Professor and Vice Chair, Board of Governors Representative Cleveland Clinic Cleveland, Ohio, United States
Objectives: To discuss vaginal natural orifice transluminal endoscopic surgery (vNOTES) techniques for performing hysterectomy, salpingectomy, and uterosacral ligament suspension. Methods for proper port placement and vNOTES system organization will be discussed. To discuss indications for vNOTES from the perspective of a skilled vaginal surgeon.
Methods: This video highlights how to perform a hysterectomy, bilateral salpingectomy, and uterosacral ligament colpopexy utilizing the vNOTES system. To begin the procedure, a traditional vaginal hysterectomy approach is taken until intraperitoneal cavity is entered anterior and posteriorly. The vNOTES system is then placed. The remaining portion of the hysterectomy is completed. It is helpful to place cephalad and medial traction on the uterus when sealing and transecting the uterine arteries. A portion of the utero-ovarian ligament is kept intact on one side to prevent the uterus from twisting while completing the contralateral side of the hysterectomy. A salpingectomy is performed by grasping the fimbria and placing traction medially. Using electrosurgery, the mesosalpinx is sealed and transected and the fallopian tube is removed. The uterus and bilateral fallopian tubes are removed. The uterosacral ligament colpopexy is performed. Tension is placed on the previously tagged uterosacral ligament to aid in identifying the ligament. Ureterolysis is performed to increase the margin of safety from the ureter when placing the uterosacral sutures. Three uterosacral sutures are placed bilaterally. The sutures are placed through the ligament in a lateral to medial method. The sutures are subsequently pulled through the gelport and tagged accordingly in a way that maintains suture organization. The first, most distal suture is tagged with a hemostat and pulled through the most lateral port. The second more cephalad suture is tagged with a Kelly clamp and pulled through the gel port itself. The third, most cephalad suture is tagged with a Kocher clamp and pulled through the medial port. The vNOTES system is then removed and sutures are placed through the vaginal cuff and tied down revealing excellent apical suspension.
Clinical Relevance: The technique described in this video demonstrates an alternative vaginal approach to hysterectomy, salpingectomy, and uterosacral ligament suspension. This technique is useful for certain circumstances that make the traditional vaginal approach difficult such as large fibroid uteri.
