• adnexal surgery
• adnexectomy
• minimally invasive surgery
• natural orifice transluminal endoscopic surgery
• vNOTES

Aim: Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) is an innovative, minimally invasive surgical approach that combines the advantages of both vaginal and laparoscopic surgery, enabling access to the pelvic cavity through the vagina. This emerging procedure is used to treat different benign adnexal pathologies and to perform prophylactic bilateral adnexectomy in BRCA mutation carriers. Its safety, feasibility and efficacy in gynecology have been widely demonstrated by several retrospective analyses. However, evidence regarding the superiority (or non-inferiority) of vNOTES over Conventional Multiport Laparoscopy (CML) for the treatment of adnexal pathologies is still limited. The aim of this retrospective single-center study was to compare the perioperative outcomes of vNOTES adnexal procedures with those of Conventional Multiport Laparoscopy (CML), which is currently the gold standard technique for the surgical management of benign adnexal diseases. In addition, postoperative pain scores were evaluated in the vNOTES group, to assess the impact of transvaginal endoscopic surgery on patient recovery.

Materials and methods: We retrospectively analyzed the perioperative outcomes of patients who underwent adnexal surgery either by vNOTES (n=62) or Conventional Multiport Laparoscopy (CML) (n=50) in our hospital between January 2020 and September 2024, for presumed benign pathologies of ovaries and/or fallopian tubes, or for prophylactic purpose. Demographic data were collected. Duration of surgery, estimated intraoperative blood loss, need for conversion, the presence of intraoperative and postoperative complications, and length of postoperative hospital stay were analyzed in both groups. In the vNOTES group, VAS (Visual Analogue Scale) postoperative pain scores were recorded at 6 hours, at hospital discharge and 7 days after surgery.

Results: The vNOTES group was characterized by a shorter duration of surgery (42.2716.19 vs. 67.0022.38 min.; p<0.001) and a reduced postoperative hospital stay (17.138.57 vs. 25.5413.54 hours; p<0.001), compared to the CML group. Intraoperative bleeding was comparable between the two surgical techniques (27.0318.32 vs. 24.2015.92 ml in vNOTES and CML, respectively; p=0.329). A conversion rate to conventional laparoscopy of 3.23% (n=2) was observed in the vNOTES group, mainly due to pelvic adhesions, while no switch to laparotomy occurred in the CML group (p=0.501). No statistically significant difference was noticed between the two surgical approaches in terms of intraoperative and postoperative complications, which were infrequent in both samples. In the vNOTES group, very low VAS pain scores were observed 6 hours post-surgery, with an additional decrease by the time of discharge.

Conclusion: vNOTES appears to be an excellent alternative to CML for the treatment of different adnexal pathologies in suitable patients. Its advantages include the lack of visible scars, a minor duration of the surgical procedure, a shorter hospitalization and a faster recovery.