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articulated laparoscopic camera was introduced. The ab- domen was surveyed, and the surgeon made a decision regarding placement of the second abdominal trocar: ei- ther in the right lower quadrant of the umbilicus, right lower quadrant of abdomen, or left lower quadrant of the abdomen ( Figure 1 ). The patient was then placed in the Trendelenburg position. To perform the posterior colpotomy, a STEP access needle with a VersaStep radially expandable sleeve was placed through the vagina into the posterior cul-de-sac between the uterosacral ligaments under direct visualization. This is done at a level 1–2 cm below the cervix in the posterior fornix. A 12-mm trocar was then placed through the ex- pandable sleeve ( Figure 2 ). The operator utilizing that site used an articulated grasper to assist the primary sur- geon ( Figure 3 ). In the setting of adnexal surgery, the freed specimen was placed in a laparoscopic specimen retrieval bag and re- moved from the posterior colpotomy port site. If neces- sary, they were morcellated vaginally within the bag. In the setting of hysterectomy, the posterior colpotomy inci- sion was incorporated into the full colpotomy at the end of the procedure. The colpotomy incision was then closed vaginally with a delayed absorbable suture. At completion of the procedure, the patients had 2 5-mm laparoscopic incisions and a reapproximated colpotomy incision ( Fig- ure 4 ). Figure 1. Two trocars are noted at the patient’s umbilicus. In this case series, we present a group of patients who underwent a combined vaginal and laparoscopic ap- proach to benign gynecological surgery by a single sur- geon. Our approach involves only 2 5-mm abdominal incisions in addition to a posterior colpotomy. We seek to assess the safety and feasibility of this technique in diffi- cult surgical candidates such as those with obesity or prior laparotomies, as well as to detail intra- and postoperative complications associated with the procedure. MATERIALS AND METHODS Forty-five women underwent combined vaginal and laparo-scopic surgery for benign indications by a single surgeon between February 2013 and August 2017. Demographic and clinical data were abstracted from the electronic medical records including age, parity, body mass index (BMI), prior surgery, medical comorbidities, indication for gynecologic surgery, and preoperative pel- vic pain or dyspareunia. Data relating to the surgery were also collected, including surgical procedures performed; number, size, and location of abdominal laparoscopic incisions; operative time; estimated blood loss; intra-op- erative complications; preoperative antibiotics used; post- operative complications; hospital length of stay; specimen size; and postoperative pain. Estimated blood loss values denoted as “minimal” were treated as 15 cc. Surgical Technique This posterior colpotomy technique has been described in detail in a prior study published from our institution. 3 Briefly, all patients provided informed consent. The pa- tients received intravenous prophylactic antibiotics for prevention of surgical-site infection according to our hos- pital protocol. After induction of general anesthesia, pa- tients are placed in the dorsal lithotomy position, and prepped and draped. A disposable uterine manipulator, such as the Kronner Manipujector Uterine Manipulator/ Injector (Cooper Surgical, Inc, Trumbull, CT, USA) was placed. Pneumoperitoneum was established at the left upper quadrant of the umbilicus with a Veress needle. In this technique, Veress needle with a VersaStep radially ex- pandable sleeve (Covidien, Mansfield, MA, USA), was inserted into the abdomen and insufflation to the sur- geon’s desired intra-abdominal pressure was obtained. At that point, a 5-mm trocar was introduced, and a 5-mm | The Surgical Technologist | NOVEMBER 2021 496