Successful Vaginal Natural Orifice Transluminal Endoscopic Surgery (V-NOTES) Hysterectomy Under Spinal Anesthesia for an Obese Patient.

Vaginal natural orifice transluminal endoscopic surgery (V-NOTES) hysterectomy combines the scarless vaginal hystrectomy approach with the precision of laparoscopy, offering less postoperative pain, quicker recovery, and fewer complications compared to abdominal or conventional laparoscopic hysterectomy. While general anesthesia is commonly used for laparoscopic procedures, spinal anesthesia offers benefits that are especially valuable in obese patients. We report the case of a 46-year-old woman (body mass index: 30 kg/m²) with stage 2 utero-vaginal prolapse and rectocele who underwent V-NOTES hysterectomy with anterior-posterior vaginal repair and high intraperitoneal colpopexy under spinal anesthesia. The patient received intrathecal bupivacaine with morphine, followed by sedation with midazolam. The procedure lasted for three hours with low CO₂ insufflation pressure (8-12 mmHg) and minimal Trendelenburg positioning <10 degrees. She remained stable intraoperatively, with an estimated blood loss of 400 cc. Postoperatively, she experienced minimal pain controlled with oral analgesics, no nausea or vomiting, and was ambulatory within hours. To our knowledge, this is the first reported case of V-NOTES hysterectomy done under spinal anesthesia in an obese patient, highlighting its feasibility, safety, and potential for broader clinical use.