VNOTES Hysterectomy, Adnexectomy and Uterosacral Ligament Suspension: A Walk-through Guide

Abstract

<h3>Study Objective</h3> To provide a stepwise guide to performing vNOTES hysterectomy, adnexectomy and vault suspension, using two access platform methods. <h3>Design</h3> Video demonstration. <h3>Setting</h3> A single tertiary-care academic centre. <h3>Patients or Participants</h3> Two women consented for surgery for abnormal uterine bleeding and endometrial intra-epithelial neoplasia. <h3>Interventions</h3> Vaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomy and adnexectomy are performed for both women, in addition to uterosacral ligament suspension for one. <h3>Measurements and Main Results</h3> Step-by-step walk-through is shown to demonstrate the successful completion of a hysterectomy, adnexectomy, and vault suspension. Use of a traditional glove platform and that of an advanced access system, the GelPOINT Access System® (Applied Medical, Rancho Santa Margarita, CA, USA), are illustrated. The surgical steps are summarized as: (1) colpotomy and abdominal entry; (2) transection of the uterosacral ligaments; (3) placement of an access platform; (4) upper abdominal survey; (5) transection of the uterine and cornual pedicles; (6) identification of the ureters; (7) bilateral salpingo-oophorectomy; (8) uterosacral ligament suspension; (9) cystoscopy; (10) vaginal vault closure and tying of the suspension sutures. <h3>Conclusion</h3> This video demonstrates the steps to safely reproduce a vNOTES hysterectomy, adnexectomy and uterosacral ligament suspension with two techniques of achieving pneumoperitoneum. vNOTES offers scar-free surgery, improved access to high pedicles and surgical fields, and a favourable recovery profile, making it an attractive surgical route in appropriate candidates.