Transvaginal Natural Orifice Transluminal Endoscopic Surgery Sacrocolpopexy: Tips and Tricks

Study Objective: To demonstrate helpful tips and tricks for the successful use of transvaginal natural orifice transluminal endoscopic surgery (NOTES) for performing sacrocolpopexy and salpingo-oophorectomy surgery. Minimally invasive approaches for treating pelvic organ prolapse via sacrocolpopexy have traditionally included laparoscopy either with or without robotic assistance. Transvaginal NOTES is a novel minimally invasive approach that both avoids abdominal incisions and provides improved visualization; however, it can be technically challenging. Design: Stepwise demonstration with narrated video footage (Canadian Task Force classification III). Setting: An academic tertiary care hospital in Guangdong, China. Patient: A 61-year-old gravida 3, para 3 woman with 3 spontaneous vaginal deliveries and stage III uterine prolapse, stage III cystocele, and stage III rectocele. The preoperative vaginal length was 6 cm. Intervention: After performing vaginal hysterectomy, we show the usefulness of NOTES for salpingo-oophorectomy. We also demonstrate useful techniques for transvaginal NOTES sacrocolpopexy including hydrodissection, division of the Y mesh, anchoring of the anterior mesh before reducing prolapse, retroperitoneal tunneling, and hand suturing of the mesh and vaginal cuff. Measurements and Main Results: The procedure was successfully performed in approximately 190 minutes. The postoperative vaginal length was 5 cm. Postoperative pelvic organ prolapse quantification was stage 0. Conclusion: The transvaginal NOTES approach is feasible and efficient for sacrocolpopexy and salpingo-oophorectomy; additionally, it is a reasonable option for patients who desire a minimally invasive approach with excellent cosmetic results. Surgical techniques that aid in effectively performing transvaginal NOTES sacrocolpopexy include the use of hydrodissection, Y mesh division, anterior mesh anchoring before reducing prolapse, retroperitoneal tunneling, and hand suturing. Using the techniques presented here, we were able to insert the port only 1 time, which improves the efficiency and safety of this surgery. © 2018 American Association of Gynecologic Laparoscopists