Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) is a widely performed, minimally invasive procedure. However, transvaginal access to the abdominal cavity can be difficult for physicians, carrying the risk of bladder or rectal injury. We encountered 16 cases of Vaginally Assisted NOTES Hysterectomy (VANH) between April 2023 and April 2024. We report three cases in which we could not complete VANH and changed the procedure.
Case 1. A 41-year-old woman with para four who had undergone two previous cesarean sections. She had excessive menstruation because of a uterine myoma. We incised the cystouterine fossa peritoneum, and placed the GelPOINT V-Path. Upon initiating pneumoperitoneum, we realized we had reached into the bladder. We performed a laparotomy, a total hysterectomy, and a bladder repair. Cases 2 and 3 had no previous surgeries. Due to the presence of multiple uterine fibroids and hypermenorrhea, VANH was selected. They had a thick peritoneum of Douglas fossa, which was difficult to reach intraperitoneally. Therefore, we placed a trocar at the umbilicus and found rectal adhesions. We stopped VANH and performed a total laparoscopic hysterectomy.
For VANH, our selection criteria included: a history of vaginal delivery, less than fist-sized uterus, and no history of endometriosis or rectal surgery. However, in case 1, there was an adhesion between the cystouterine peritoneum and bladder due to a previous cesarean section, and in cases 2-3, there was a firm adhesion due to endometriosis, which went unrecognized before surgery. We discuss the case selection and intraoperative approach to prevent complications.
