V-NOTES Hysterectomy: Surgery in 10 Steps

OBJECTIVE

This is an educative video of a 10-step V-NOTES hysterectomy.

DESIGN

Comprehensive V-NOTES Hysterectomy Performed Step-by-Step with Video Documentation.

PATIENT

The patient was a 53-year-old woman with recurrent bleeding after medical treatment for adenomyosis. She also had an 8 cm benign adnexal mass.

INTERVENTION

The patient was administered general anesthesia. Aseptie was performed with betadine. A Foley catheter was inserted for urinary drainage [Video 1].

Step 1: Circular colpotomy and Douglas opening

We placed two Pozzi forceps on the cervix. We do an infiltration of ropivacaine and adrenaline and perform a circular paracervical colpotomy.

We continue by the dissection of the posterior vaginal pouch down to the peritoneum, which is opened.

Step 2: Ligation and section of uterosacral ligaments

We begin with a blunt dissection of the vesicouterine space up to the peritoneum, which is not opened. The dissection allows the exposure of the uterosacral ligaments. They are sectioned and ligated. The uterosacral ligament will be left in place, and it will be reattached to the vaginal vault at the end of the procedure.

Step 3: Opening of the vesicouterine pouch and inserting the Alexis retractor

The vesicouterine peritoneum is opened to insert the Alexis retractor. We then place the posterior part. The platform can now be placed [Figure 1].

Figure 1.

V-NOTES platform positioned http://www.apagemit.com/page/video/show.aspx?num=310&kind=2&page=1

The patient is then placed in a 20° Trendelenburg. The cavity is inflated with 8 mmHg gas.

Step 4: Peritoneal exploration + left uterine pedicle coagulation and section

We can then coagulate/section the utero-ovarian pedicle, followed by the coagulation and section of the mesosalpinx.

Step 5: Coagulation/section of the left broad ligament

We remain parallel to the infundibulopelvic ligament to dissect it; the IFP is not sectioned to prevent the uterus from twisting during the procedure.

Step 6: Coagulation/section of the right uterine pedicle

We coagulate/section the right uterine pedicle. Using the left instrument against the Alexis retractor helps push the ureter laterally to avoid urethral injury.

Step 7: Coagulation/section of the right broad ligament and round ligament

We continue the coagulation and section of the broad ligament, staying as close to the adnexa as possible.

Step 8: Coagulation/section of the right infundibulopelvic ligament

We can then coagulate and section the right IFP ligament, always staying as close as possible to the adnexa.

Step 9: Coagulation/section of the left infundibulopelvic ligament

We then go back to the left side of the patient and coagulate/section the left IFP ligament.

The uterus is free and can be removed.

Step 10: Vaginal suture

We prefer a marsupialization of the border for the postperitoneum and posterior vaginal. We then perform a transverse running suture with Vicryl 1 and reattach the US ligament.

The Foley catheter was removed when leaving the recovery room.

RESULTS

V-NOTES provides a continuous visualization compared to vaginal surgery. Compared to laparoscopy, it has shown fewer complications and less postoperative pain, yet shorter hospitalization.[1,2]

CONCLUSION

V-NOTES is a safe and reproductive minimally invasive surgical technique.[3]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.