Pelvic organ prolapse (POP) and symptomatic adenomyosis often coexist, requiring surgical interventions that balance efficacy with optimal patient recovery. The Vaginal Natural Orifice Transluminal Endoscopic Surgery (V-NOTES) approach combines the benefits of traditional vaginal surgery—namely, the absence of visible abdominal scars—with the enhanced visualization provided by laparoscopy. By integrating high uterosacral ligament suspension during a vNOTES hysterectomy, surgeons can ensure robust apical support, correcting existing uterine prolapse and providing a preventive measure against future vaginal vault prolapse.

The patient is a 41-year-old premenopausal woman with a history of three vaginal deliveries. She presented with chronic menometrorrhagia, pelvic heaviness, and postcoital pain. Her medical history is notable for inflammatory bowel syndrome and recurrent urinary tract infections, with no prior surgical interventions.
Clinical examination revealed a stage II cystocele and uterine prolapse, while pelvic MRI confirmed underlying adenomyosis. Given these findings, after multidisciplinary team meeting, she was scheduled for a vNOTES hysterectomy with bilateral salpingectomy, high uterosacral ligament suspension, and anterior colporrhaphy.

The patient was placed in the lithotomy position with a 30° Trendelenburg under general anesthesia. The procedure began with cystoscopy, during which bilateral ureteral injection of indocyanine green (ICG) was performed to enable real-time ureteral identification.
The vaginal phase was initiated with an anterior and circumferential colpotomy, followed by retrograde dissection of the vesicouterine space. The bladder was carefully mobilized and retracted anteriorly, and the anterior peritoneum was opened. A posterior dissection was then performed to enter the pouch of Douglas, allowing identification and control of the uterosacral ligaments.
To transition to the endoscopic phase, a 9.5 cm GelPOINT® multi-channel transvaginal access platform was introduced. After CO₂ insufflation and endoscopic visualization, the cervicouterine pedicles, followed by the uterine arteries and pedicles, were coagulated and transected in a controlled manner, maintaining a safe distance from the ICG-labeled ureters.
Subsequently, the round ligaments were coagulated and transected bilaterally. Attention was then turned to the adnexa: the utero-ovarian ligaments and mesosalpinx were transected completing a bilateral salpingectomy.
High uterosacral ligament suspension was then performed under direct visualization using bilateral Ethibond 2-0 sutures, ensuring restoration of the vaginal vault’s anatomical position. The surgical specimen, including the uterus and fallopian tubes, was removed transvaginally without complications. An anterior colporrhaphy was performed at the end of the procedure. Operative time was 150minutes and estimated blood loss was less than 100ml.
A vaginal pack and Foley catheter were left in place for 36 hours. 
The patient was discharged on postoperative day 2 without complications. At the 6-week follow-up visit, examination showed a stage I residual cystocele with a well-supported vaginal vault and no urinary symptoms.

The V-NOTES approach for hysterectomy combined with high uterosacral ligament suspension represents a safe and effective minimally invasive option for the management of adenomyosis and pelvic organ prolapse. This technique offers excellent visualization of the ureters and uterosacral ligaments while providing the patient with a scarless recovery and optimal apical support.