Optimizing Vaginal Natural Orifice Transluminal Endoscopic Surgery for the Non-Prolapsed Uterus: Revisiting the Age-Old Technique of Uterosacral Ligament Massage

Background: Hysterectomy is one of the most commonly performed gynecological procedures worldwide. Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) is an innovative approach that combines the precision and enhanced visualization of endoscopic surgery with the well-established advantages of the vaginal route. The vNOTES hysterectomy procedure is performed in three distinct phases, with the initial and final phases completed vaginally. Insufficient uterine prolapse often presents a challenge during the vaginal phase, leading surgeons to opt for non-vaginal surgical approaches. Methods: This article revisits the uterosacral ligament massage technique, described in older gynecological literature, which involves stretching the uterosacral–cardinal ligament complex under steady cervical traction to improve uterine descent. Results: A step by step description, supported by figures and video, illustrates the uterosacral ligament massage technique and its application during the vNOTES procedure. Conclusion: Incorporating uterosacral ligament massage into vNOTES protocols could improve uterine mobility and enhance accessibility during the vaginal phase. This simple yet effective technique has the potential to expand the indications for vNOTES, making it a viable and accessible option for a broader range of patients, including those with limited uterine descent.