In Conversation with: Dr Ravichandran Nadarajah on scarless surgery for gynaecology cancers

The prospect of visible scarring, post-operative pain and extended recovery can be daunting, particularly for women who are also navigating a cancer diagnosis.

A surgical technique known as vNOTES (vaginal Natural Orifice Transluminal Endoscopic Surgery) offers an alternative approach. Leaving no visible scar with minimal blood loss, it is performed through a small cut in the vagina using laparoscopic instruments, and provides faster recovery compared to conventional surgery.

KKH Special Delivery speaks with Dr Ravichandran Nadarajah, Head and Senior Consultant, Department of Gynaecological Oncology, KKH, about vNOTES, and what it means for women and referring clinicians.

Q: What can vNOTES be used for?

Dr Ravichandran: vNOTES can be used for common to complex procedures such as hysterectomy, removal of fallopian tubes and ovaries, ovarian cyst removal, and advanced urogynaecological and gynae-oncological surgeries. KKH is one of the first hospitals in Singapore to offer this surgical option since 2021.

Q: In what types of patients might vNOTES be particularly beneficial?

Dr Ravichandran: vNOTES offers significant benefits across a wide range of patients, and the evidence supporting its advantages is strong.

Several groups stand to benefit most:

• Women with obesity are among the clearest beneficiaries. Avoiding large abdominal incisions substantially reduces the risk of wound complications, infections and hernias – all of which are more prevalent in this group with conventional open surgery. I have successfully applied vNOTES in cases of extreme obesity, with the highest body mass index (BMI) exceeding 70, and the patient recovered well with no requirement for painkillers.
• Elderly women represent another important group, particularly in Singapore’s ageing population, where endometrial cancer is now a leading gynaecological malignancy. These women frequently present with multiple comorbidities that elevate their surgical risk and can delay treatment. vNOTES helps address this by enabling faster recovery and earlier return to independence – both of which are especially meaningful for them.
• Women who have had prior abdominal surgeries also benefit, as this approach avoids the challenges and risks associated with re-entering a scarred abdominal cavity. Similarly, women prone to keloid formation are spared from this concern with the absence of abdominal incisions.

Beyond clinical benefits, vNOTES is also cost-effective, making it a compelling option not just for patients but from a broader healthcare perspective as well.

Q: Is vNOTES better than conventional surgical approaches?

Dr Ravichandran: Based on available evidence, vNOTES compares favourably against open surgery and minimally invasive approaches. At KKH, we consider it the preferred method and an emerging standard of care, particularly in managing gynaecological cancers.

The advantages of vNOTES stem largely from the vaginal approach itself. As the procedure is performed without abdominal incisions, patients experience significantly less pain and require fewer or no painkillers post-operatively. The absence of external cuts also means no visible scarring, eliminating concerns around cosmesis and the risks of keloid formation and incisional hernias. These complications can be a real concern, especially for patients with obesity or have a tendency towards poor wound healing.

Recovery is notably faster compared to open surgery and comparable to laparoscopic approaches. This matters not just for patient comfort and independence, but a quicker recovery also means women with cancer can proceed to adjuvant treatments such as chemotherapy more promptly.

Taken together, the evidence strongly supports vNOTES as a superior option across multiple dimensions: safety, recovery, cosmetic outcomes and oncological efficacy. Where a patient is deemed suitable, it is our preferred approach.

Q: How does vNOTES fit into the management of gynaecological oncology cases at a medical centre?

Dr Ravichandran: KKH manages a high volume of gynaecological oncology cases in Singapore, and vNOTES has become an integral approach to our surgical care across this spectrum. A wide range of procedures are performed using this technique, including staging surgery for endometrial cancer and, in selected cases, ovarian cancer.

One of the strengths of vNOTES in this setting is its versatility across different patient groups. For younger women, the technique also allows for a more tailored approach, including the option to preserve the ovaries for fertility, where clinically appropriate.

By offering a minimally invasive route that does not compromise oncological outcomes, vNOTES fits naturally into a comprehensive gynaecological oncology programme – supporting surgical precision, and the broader goal of helping patients recover well and return to their daily lives as quickly as possible.

Q: What should clinicians know when considering a referral for vNOTES?

Dr Ravichandran: vNOTES has evolved considerably beyond its early applications. Previously, the technique was largely limited to benign procedures such as hysterectomy for small fibroids. Today, it is performed safely across a much broader range of conditions – both benign and malignant. This includes complex cases such as hysterectomy for large fibroids or endometriosis, myomectomy, ovarian cystectomy and the removal of fallopian tubes. At KKH, approximately 60 per cent of benign gynaecological procedures are now performed via vNOTES.

This technique is worth considering for any patient requiring a hysterectomy or other gynaecological surgery, regardless of whether the indication is benign or oncological. Women who may be particularly suitable include those with a higher BMI, a history of upper abdominal surgery or prior umbilical hernia repair. It is also beneficial to women who can benefit from a faster return to daily activities, or who need to commence adjuvant treatment promptly.

At KKH, suitability for vNOTES is determined through a thorough clinical assessment on a case-by-case basis. We encourage early referral for evaluation where possible, so that patients can be considered for this approach in a timely manner.

How vNOTES is being applied at KKH