Pelvic organ prolapse significantly impacts quality of life, with high uterosacral ligament suspension (HUSLS) being a well-established technique for apical support. The conventional vaginal approach carries risks of ureteric and bladder injury [1], while laparoscopic and robotic approaches require abdominal entry—risking vascular and organ injury and leaving visible scars. 
Vaginal natural orifice transluminal endoscopic surgery (vNOTES) offers a compelling alternative that combines the benefits of minimally invasive endoscopic surgery with a scarless approach [2,3]. This video demonstrates a minimally invasive, vaginal technique for HUSLS performed entirely via the vNOTES platform.

The procedure begins with transvaginal entry into the peritoneal cavity, followed by systematic inspection of pelvic anatomy. In this case, bowel adhesions required meticulous adhesiolysis using sharp dissection to visualise the anatomy and ensure adequate operative space.
After introduction of a warm, moistened surgical mop to retract the bowels from the surgical field, the uterosacral ligaments are identified close to their sacral attachment. Bilateral ureteric identification confirms correct ligament orientation and prevents injury. Two Prolene sutures (1-0) are placed bilaterally into each uterosacral ligament at the intermediate part, under direct endoscopic visualization.
These sutures are anchored to the vaginal cuff symmetrically to achieve optimal suspension and restore the vaginal axis. Key technical considerations include appropriate suture depth, spacing, and tension adjustment, all critical for durable outcomes.

The technique successfully achieves HUSLS with excellent visualization and anatomical restoration. Adhesiolysis was performed safely without bowel injury, demonstrating that complex intra-abdominal adhesions can be managed effectively via vNOTES. Intraoperatively, robust apical support was established with symmetrical vaginal vault elevation. 
The vNOTES platform offers several advantages over conventional vaginal surgery: ergonomic suturing, improved access to deep pelvic structures, and enhanced visualization enabling accurate identification of critical structures. These features may reduce complications such as ureteral injury while avoiding abdominal incisions and high intraabdominal pressure.

This video presents a safe and reproducible technique for high uterosacral ligament suspension using vNOTES. By combining minimally invasive scarless access with high uterosacral fixation and superior endoscopic visualization, this approach represents a promising advancement in apical prolapse surgery. Further studies are warranted to evaluate long-term anatomical and functional outcomes.

Sheyn D, Gupta A, Boyd S, Wu X, Shoag J, Bretschneider CE. Incidence and Risk Factors for Genitourinary Tract Injury Within 1 Year After Surgery for Pelvic Organ Prolapse. UROGC. 2022 Aug;28(8):506–17.
Arkan K, Colak GC, Ilter PB, Akdeniz E, Akgol S. Effectiveness and comparison of vnotes assisted uterosacral ligament suspension and vaginal Mccall culdoplasty in apical prolapse. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2025 Nov 28:114861.
Atilgan AE, Biyik I, Uzun A, Altuntas SL, Kiliç F. vNOTES as a salvage method for adnexectomy and high uterosacral ligament suspension after vaginal hysterectomy under epidural anesthesia: A feasibility and safety study. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2025 Mar 1;306:112-6.