Initial experience in the total hysterectomy (VANH) using vNOTES: the review of cases that hybrid vNOTES requires an umbilical port during operation

GelPOINT V-Path (Applied Medical Japan, Tokyo) was released in Japan in April 2021. It is used for Vaginally Assisted NOTES Hysterectomy (VANH) employing vaginal NOTES (vNOTES), and has become popular in the past few years. VANH is expected to be applied not only to uterine fibroids but also to various other gynecological diseases. Because in some surgical procedures, it is difficult to accomplish VANH only using a complete transvaginal technique, situation. VANH was performed for (1) uterine fibroids or adenomyosis, (2) sex reassignment surgery for transgender men (TM), and (3) pelvic organ prolapse (POP) complicated by uterine fibroids or ovarian cysts. This treatment for POP is based on a combination with total colpocleisis and is aimed at elderly patients who do not wish to preserve their sexual function. This hybrid VANH method has the advantage that the light of endoscope from an umbilical port can serve as a guide even in cases in which it is difficult to open the bladder uterine fossa because of a narrow vagina. Especially in cases of TM or nulliparous uterine fibroids, we adopted this hybrid method from the beginning of operation. However, in some POP cases in which the uterus was descending, we employed an umbilical port during surgery. This is because these patients had larger uterine fibroids, which made it difficult to open the bladder uterine fossa. It was noted that using an umbilical port can extend the range of application of VANH according to the situation.