Laparoscopy has advanced over the last three decades with residency training programs focusing on trans-abdominal laparoscopic techniques whether conventional or robotic. Despite attempts over many years to adopt vaginal surgery as the preferred method of hysterectomy, traditional vaginal surgery has largely fallen out of favor. Vaginal natural orifice transluminal endoscopic surgery (vNOTES) has gained popularity with patients and promises to provide an attractive option, but the surgical skills of many gynecologists have limited its widespread adoption. We explore the use of robot-assisted vNOTES (RA-vNOTES), which offers improved ergonomics, visualization, and wristed instruments for more precise surgery. Robotic vNOTES, was originally performed in Taiwan by Dr. Chyi-Long Lee in 2014.1 Our center has used the robotic vaginal approach for hysterectomy, myomectomy, sacrocolpopexy, adnexal surgery, endometriosis excision, and more. We have also shown feasibility in performing surgery on patients with a completely obliterated posterior cul-de-sac, long been thought to be a contraindication for the transvaginal approach. Enhancements have been made to improve safety and efficiency,
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