Transvaginal Natural Orifice Transluminal Endoscopic Surgery Hysterectomy Aided by Transcervical Instrumental Uterine Manipulation.

STUDY OBJECTIVE: To describe the technique of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomy with the aid of transcervical instrumental uterine manipulation. DESIGN: Video with step by step description of technique. SETTING: Minimally Invasive Gynaecological Surgery Department, Naval Multi Speciality Hospital, Jalgaon, India. PATIENT: A 47-year-old woman. INTERVENTION: vNOTES hysterectomy. MEASUREMENTS AND MAIN RESULTS: A 47-year-old patient presented with history of menorrhagia since 4 years as well as a history of failed medical management for menorrhagia. Ultrasonography showed an enlarged uterus with findings suggestive of adenomyosis. Body mass index of the patient was 27. She had a history of 2 normal vaginal deliveries and had undergone laparoscopic tubal sterilization in the past. During vNOTES hysterectomy, an instrument was placed transcervically into the uterus for manipulation, providing leverage that helped gain good exposure of all uterine attachments. It also prevented unintentional rotation of uterus and its attachments. Therefore, the surgeon did not need to use a second hand for retraction of the uterus during surgery, allowing that second hand for retraction of bowel and adnexa. Hysterectomy was completed without any complications. Total estimated blood loss was 55 mL, and the patient was discharged on the third day. CONCLUSION: Because the tip of instrument is not completely visible in vNOTES surgery, manipulation helps to deflect the uterus and its attachments away from important structures, thus preventing inadvertent thermal damage from the tip of the instrument. This is a feasible and safe technique for vNOTES hysterectomy.

Tips for Safe Laparoscopic Multiple Myomectomy.

STUDY OBJECTIVE: To demonstrate key steps in performing safe laparoscopic multiple myomectomy. DESIGN: Video focuses on stepwise description of all major steps of the surgical technique. PATIENT: Twenty-seven-year-old woman. Informed consent was taken from the subject, and the institutional review board approved this research. INTERVENTION: Laparoscopic multiple myomectomy with morcellation in bag. MEASUREMENTS AND MAIN RESULTS: About one-third of women with fibroids present with symptoms severe enough to warrant treatment. We demonstrate a case of a 27-year-old woman with complaints of secondary infertility and menorrhagia. On examination the uterus was enlarged up to 24 weeks size. Ultrasonography mapping located 7 myomas ranging in size from of 3 to 10 cm and classified as International Federation of Gynecology and Obstetrics classes 2, 3, 4, 5, 6, and 7. Generally, laparotomy or laparoscopy and mini-laparotomy is performed for such cases of multiple myomas. However, the total laparoscopic approach can confer benefits if performed following safe steps and within good time. The following were the key steps of surgery: (1) Higher port position using Lee Huang point for primary port, (2) intermittent vasopressin use for each myomectomy, (3) cold technique of myomectomy, (4) myoma lace creation, (5) multiple layer suturing using double-ended barbed sutures, (6) myoma garland creation, and (7) morcellation in a stomach-shaped bag. CONCLUSION: The intermittent use of vasopressin is effective in reducing blood loss. Suturing using barbed sutures is less time consuming. Creating lace of myomas by passing a thread through each myoma, prevents losing them in the abdominal cavity and creating garland of myomas by tying two free ends of the lace helps in easier bagging. Morcellation in bag prevents dissemination of bits of myoma and visceral injury. These steps help in performing laparoscopic multiple myomectomy safely. However, this technique should be reserved for selected cases and should be performed by surgical teams with the required expertise and experience.