Design: A single case of a patient with abnormal uterine bleeding and bulk symptoms undergoing vNOTES hysterectomy for 3800g fibroid uterus.

Setting: The patient underwent surgery at a university hospital. The patient was placed in dorsal lithotomy position and 10 degrees of Trendelenburg for the duration of the case. Video footage was obtained during this procedure.

Patients or Participants: A 50-year-old woman with history of 3 prior cesarean sections who desired definitive surgical management for abnormal uterine bleeding and bulk symptoms. Pelvic MRI demonstrated a 20 x 10cm enlarged fibroid uterus. The patient strongly desired to avoid a midline vertical incision and after counseling, elected to undergo vNOTES hysterectomy with partial use of existing Pfannenstiel incision for specimen morcellation and extraction.

Interventions:

vNOTES hysterectomy was achieved in this patient with a large uterus and dense anterior adhesive disease with use of the following techniques:

1. Placement of Alexis ring retractor prior to anterior colpotomy to facilitate adhesiolysis

2. Utilization of “up-and-away" technique, displacing the uterus cephalad and medially to access the lateral attachments and blood supply

3, Use of a 10mm advanced bipolar device for desiccation and ligation of large vascular pedicles

Measurements and Main Results: The presented case demonstrates safe and reproducible techniques for managing the large fibroid uterus and dense anterior adhesive disease via vNOTES approach.

Conclusion: By employing the techniques outlined above, hysterectomy for the large fibroid uterus can be completed via vNOTES and can avoid the large midline vertical skin incision often necessitated during an open approach to this pathology. This allows surgeons to offer patients a wider variety of surgical options at time of counseling, further empowering patients during the shared decision-making process.