Scarless Sterilization? A Comparative Study of Vaginal Notes and Laparoscopic Tubal Ligation

Background Tubal ligation is a common permanent contraception method. Vaginal natural orifice transluminal endoscopic surgery (vNOTES) offers a scarless alternative to laparoscopy, but comparative evidence for interval tubal ligation is limited.

To compare surgical outcomes and recovery between vNOTES and conventional laparoscopic tubal ligation.

Retrospective cohort at a tertiary center (August 2024–May 2025). Women aged 30–50 seeking permanent contraception with ASA ≤ 3 were included. Exclusions: prior pelvic surgery or known pelvic pathology, salpingectomy or non‐contraceptive indications (e.g., hydrosalpinx), concomitant procedures, incomplete records. Patients were grouped by technique: vNOTES (n = 20) or laparoscopy (n = 27). Outcomes: operative time, hospital stay, time to mobilization, analgesia use, Δhemoglobin/Δhematocrit, complications. Tests: t‐test/Mann–Whitney, Chi‐square/Fisher; effect sizes (Cohen's d) and 95% CIs reported (α = 0.05).

Baseline demographics were comparable. Operative time did not differ (mean difference −3.77 min, 95% CI −9.70 to 2.15; p = 0.199; d = −0.32). vNOTES was associated with shorter hospitalization (−3.40 h, 95% CI −6.51 to −0.29; p = 0.033; d = 0.47), earlier mobilization (−0.80 h, 95% CI −1.27 to −0.33; p < 0.001; d = 0.94), and lower postoperative analgesia use (−1.05 doses, 95% CI −1.48 to −0.63; p 0.40). One vNOTES case required conversion to laparoscopy due to adhesions; no conversions occurred in the laparoscopy group.

vNOTES and laparoscopy are both safe for interval tubal ligation. vNOTES confers clinically meaningful recovery advantages—shorter hospitalization, faster mobilization, and reduced analgesic need—while maintaining comparable operative time and blood loss surrogates. These findings support vNOTES as a promising, patient‐centered alternative.

contraception, laparoscopy, natural orifice surgery, tubal ligation, vNOTES 1. Introduction Tubal ligation remains one of the most reliable and widely used permanent contraception methods worldwide, particularly among women who have completed childbearing. Traditionally performed via laparotomy, this approach has evolved significantly over the past decades, transitioning toward less invasive techniques with reduced morbidity and faster recovery. With the advent of laparoscopy, tubal ligation procedures became associated with smaller incisions, shorter hospital stays, and fewer postoperative complications, making laparoscopic tubal ligation the standard approach in many centers [1]. In recent years, the focus on further minimizing surgical trauma and improving cosmetic outcomes has led to the development of natural orifice transluminal endoscopic surgery (NOTES), which utilizes natural body orifices to access the abdominal cavity. Among these, vaginal NOTES (vNOTES) has gained increasing popularity in gynecologic surgery. First reported for hysterectomy and adnexal procedures, vNOTES offers a scarless alternative to laparoscopy by eliminating abdominal incisions while maintaining similar visualization and operative control [2, 3]. As surgical techniques and instruments have advanced, the applications of vNOTES have expanded significantly. Beyond benign indications, it has been successfully implemented in adnexal surgeries such as cystectomies and salpingo‐oophorectomies [4]. Moreover, growing evidence supports its use in selected cases of gynecologic malignancies, particularly early‐stage endometrial cancer, where it enables adequate staging with favorable outcomes [5, 6]. vNOTES has also shown promise in the management of acute gynecologic emergencies, such as adnexal torsion or ruptured cysts, offering a minimally invasive solution even in urgent settings [7]. These advancements underscore vNOTES as a versatile and evolving modality within gynecologic surgery. In this study, we aimed to compare vNOTES and conventional laparoscopic tubal ligation in terms of surgical outcomes, recovery parameters, and patient experience. In an era where minimally invasive surgery continues to evolve, evaluating and embracing techniques that reduce physical and psychological burden is critical. By comparing these two approaches, we hope to contribute to the growing body of evidence supporting the adoption of newer, less invasive methods in line with global trends toward improved quality of care and patient‐centered surgical practice. 2. Materials and Methods This retrospective cohort study included patients who underwent tubal ligation procedures between August 2023 and May 2025 at [Institution name removed for blind review]. Ethical approval was obtained from the [Institution name removed for blind review] Ethics Committee (Date: 25.06.2025, Number: 72), and all stages of the study adhered to the principles of the Declaration of Helsinki. With the widespread adoption of the vNOTES technique in our institution, bilateral tubal ligation via vNOTES has been performed since August 2024, and these patients constituted the study group. The control group consisted of patients who had undergone laparoscopic tubal ligation by the same three surgeons during the one‐year period preceding the introduction of vNOTES. Eligible patients were women aged 30–50 years who requested permanent contraception and had an American Society of Anesthesiologists (ASA) score of ≤ 3. Exclusion criteria were a history of prior pelvic surgery or known pelvic pathology (e.g., severe adhesions, endometriosis), cases in which salpingectomy rather than tubal ligation was performed, tubal ligation undertaken for indications other than contraception (such as hydrosalpinx), concomitant surgical procedures, and incomplete medical records. A total of 53 patient files who underwent tubal ligation were reviewed; 49 cases meeting the inclusion criteria were analyzed, and 2 cases were excluded due to missing data. In total, 47 patients were included: 20 in the vNOTES group and 27 in the laparoscopic group. All patients underwent interval tubal ligation under general anesthesia. In the laparoscopic group (group 1—LS), the procedure began with direct trocar insertion using a 10 mm umbilical trocar, through which CO2 pneumoperitoneum was established. Subsequently, two 5 mm ancillary trocars were placed bilaterally in the inguinal regions under direct visualization. After identifying the fallopian tubes, approximately 1 cm isthmic segment of each tube was excised bilaterally using a Ligasure vessel sealing device. Hemostasis was confirmed, and the instruments were removed under vision prior to desufflation and trocar removal. In the vNOTES group (group 2—vNOTES), after entering to the peritoneal cavity was achieved via a posterior colpotomy, a small‐sized (7.5 cm) wound protector/retractor (Alexis Bag) was placed in the vaginal cuff. A GelPoint port was inserted into the vaginal surface of the wound protector/retractor. A 10 mm 30° laparoscope was introduced, and pneumoperitoneum was maintained through CO2 insufflation. The fallopian tubes were identified (Figure 1a) and similarly excised approximately 1 cm on each side using the Ligasure vessel sealing device inserted through the transvaginal port (Figure 1b,c). Following the procedure, the colpotomy incision was closed with absorbable sutures under direct visualization. All procedures were performed by the same three experienced gynecologic surgeons to minimize operator‐related variability. To reduce information bias, surgical and clinical data were extracted from electronic medical records using standardized forms, and two independent investigators reviewed the records. Data extracted from electronic medical records included demographic characteristics, operative time, estimated blood loss, intraoperative and postoperative complications, need for analgesia, length of hospital stay, and laparoscopic or laparotomic conversion. Standardized postoperative pain scores were not routinely recorded; therefore, analgesic consumption was used as a surrogate marker for postoperative pain. Statistical analysis was conducted using Statistical Package for the Social Sciences (SPSS) 25.0 software. Normality was assessed using the Shapiro–Wilk test. Student's t‐test was applied for normally distributed variables, while the Mann–Whitney U test was used otherwise. Categorical variables were analyzed using Chi‐square or Fisher's exact test. A p‐value < 0.05 was considered statistically significant. Effect sizes (Cohen's d, Hedges' g) with 95% confidence intervals were reported. A post hoc power analysis was performed for the main secondary outcomes (hospital stay). Assuming α = 0.05 and two‐sided testing, statistical power was approximately 0.51 for hospital stay, whereas mobilization time and analgesia requirement achieved power ≥ 0.99. (see Data S1) To adjust for potential confounders, multiple linear regression models were performed with length of hospitalization, time to mobilization, and analgesic requirement as dependent variables. Independent variables included surgical approach (NOTES vs. laparoscopy), age, parity, body mass index, and history of previous abdominal surgery. Heteroskedasticity‐robust standard errors (HC3) were used. Multicollinearity was assessed using variance inflation factors (all < 2). 3. Results Demographic characteristics of the patients are presented in Table 1. There were no statistically significant differences between the two groups in terms of age, BMI, parity, or the number of previous cesarean deliveries. TABLE 1. | Variable | Group 1 (n = 27) | Group 2 (n = 20) | p‐value | |---|---|---|---| | LS | vNOTES | || | Age (mean, SD) | 35.93 ± 3.71 | 38.55 ± 4.87 | 0.101 | | BMI (mean, SD) | 26.93 ± 5.14 | 26.37 ± 5.04 | 0.116 | | Parity (median, min‐max) | 2 (1–7) | 2 (1–4) | 0.972 | | Previous cesarean (median, min‐max) | 1 (0–3) | 1 (0–3) | 0.890 | Note: p‐value: Indicates statistical significance, with values < 0.05 considered significant. Abbreviations: BMI, body mass index (kg/m2); LS, laparoscopic; vNOTES, vaginal natural orifice transluminal endoscopic surgery. Operative times were comparable between the laparoscopic and vNOTES groups (36.48 ± 10.99 vs. 40.25 ± 12.62 min; mean difference −3.77 min [LS − vNOTES], 95% CI −9.70 to 2.15; p = 0.199; Cohen's d = −0.32; Table 2). Postoperative analgesia was administered upon patient request. Early ambulation was recommended at the 4th postoperative hour for all patients; if not tolerated, mobilization was reattempted at the 6th hour. When comparing hospital stay duration, time to mobilization, and analgesia requirement, all three parameters were significantly lower in the vNOTES group: hospital stay 18.60 ± 4.73 versus 22.0 ± 8.41 h (mean difference 3.40 h, 95% CI 0.29–6.51; p = 0.033; d = 0.47), time to mobilization 4.9 ± 1.02 versus 5.7 ± 0.72 h (mean difference 0.80 h, 95% CI 0.33–1.27; p < 0.001; d = 0.94), and analgesia requirement 0.95 ± 0.69 versus 2.0 ± 0.78 doses (mean difference 1.05 doses, 95% CI 0.63–1.48; p < 0.001; d = 1.55) (Table 2). Multivariate linear regression analysis was performed to evaluate independent predictors of postoperative outcomes. Compared with laparoscopic sterilization, the vNOTES approach was associated with a significantly shorter time to ambulation (β = −0.7 h, p = 0.02) and a markedly lower need for analgesics within the first 24 h (β = −1.0, p < 0.001). Although the length of hospitalization tended to be shorter in the vNOTES group (β = −5.0 h), this difference did not reach statistical significance (p = 0.10). Patient age, parity, body mass index, and history of previous abdominal surgery were not significantly associated with any of the postoperative outcomes (p > 0.05). Model explanatory power was moderate for time to ambulation (R2 = 0.14) and highest for analgesic requirement (R2 = 0.32). No collinearity was detected among variables (all VIF < 1.2).(see Data S1). TABLE 2. | Variable | Group 1 (n = 27) | Group 2 (n = 20) | p‐value | Mean diff (LS—vNOTES) | 95% CI | Cohen's d | |---|---|---|---|---|---|---| | LS | vNOTES | ||||| | Operative time (min) | 36.48 ± 10.99 | 40.25 ± 12.62 | 0.199 | −3.77 | [−9.70, 2.15] | −0.32 | | Hospital stay (h) | 22.0 ± 8.41 | 18.60 ± 4.73 | 0.033* | 3.40 | [0.29, 6.51] | 0.47 | | Time to mobilization (h) | 5.7 ± 0.72 | 4.9 ± 1.02 | < 0.001* | 0.80 | [0.33, 1.27] | 0.94* | | Analgesia requirement (dose) | 2.0 ± 0.78 | 0.95 ± 0.69 | < 0.001* | 1.05 | [0.63, 1.48] | 1.55* | | ΔHemoglobin (g/dL) | 1.75 ± 1.42 | 2.09 ± 1.56 | 0.444 | −0.34 | [−1.14, 0.46] | −0.22 | | ΔHematocrit (%) | 5.24 ± 4.03 | 5.37 ± 4.19 | 0.919 | −0.13 | [−2.17, 1.90] | −0.03 | Note: p‐value: Indicates statistical significance, with values < 0.05 considered significant. Bold value indicates Cohen’s d value greater than 0.5 indicates a moderate to large effect size, suggesting a practically meaningful difference between groups. Abbreviations: LS, laparoscopic; vNOTES, vaginal natural orifice transluminal endoscopic surgery. *Means significance. Evaluation of preoperative and postoperative hemoglobin and hematocrit levels revealed no statistically significant differences between the two groups (ΔHb: −0.34 g/dL, 95% CI −1.14 to 0.46; p = 0.444; d = −0.22; ΔHct: −0.13%, 95% CI −2.17 to 1.90; p = 0.919; d = −0.03; Table 2). Post hoc power analysis indicated that the sample size provided sufficient power for mobilization time and analgesia requirement (power ≥ 0.99), while the power for detecting differences in operative time and perioperative hemoglobin/hematocrit changes was limited. There was no need for conversion to laparotomy in any patient in the laparoscopic group. In the vNOTES group, one case required conversion to laparoscopy. Although right tubal ligation was completed, dense adhesions prevented access to the left tube, necessitating conversion. Upon laparoscopic entry, the left tube was found adherent between the anterior uterine wall and the bladder. After left tubal ligation was completed, the procedure was concluded. No intraoperative complications occurred; however, this patient developed a postoperative trocar‐site infection. No intraoperative complications were observed in either group. When late complications were evaluated, no major complications such as postoperative vaginal bleeding, pelvic infection, or dyspareunia were observed. However, one patient in each group developed a urinary tract infection. 4. Discussion Over the past decade, vNOTES has emerged as an increasingly preferred technique in minimally invasive gynecologic surgery. Originally evolved from vaginal hysterectomy, vNOTES has expanded rapidly from hysterectomy in non‐prolapsed uteri to more complex procedures including adnexal surgery, oncologic staging, pelvic organ prolapse repair, and even chromopertubation for tubal assessment [8, 9, 10, 11]. Compared to conventional laparoscopy, vNOTES offers significant advantages such as absence of abdominal incisions, which translates into superior cosmetic outcomes and lower postoperative pain scores, making it a more patient‐centered approach [12]. Although the technique was initially adopted by surgeons experienced in vaginal procedures, there is now growing evidence that vNOTES can be safely and effectively applied in a wide range of pelvic and even retroperitoneal surgeries. In studies evaluating vNOTES in adnexal pathologies, operative time was often reported to be significantly shorter than with laparoscopy, contrary to the findings of our study. Nevertheless, consistent with prior literature, vNOTES has been associated with favorable postoperative recovery parameters. Similarly, no significant differences in perioperative hemoglobin and hematocrit levels were observed between the two approaches [4]. Although vNOTES was associated with a statistically significant reduction of approximately 3–4 h in hospital stay, the clinical interpretation of this difference must consider institutional practice patterns; indeed, while unadjusted analyses demonstrated a shorter hospital stay in the vNOTES group, this association did not remain statistically significant after adjustment for potential confounders, suggesting that institutional discharge protocols and temporal factors may have influenced this outcome. At present, neither vNOTES nor laparoscopic tubal ligation is routinely performed as a true day‐surgery procedure in our center. Nevertheless, as surgeon experience and procedural volume continue to increase, it is highly plausible that vNOTES sterilization could evolve into a feasible outpatient procedure in the near future. The current findings may thus represent early indicators of this potential shift toward shorter, ambulatory‐care pathways. Given that tubal ligation is typically performed in women of reproductive age, concerns about the impact of transvaginal access and colpotomy on sexual function are legitimate. However, current literature suggests that total FSFI scores do not differ significantly between vNOTES and laparoscopy, and in some cases, higher scores have even been observed in the vNOTES group [13, 14]. The isolated finding of reduced lubrication scores in vNOTES patients has been hypothesized to result from transient local irritation, altered vascular dynamics, or temporary changes in vaginal sensitivity following colpotomy. Importantly, these effects appear to be self‐limiting and do not compromise overall sexual well‐being. Given that tubal ligation is a relatively short and straightforward procedure, selecting vNOTES over laparoscopy requires clear rationale. Patients who place high value on cosmetic outcomes, or prefer to avoid abdominal incisions, may particularly benefit from a transvaginal approach. Conversely, individuals with suspected endometriosis, prior pelvic inflammatory disease, or deep cul‐de‐sac pathology may not be ideal candidates due to the risk of difficult access or distorted anatomy. Establishing such a selection framework may help guide clinicians in determining which patients are most likely to benefit from vNOTES sterilization. Conversion rates in gynecologic vNOTES procedures vary by indication and complexity. While no conversions were reported in pelvic organ prolapse surgeries using vNOTES, conversion to laparoscopy or laparotomy was necessary in 1.47% of myomectomies and as high as 6.8% in adnexal surgeries, reflecting the procedural challenges associated with dense adhesions or distorted anatomy in such cases [15]. In our series, only one patient in the vNOTES group required conversion to laparoscopy due to extensive adhesions, reinforcing the importance of case selection and surgeon experience in optimizing outcomes. The current vNOTES literature predominantly focuses on hysterectomy and adnexal surgery, while evidence specifically addressing its use for interval sterilization remains scarce. Therefore, caution is warranted when extrapolating outcomes from more complex procedures to a simple tubal ligation, as the technical requirements and anatomical challenges may differ considerably. Our study contributes to this limited body of evidence by providing direct comparative data on vNOTES sterilization and demonstrating that advantages observed in more extensive procedures—such as reduced pain and faster recovery—may likewise apply to less complex interventions. This study has several limitations. First, its retrospective, single‐center design and nonrandom allocation introduce risks of selection bias and unmeasured confounding; comparison with historical laparoscopic controls may also entail time‐period effects, despite the same three surgeons operating in both periods. Second, the sample size was modest; although post hoc power was adequate for mobilization time and analgesic use, it was limited for operative time and perioperative hemoglobin/hematocrit changes, so these estimates should be interpreted cautiously. Analgesic consumption was used as a surrogate for postoperative pain, which may be influenced by individual pain perception and prescribing practices. In addition, the introduction of vNOTES during a later time period raises the possibility of time‐related changes in perioperative protocols or discharge criteria, which may have influenced some outcomes. However, the adoption of vNOTES during a later period likely introduced a learning‐curve effect, which may have influenced operative performance metrics. While it is plausible that outcomes could further favor vNOTES once the technique is fully mastered, this hypothesis remains speculative and requires confirmation in prospective studies or larger‐volume series to avoid overinterpretation. Moreover, given the highly selected patient population and the procedures being performed by experienced surgeons at a single center, the generalizability of these findings to lower‐volume centers or less‐selected patient populations may be limited. Finally, residual confounders—such as variations in pain threshold, mobilization motivation, or unrecorded clinical characteristics—could not be fully accounted for in the regression models. These factors should be considered when interpreting the findings. The learning curve for vNOTES in adnexal surgery has been reported to require approximately 36 cases before operative performance stabilizes [16]. Therefore, it should be acknowledged that the present outcomes were obtained while our team was still within the early learning phase of vNOTES sterilization. Nevertheless, our surgical team has extensive experience in laparoscopy and was simultaneously performing other vNOTES procedures during the study period, which likely reduced the practical impact of this learning threshold. From a cost perspective, most instruments used in vNOTES are reusable and shared with laparoscopy; the additional expense is primarily determined by the wound retractor and GelPoint platform. However, low‐cost alternatives such as the ‘glove technique’ have been described, potentially minimizing the incremental cost associated with the transvaginal access system [2, 17]. Entry into the pelvic cavity may be challenging in cases with posterior cul‐de‐sac obliteration or dense rectouterine adhesions, potentially prolonging the procedure or necessitating conversion. The risk of rectal or vaginal wall injury during colpotomy, albeit low, has been described in the literature and must be considered even in low‐complexity procedures such as tubal ligation [18, 19]. Moreover, postoperative cuff cellulitis or vaginal infection represents another potential complication requiring attention. Visualization may also be limited in obese or nulliparous patients due to restricted working space and suboptimal exposure. These factors emphasize the importance of proper case selection and highlight that vNOTES should not be considered universally applicable to all sterilization candidates. 5. Conclusion Our findings demonstrate that both vNOTES and laparoscopic approaches are safe and effective for tubal ligation procedures. While operative time was comparable between the two techniques, vNOTES was associated with significantly earlier mobilization and reduced need for postoperative analgesia. The observed reduction in hospital stay should be interpreted cautiously, as this difference was not confirmed as an independent predictor in adjusted analyses. Importantly, there were no significant differences in perioperative blood loss or complication rates. Given its minimally invasive nature, absence of abdominal scars, and overall favorable recovery profile, vNOTES appears to be a promising alternative to conventional laparoscopy, especially in patients prioritizing rapid return to daily life and improved cosmetic outcomes. Author Contributions Ayşe Betül Albayrak Denizli: conceptualization, methodology, supervision, writing – review and editing. Eralp Bulutlar: data curation, formal analysis, visualization, writing – original draft. Gizem Boz İzceyhan: investigation, resources, project administration. Narin Ece Rol: methodology, statistical analysis, validation. Sadık Şahin: methodology, supervision. All authors read and approved the final version of the manuscript. Funding The authors have nothing to report. Disclosure Approval of the research protocol: Zeynep Kamil Ethics Comitee—25.06.2025, Number: 72. Conflicts of Interest The authors declare no conflicts of interest. Supporting information Data Availability Statement The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Supplementary Materials Data Availability Statement The data that support the findings of this study are available from the corresponding author upon reasonable request.