Asst. Prof. Dr. Resmiye Ermis is a renowned gynecologist specializing in minimally invasive gynecological surgery. She founded the Klinik Rotes Kreuz and the MIC and Myoma Center Rhein-Main in Frankfurt am Main. She is one of Germany’s leading experts in modern endoscopy and minimally invasive procedures for conditions such as fibroids, endometriosis, uterine prolapse, and many other gynecological indications. Her outstanding expertise is confirmed by her MIC-III surgeon certification, which she received for the third consecutive time in 2024.
Under her leadership, the center has earned an excellent reputation for advanced outpatient and inpatient treatments that provide women with a high quality of life. Asst. Prof. Dr. Ermis is a pioneer in introducing innovative techniques. For example, in 2015 she established the safe removal of abdominal findings via in-bag morcellation, a technique now practiced nationwide. Her expertise covers the holistic treatment of uterine fibroids, endometriosis, unexplained infertility, fallopian tube diagnostics, hysterectomy, pelvic floor prolapse, as well as surgical interventions for bleeding disorders and other gynecological conditions. The modern laparoscopic techniques she applies enable gentle procedures, mostly on an outpatient basis, leading to excellent treatment outcomes.
Asst. Prof. Dr. Ermis is among the few selected gynecologists in Germany holding the highest certificate of the German Association for Gynecological Endoscopy (AGE) – proof of her leading role in minimally invasive surgery. She places great value on individualized care and is highly attuned to her patients’ wishes. Thanks to her innovative methods, exceptional medical expertise, and compassionate approach, she has helped countless women overcome pain and significantly improve their quality of life.
The MIC and Myoma Center Rhein-Main at the Frankfurt Klinik Rotes Kreuz is highly regarded by both specialists and patients and stands for top-level medical care.
In a conversation with Asst. Prof. Dr. Ermis, the editorial team of the Leading Medicine Guide learned more about innovative minimally invasive gynecological procedures.
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In the past, gynecological surgeries were performed as open procedures until laparoscopic techniques were developed. Open approaches are still carried out in some patients, but they are often associated with longer recovery times, stronger pain, and larger scars. With the advancement of minimally invasive methods such as the VNotes technique (Vaginal Natural Orifice Transluminal Endoscopic Surgery), the approach has changed significantly: Instead of large incisions, the surgery is performed through a small vaginal opening, reducing complications, shortening recovery times, and providing greater comfort for patients. This innovation has significantly improved treatment standards in gynecology.
„The VNotes technique enables a minimally invasive surgical approach in gynecology, creating access through the vagina. Unlike conventional laparoscopy, where instruments are inserted through several small abdominal incisions, VNotes involves an incision beneath the cervix in the vagina. Gas is then introduced into the abdominal cavity to provide space, making examination and surgery possible without abdominal incisions. This technique is particularly suitable for removing fibroids that are not too deeply embedded, as well as for hysterectomies, oophorectomies, or salpingectomies. Many pelvic floor prolapse treatments are also performed with this method, such as suspension system fixations of the uterus. The suitability of the technique depends on the condition and situation, with decisions based not only on the diagnosis but also on factors like tissue size or the patient’s age. Overall, VNotes is effective for many benign conditions, though it may be difficult or unsuitable for larger tumors or very elderly patients“, explains Asst. Prof. Dr. Ermis at the start of our discussion.
Because the vaginal access minimizes tissue and skin trauma, patients experience less postoperative pain and faster recovery. Healing times are significantly reduced, with many women regaining mobility within just a few days. The technique also reduces the risk of wound-healing complications or infections since no abdominal incisions are required. Additionally, the VNotes method enhances surgical precision. Direct visualization through the endoscope allows for accurate removal of fibroids or precise pelvic floor repair, increasing success rates. Improved visibility also helps control bleeding, reducing intraoperative blood loss. Furthermore, VNotes offers improved access to complex or larger fibroids and prolapse findings that might otherwise require longer or more extensive surgery with traditional methods.
Fibroids, also called uterine fibroids or leiomyomas, are benign tumors that develop from the muscle cells of the uterine wall. They arise from a combination of genetic, hormonal, and vascular factors. Hormonal influences, particularly an excess of estrogen, promote fibroid growth. Genetic predisposition, age, obesity, hypertension, and family history can increase risk. Fibroids result from hormonally driven cell proliferation and may range in size from small nodules to large uterine growths. Regarding prolapse – also known as pelvic floor weakness – this refers to the descent of pelvic organs such as the uterus, vagina, or bladder due to weakened pelvic muscles and ligaments. There are several types of pelvic organ prolapse: vaginal prolapse (when the vaginal wall descends), uterine prolapse (when the uterus drops), cystocele (bladder descent), or enterocele (descent of intestinal sections). These conditions often occur with age but can also result from pregnancy, childbirth, obesity, or chronic pelvic pressure.
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„VNotes is particularly beneficial in patients with a history of multiple abdominal surgeries, such as prior mesh placement in the abdominal wall or adhesions that make abdominal access difficult. Through the vaginal route, the surgeon can reach the pelvis directly, bypassing abdominal adhesions that complicate laparoscopic access via the navel. This avoids problems common in patients with prior abdominal operations and allows treatment directly in the pelvis. However, there are situations where VNotes is not feasible. For example, in deep infiltrating endometriosis with adhesions between the uterus and bowel, the area is often inaccessible due to complete scarring. Another limitation arises if the patient wishes to preserve the cervix, since removing it facilitates access and makes recovery less painful. While preserving the cervix does not fundamentally compromise pelvic stability, it complicates access. Operative time can also vary: with an enlarged uterus, surgery may be quicker since less tissue requires fragmentation, while smaller uteri removed vaginally may require piecemeal extraction in a containment bag, which can be more complex laparoscopically. Though it may sound unusual, this approach is a well-considered alternative“, explains Asst. Prof. Dr. Ermis, adding:
„For a surgeon, mastering the VNotes technique requires training. It is not something you can perform proficiently right away; therefore, I have attended advanced courses and specialized training to safely integrate this method into our clinical practice. Essentially, the technique extends laparoscopic surgery since it requires the same core skills. The difference lies in perspective: instead of working from above through the abdominal wall, the surgeon operates via the vaginal route – just a different angle and viewpoint. With sufficient practice, the technique is very manageable“. .jpg "Photo Asst. Prof. Dr. Ermis with her senior physician.")
The use of advanced imaging techniques such as MRI or ultrasound helps assess individual anatomy and identify potential risks early. During surgery, highly precise instruments and controlled procedures allow exact navigation in confined spaces. Specialized safety systems, such as incision and bleeding management tools or controlled tissue removal, also contribute to minimizing risks.
The main exclusion criteria include anatomically unfavorable findings that prevent safe and controlled surgery. Severe adhesions, unclear findings, extensive contamination, or poor visibility of the operative field usually require an open or laparoscopic approach. Other exclusion criteria include significant anatomical anomalies, such as pelvic malposition or organ malformations. VNotes is also unsuitable in cases of pelvic or abdominal infections, uncontrolled bleeding, large tumors obstructing safe access, or unclear diagnoses requiring further investigation.
The risks of this procedure are similar to those of conventional surgeries and are considered normal surgical risks.
„Particularly in patients with prior abdominal surgeries, the risk of bowel injury is often lower with VNotes, since vaginal access is not performed blindly. With prior laparotomies, surgeons usually proceed cautiously: instead of blindly inserting trocars, an open laparoscopy is performed to inspect and avoid adhesions. Still, hidden adhesions may remain undetectable, posing risks. The VNotes method has existed for some time. With the increasing number of laparoscopic surgeries in Germany over the past 10 to 15 years, the technique has become more standard. Previously, gynecological surgeries were primarily vaginal, with laparoscopy introduced later. I personally learned laparoscopic hysterectomy only after my board certification, after 2005. Understanding the advantages of both vaginal and laparoscopic methods has led us to tailor the technique to each patient’s situation and preference. Our goal is always to operate as gently as possible and adapt treatment to individual needs“, says Asst. Prof. Dr. Ermis.
Current long-term studies and clinical experience with VNotes for the treatment of fibroids and pelvic organ prolapse show high efficacy and patient satisfaction.
After minimally invasive procedures such as those performed with VNotes – particularly for fibroids or pelvic prolapse – patients typically face fewer restrictions compared to open surgeries. Nonetheless, certain precautions and guidance are necessary to ensure optimal healing and long-term function.
„For vaginal procedures, general behavioral guidelines remain the same, particularly regarding later sexual activity or future pregnancy. After surgery, recommendations are identical to other approaches: for instance, if the uterus has been removed, there are no restrictions regarding sexual activity or future childbirth planning. Patients may experience less pain and regain mobility sooner, which supports recovery, but overall recommendations do not change. Even with oophorectomy performed vaginally, healing of the vaginal wound is similar to healing after abdominal incisions. Therefore, no special restrictions or behavioral differences apply after surgery, regardless of whether the incision is inside the vagina or on the abdominal wall“.
It is important for patients to rest for several weeks after surgery, avoid heavy physical strain, and carefully follow postpartum guidelines. Especially in pelvic floor surgeries, intensive stress on the pelvic region should be avoided to support ligament healing and tissue adherence.
At the MIC and Myoma Center Rhein-Main at Klinik Rotes Kreuz Frankfurt a.M., the focus is on minimally invasive approaches such as VNotes and laparoscopic surgery that preserve organs and shorten recovery time. Compassionate care by an all-female team makes it one of the leading clinics in Germany. .jpg "Photo team of the MyoBlate radiofrequency ablation method.")
„At our center, we offer various techniques for treating pelvic organ prolapse. These include the VNotes method, which strengthens natural structures without mesh, and laparoscopic procedures involving mesh insertion. Mesh can also be applied vaginally, for example in older patients where it is fixed to the cervix, or in younger women. Additional options include vaginal plication procedures that do not use mesh. The choice of technique is always tailored individually based on age, anatomy, and necessity, to minimize strain and accelerate recovery. While many approaches exist in Germany, we stand out with our particularly gentle, patient-centered methods. We always aim to avoid unnecessary procedures, such as full hysterectomy, when not required, to reduce recovery time. Each method has pros and cons, but our focus is always on finding the best, least invasive solution for the patient“, emphasizes Asst. Prof. Dr. Ermis, adding:
„As far as I know, we are one of the few clinics in Germany with an exclusively female surgical team. From my perspective, this makes perfect sense. Regarding procedures, we rank among the top ten centers in Germany for fibroid removal. Since we do not provide obstetric services, we can focus entirely on surgical procedures. We also place particular emphasis on treating endometriosis, carefully evaluating which therapy is best for each patient. For endometriotic cysts, complete removal is not always necessary. Instead, we individually assess whether less invasive treatments, such as alcohol solution therapy, are sufficient. Excision or complete removal is not always the most effective option. Our priority is to preserve organs whenever possible, in line with patient wishes. We also aim to minimize scarring and perform surgeries without abdominal incisions. We are distinguished by highly empathetic care and excellent nursing, which consistently earn positive feedback. Furthermore, we perform procedures without general anesthesia, such as office hysteroscopies, where uterine endoscopy enables accurate diagnosis and minor therapeutic removal without the burden of full anesthesia“.
Thank you very much, Asst. Prof. Dr. Ermis, for your valuable insights!
