Table 1.

Patient Selection for Vaginal Natural Orifice Transluminal Endoscopic Surgery Hysterectomy

Factors	Rationale	Preoperative evaluation	Surgical considerations
Contraindications
Obliterated posterior cul-de-sac	• Inability to enter the peritoneal cavity that prevents inner-ring placement & ability to initiate laparoscopic part of vNOTES • Inability to see if the colon is adherent to the posterior uterus, which puts the patient at risk for bowel injury at the time of entry	• Extensive history taking with a focus on pelvic pain & endometriosis symptoms • Obtaining the most accurate surgical history possible, including operative reports, hospitalization records & treatment history • Preoperative examination & examination under anesthesia at the beginning of the case with suspicion of uterosacral & rectovaginal nodularity, limited mobility & adhesions • Advanced imaging, such as MRI, protocoled for endometriosis or dynamic pelvic US performed by a sonologist	• Conditions that might cause obliteration include endometriosis, severe PID, pelvic radiation & colorectal surgery such as low anterior resection • Best practice to address obliteration is to perform adhesiolysis via a transabdominal laparoscopic approach
Endometriosis	• Standard-of-care is to excise disease via transabdominal laparoscopic or robotic approach	• Extensive history taking with a focus on pelvic pain & endometriosis symptoms • Preoperative examination & examination under anesthesia at the beginning of the case with suspicion of uterosacral & rectovaginal nodularity, limited mobility & adhesions • Advanced imaging, such as MRI, protocoled for endometriosis or dynamic pelvic ultrasound performed by a sonologist	• Robotic platforms & various surgical approaches are being investigated to be able to perform endometriosis excision, including sidewall & rectovaginal lesions; these techniques are not ready for widespread clinical adoption
Severe distortion of pelvic sidewall anatomy due to fibroids	• Cervical, lower uterine segment, broad ligament fibroids & fibroids extending into the sidewall prevent surgeon from visualizing uterine arteries at the site of the transection & limit ability to isolate them from sidewall • In cases of advanced pathology requiring extensive ureterolysis and sidewall dissection, transabdominal laparoscopic & robotic approaches are required	• History suggestive of sidewall compression (asymmetric lymphedema & unilateral hip & pelvic floor pain) • Preoperative examination & examination under anesthesia indicating sidewall involvement with limited mobility & minimal space between fibroids in lower uterine segment & lateral sidewall • Advanced imaging, such as MRI, protocoled or dynamic pelvic US performed by a sonologist, close collaborative relationship with radiologists and sonologists & case-by-case treatment planning in a multidisciplinary setting	• Need to be able to secure uterine blood supply by visualizing & transecting uterine arteries at the beginning of laparoscopic part • If able to secure uterine blood supply on 1 side, surgeon can detach entire side to rotate the uterus internally & obtain adequate exposure to transect uterine arteries on the contralateral more challenging side • Fibroids can be dissected out of the sidewall with adequate visualization of the ureter, vessels & all sidewall structures, but that depends on ability to see those structures, dissect & secure uterine arteries, and on surgeon's skill set

Indications
AUB	• Benefits of vaginal route	• Follow standard evaluation protocols	• Contained tissue extraction is an option in case of enlarged uterus & suspicion for hyperplasia
Fibroids	• Benefits of vaginal route • “Ideal” fibroid distribution would be such that the cervix & lower uterine segment are not involved & the uterus has a shape of a “mushroom”—narrow where uterine blood supply comes in with adequate lateral sidewall access that, in turn, would enable surgeon to secure the uterine blood supply	• History suggestive of sidewall compression (asymmetric lymphedema & unilateral hip & pelvic floor pain) • Preoperative examination & examination under anesthesia indicating sidewall involvement with limited mobility & minimal space between fibroids in the lower uterine segment & lateral sidewall • If sidewall involvement is suspected, advanced imaging, such as MRI, protocoled or dynamic pelvic US performed by a sinologist should be considered; close collaborative relationship with radiologists & sonologists & case-by-case treatment planning in a multidisciplinary setting	• No “size” cutoff exists clinically as long as physical examination & imaging are consistent with the ability to access uterine blood supply • Uterus can be rotated in the pelvis sequentially into a more favorable orientation to improve exposure as hysterectomy proceeds (example: 1 “easier” side of the hysterectomy can be completed first to gain access to the more-difficult side) • All blood supply is secured before specimen extraction begins; this decreases blood loss
Adenomyosis	• Benefits of vaginal route	• Extensive history taking with a focus on pelvic pain & endometriosis symptoms • Preoperative examination & examination under anesthesia at the beginning of the case with suspicion of uterosacral & rectovaginal nodularity, limited mobility & adhesions • Advanced imaging, such as MRI, protocoled for endometriosis or dynamic pelvic US performed by a sonologist	• If clinically suspicious of comorbid endometriosis, transabdominal approach is standard-of-care to perform endometriosis excision at the time of hysterectomy

Patient factors
C-section(s) scar	• Adhesiolysis can be started during vaginal part & completed during laparoscopic part	• Preoperative examination enables surgeon access to extent of adhesions	• Laparoscopic portion of vNOTES adhesiolysis enables surgeon to reach further cephalad & perform more extensive manipulation, compared to conventional vaginal route, enabling surgeon to address more extensive adhesions & convert transabdominal cases to vNOTES route • Inner ring is placed between the colpotomy incision on the vaginal epithelium & C-section scar adhesions and peritoneum • Using “lateral-to-medial” technique by securing uterine blood supply first, then lysing adhesions from lateral–to–medial to reflect ureters, minimize bleeding & decrease bladder injury risk • Anterior peritoneum is blue or gray because it's translucent, unlike the dense white scar; also, peritoneum moves in & out slightly from intermittent insufflation of pneumoperitoneum or patient ventilation, showing “wave” or the “sail” sign • Can retrograde fill the bladder, but that is rarely necessary due to “upside down” view of bladder, which is retracted by the inner ring
Abdominal wall mesh from prior surgery	Mesh avoidance	• Preoperative evaluation, including prior operative reports & imaging	• Vaginal route enables surgeon to avoid having to place ports & navigate around the mesh or having to cut through it
Adhesions in the mid-& upper-abdomen, multiple prior abdominal surgeries	Avoid adhesiolysis	• Preoperative evaluation, including prior operative reports	• Vaginal route enables surgeon avoid having to place ports & navigate around the adhesions &/or having to perform extensive adhesiolysis
Rigid abdomen, resulting in limited insufflation (nulliparity, abdominoplasty)	• Benefits of vaginal route	—	• Low pressures (8–10 mm Hg) are sufficient for visualization, because most of the surgical work occurs in the pelvis, which is a rigid bony structure & does not need to be insufflated to the same pressures as the transabdominal approach to obtain adequate visualization • Laparotomy pad or 4 x 4 sponge inserted into the pelvis at the beginning of the case helps bowel retraction and visualization
Limited vaginal access	Conditions that contribute to narrow introitus & vaginal canal (examples: obesity, nulliparity, postmenopausal status & gender-affirming surgery) limit ability to perform conventional vaginal hysterectomy	—	• Compared to conventional vaginal hysterectomy, in which limited access may preclude ability to complete entire case, with vNOTES, surgeon only needs to be able to perform colpotomies & place vNOTES port, to complete procedure laparoscopically • Improved access enables the surgeon to convert transabdominal cases to the vNOTES route • For obese patients, vNOTES bypasses challenges of addressing abdominal fat, enables shortest distance to target anatomy & requires less Trendelenburg positioning, as laparotomy pads can be used to move intestines out of the surgical field & lower insufflation pressures
Cosmesis	• Avoidance of abdominal incisions is integral part of patient-centered care, wherein patient preference is considered		• Special consideration for gender-affirming hysterectomies wherein abdominal incisions could worsen gender dysphoria

vNOTES, vaginal natural orifice transluminal endoscopic surgery; MRI, magnetic resonance imaging; US, ultrasound; PID, pelvic inflammatory disease; AUB, abnormal uterine bleeding; C-section, cesarean section.