Transvaginal Natural Orifice Transluminal Endoscopic Surgery Hysterectomy (VNOTES): A Walkthrough

Abstract

Video Objective To present a thorough yet concise explanation of the methodology for the completion of a successful transvaginal hysterectomy via natural orifice transluminal endoscopic surgery. Design A narrated instructional video guide detailing each procedure (Canadian Task Force Classification III). Setting University Hospital, Baylor College of Medicine, Houston, Texas Patients Our patient is a 46-year-old G2P1011 who had two notable previous surgeries: a tubal ligation and an adnexa removal surgery. She possessed a narrow vagina and non-descent uterus while having a strong preference for maintaining a high level of cosmesis. Interventions A complete transvaginal hysterectomy utilizing solely natural orifice transluminal endoscopic surgery was performed on the patient. Transvaginal entry was established and with the gelpoint mini port in place we began circumferential dissection of the cervix anteriorly at the bladder fold. Utilizing the laparoscopic single tooth tenaculum, we hooked the anterior lip of the cervix for countertraction and hydro dissected the anterior cervix with 20 units of Vasopressin (Pitressin) in 20 ml of saline. Next, the monopolar hook was employed to cut the anterior colpotomy and begin the circumferential incision around the cervix. Following this, we used the LigaSure bipolar forceps to sever bilateral ureteral sacral ligament. The same strategy is used at the anterior cervix to separate the bladder from the uterus. Following bladder mobilization, the cardinal ligaments and uterine arteries were cauterized and transected by LigaSure. The right fallopian tube was removed utilizing the LigaSure first, before proceeding with the left fallopian tube; the pelvis was inspected with hemostasis noted throughout. Finally, the vaginal cuff was closed in traditional vaginal fashion after the deflation of the abdomen. Conclusion Despite certain drawbacks, utilizing pure natural orifice transluminal endoscopic surgery in hysterectomy is a safe and feasible procedure that maintains a high-level of cosmesis for patients while still offering the most minimally invasive route.