vNOTES hysterectomy reduces laparotomy conversion rates in class III obesity - a retrospective comparative study

Area of Science:

• Minimally Invasive Gynecological Surgery
• Bariatric Surgery Outcomes
• Surgical Technology Advancement

Background:

• Obesity presents unique challenges in gynecological surgery, potentially increasing complication rates and conversion to open procedures.
• Laparoscopic hysterectomy (LH) is a standard minimally invasive approach, but its effectiveness in severely obese patients requires further evaluation.
• Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) offers a scarless approach, potentially beneficial for managing surgical complexities in obese individuals.

Purpose of the Study:

• To compare the outcomes of laparoscopic hysterectomy (LH) versus vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) hysterectomy (vNH) in obese patients (BMI ≥ 30 kg/m²).
• To analyze surgical outcomes stratified by obesity class (I, II, and III).
• To assess the impact of vNOTES on conversion rates to laparotomy compared to LH in different obesity classes.

Main Methods:

• Retrospective review of 134 patients (70 LH, 64 vNH) with BMI ≥ 30 kg/m² undergoing hysterectomy for benign indications.
• Data collected between January 2020 and December 2024 at a tertiary teaching and research hospital.
• Outcomes analyzed included operative time, major complications, and conversion rates to laparotomy, stratified by obesity class.

Main Results:

• While operative time was longer for vNH (205 min vs. 178 min; P < 0.01), overall major complication rates were similar between LH and vNH.
• A significant finding was the reduced conversion rate to laparotomy with vNOTES in patients with class III obesity (BMI ≥ 40 kg/m²) compared to laparoscopy (0% vs. 23.5%; P = 0.035).
• vNOTES statistically eliminated the risk of conversion to laparotomy in class III obese patients (OR 0.08; 95% CI 0.00-0.91; P = 0.035).

Conclusions:

• vNOTES hysterectomy demonstrates a significant advantage in reducing conversion to laparotomy for obese patients, particularly those with class III obesity.
• The choice of minimally invasive surgical approach for obese patients should consider BMI-based risk stratification.
• vNOTES emerges as a promising alternative for managing complex hysterectomies in severely obese patients, minimizing the need for open surgery.