Hysterectomy via transluminal endoscopic surgery from vaginal natural orifices under regional anesthesia

Objective Transvaginal natural orifice transluminal endoscopic surgery (v-NOTES) combines the advantages of vaginal and laparoscopic approaches. While laparoscopic pelvic procedures typically require general anesthesia, performing v-NOTES under regional anesthesia may facilitate early recovery. This study evaluated the feasibility, safety, and early postoperative outcomes of v-NOTES hysterectomy under spinal anesthesia. Materials and Methods In this prospective cohort study (IDEAL Stage 1–2a) conducted between July and October 2024, 17 patients with benign gynecological indications (ASA physical status I–II) underwent v-NOTES hysterectomy under spinal anesthesia with low-pressure pneumoperitoneum (8–12 mmHg) and mild Trendelenburg positioning (10–20°). The primary feasibility endpoint was the rate of successful procedure completion under spinal anesthesia without conversion to general anesthesia, reported with a 95% confidence interval (CI). Secondary outcomes included operative time, Visual Analog Scale (VAS) pain scores at 6 and 12 hours, intraoperative hemodynamic trends, and 30-day post-discharge outcomes. Results Sixteen of 17 patients successfully completed v-NOTES hysterectomy under spinal anesthesia, yielding a primary feasibility success rate of 94.1% (95% CI: 71.3% to 99.9%). One patient (5.9%) was converted to general anesthesia electively due to an anticipated prolonged operative duration (>150 minutes) rather than an acute intraoperative complication or regional anesthesia failure. The overall mean operative time was 96.2 ± 27.6 minutes. Postoperative Visual Analog Scale (VAS) pain scores decreased significantly from 4.5 ± 0.7 at 6 hours to 1.7 ± 0.7 at 12 hours (p < 0.001, Wilcoxon signed-rank test). All patients met standardized hospital discharge criteria within 12 hours (0.5 days). At 30-day follow-up, no major complications or hospital readmissions occurred. Conclusions v-NOTES hysterectomy under spinal anesthesia is feasible and well-tolerated in carefully selected patients. Larger comparative studies are required to establish its comparative safety, recovery profile, and cost-effectiveness relative to general anesthesia.