Vnotes as a salvage method for adnexectomy and high uterosacral ligament suspension after vaginal hysterectomy under epidural anesthesia: a feasibility and safety study

Objective: To evaluate the feasibility and safety of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) for performing adnexectomy and high uterosacral ligament suspension (HUSLS) after vaginal hysterectomy (VH) under epidural anesthesia. Method: This was a retrospective case series of 42 women who underwent VH for stage II or greater apical prolapse according to pelvic organ prolapse quantification (POP-Q); however, adnexectomy could not performed and replace the vNOTES technique. The procedure continued with vNOTES adnexectomy and bilateral HUSLS under epidural anesthesia. Patient demographics, operation outcomes, and short-term and long-term complications were analyzed. Patients’ quality of life was assessed with the Pelvic Floor Distress Inventory-20 (PFDI-20) at the 24-month visit. Results: vNOTES procedures were performed successfully under epidural anesthesia in all patients. One patient was converted to general anesthesia due to ureter injury. The mean age of the patients was 54 years. The mean operating time for all procedures was 55 min (range 42–122). The mean blood loss was 90 ml. All patients ambulated 6 h later. The mean pain score 24 h later according to the visual analog scale (VAS) was 2 (range 0–5). The median length of hospital stay was 1 night (range 1–3). There were no complications or morbidities during the postoperative period. Each POP-Q score significantly improved at the 6-month visit (p < 0.05). While the preoperative mean total PFDI-20 score was 20.4 ± 6.6, it significantly decreased to 8 ± 1.2 24 months later (p < 0.05). Conclusion: The vNOTES technique is a good option when adnexectomy can not be performed after VH. The procedure can be completed safely under epidural anesthesia by performing HUSLS for apical support along with adnexectomy. In this way, patients combine the advantages of scarless minimally invasive surgery with the advantages of epidural anesthesia. Introductıon.