Surgical Technique for Vaginal Natural Orifice Transluminal Endoscopic Surgery (VNOTES) Sacrocolpopexy

To show the technical feasibility of a novel vaginal natural orifice transluminal endoscopic surgery (VNOTES) sacrocolpopexy (SCP) technique for patients with pelvic organ prolapse who are unsuitable for trans-abdominal approach and require durable apical support. Previously described VNOTES SCP techniques lack adjustable tissue tensioning [1-4]. This technique allows for dynamic apical tensioning to optimize the prolapse repair [5].

Stepwise surgical demonstration with narrated video.

Tertiary care academic center. A 60-year-old woman with earlier kidney transplant and mesh-augmented ventral hernia repair presented with recurrent stage IV pelvic organ prolapse 9 months after robotic hysterectomy and uterosacral ligament suspension. Given the rapid recurrence, VNOTES SCP was recommended to avoid the trans-abdominal approach while ensuring durable support. Laparoscopy noted omental adhesions to ventral hernia mesh (Fig. 1) and a retropubic peritoneal bulge from the transplanted kidney, limiting sacral visualization (Fig. 2).

VNOTES offers laparoscopic visualization, magnification, and access to deep pelvic structures while avoiding abdominal incisions and upper abdominal pathology. A previously described three-arm mesh configuration was used (the DZOH technique, Fig. 3). The apical arm was secured to the anterior longitudinal ligament using extracorporeal knot tying and retroperitoneal with a tunneling technique. The anterior and posterior arms were anchored separately to the vaginal wall. The three mesh arms were connected using a tensioning suture placed along the sacral arm and then passed through the anterior and posterior arms sequentially to create the Y mesh. Subsequently, the suture, involving all three arms, was tensioned to suspend the vaginal apex.

VNOTES SCP is a feasible and valuable option for patients requiring durable apical support who are not suitable for trans-abdominal surgery. Refining the specific steps and technique is essential for further implementation of this novel surgical approach. Further follow up and larger studies are needed to determine long-term outcomes. VIDEO ABSTRACT.