Hybrid Vaginal-Assisted Natural Orifice Transluminal Endoscopic Hysterectomy Under Laparoscopic Guidance in Complex Pelvic Anatomy: A Case-Based Educational Video

Abstract

Background:

Hybrid vaginal-assisted natural orifice transluminal endoscopic hysterectomy (VANH) combines vaginal surgery with laparoscopic assistance, offering a minimally invasive option in patients with prior pelvic surgery or altered anatomy where standard vaginal hysterectomy may be unfeasible.

Methods:

We present a video-based technical report of a VANH performed in a 43-year-old woman with symptomatic adenomyosis, previous cesarean section, and extensive pelvic adhesions. The procedure begins with a purely vaginal phase: anterior and posterior colpotomy and transection of uterine pedicles. Following this, an Alexis retractor is introduced transvaginally through the colpotomies, establishing communication with the peritoneal cavity. Pneumoperitoneum is created via transvaginal insufflation. The hysterectomy is completed using standard endoscopic instruments inserted through the Alexis port, under simultaneous laparoscopic guidance via a single umbilical trocar. The vaginal cuff is closed vaginally.

Results:

The procedure was completed without complications. Total operative time was 80 minutes, with minimal blood loss. The patient was discharged within 24 hours. The video demonstrates step-by-step execution of this hybrid approach, with emphasis on anatomical orientation, safe energy use, and team coordination between the vaginal and laparoscopic phases.

Conclusions:

Hybrid VANH with transvaginal pneumoperitoneum and laparoscopic assistance is a safe, effective alternative for complex hysterectomy. It allows reduced abdominal port use while preserving visual control and access. This Video 1 serves as a practical educational resource for advanced gynecological surgeons.