Design: Retrospective review.

Setting: Two teaching hospitals, one community hospital

Patients or Participants: Gynecologic procedures performed by three surgeons on women with a body mass index (BMI) > 40 kg/m² from 2017 to 2023. A subset of women with a BMI > 50 kg/m² were also analyzed.

Interventions: vNOTES procedures including hysterectomy, adnexectomy, and lymphadenectomy.

Measurements and Main Results: 103 women with a BMI > 40kg/m² were identified, 19 of whom had a BMI > 50 kg/m². Preoperative characteristics, procedures performed, operative characteristics, conversions to laparoscopy or laparotomy, and postoperative characteristics were reviewed. For the entire population the mean BMI was 45.7 kg/m2 (40-62). 29 women were nulliparous and 23 had at least one prior cesarean delivery. 51 had no prior abdominal surgery. The procedures performed were hysterectomy and removal of adnexae in 77 patients, hysterectomy alone in six, adnexal surgery alone in nine, and hysterectomy with adnexectomy and lymph nodes in five. Three surgeries were converted to laparoscopy and three to laparotomy. Average surgical time was 87 minutes (30-232). Average blood loss was 82 mL (10-400). Mean uterine weight was 206 g (29-2890). 53 procedures were performed as outpatient, 44 had overnight observation, four had a length of stay of two days, one each for four days and five days. The laparoscopies occurred in two patients with an obliterated cul-de-sac and in one patient for lymph node removal. The laparotomies occurred for adnexal adhesions in one, bleeding in one, and cystotomy in one requiring urology consultation. One patient developed a postoperative vaginal cuff hematoma not requiring intervention.

Conclusion: vNOTES gynecologic procedures are feasible in this high-risk population and may result in shorter recovery times and fewer complications than with standard laparoscopy or laparotomy.