vNOTES Hysterectomy Reduces Laparotomy Conversion Rates in Class III Obesity: A Retrospective Comparative Study

Objective: This study aims to compare the outcomes of laparoscopic hysterectomy (LH) and vNOTES (Vaginal Natural Orifice Transluminal Endoscopic Surgery) hysterectomy (vNH) in obese patients undergoing the procedure for benign gynecological indications, with results stratified by obesity class (Class I, II, and III). Materials and Methods: We retrospectively reviewed the data of patients with a Body Mass Index (BMI) ≥30 kg/m² who underwent either LH or vNH for benign indications at a tertiary teaching and research hospital between January 2020 and December 2024. Results: A total of 134 patients (70 LH, 64 vNH) were included in this single-center study. The median operative time was significantly longer in the vNH group (205 min vs. 178 min, p<0.01). Overall, major complication rates were similar between the two groups. The most striking finding of the study was that in patients with Class III obesity (BMI ≥40 kg/m²), the vNOTES approach significantly reduced the conversion rate to laparotomy compared to laparoscopy (0% vs. 23.5%, p=0.035). Conclusion: Our study demonstrates that the most significant advantage of vNOTES surgery in obese patients undergoing benign hysterectomy is the reduction in the conversion rate to laparotomy, particularly within the Class III obesity group. vNOTES statistically eliminated the risk of conversion to laparotomy compared to laparoscopy in patients with Class III obesity (OR: 0.08; 95% CI: 0.00-0.91; p=0.035). These findings underscore the importance of risk stratification based on patient BMI when selecting a minimally invasive surgical approach for obese patients.