes into a surgeon’s decision regarding the type of hysterectomy to recommend. Some conditions may require a traditional hysterectomy due to the sheer size of the uterine fibroid; other surgeons may prefer to perform the type of hysterectomy with which they are most familiar. However, in general, if all else is equal, the best hysterectomy procedure is the one that is the least invasive.

Why? Less invasive surgeries require smaller (or no, in the case of vaginal hysterectomy) external incisions. Utilizing fewer or smaller incisions, particularly through the muscular tissue of the abdominal wall, reduces blood loss during the surgery, minimizes the pain associated with the procedure, and shortens recovery time afterward. Also, fewer complications exist with minimally invasive procedures, reducing your chances of needing to re-enter the hospital or undergo another procedure.

ACOG-Recommended Hysterectomy Procedure [H2] As noted, of the various hysterectomy procedures available today, the American College of Gynecologists and Obstetricians (ACOG), as well as the American Association of Gynecologic Laparoscopists, recommends vNOTES over the others, whenever possible. HALON study research discovered that a vNOTES hysterectomy is just as effective as other methods and offers a superior outcome compared to laparoscopic and traditional hysterectomies. Also, this method is minimally invasive, carries fewer risks, and offers a shorter recovery time than other methods.

Another reason ACOG recommends vNOTES is patient satisfaction. Since this method requires a much shorter surgical time than other methods of hysterectomy and requires less hospital time after surgery, it is also less costly. Also, when surveyed after the surgery and recovery are complete, more patients say they are satisfied with the results of their hysterectomy than patients experiencing either laparoscopic or traditional hysterectomy.

Availability of vNOTES

While the ACOG and gynecologic surgeons alike see the benefits of vaginal hysterectomy over other procedures, the procedure cannot be accessed everywhere. In fact, less than 25% of all hysterectomies are performed vaginally. Two-thirds were performed using the traditional method—despite ACOG support and evidence of better outcomes achieved by vaginal hysterectomy. The reasons for using the method differ, but many surgeons cited lack of training for performing the more effective vaginal method and lack of comfort with the low degree of visibility available in most vaginal hysterectomy surgeries.

This is a set of circumstances especially notable to Dr. Zechman. “Surgical societies see the benefits of minimally invasive vaginal hysterectomy, but the procedure is rarely performed because of the difficulties involved in seeing and accessing critical anatomy. vNOTES solves these challenges using innovative technology designed to enhance patient outcomes,” Dr. Zechman says.

Implementation of vNOTES devices means surgeons can experience greater visibility of the abdominal area necessary for effective hysterectomy surgery. With the device and proper training, more surgeons can perform vNOTES surgery, resulting in a greater overall rate of effectiveness for hysterectomy surgeries.

What to Expect from Your vNOTES Procedure

Like other laparoscopic surgeries, vNOTES takes place while you are under general anesthesia, which means you’ll be asleep during the procedure. A small incision will be made internally, via the vaginal opening, allowing your surgeon to place the special vNOTES device that will provide access to the uterus and any other organs necessary. As with other laparoscopic surgeries, your abdomen will be gently inflated with carbon dioxide to provide room for the procedure.

vNOTES Procedure

The surgeon will utilize the specially placed openings within the vNOTES device to place a high-definition camera. Using the camera to visualize the area, the surgeon will remove the necessary structures with specialized vNOTES instruments. Once complete, the surgeon will remove the vNOTES device, close the internal incisions, and remove excess carbon dioxide.

In most cases, you’ll be able to return home the same day and will need minimal pain relief for a brief time. Most patients can return to normal activities after two to four weeks and heavy lifting, vigorous exercise, and even sex after about six weeks. However, it is critical that you speak with your physician to determine the appropriate recovery time necessary for your unique case.

vNOTES at Arizona Gynecology Consultants

Arizona Gynecology Consultants is pleased to announce the availability of the minimally invasive vNOTES at our facility. This advanced technique offers many of our hysterectomy patients the option to experience a shorter hospital stay, reduced recovery times, minimal pain, and zero external scarring. Dr. Heather Zechman is a minimally invasive gynecologic surgery (MIGS) specialist and continues to be one of Arizona’s foremost practitioners of this innovative technique.

As with any gynecologic procedure, it is essential to consult with your OB/GYN and Arizona Gynecology Consultants to discuss whether a hysterectomy utilizing vNOTES is right for your condition. We are committed to helping you develop a better understanding of your condition and your treatment options, including vNOTES. Reach out today to see how vNOTES may be a viable option for you.

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*Editor’s Note: This article was originally published Sep 29, 2020 and has been updated May 7, 2021.



What is a Hysterectomy?

What is a Hysterectomy?

A hysterectomy is uterus removal surgery. There are many reasons that a uterus must be removed, but in all cases, the woman’s health calls for such a procedure.

Reasons For A Hysterectomy

A woman’s reproductive system goes through three major hormonal changes during her lifetime. Puberty, pregnancy, and menopause all cause dramatic hormone shifts that can cause complications with the uterus, ovaries, or fallopian tubes.

Uterine Fibrosis

Uterine fibrosis is the development of benign lumps that grow in the uterus. These lumps are not cancerous but cause pain, bleeding, cramping, painful sex, and the urge to urinate. A hysterectomy will remove these lumps and the uterus, relieving the symptoms and guaranteeing they do not come back.


Cancer of the uterus, cervix, or ovaries can call for the removal of all or some of these organs. The procedure must happen before cancer spreads.

Uterine Prolapse

Prolapse is when the uterus slides from its normal position into the vaginal canal. Prolapse can cause the collapse of other structures, such as the vagina and rectum. Removal of the uterus will maintain the structures of other pelvic organs.


Endometriosis is when uterine tissue develops outside the uterus. It often causes extreme pain, heavy periods, and infertility. Endometriosis makes certain hysterectomy procedures more difficult.

Abnormal Vaginal Bleeding

If the uterus cannot maintain the uterine lining, a woman can experience bleeding not connected to menstruation.

Chronic Pelvic Pain

A uterus that is not performing correctly can cause severe pain in the pelvis.


Adenomyosis is the thickening of the uterus, which causes pain and makes it unfit for a fetus.

Types Of Hysterectomy

There are several different hysterectomy types; the procedure may not refer just to the removal of the uterus but to the removal of any combination of the reproductive organs.

Supracervical/Subtotal Hysterectomy

Removal of the upper part of the uterus takes place but the cervix remains. Some OB/GYNs will recommend this if they are uncomfortable or untrained in the removal of the cervix. See the advantages and disadvantages of leaving the cervix intact below.

Partial Hysterectomy

A partial hysterectomy is the removal of the uterus and the cervix. The ovaries and fallopian tubes remain intact.

Radical Hysterectomy

The uterus, cervix, and upper portion of the vagina are removed. Radical hysterectomies usually take place when cancer is present. No other hysterectomy removes any part of the vaginal canal.


Oophorectomy is the removal of the ovaries. This can take place with or without the removal of the uterus, especially in cases of ovarian cancer. One or both ovaries can be removed.


The removal of the fallopian tubes is a salpingectomy. The fallopian tubes connect the ovaries to the uterus. When a woman gets her “tubes tied,” the fallopian tubes are severed and tied to prevent pregnancy. One or both fallopian tubes can be removed.

Total Hysterectomy and Bilateral Salpingectomy-Oophorectomy

This is the term for the procedure in which the uterus, cervix, both ovaries, and both fallopian tubes are removed. It is also called a total hysterectomy. This occurs in the case of progressed cancer.

Reproductive Anatomy

In order to fully understand the effects of the different types of hysterectomies, one must understand the purpose of the various reproductive organs and the effects of their removal. Some organs produce hormones and removing them will spur changes in the body.


The uterus, or womb, is the organ that houses the fetus during pregnancy. It does not produce hormones, but removing the uterus makes the body unable to become pregnant. Once the uterus is removed, there will no menstruation as there is no uterus to shed its uterine lining.


The ovaries house and release the eggs, or ovum. The ovaries also produce estrogen and other hormones that a woman uses post-puberty, during pregnancy, and in perimenopause. Menopause is the process of the ovaries no longer producing these hormones. The removal of the ovaries will prompt menopause, and women will experience hot flashes, mood swings, and the other symptoms that go along with this change. If only one ovary is removed, a woman will not experience this until she is at the age of menopause. Women who have already completed menopause will not go through it again at the removal of the ovaries. A woman can no longer become pregnant when her ovaries are removed. Pregnancy is still possible if only one ovary has been removed.

Fallopian Tubes

The fallopian tubes are the tubes between the ovaries and the uterus that houses the egg while it waits for fertilization. The removal of the fallopian tubes will not affect hormones but will prevent a woman from becoming pregnant.


The cervix is the opening between the uterus and the vaginal canal. During pregnancy, the cervix prevents the fetus from moving outside of the uterus and dilates during birth to let the baby out. The cervix does not produce hormones. The removal of the cervix does not affect vaginal lubrication, cause prolapse, lessen sexual satisfaction, or guarantee a safer hysterectomy procedure. A cervix that has not been removed with the uterus during a hysterectomy can cause vaginal bleeding, a higher potential for cancer developing, and thus the need for more pap smears. The cervix may need to be removed to prevent the risk of cancer.

Methods For Hysterectomy Surgeries

An OB/GYN can use one of several different methods when performing a hysterectomy. Each has its all own advantages and disadvantages. Ask for information about which procedure is best for your situation.

Vaginal Hysterectomy

A vaginal hysterectomy is a procedure in which the uterus and other organs are removed through the vaginal canal.


There are no incisions with a vaginal hysterectomy, making it the least-invasive form of hysterectomy, and the recovery is very quick as a result. It is especially effective in correcting prolapse. A vaginal hysterectomy is also cost-effective.


A vaginal hysterectomy requires room in the vaginal canal to remove the uterus, as a result, it is not the best option for women who have not give birth vaginally. Larger uteri masses are more difficult to remove as well. There is a larger risk of bleeding due to an injury of the uterine or ovarian arteries and high risk of complications with patients who have had a cesarean section or previous pelvic surgery because the surgeon will have difficulty seeing other issues or complications in the area.

Laparoscopic Hysterectomy

A laparoscopic hysterectomy requires three to five small incisions in the abdomen. The procedure is then completed using long tools to remove the uterus or other organs.


Laparoscopic surgery offers a faster recovery time. The patient is out of the hospital the next day and can go back to work two weeks later. It is safe to use if patients have undergone other pelvic procedures, such as a cesarean section, in the past. It is generally a better option for those who have large uterine masses to be removed or who are not candidates for vaginal hysterectomies. The OB/GYN completing the procedure has full access and visibility, lowering the risks of complications.


There is a risk of injury to other organs, such as the bladder, and possible conversion to an open hysterectomy due to extreme endometriosis. It is less readily available because specialized training is required to complete the procedure safely.

Open Abdominal Hysterectomy

Open abdominal hysterectomies are still the most common procedures that take place. This is due to lack of training for laparoscopic hysterectomies.


An open hysterectomy surgery allows for removal of any size masses.


A large, 6- to 12-inch incision is made across the abdomen. This causes severe pain and 6 to 8 weeks of recovery. There are also higher hysterectomy complication rates, due to the invasive nature of the procedure.