Transvaginal Natural Orifice Transluminal Endoscopic Surgery Hysterectomy Aided by Transcervical Instrumental Uterine Manipulation

STUDY OBJECTIVE: To describe the technique of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomy with the aid of transcervical instrumental uterine manipulation. DESIGN: Video with step by step description of technique. SETTING: Minimally Invasive Gynaecological Surgery Department, Naval Multi Speciality Hospital, Jalgaon, India. PATIENT: A 47-year-old woman. INTERVENTION: vNOTES hysterectomy. MEASUREMENTS AND MAIN RESULTS: A 47-year-old patient presented with history of menorrhagia since 4 years as well as a history of failed medical management for menorrhagia. Ultrasonography showed an enlarged uterus with findings suggestive of adenomyosis. Body mass index of the patient was 27. She had a history of 2 normal vaginal deliveries and had undergone laparoscopic tubal sterilization in the past. During vNOTES hysterectomy, an instrument was placed transcervically into the uterus for manipulation, providing leverage that helped gain good exposure of all uterine attachments. It also prevented unintentional rotation of uterus and its attachments. Therefore, the surgeon did not need to use a second hand for retraction of the uterus during surgery, allowing that second hand for retraction of bowel and adnexa. Hysterectomy was completed without any complications. Total estimated blood loss was 55 mL, and the patient was discharged on the third day. CONCLUSION: Because the tip of instrument is not completely visible in vNOTES surgery, manipulation helps to deflect the uterus and its attachments away from important structures, thus preventing inadvertent thermal damage from the tip of the instrument. This is a feasible and safe technique for vNOTES hysterectomy.