vNOTES as an Approach to Pelvic Surgery in the Hostile Abdomen

INTRODUCTION: A minimally invasive approach to pelvic surgery, such as laparoscopic or robotic procedures, has typically been considered preferable in appropriate patients, given that it is associated with lower morbidity than open procedures. In more recent years, vaginal natural orifice transluminal endoscopic surgery (vNOTES) has emerged as an alternative and novel approach to minimally invasive pelvic surgery. The many benefits of vNOTES surgery include lower operative times and estimated blood loss, better cosmetic outcomes, shorter hospital stays, and fewer perioperative complications. Often, patients may present with complex surgical histories that may preclude them from traditional surgical approaches such as laparoscopic or robotic-assisted adnexal surgery. This surgical video presents one such patient, in which vNOTES was deemed the preferred surgical approach. OBJECTIVE: The objective of this video is to present a surgical case in which vNOTES was deemed the preferred surgical approach to a bilateral salpingo-oophorectomy in a patient with a history of extensive abdominal surgeries, including three prior cesarean sections, a tubal ligation, an umbilical hernia repair with mesh, and debridement and irrigation of a postoperative abdominal abscess. METHODS: This surgical video presents the steps required to perform adnexal surgery by way of vNOTES in a safe and effective manner. We also demonstrate relevant anatomy encountered during this procedure, including the bilateral ureters. RESULTS: The patient underwent bilateral salpingo-oophorectomy by means of vNOTES without complication. Significant intra-abdominal adhesions were encountered, that may have potentially risked injury, if an abdominal approach was performed. The patient recovered well from her surgery without complication. CONCLUSIONS: We demonstrate that vNOTES bilateral salpingo-oophorectomy is a safe and effective approach for a patient with an extensive surgical history and concern for significant adhesive burden and a hostile abdomen. With this approach, inadvertent injury to bowel, omentum, and the bilateral ureters may be avoided.