Vaginal-Assisted NOTES Hysterectomy for Large Uterus Using the da Vinci SP.

Abstract

Objective: Recent advancements of minimally invasive gynecologic surgery have led to the development of transvaginal natural orifice translumenal endoscopic surgery (vNOTES) [1,2]. Robot-assisted vNOTES has also been explored as a method providing accurate and fine surgical procedures with improved ergonomics, visualization, wristed instruments, elimination of the hand tremor [3,4]. The objective of this video is to demonstrate the technical and anatomical highlights of a vaginal-assisted NOTES hysterectomy (VANH) using the da Vinci SP (SP).

Setting: An urban general hospital. Stepwise demonstration of the technique with narrated video footage.

Participants: A 51-year-old woman, para 2 with no previous history of abdominal surgery, who presented with dysmenorrhea and urinary frequency. Magnetic resonance imaging revealed a large uterus with multiple fibroids.

Interventions: The surgical steps are completely identical to conventional laparoscopic or robotic VANH [2,3]. This suggests that conventional laparoscopic skills are highly transferrable to SP. SP offer several advantages, including high-resolution three-dimensional visualization, articulating instruments, and improved dexterity and range of motion. In addition, conventional multi-arm robotic platforms have difficulty docking and adjusting the arm angle for vNOTES, but SP allows easy docking due to its single-arm design [5]. A Gelpoint V-Path is used as the vNOTES platform to hold the SP metal cannula. This cannula contains four channels, allowing the use of three instruments and a camera. The double bipolar method is used since this facilitates precise dissection with minimal thermal spread. The total operative time was 102 minutes. The estimated blood loss was 50ml without any complications. The uterus weighed 970 g. The postoperative course was uneventful.

Conclusion: VANH using SP is technically safe and feasible for benign uterine diseases in selected patients. Maneuverability of articulating instruments used in SP may allow broad expansion of the indication for vNOTES to more challenging cases. VIDEO ABSTRACT.