V-NOTES Hysterectomy: Surgery in 10 Steps

Comprehensive V-NOTES Hysterectomy Performed Step-by-Step with Video Documentation.

The patient was administered general anesthesia. Aseptie was performed with betadine. A Foley catheter was inserted for urinary drainage [ Video 1 ]. We placed two Pozzi forceps on the cervix. We do an infiltration of ropivacaine and adrenaline and perform a circular paracervical colpotomy. We continue by the dissection of the posterior vaginal pouch down to the peritoneum, which is opened. We begin with a blunt dissection of the vesicouterine space up to the peritoneum, which is not opened. The dissection allows the exposure of the uterosacral ligaments. They are sectioned and ligated. The uterosacral ligament will be left in place, and it will be reattached to the vaginal vault at the end of the procedure. The vesicouterine peritoneum is opened to insert the Alexis retractor. We then place the posterior part. The platform can now be placed [ Figure 1 ]. V-NOTES platform positioned http://www.apagemit.com/page/video/show.aspx?num=310&kind=2&page=1 The patient is then placed in a 20° Trendelenburg. The cavity is inflated with 8 mmHg gas. We can then coagulate/section the utero-ovarian pedicle, followed by the coagulation and section of the mesosalpinx. We remain parallel to the infundibulopelvic ligament to dissect it; the IFP is not sectioned to prevent the uterus from twisting during the procedure. We coagulate/section the right uterine pedicle. Using the left instrument against the Alexis retractor helps push the ureter laterally to avoid urethral injury. We continue the coagulation and section of the broad ligament, staying as close to the adnexa as possible. We can then coagulate and section the right IFP ligament, always staying as close as possible to the adnexa. We then go back to the left side of the patient and coagulate/section the left IFP ligament. The uterus is free and can be removed. We prefer a marsupialization of the border for the postperitoneum and posterior vaginal. We then perform a transverse running suture with Vicryl 1 and reattach the US ligament. The Foley catheter was removed when leaving the recovery room.

This is an educative video of a 10-step V-NOTES hysterectomy.

The patient was a 53-year-old woman with recurrent bleeding after medical treatment for adenomyosis. She also had an 8 cm benign adnexal mass.

V-NOTES provides a continuous visualization compared to vaginal surgery. Compared to laparoscopy, it has shown fewer complications and less postoperative pain, yet shorter hospitalization.[ 1 2 ]

V-NOTES is a safe and reproductive minimally invasive surgical technique.[ 3 ] The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Nil. There are no conflicts of interest.