Design: Surgical video case report

Setting: Single academic tertiary care hospital in Houston, Texas, USA.

Patients or Participants: 36-year-old (G3P0305), presenting for chronic pelvic pain since age 13 exhibiting deep dyspareunia, but no dyschezia, with surgical history of three cesarean sections. MRI revealed pelvic adhesions and active deep infiltrative endometriosis implants in the posterior cul-de-sac.

Interventions: Utilizing the novel single-port robot-assisted vNOTES (Intuitive Da Vinci SP Platform), transvaginal hysterectomy with bilateral salpingectomy was performed. The surgery initiated as a conventional vaginal hysterectomy, with anterior and posterior colpotomy to enhance visibility and aid in descensus. Inspection with the laparoscopic camera confirmed suspected adhesions, notably in the anterior cul-de-sac. Benefits of the SP platform used vaginally include elbowed robotic instruments, in addition to the “cobra” camera function, both enhancing navigation in the confined surgical space. The remainder of the surgery proceeded smoothly, which included lysis of dense adhesions. A 1.5 cm rectal endometriotic nodule was shaved using monopolar scissors with intact rectal mucosa. The bowel defect was reapproximated with 3-0 uni-directional barbed suture and imbricated with interrupted 3-0 polyglactin 910 sutures. A “flat tire” test confirmed proper closure. Interceed was placed bilaterally for adhesion prevention after hemostasis was assured. The vaginal cuff was closed with 0-barbed suture.

Measurements and Main Results: The surgery was completed without complications, and the patient reported no postoperative complaints at her six-week follow-up. Pathology confirmed the presence of pelvic and bowel endometriosis.

Conclusion:

RSP-vNOTES presents a viable alternative for transvaginal hysterectomy with endometriosis resection, particularly in cases necessitating bowel surgery and suturing techniques. SP Robot assistance, with its articulating camera and elbowed instruments enhances access in confined operative fields, making it superior to conventional laparoscopic surgery in certain scenarios.