Design: The presented study includes a surgical video example to present this technique.

Setting: Patient was placed in dorsal lithotomy Trendelenburg position.

Patients or Participants: The presented case example is a patient who underwent vNOTES hysterectomy with history of cesarean section.

Interventions: Hysterectomy via a vNOTES approach.

Measurements and Main Results: The presented case began with dissection of the anterior and posterior colpotomies. Due to previous cesarean section and resulting scarred tissue, the anterior colpotomy was difficult to create. Rather than continuing the dissection with uncertainty, the Alexis retractor was inserted prior to completion of the anterior colpotomy. The posterior aspect of retractor was inserted intraperitoneally via posterior colpotomy. The anterior aspect was placed in the anterior superior portion of vaginal vault. The GelPoint was then attached, and insufflation obtained. With intraabdominal distension, the anterior peritoneal reflection becomes much clearer, allowing for differentiation of peritoneum from bladder. The anterior colpotomy is then completed without hesitation or concern for possible injury. The remainder of the hysterectomy is completed in the usual fashion.

Conclusion: In conclusion, in cases of difficult anterior colpotomy, this can be delayed until after abdominal insufflation to aid in detection of peritoneal reflection and allow easier and more certain anterior peritoneal access during vaginal surgery.