A Novel Approach to Combined Vaginal and Laparoscopic Gynecological Surgery Christina Tierney, MD, Sophie H. Chung, Jacqueline Feinberg, MD, Kaitlin Haines, MD, Ghanshyam Yadav, MD, Masoud Azodi, MD, Gulden Menderes, MD ABSTRACT Background and Objectives: In this case series, we propose a novel approach to combined vaginal and lapa- roscopic surgery in which a posterior colpotomy and 2 5-mm abdominal incisions are used to perform benign gynecological procedures. We seek to assess the safety and feasibility of this technique in difficult surgical candi- dates such as those with obesity or prior laparotomies, as well as to detail intra- and postoperative complications associated with the procedure. Methods: We collected demographic, clinical, intra-oper- ative, and postoperative data on 45 women who under- went a combined vaginal and laparoscopic gynecological surgery for benign indications by a single surgeon be- tween February 2013 and August 2017. Results: From February 2013 through August 2017, 45 women underwent a combined vaginal and laparoscopic surgery at 2 institutions. Procedures included adnexal sur- gery (n 32, 71%), and total hysterectomy (n 13, 29%). Of patients who underwent adnexal surgery, two had minor postoperative complications. No patients had major complications. In addition, no patients had postoperative vaginal infections or pelvic abscesses, and there were no readmissions within 30 days after the procedures. Conclusion: Our proposed combined vaginal and lapa- roscopic approach to benign gynecological surgery can be utilized in difficult surgical candidates including those with obesity, nulliparous patients, and those with prior abdominal surgery. Our data has shown that this ap- proach is safe and effective. Key Words: Colpotomy, Laparoscopy, Transvaginal, Gy- necology, Benign. INTRODUCTION The use of a posterior colpotomy has been one of the mainstays of gynecologic surgery, and surgeons have utilized this incision to perform simple vaginal hyster- ectomies, to drain pelvic abscesses or sample fluid collections, and more recently to perform adnexal sur- gery and hysterectomies through the transvaginal nat- ural orifice transluminal endoscopic surgery (NOTES) technique. 1,2 Moreover, several studies have been published recently demonstrating the use of a posterior colpotomy incision to remove specimens during benign gynecologic surgery. 3–6 As these studies have demonstrated, traditional removal of gynecologic specimens had included an extension of one of the laparoscopic port sites. However, with specimen removal through a posterior colpotomy, extension of laparoscopic incisions can be avoided for faster wound healing, less pain and better cosmesis. The use of poste- rior colpotomy incisions may have been relatively unde- rutilized due to concerns for postoperative infections, de- hiscence or dyspareunia, which are nonproven concerns in the literature. Given that cosmesis is a priority for many patients with benign disease, and its low rate of adverse events, we propose to expand on the use of posterior colpotomy, and utilize it as an additional surgical port site with an assistant surgeon operating from the vagina. This is an attractive addition, as it will decrease the number of abdominal incisions necessary to perform benign gynecologic lapa- roscopic surgery. Department of Obstetrics and Gynecology, Bridgeport Hospital, Yale New Haven Health, Bridgeport, Connecticut, USA (Dr. Tierney). Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut, USA (Ms. Chung, Drs Feinberg, Haines, Azodi). Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA (Dr. Yadav). This study was made possible by the Richard A. Moggio, M.D. Student Research Fellowship at the Yale School of Medicine. Conflicts of Interest: The authors does not cite any conflicts of interest. Informed consent: Dr. Menderes declares that written informed consent was ob- tained from the patient/s for publication of this study/report and any accompany- ing images. Address correspondence to: Gulden Menderes, MD, Department of Obstetrics and Gynecology, and Reproductive Sciences, 333 Cedar Street, New Haven CT 06520. Telephone: 203-785-7385, Fax: 203-384-3579, E-mail: [email protected] DOI: 10.4293/JSLS.2019.00006 © 2019 by JSLS, Journal of the Society of Laparoendoscopic Surgeons . Published by the Society of Laparoendoscopic Surgeons, Inc. NOVEMBER 2021 | The Surgical Technologist | 495