Vaginal natural orifice specimen extraction for anterior resection performed alongside hysterectomy in a case of deep infiltrating endometriosis: a video vignette

This video vignette demonstrates a technique utilizing the natural orifice at the opened vaginal vault during a total laparoscopic hysterectomy to opportunistically deliver the rectosigmoid colon and complete low anterior resection, in this case for the treatment of deep-infiltrating endometriosis. This natural orifice specimen extraction (NOSE) technique facilitates bowel resection without the requirement for an abdominal incision. During low anterior resection, the standard technique for specimen extraction is via suprapubic mini-laparotomy [1]. NOSE has increasingly been deployed in the context of colorectal cancer to maximize the advantages of a laparoscopic approach, utilizing both the anus and vagina to deliver the specimen [2]. Our video (Video S1) demonstrates opportunistic adaptation of that technique, where the vaginal vault was already open to deliver the uterus at laparoscopic hysterectomy. Following the hysterectomy and bilateral pelvic sidewall dissection, the rectum was dissected from the vagina anteriorly and the colon mobilized to the splenic flexure. Endo GIA staplers were used to divide and secure the healthy rectum from the diseased proximal rectosigmoid colon. The proximal end of the colon was extruded through the vagina via an Alexis wound protector, where the resection was performed. A circular stapler anvil was secured into the cut end of the proximal colon and the colon reinserted into the abdomen via the vagina. The circular stapler was used rectally to fashion an end-to-end anastomosis, followed by suture closure of the vaginal vault. This patient recovered well postoperatively and was discharged on day four. She reports complete resolution of her pelvic pain symptoms. The authors above have no conflicts of interest that they wish to declare. No funding was received for the production of this publication. Formal ethical approval was not sought for this video vignette as it reports an individual case which formed part of the subject's treatment plan regardless of publication. Furthermore, this content does not constitute research as per the NHS Health Research Authority and therefore did not require submission for health ethics commit - tee approval. Informed consent was obtained from the subject prior to submission. Written consent from the patient involved in the case was obtained and included in the submission process. Data sharing is not applicable to this article as no new data were created or analyzed in this study. Video S1 Data S1 Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.