FCV-301 vNOTES hysterectomy and BSO; demonstrating the management of Left broad ligament fibroid

Broad ligament fibroid is a challenging entity in hysterectomy whatever is the mode of the procedure. It does impose technical difficulty particularly with regard of the relationship of the fibroid to the pelvic sidewall structures including the ureter. 

This is a case of 55 year nulliparous woman who required a hysterectomy for persistent dyskaryosis smear despite having three LLETZ procedure including a recent one. She had 16 week multi fibroid uterus with recurrent left iliac fossa pain. CT investigation for this pain confirmed big fibroid uterus but other concerns. Past history was otherwise not  remarkable. She was consented for vNOTES. hysterectomy and BSO.

The hysterectomy started with successful application of the Alexis retractor and Gelpoint platform and pneumoperitoneum of 8mm Hg. Voyant energy devise was used and it was sufficient. The laparoscopic phase of the procedure indicated difficulty on the left side due to broad ligament fibroid. It was feasible to open the sidewall and visualise the ureter before fully sealing and dividing the uterine attachments and the IP ligaments. The laparoscopy element took 45 min and there was no need for morcellating or contained retrieval. Total procedure duration was 90 minutes and final check cystoscopy was normal. 

Patient made an efficient recovery and discharged home next day with minimal pain scores. Further follow up indicated full healing and resolution of the dyskaryosis on the vault smear.

Conclusion; the case demonstrated feasibility of advanced concept of navigating the pelvic sidewall in vNOTES a difficult unexpected anatomical findings. This also demonstrated the advantage of having or acquiring advanced minimal access skills in performing vNOTES on more complex cases.