VNOTES Lateral Window Approach to Hysterectomy in a Case with Previous History of Multiple Surgeries Resulting in Keloid Scars and Enlarged Uterus with Dense Bladder Adhesions

Abstract

To demonstrate transvaginal natural orifice transluminal endoscopic surgery (vNOTES) lateral window approach to hysterectomy in a case with a history of multiple surgeries resulting in keloid scars and enlarged uterus with dense bladder adhesions. Stepwise demonstration of the technique with narrated video. A minimally invasive gynecologic surgery department of tertiary care private hospital. A 43-year-old female presented with menorrhagia and dysmenorrhea in the last 8 months. She had a history of undergoing cesarean section twice and an open appendectomy. These surgeries had resulted in keloid scar formation. She was very anxious about keloid formation and desired to avoid abdominal scars. Examination and transvaginal ultrasound revealed enlarged uterus with multiple fibroids. The largest intramural fibroid measured 11×9.4 cm. vNOTES hysterectomy with the following key strategies was performed: (1) anterior colpotomy with bilateral lateral window dissection, (2) posterior colpotomy with opening of posterior peritoneal pouch, (3) application of wound retractor and vNOTES glove port, (4) continued dissection of lateral window aiding to the completion of hysterectomy, (5) uterine rotation maneuver aiding to bladder adhesiolysis, and (6) transvaginal retrieval of specimen and closure of colpotomy. vNOTES is a feasible method of approaching lateral window dissection in scarred uteri. It allows safe dissection and bladder adhesiolysis. It allows excellent visualization of all pedicles and safe hysterectomy for large uteri. Hysterectomy for adherent uteri can be performed by vNOTES.