Robotic-assisted vNOTES for Emergency Detorsion in a Patient with Morbid Obesity: Case Presentation.

Objective: To provide a case presentation of surgical management of adnexal torsion through robotic-assisted vaginal natural orifice transluminal endoscopic surgery (vNOTES) in a patient with morbid obesity.

Setting: Single academic center.

Participant: A 20-year-old woman, who is a G0 and has class III obesity (body mass index 49) presented to the emergency room with right pelvic pain and vomiting. Imaging revealed a 15 cm cystic lesion in the right adnexa, with concern for right adnexal torsion on exam. She was posted for emergency surgery.

Interventions: An educational video with a narrated step-by-step approach of robotic-assisted vNOTES adnexal detorsion and paratubal cystectomy. This surgery was performed with the DaVinci Xi Robot docked vaginally through a gelpoint device. After the cystectomy, anatomy was restored, and a salpingectomy was performed because of significant edema and damage of the right fallopian tube [1-3].

Conclusion: This video shows a surgical approach to adnexal detorsion through robotic vNOTES. It provides instruction on the setup and the surgical steps in a vNOTES surgery through a posterior colpotomy [4,5]. It shares tips to successfully complete the procedure, including how to use the surgical assistant when only using 2 robotic arms because of limited space of the pelvis, such as during the cystectomy, providing traction and countertraction. By presenting this case, this video hopes to make the vNOTES procedure more accessible and an option for patients in an emergency surgery setting. At our institution, there is a dedicated gynecologic robot room, and the case was not delayed using the robot. If this is not the case in other institutions, the surgery can be completed in a laparoscopic manner with similar techniques used in this video. The vNOTES method provides a safe option for patients, including those with obesity or extensive surgical histories, and avoids an abdominal incision, which can decrease intraoperative and postoperative complications.