Transvaginal Natural Orifice Transluminal Endoscopic Surgery as a Rescue for Total Vaginal Hysterectomy

BACKGROUND: Transvaginal surgery is the most minimally invasive surgery for a gynecologic procedure but can be challenging for many to perform as evidenced by its declining rate. Vaginal removal of the adnexal structures can be difficult because of poor visualization. Factors such as abnormal pathology, incidental finding of early-stage endometriosis or adhesions from previous cesarean section or surgery, and obesity may further complicate the procedure. Transvaginal natural orifice transluminal endoscopic surgery (NOTES) may be performed during vaginal surgery using basic laparoscopic single-site skills as a "rescue" procedure for the complete removal of the adnexae. This allows the surgeon to complete the procedure vaginally without requiring conversion or addition of abdominal incisions. The combination of total vaginal hysterectomy (TVH) with NOTES as a "rescue" procedure may be a useful tool for gynecologic surgeons for removal of the adnexae and performance of other pelvic procedures. STUDY OBJECTIVE: To demonstrate various common pelvic procedures that can be performed by transvaginal NOTES after completion of TVH. DESIGN: Variety demonstrations of the transvaginal NOTES technique as a "rescure" for total vaginal hysterectomy with narrated video footage (Canadian Task Force classification III). SETTING: Academic tertiary care hospital. PATIENTS: Patients with various surgeries including prophylactic bilateral salpingectomy, salpingo-oophorectomy, adhesiolysis, and incidental finding of superficial endometriosis resection. This video is exempt from institutional review board review at our institution. INTERVENTIONS: Transvaginal NOTES adnexal surgery and other procedures using basic laparoscopic single-site surgical skills. MEASUREMENTS AND MAIN RESULTS: Salpingectomy, oophorectomy, lysis of adhesions, and resection of endometriosis can be performed using NOTES at the time of vaginal hysterectomy. CONCLUSION: NOTES allows the surgeon to survey the pelvis for pathology and to complete other pelvic procedures transvaginally during TVH with no additional abdominal incisions. Transvaginal NOTES can be considered a "rescue" approach and can be a helpful tool for the pelvic surgeon.