Transvaginal Natural Orifice Transluminal Endoscopic Surgery High Uterosacral Ligament Suspension (NOTES-HUS) for Apical Prolapse

Abstract

Study Objective To demonstrate practical tips and tricks for successful use of the transvaginal NOTES technique for preforming HUS. Design Stepwise demonstration with narrated video footage (Canadian Task Force classification III). Setting An academic tertiary care hospital. Patients or Participants A 58-year-old G2P2, NSVDx2 with Stage III anterior vaginal prolapse, Stage II uterine prolapse & posterior vaginal prolapse. The preoperative vaginal length was 7 cm. Interventions High uterosacral ligament suspension (HUS) is well accepted for apical prolapse due to its advantages of good apical support and simplification of intraperitoneal suture passage. Transvaginal natural orifice transluminal endoscopic surgery (NOTES) is a novel minimally invasive approach that avoids an abdominal incision while providing improved visualization, leading to simplified intraperitoneal suture placement. However, this approach may be technically challenging. After performing transvaginal hysterectomy and anterior repair, the single-site port was placed, and BSO was subsequently performed. The following key techniques were utilized to perform NOTES-HUS: ○ Tagging the sutures for bilateral uterosacral ligament before single-site port placement ○ Identifying the ischial spine and ureters ○ Pulling the tagged uterosacral ligament suture to assist in locating the high uterosacral ligament ○ Grasping and lifting uterosacral ligament while placing a suture ○ Giving the suture a tug after placement to confirm the correct location Measurements and Main Results The procedure was successfully performed in approximately 160 minutes with a postoperative vaginal length of 6 cm. Postoperative pelvic organ prolapse quantification was stage 0. Conclusion The transvaginal NOTES-HUS is a feasible and practical technique for apical vaginal prolapse. Applying the tips and tricks presented here, such as tagging uterosacral ligament before port placement, etc., the challenging transvaginal NOTES-HUS can be performed efficiently and safely.