Perioperative outcomes of vNOTES versus vaginal hysterectomy in obese women

Obesity increases the technical difficulty of gynecologic surgery and is associated with higher perioperative morbidity. Vaginal hysterectomy (VH) is generally considered the preferred route for benign indications. However, transvaginal natural orifice transluminal endoscopic surgery (vNOTES) provides improved visualization compared with conventional VH and facilitates the performance of concurrent adnexal procedures. This study aimed to compare the perioperative outcomes of vNOTES hysterectomy and VH in obese patients (BMI ≥30 kg/m²).

This single-center retrospective cohort study included 174 obese women who underwent hysterectomy for benign or premalignant conditions between January 2023 and December 2025. Patients were divided into two groups according to the surgical approach: vNOTES (n = 88) and VH (n = 86). The primary outcome was successful completion of the procedure without conversion. Secondary outcomes included operative time, hemoglobin (Hb) decrease, Clavien-Dindo complication rates, and the feasibility of performing concurrent adnexal surgery.

There were no significant differences between the groups regarding operative time, length of hospital stay, postoperative pain scores, or readmission rates. Conversion rates were low and comparable between the vNOTES and VH groups (3.4%vs. 3.5%, respectively). Although the median Hb decrease was significantly greater in the vNOTES group (p = 0.006), intraoperative and postoperative complication rates were similar between the two groups. The rate of concurrent adnexal surgery was significantly higher in the vNOTES group (p < 0.001).

vNOTES hysterectomy is a safe and feasible alternative to conventional VH in obese patients, with comparable perioperative outcomes. In addition to improved visualization, vNOTES enables a higher rate of concurrent adnexal procedures, which may be particularly advantageous in obese patients with a higher likelihood of incidental endometrial pathology.