Ruptured Tubal Ectopic Pregnancy Managed by Salpingectomy: vNOTES versus Conventional Laparoscopy.

Background: Ruptured tubal ectopic pregnancy continues to pose a critical challenge in gynecologic emergencies. While conventional laparoscopy (CL) has long been the preferred operative method, transvaginal natural orifice transluminal endoscopic surgery (vNOTES) is increasingly recognized for its minimally invasive characteristics. However, comparative data between these techniques in acute cases remain scarce.

The present retrospective analysis reviewed women treated with salpingectomy for ruptured tubal ectopic pregnancy between Sep 2023 and Jan 2025. Twenty-four patients were evaluated, of whom 12 underwent vNOTES and 12 underwent CL. Baseline clinical and demographic features were similar across both groups. Perioperative and short-term postoperative outcomes were systematically analyzed.

The vNOTES technique demonstrated a significantly reduced operative time (30 ± 10 minutes) compared to CL (41 ± 14 minutes, p < 0.05). Insufflation pressure averaged lower in the vNOTES group (8 mmHg) than in the CL group (13 mmHg), with a statistically significant difference (p < 0.05), whereas hematocrit variations and postoperative opioid requirements remained comparable between the two methods. Pain evaluations at 1, 6, and 24 hours postsurgery indicated lower pain levels in the vNOTES cohort versus the CL cohort (p < 0.05). Shoulder tip discomfort was reported by 17% of vNOTES patients, in contrast to 83% of CL patients (p < 0.05). Hospital stay duration was markedly shorter for vNOTES recipients (36 ± 13 hours) compared to CL patients (55 ± 14 hours, p < 0.01). Pelvic drains were needed in 8 out of 12 CL cases, but none were required in the vNOTES group (p < 0.01). Neither group experienced intraoperative complications or required conversion to laparotomy. This single-center, retrospective study has limitations due to its small sample size (n = 24), limited generalizability, and reduced statistical power to detect rare complications.

In this cohort, vNOTES demonstrated shorter operative times, reduced insufflation pressures, and enhanced postoperative recovery compared with conventional laparoscopy. The results indicate that vNOTES could serve as a promising surgical alternative for selected patients presenting with ruptured ectopic pregnancy. Future multicenter investigations involving larger populations and extended follow-up periods—including assessments of fertility and quality of life—will be crucial to validate these findings.

vNOTES, Laparoscopy, Ectopic pregnancy, Salpingectomy, Minimally invasive surgery, Postoperative pain, Perioperative outcomes

Ectopic pregnancy, defined as the implantation of a fertilized e.g., outside the uterine cavity, affects roughly 2% of all pregnancies and remains a critical issue in early maternal care.1 Its rising prevalence in developed countries is linked to changing reproductive trends, including increased rates of pelvic inflammatory disease, greater use of assisted reproductive techniques, and older maternal age at conception. Although tubal ectopic pregnancies account for only 0.5–2.3% of total pregnancies, they continue to be a leading cause of maternal death during the first trimester.2–5 Conventional laparoscopy (CL) is the standard method for both diagnosing and treating tubal ectopic pregnancy, providing rapid visualization, minimal invasiveness, quick postoperative recovery, and a low rate of complications. In routine practice, CL generally requires three to four abdominal entry sites for the performance of salpingostomy or salpingectomy.6–8 Nevertheless, trocar access may still result in postoperative pain, visible abdominal scars, and occasionally port-site hernia or adhesions. Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) avoids abdominal trocar placement by creating a posterior colpotomy for pelvic entry. Its feasibility has been documented in several benign gynecological interventions, including adnexal surgery, ovarian cyst removal, myomectomy, and hysterectomy.9–12 Reported benefits include reduced early postoperative pain, hidden scars, and good compatibility with Enhanced Recovery After Surgery (ERAS) protocols. Despite these potential advantages, direct comparative data evaluating vNOTES against CL specifically for salpingectomy in tubal ectopic pregnancy are still scarce. Furthermore, adoption of vNOTES is limited by the need for specialized instruments and a structured learning curve, reinforcing the necessity of reliable clinical studies to support surgical decision-making. Accordingly, this analysis, based on data from a single institution, sought to compare vNOTES and conventional laparoscopy in the management of tubal ectopic pregnancy. The assessment emphasized perioperative indicators including surgery duration, intra-abdominal pressure, postoperative discomfort, hospitalization period, and pelvic drainage requirements to appraise both procedural safety and clinical performance.

This retrospective analysis included patients treated between Sep 20, 2023, and Jan 1, 2025. This study was reviewed and approved by the institutional review board. All procedures involving human participants adhered to applicable ethical standards and the principles of the Declaration of Helsinki, as revised. Study Population In this retrospective cohort, we enrolled women aged 18 years or older who required emergency minimally invasive surgery for a ruptured tubal ectopic pregnancy confirmed at operation. Patients considered unsuitable for the vNOTES approach were those with comorbid systemic disease, a history of major pelvic or rectal operations, prior pelvic radiotherapy or brachytherapy, severe pelvic inflammatory disease, suspicion of malignancy, deep infiltrating endometriosis involving the rectovaginal or retrocervical area, or those without sexual activity or with sexual dysfunction.13 Prior to the surgical intervention, all patients were provided with comprehensive details regarding the two available techniques, encompassing potential risks and benefits. They were informed that a switch from vNOTES to conventional laparoscopy, or to open surgery if circumstances demanded, might be necessary during the procedure. The selection of the surgical method was based on each patient’s informed choice following thorough discussion. When patients opted for vNOTES, the procedure was performed only in the presence of an experienced vNOTES surgical team and with the necessary equipment immediately available; otherwise, conventional laparoscopy was undertaken. Initial demographic and clinical profiles, including age, body mass index, parity, and records of prior abdominal or pelvic surgeries, were carefully documented in advance for both groups.14 The sample size was precalculated using G*Power software (version 3.1.9.7, University of Düsseldorf, Germany). Assuming a medium effect size (d = 0.5), a significance threshold (α) of 0.05, and 80% statistical power, the minimum participant count was set at 20. In total, 24 women met the eligibility criteria, with 12 assigned to the vNOTES group and 12 to the conventional laparoscopy group. Surgical Procedure All operations were performed by gynecologic surgeons well-versed in both conventional laparoscopy and vNOTES methods. Preoperatively, a 2 g intravenous dose of cefazolin was administered as per hospital protocols to prevent infection. Surgeries were conducted under general anesthesia, with patients positioned in the lithotomy posture and a gentle Trendelenburg incline. Following the procedure, patients were counseled to abstain from sexual activity for roughly two weeks to aid vaginal recovery and lower infection risk.14 vNOTES Group A 2.5 cm incision was made in the posterior vaginal wall to access the pouch of Douglas, employing a technique previously detailed.14 The GelPOINT V-Path access platform (Applied Medical, Rancho Santa Margarita, CA, USA) was then placed to accommodate surgical instruments. The salpingectomy was completed using a 30° 10-mm laparoscope and reusable tools, such as graspers and a bipolar energy-sealing device (LigaSure™, Medtronic, Minneapolis, MN, USA). Conventional Laparoscopy Group (CL) For the CL group, pneumoperitoneum was initiated through a 10-mm umbilical incision, followed by the insertion of two additional 5-mm trocars under direct observation, as noted earlier.14 The procedure involved a 30° 10-mm laparoscope and standard reusable laparoscopic equipment, including graspers and a bipolar vessel-sealing device (LigaSure™, Medtronic, Minneapolis, MN, USA). Salpingectomy was carried out using established laparoscopic approaches. Statistical Analysis Statistical evaluations were performed using IBM SPSS Statistics software (version 26.0; IBM Corp., Armonk, NY, USA). Continuous variables were presented as mean values with standard deviation or as medians accompanied by interquartile ranges, depending on their distribution patterns. Categorical data were reported as frequencies and proportions. Normality of the data was assessed with the Shapiro-Wilk test for samples smaller than 50. Group comparisons were conducted using the independent t test for normally distributed data or the Mann-Whitney U test for non-normal distributions. Relationships among categorical variables were explored using the χ2 test. Statistical significance was set at a P-value less than 0.05 for two-tailed tests.

This study sought to compare the clinical performance and safety profile of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) with conventional laparoscopy (CL) in patients undergoing salpingectomy for ruptured tubal ectopic pregnancy. The evaluation covered preoperative conditions, intraoperative parameters, and the postoperative recovery phase. A total of 24 women who met the eligibility criteria were included, with 12 treated using the vNOTES approach and 12 managed through conventional laparoscopy. The average age of the participants was 34 ± 6 years in the vNOTES cohort and 36 ± 4 years in the CL cohort, without a statistically significant difference (P > 0.05). Similarly, no notable variations were observed between groups regarding body mass index, parity, prior abdominal or pelvic surgeries, preoperative β-hCG levels, or the use of an intrauterine device (all P > 0.05). The similarity in these baseline factors demonstrates the internal validity and balance of the comparative analysis. A detailed summary of demographic and preoperative characteristics is provided in Table 1. Table 1. | Overall (n:24) | CL (n:12) | vNOTES (n:12) | P | | |---|---|---|---|---| | Age | 35 ± 5 | 36 ± 4 | 34 ± 6 | 0,312 | | Height | 159 ± 6 | 158 ± 8 | 160 ± 5 | 0,446 | | Weight | 70 ± 9 | 70 ± 10 | 70 ± 9 | 0,917 | | BMI | 27,7 ± 4,1 | 28 ± 4,9 | 27,3 ± 3,9 | 0,70 | | Prev. surgery | |||| | None | 14 (%58) | 7 (%58) | 7 (%58) | | | Present | 10 (%42) | 5 (%42) | 5 (%42) | | | Parity | 2 ± 1 | 2 ± 1 | 2 ± 1 | 0,680 | | Preoperative B-HCG level | 3.746 ± 1.540 | 3.696 ± 1.603 | 3.796 ± 1.486 | 0,88 | | Intra-uterine device | 13 (54 %) | 7 (58 %) | 6 (50 %) | 0,680 | Continuous data are displayed as mean values accompanied by standard deviations, whereas categorical data are shown as counts and corresponding percentages. No statistically meaningful differences were detected between the groups in baseline demographic or clinical parameters (P > 0.05). The average duration of surgery showed a notable difference between the two approaches, with vNOTES taking 30 ± 10 minutes compared to 41 ± 14 minutes for CL, a difference that reached statistical significance (P < 0.05). Similarly, the mean intra-abdominal pressure was significantly reduced in the vNOTES cohort (8 mmHg) relative to the CL cohort (13 mmHg), with a P-value of less than 0.05. However, variations in perioperative hematocrit levels did not differ significantly between the groups, recording 4.3 ± 2.8 for vNOTES and 4.0 ± 1.6 for CL (P > 0.05). A detailed summary of intraoperative and hemodynamic results is provided in Table 2.14 Table 2. | Overall (n:24) | CL (n:12) | vNOTES (n:12) | P | || |---|---|---|---|---|---| | Duration of surgery | 35 ± 13 | 41 ± 14 | 30 ± 10 | 0,030 | | | Intra-abdominal pressure | 10 ± 2 | 13 ± 1 | 8 ± 0 | p < 0,001 | | | Peri-operative haematocrit change | 4,2 ± 2,3 | 4.0 ± 1.6 | 4.3 ± 2.8 | 0,750 | Continuous data are displayed as mean values accompanied by standard deviations, whereas categorical data are shown as counts and corresponding percentages. No statistically meaningful differences were detected between the groups in baseline demographic or clinical parameters (P > 0.05). In terms of postoperative outcomes, neither group experienced intraoperative or postoperative complications. Pain levels assessed using the Visual Analog Scale (VAS) were consistently lower among patients treated with vNOTES at all measured intervals—1, 6, and 24 hours following surgery—when compared with those who underwent CL (P < 0.05 for each time point). Shoulder tip discomfort, which frequently occurs after laparoscopic procedures, was noted in 17% of the vNOTES group but in 83% of the CL group (P < 0.05). The average hospitalization period was significantly shorter in the vNOTES cohort, with a mean stay of 36 ± 13 hours compared with 55 ± 14 hours in the CL cohort (P < 0.01). None of the patients in the vNOTES group required postoperative pelvic drainage, while this intervention was necessary in eight out of twelve patients (67%) in the CL group (P 0.05). A detailed comparison of postoperative outcomes is displayed in Table 3. Table 3. | Overall (n:24) | CL (n:12) | v-NOTES (n:12) | P | | |---|---|---|---|---| | Postop 1. (VAS) | 7 ± 2 | 8 ± 1 | 5 ± 2 | p < 0,001 | | Postop 6. (VAS) | 6 ± 2 | 7 ± 1 | 4 ± 1 | p < 0,001 | | Postop24. (VAS) | 4 ± 1 | 4 ± 1 | 3 ± 1 | 0,015 | | Postop Shoulder pain | |||| | None | 12 (%50) | 2 (%17) | 10 (%83) | p < 0,001 | | Present | 12 (%50) | 10 (%83) | 2 (%17) | | | Length of hospital stay (hours) | 45,8 ± 16,7 | 55,3 ± 13,6 | 36,2 ± 13,4 | 0,002 | | Postoperative pelvic drain | |||| | None | 16 (%67) | 4 (%33) | 12 (%100) | 0,002 | | Present | 8 (%33) | 8 (%67) | 0 | | | Postoperative opioid requirement | |||| | None | 4 (%17) | 0 | 4 (%33) | 0,100 | | Present | 20 (%83) | 12 (%100) | 8 (%67) | Continuous data are displayed as mean values accompanied by standard deviations, whereas categorical data are shown as counts and corresponding percentages. No statistically meaningful differences were detected between the groups in baseline demographic or clinical parameters (P > 0.05). Postoperative opioid use showed no statistical difference.

This study demonstrates that transvaginal natural orifice transluminal endoscopic surgery (vNOTES) represents a feasible and effective alternative to conventional laparoscopy (CL) for the management of ruptured tubal ectopic pregnancy. Compared with CL, the vNOTES approach resulted in lower postoperative pain intensity, fewer complaints of shoulder tip pain, shorter operative duration, and reduced hospitalization. These perioperative outcomes are consistent with those previously reported in gynecologic surgery, highlighting the potential of vNOTES to offer meaningful clinical advantages. Pain control emerged as one of the most prominent benefits of vNOTES. Patients treated with this technique consistently reported lower visual analog scale (VAS) scores at 1, 6, and 24 hours after surgery. Shoulder tip discomfort—commonly associated with carbon dioxide–induced diaphragmatic irritation—was markedly less frequent among vNOTES patients (17% vs. 83%). This finding is likely attributable to the lower intra-abdominal pressure employed during vNOTES procedures (approximately 8 mmHg), in contrast to the 12–14 mmHg typically applied in CL. Previous investigations have demonstrated that reduced insufflation pressure minimizes postoperative shoulder pain without compromising surgical visualization or operative efficiency.15,16 Comparable outcomes have been observed in prior studies. The NOTABLE randomized controlled trial, for instance, reported that vNOTES was associated with shorter operative times and reduced postoperative pain during benign adnexal surgery compared with laparoscopy.12,14 Similarly, Kaya et al. noted decreased surgical duration, shorter hospital stays, and improved postoperative pain outcomes with vNOTES in adnexal procedures.17 Furthermore, a meta-analysis synthesizing findings from over 20 studies reinforced these advantages, demonstrating lower pain levels, earlier discharge, and fewer complications with vNOTES compared to CL.18 Our findings also indicated that vNOTES significantly shortened operative time. The transvaginal route eliminates the requirement for abdominal trocar placement and reduces the number of abdominal incisions, which simplifies the procedure. This streamlined pathway likely decreases operative complexity and duration. Similar patterns have been observed in prior work on vNOTES hysterectomy and adnexal surgery, where faster operative completion and earlier patient mobilization were also reported.12,18 The difference in hospitalization duration between the two groups carried both clinical and economic significance. Patients who underwent vNOTES were discharged nearly one day earlier than those treated with CL. Earlier discharge not only enhances patient comfort but also decreases hospital expenditures and optimizes bed utilization. In light of the growing focus on Enhanced Recovery After Surgery (ERAS) principles, surgical techniques that facilitate faster recovery such as vNOTES are becoming increasingly important in both routine and emergency gynecologic practice. From a safety perspective, neither intraoperative adverse events nor conversions occurred in either group. This finding supports the feasibility and reassuring safety profile of vNOTES, even in urgent conditions such as ruptured ectopic pregnancy. While CL has traditionally been considered the reference standard for such cases, our data suggest that vNOTES may offer a comparable level of safety together with enhanced patient-centered outcomes. The perioperative advantages observed in our series may partly reflect familiarity with vNOTES. All procedures were performed by surgeons experienced in both approaches; such experience can shorten operative time, optimize instrument handling, and facilitate low-pressure pneumoperitoneum, potentially favoring vNOTES in selected cases. Therefore, reproducibility may be limited in less-experienced settings or early in the learning curve. There are several limitations to this study. First, its single-center, retrospective design with a small sample size (n = 24) restricts external validity and reduces the power to detect rare intraoperative and postoperative adverse events. In addition, in the emergency setting, the surgical approach was determined by informed patient preference, on-call team experience, and real-time equipment availability; therefore, selection bias cannot be ignored. Second, because all procedures were performed by surgeons experienced in both techniques, operative efficiency may have been favored—potentially toward vNOTES—and similar results may not be reproducible early in the learning curve. Finally, our analysis was limited to perioperative endpoints and did not assess long-term outcomes such as fertility, adhesion formation, chronic pelvic pain, and quality of life. These considerations warrant cautious interpretation of the findings and underscore the need for larger, multicenter studies with standardized selection criteria and extended follow-up. In conclusion, our results suggest that vNOTES may evolve into a primary option for carefully selected patients with ruptured tubal ectopic pregnancy. Its advantages—reduced pain, earlier discharge, and quicker recovery—are consistent with contemporary surgical objectives emphasizing patient comfort and efficient resource utilization. The absence of visible abdominal scars and reduced morbidity may further enhance patient acceptance. As surgeon familiarity and proficiency increase, broader application of vNOTES could contribute to redefining standards of care in both elective and emergency gynecologic surgery.

Within the limitations of this single-center analysis, vNOTES was associated with favorable perioperative outcomes compared with conventional laparoscopy for ruptured ectopic pregnancy. These results underscore the importance of evaluating vNOTES beyond elective procedures, as it may represent a valuable option even in emergency settings. Future directions: In addition to larger multicenter studies with broader and more diverse populations, there is a clear need for long-term outcome data—including fertility, adhesion formation, and chronic pelvic pain, as well as patient-reported quality of life—which are particularly relevant in reproductive-age patients. Footnotes Acknowledgments: The authors thank the surgical team and nursing staff of Iğdır Dr. Nevruz Erez State Hospital for their support during the study. We also appreciate the contributions of the ethics committee members for their guidance and approval of the research protocol. Funding sources: none. Conflict of interest: none. Contributor Information Mehmet Genco, Department of Obstetrics and Gynecology, Kayseri City Hospital, Kayseri, Türkiye. (Dr. Meh. Genco) Merve Genco, Department of Obstetrics and Gynecology, Kayseri State Hospital, Kayseri, Türkiye. (Dr. Mer. Genco).

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