(Video Poster 18) vNOTES Assisted Difficult Anterior/Posterior Entry During Vaginal Hysterectomy

Objectives: Our objective is to provide a video demonstrating how the vaginal natural orifice transluminal endoscopic surgery (vNOTES) approach can be used to assist with limited vaginal access in the case of an elongated cervix and bulky immobile uteri. The demonstration of these surgical tips may improve surgeons' ability to approach challenging hysterectomies through a vaginal route.

Methods: Two cases of difficult anterior and posterior entry during vaginal hysterectomy which were aided by endoscopic visualization were recorded. A literature review was performed to review already published techniques for involving vNOTES in similar cases. Video and audio were synthesized to create a surgical tips educational video.

Clinical Relevance: All professional gynecologic surgical societies, including the American Congress of Obstetricians and Gynecologists (ACOG), assert that vaginal hysterectomy, when feasible, is the preferred route for benign hysterectomy; however, surgical data in the US continues to demonstrate that the very opposite is true. For example, between 2016-2018, vaginal hysterectomies dropped by 19%. Vaginal natural orifice transluminal endoscopic surgery, or vNOTES, may help to reverse this trend. By providing enhanced visualization and the ability to utilize endoscopic instrumentation, vNOTES allows for safer and more precise dissection, particularly in cases of cervical elongation, bulky uteri, and dense adhesions. This innovative technique expands the feasibility of vaginal surgery while minimizing abdominal incisions, leading to faster recovery and improved patient outcomes.