7976 Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) with a Retroverted Uterus: Should the Approach Change?

Abstract

<h3>Study Objective</h3> To demonstrate techniques that improve visualization and operative field for the removal of fallopian tubes in patients with retroverted or enlarged uterus encountered during vaginal natural orifice transluminal endoscopic surgery (vNOTES). <h3>Design</h3> Video demonstration. <h3>Setting</h3> Tertiary care center. <h3>Patients or Participants</h3> A reproductive-age patient was seen in the office for surgical sterilization. She was deemed a good candidate for VNOTES as she had no prior abdominal surgery and a small uterus. However, upon entry into the abdomen, the uterus was found to be retroverted. <h3>Interventions</h3> Routinely, three instrument sleeves are utilized with the vaginal access point in order to use a laparoscopic camera, a grasping instrument, and an instrument that cauterizes and excises the fallopian tubes. For a retroverted uterus, strategic access point preparation and instrument positioning techniques can improve visualization, maximize the operative working diameter, and decrease instrument collision. The instrument sleeves are placed in an inverted triangle, with the grasping instrument in the ipsilateral side of the fallopian tube being excised and the 30-degree laparoscope in the contralateral sleeve. The excising instrument is placed in the most inferior, most medial sleeve, maximizing the operative field. A fourth instrument placed directly in the air-tight gel below the inferior sleeve can lift the uterus to improve visualization of the fallopian tubes. <h3>Measurements and Main Results</h3> Patient was discharged home on thesame day. Two weeks post-operatively, there were no recovery complications. <h3>Conclusion</h3> The vNOTES procedure provides patients a minimally invasive option for surgical sterilization with fast recovery and negligible scarring. Surgeons may still consider a patient with a retroverted uterus a candidate for vNOTES by optimizing sleeve placement, instrument positioning, and utilizing a a fourth instrument to lift the uterus and better visualize the operative field. This technique may also be useful to improve visualization of fallopian tubes in the setting of a bulky or enlarged uterus.