Vaginal Natural Orifice Transluminal Endoscopic Surgery Versus Laparoscopic Tubal Ligation for Interval Sterilization: A Retrospective Cohort Study.

Background To compare the transvaginal natural orifice transluminal endoscopic surgery (vNOTES) approach versus conventional laparoscopy in bilateral tubal ligation for interval sterilization regarding perioperative outcomes, postoperative pain, and sexual function.

This retrospective cohort study at a tertiary center included 88 women who underwent elective tubal ligation between February 2024 and October 2025 (vNOTES: n = 39; laparoscopy: n = 49). Women aged 18–45 years seeking permanent contraception with American Society of Anesthesiologists (ASA) physical status classification ≤ 3 were included. Primary outcomes included operative time and estimated blood loss (assessed by hemoglobin/hematocrit changes). Secondary outcomes included length of hospital stay, postoperative pain assessed using a visual analog scale (VAS) at 6 and 24 h postoperatively, total amount of analgesic requirements and sexual function evaluated using the Female Sexual Function Index (FSFI) preoperatively and at 1 and 6 months postoperatively. Statistical analysis used t‐test/Mann–Whitney U test and chi‐square/Fisher's exact test (α = 0.05).

Baseline characteristics were comparable between groups (vNOTES: n = 39; laparoscopy: n = 49). No significant differences were found in hemoglobin changes or operative time. vNOTES demonstrated significantly shorter hospital stay (14.90 ± 7.27 vs. 20.10 ± 3.96 h, p < 0.001), lower postoperative total amount of analgesic requirements (1.72 ± 0.76 vs. 4.88 ± 1.63 doses, p 0.999). FSFI scores showed no significant differences at baseline, 1, or 6 months postoperatively.

vNOTES for tubal ligation offers significant advantages in postoperative pain reduction, decreased analgesic requirements, and shorter hospital stay while maintaining comparable operative times, safety, and sexual function outcomes.

contraception, female sexual function, laparoscopy, tubal ligation, vNOTES 1. Introduction Tubal sterilization represents one of the most widely adopted contraceptive methods globally, involving the intentional occlusion or partial to complete surgical removal of the fallopian tubes [1]. Permanent tubal ligation is a clinically established intervention for individuals seeking definitive, nonreversible contraception. On a global scale, the vast majority of these surgical occlusions are performed in the immediate postpartum phase [2]. Conversely, sterilization procedures that occur independently from the postpartum or postabortal period are categorized as interval procedures [3]. Traditionally, interval sterilization was most commonly performed via laparotomy using tubal occlusion methods including clips, bands, or electrocautery [4]. The paradigm of permanent contraception has shifted significantly over the past decade due to advancements in minimally invasive technology. The current clinical preference has transitioned toward laparoscopy, a modality favored for its ability to minimize surgical morbidity and facilitate a more rapid return to baseline activity for patients [5]. Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) represents a significant advancement in minimally invasive gynecology [6]. This approach facilitates direct pelvic access via a natural orifice, effectively eliminating the morbidity associated with traditional abdominal entry. The clinical utility of vNOTES spans a diverse range of gynecological surgeries. While hysterectomy remains the primary indication for this approach, its application has expanded to include adnexal surgery, urogynecological reconstructions, and fertility‐sparing interventions [7, 8, 9]. Furthermore, its role is increasingly recognized in the management of oncological pathologies and the surgical excision of complex endometriosis [10, 11]. However, despite demonstrating safety and efficacy in other gynecological procedures, the clinical application and adoption of vNOTES in tubal ligation remain limited. This study aims to compare the efficacy, perioperative, and surgical outcomes of vNOTES vs. conventional laparoscopic (CL) tubal ligation for patients who desire interval sterilization to elucidate their relative merits and appraise clinical decision‐making. 2. Material and Methods This retrospective cohort study included patients referred to our institution's family planning outpatient clinic for request of permanent sterilization and underwent tubal ligation procedures between February 2024 and October 2025 at the Department of Gynecology and Obstetrics. Ethical approval was obtained from the institution's Ethics Committee (KAEK/22.10.2025.230), and all stages of the study adhered to the principles of the Declaration of Helsinki. The study cohort included women aged 18–45 years who sought definitive permanent surgical contraception via bilateral tubal ligation, regardless of parity, and had an American Society of Anesthesiologists (ASA) score of ≤ 3. Eligibility required a nonprolapsed uterus and the absence of anatomical or systemic contraindications to either vNOTES or CL surgery. Although the minimum inclusion age was set at 18 years to ensure legal capacity for informed consent, interval sterilization at our institution is predominantly performed in women aged 30 years or older who have completed their desired family size, reflecting local sociodemographic and cultural patterns. All patients, regardless of age, received comprehensive preoperative counseling that included detailed discussion of reversible long‐acting contraceptive alternatives, including combined oral contraceptives and intrauterine devices (IUDs). Written informed consent was obtained from all participants prior to enrollment. Patients with a history of major pelvic surgery (e.g., myomectomy or endometriosis surgery), history of rectal surgery, suspected endometriosis of the rectovaginal septum, pelvic inflammatory disease (PID) (e.g., chlamydia and gonorrhea), tubo‐ovarian abscess or malignancy were excluded. Further exclusion criteria included coagulopathy or systemic disorders rendering the patient unfit for surgery, and psychiatric or cognitive impairments preventing a full understanding of the study requirements. Additionally, individuals who were pregnant, had no prior history of sexual intercourse, or presented with symptomatic uterine descent staged at Grade ≥ 2 according to the Pelvic Organ Prolapse Quantification (POP‐Q) system were ineligible for participation. This exclusion was applied uniformly to both groups to ensure technical standardization: in the vNOTES group, significant apical or posterior vaginal descent may alter posterior colpotomy anatomy and complicate port placement, whereas applying the same criterion to the CL group eliminated anatomical confounders and maintained comparability between the two cohorts. All patients seeking permanent contraception during the study period were managed according to a standardized institutional protocol aligned with the American College of Obstetricians and Gynecologists (ACOG) Committee Opinion No. 774 [12]. During preoperative counseling, every candidate was comprehensively informed about the benefits of opportunistic salpingectomy, which was offered as the primary and preferred method for risk‐reducing permanent sterilization. Despite the recommendation for total salpingectomy to mitigate future ovarian cancer risk, tubal ligation involves bipolar electrocoagulation and transection of a 2‐cm mid‐ampullary segment of the fallopian tube, preserving the tube in situ, whereas bilateral salpingectomy entails complete excision of both fallopian tubes. While salpingectomy is currently preferred due to its additional benefit of reducing the risk of high‐grade serous epithelial ovarian cancer, believed to originate from the fimbriated end of the tube, tubal ligation was performed in this cohort exclusively at the patients' explicit request following comprehensive counseling. 253 of the 345 patients assessed during the study period opted for bilateral salpingectomy and were excluded from this analysis. An additional three patients were excluded due to obliterated pouch of Douglas (n = 2) and suspected pregnancy (n = 1). The remaining patients declined salpingectomy due to personal, cultural, or religious preferences and explicitly requested interval bilateral tubal ligation instead. The final surgical approach, either vNOTES or CL, was determined through a shared decision‐making process that respected patient autonomy while remaining aligned with evidence‐based clinical recommendations. Ultimately, a total of 88 patients were included in the study cohort. The complete patient selection and flow are illustrated in the CONSORT flow diagram (Figure 1). All patients underwent a standardized preoperative assessment, including a detailed review of medical and surgical history, pelvic examination, Pap smear test, routine ultrasonography, complete blood count (CBC), and chest radiography to ensure anesthetic safety. All surgical procedures (CL and vNOTES) were performed by a single, high‐volume gynecologic surgeon (O.K.) to ensure procedural consistency and minimize operator‐related variability. Prior to the commencement of this study, the lead surgeon had completed at least 20 vNOTES tubal ligations and 15 vNOTES salpingectomies to establish technical proficiency. 2.1. Outcome Measures Information bias was mitigated by having two independent investigators (T.A.D. and M.A.) extract clinical and surgical data from institutional electronic medical records using standardized abstraction forms. The primary objective of this study was to compare the surgical efficacy and perioperative safety of vNOTES versus CL tubal ligation. The assessed primary variables encompassed total operative time, estimated blood loss, perioperative complications (both intraoperative and postoperative), and the rate of conversion to alternate surgical modalities. Secondary outcomes focused on postoperative recovery metrics and functional quality of life indicators. The total analgesic requirements and the duration of hospital stay were recorded for all participants to evaluate the efficiency of the recovery period. Analgesic requirement was recorded as the total number of doses administered from the end of surgery until discharge. Postoperative pain intensity was assessed using a Visual Analog Scale (VAS) at 6 and 24 h postprocedure, where 0 represented “no pain” and 10 represented “the worst imaginable pain.” Longitudinal changes in sexual dysfunction were evaluated using the Female Sexual Function Index (FSFI). These assessments were recorded at baseline and at 1‐month and 6‐month follow‐up intervals. All clinical outcomes were monitored and verified by the surgical team and specialized nursing staff. The operative time for vNOTES was measured from the initial cervical incision to the completion of the vaginal cuff closure, whereas for the CL group, it spanned from the primary trocar insertion to the final closure of all port sites. 2.2. Surgical Techniques Regarding preoperative prophylaxis, patients received 2 g of intravenous cefazolin and 1 g of metronidazole exactly 1 h before the intervention. Furthermore, a 3‐days high‐fiber dietary regimen was suggested to optimize bowel preparation and patient comfort. Intraoperative access for all vNOTES procedures was achieved using the GelPoint vPath transvaginal platform (Applied Medical, Rancho Santa Margarita, CA, USA). Following the intervention, postoperative recovery protocols mandated a 2‐week period of pelvic rest, with specific instructions provided to patients regarding abstinence from sexual intercourse during this interval. 2.2.1. Laparoscopic Tubal Ligation Technique Laparoscopic tubal ligation was performed under general anesthesia with the patient in the supine position. Following the creation of a 10 mmHg CO2 (flow rate of 0.5 L/min) pneumoperitoneum via an umbilical Veress needle or after direct trocar entry, a 30° laparoscope (Karl Storz, Tuttlingen, Germany) was inserted from a 10‐mm primary trocar. Two additional 5‐mm ancillary trocars were placed in the bilateral lower quadrants of the inguinal region under direct visualization to facilitate precise instrument manipulation. Following a systematic pelvic inspection, the fallopian tubes were identified and grasped at the mid‐ampullary segment using laparoscopic forceps. Tubal occlusion was executed through bipolar electrocoagulation of a 2‐cm CO2 desufflation, which was confirmed prior to closing the fascial and skin incisions at the trocar sites with 1‐0 Vicryl (Polyglactin 910, Ethicon Endosurgery) absorbable sutures. 2.2.2. vNOTES Tubal Ligation Technique All vNOTES procedures were performed under general anesthesia with the patient placed in the dorsal lithotomy position. Access to the pouch of Douglas was achieved via a 2.5‐cm vertical posterior colpotomy, initiated with a scalpel incision approximately 2 cm inferior to the cervix. To stabilize the site for the insertion of the GelPoint vPath transvaginal platform (Applied Medical, Rancho Santa Margarita, CA, USA) and reduce the bleeding, a single 1‐0 Vicryl stay suture was placed through the vaginal mucosa. Following posterior colpotomy, the small sized (7.5 cm) Alexis wound retractor and the GelPoint vPath access platform were positioned to establish and maintain transvaginal access. Visualization was maintained using a standard 30° 10‐mm laparoscope (Karl Storz, Tuttlingen, Germany) alongside conventional reusable laparoscopic instruments. After transvaginal port placement and creation of 10 mmHg CO2 pneumoperitoneum at a flowrate of 0.5 L/min, the patient was placed in a 20° Trendelenburg position. Pelvic organs were inspected carefully for anatomical variation and any adhesions. The mid‐ampullary portion of the fallopian tube was retracted beneath the posterior uterine wall toward the ipsilateral cornua, forming a reversed U‐shaped loop (Figure 2). Simultaneously, the uterus was anteverted to enhance the operative field and protect the bowel. The resulting 2‐cm diameter loop was ligated using LigaSure (Medtronic, Minneapolis, MN, USA), and excised specimens were submitted for histopathological examination (Figure 3). Finally, the colpotomy incision was closed in a continuous fashion using 1‐0 Vicryl (Polyglactin 910, Ethicon Endosurgery) absorbable sutures under direct visualization. 2.3. Statistical Analysis Statistical analyses were performed using IBM SPSS Statistics for Windows, version 25.0 (IBM Corp., Armonk, NY, USA). The Shapiro–Wilk test was employed to assess the normality of continuous variables. For normally distributed data, independent samples Student's t‐test was utilized, while the Mann–Whitney U test was applied for nonnormally distributed variables. Categorical data were analyzed using the Chi‐square test or Fisher's exact test, as appropriate. Statistical significance was defined as a p value < 0.05. The sample size for this study was determined by the total number of eligible patients who underwent interval tubal ligation via vNOTES or CL during the study period. To validate the adequacy of this sample, a post hoc power analysis was performed using G*Power (version 3.1.9.7). For the recovery‐related outcomes, the analysis revealed that with the observed effect sizes (Cohen's d of 1.91 for hospital stay and 1.72 for 6th‐h VAS pain scores), the study achieved a statistical power (1‐beta) of > 0.99 at a significance level of alpha = 0.05. 3. Results A total of 88 patients were included in the analysis: 39 in the vNOTES group and 49 in the CL group. Baseline demographic and obstetric characteristics were comparable between the two groups (Table 1). The mean age was 36.26 ± 3.14 years in the vNOTES group and 36.47 ± 3.93 years in the CL group (p = 0.783). There were no statistically significant differences between the groups in terms of height, weight, gravidity, parity, previous abdominal surgery or previous cesarean section history (all p > 0.05). TABLE 1. | V‐NOTES (n = 39) | L/S (n = 49) | p | || |---|---|---|---|---| | Age | 36.26 ± 3.14 | 36.47 ± 3.93 | 0.783 | t | | Height | 159.49 ± 6.36 | 161.45 ± 7.51 | 0.102 | mwu | | Weight | 65.13 ± 10.48 | 73.10 ± 14.03 | 0.373 | mwu | | Gravida | 2.79 ± 1.30 | 3.29 ± 1.40 | 0.134 | mwu | | Para | 2.64 ± 1.16 | 2.82 ± 0.99 | 0.531 | mwu | | Previous abdominal surgery | 1.05 ± 1.06 | 1.39 ± 1.07 | 0.144 | t | | Previous c‐section | 0.36 ± 0.48 | 0.41 ± 0.5 | 0.619 | mwu | | Pre‐op Hb | 12.01 ± 1.41 | 12.09 ± 1.40 | 0.769 | t | | Post‐op Hb | 10.92 ± 1.43 | 10.89 ± 1.15 | 0.892 | t | | Δhemoglobin | −1.08 ± 0.67 | −1.21 ± 0.88 | 0.462 | t | | Pre‐op Hct | 37.20 ± 4.18 | 36.89 ± 3.75 | 0.717 | t | | Post‐op Hct | 34.90 ± 4.44 | 33.20 ± 2.89 | 0.622 | t | | Δhematocrit | −2.29 ± 1.36 | −2.41 ± 1.52 | 0.714 | t | Note: Values are presented as mean 6 standard deviation or number (percentage). p value: Indicates statistical significance, with values < 0.05 considered significant. Abbreviations: Δ, change from preoperative to postoperative values; Hb, hemoglobin; Hct, hematocrit; mwu, Mann–Whitney U test; t, Student's t‐test. A comparison of intraoperative data and postoperative outcomes between the two groups is presented in Table 2. Preoperative hemoglobin levels were similar between the vNOTES and CL groups (12.01 ± 1.41 vs. 12.09 ± 1.40 g/dL, p = 0.769). Postoperative hemoglobin levels were also comparable (10.92 ± 1.43 vs. 10.89 ± 1.15 g/dL, p = 0.892). The mean hemoglobin decrease did not differ significantly between the groups (−1.08 ± 0.67 vs. −1.21 ± 0.88 g/dL, p = 0.462). Similarly, no significant differences were observed in preoperative or postoperative hematocrit values or in hematocrit change (all p > 0.05). TABLE 2. | vNOTES (n = 39) | CL (n = 49) | p | || |---|---|---|---|---| | Total surgery time (min) | 30.44 ± 7.06 | 34.71 ± 13.57 | 0.194 | mwu | | From Colpotomy entry to complete tubal ligation procedure (min) | 7.84 ± 2.34 | NA | NA | mwu | | Postoperative analgesic requirement | 1.72 ± 0.76 | 4.88 ± 1.63 | < 0.001 | mwu | | VAS score at 6 h | 4.92 ± 1.53 | 7.12 ± 0.95 | < 0.001 | mwu | | VAS score at 24 h | 1.56 ± 0.72 | 2.18 ± 0.83 | < 0.001 | mwu | | Hospital stay (hours) | 14.90 ± 7.27 | 20.10 ± 3.96 | 0.999 | χ 2 | || | No complications | 38%–97.4% | 47%–96% | || | UTI | 1%–2.6% | 1%–2% | || | Surgical site infection | 0%–0.0% | 1%–2% | || | FSFI preoperative | |||| | Desire | 3.46 ± 1.18 | 3.82 ± 1.00 | 0.112 | mwu | | Arousal | 4.17 ± 1.08 | 4.18 ± 0.99 | 0.893 | mwu | | Lubrication | 3.91 ± 1.01 | 4.05 ± 0.90 | 0.330 | mwu | | Orgasm | 3.82 ± 1.07 | 3.99 ± 1.04 | 0.291 | mwu | | Satisfaction | 4.77 ± 1.22 | 4.77 ± 0.96 | 0.635 | mwu | | Pain | 3.88 ± 1.46 | 3.50 ± 1.22 | 0.140 | mwu | | Total | 24.00 ± 3.59 | 24.31 ± 2.83 | 0.785 | mwu | | FSFI postoperative 1st month | |||| | Desire | 3.47 ± 0.98 | 3.60 ± 0.84 | 0.530 | mwu | | Arousal | 4.30 ± 0.93 | 4.30 ± 0.81 | 0.889 | mwu | | Lubrication | 4.01 ± 0.90 | 4.23 ± 0.82 | 0.120 | mwu | | Orgasm | 3.78 ± 0.88 | 3.89 ± 0.87 | 0.445 | mwu | | Satisfaction | 4.53 ± 1.04 | 4.47 ± 0.90 | 0.593 | mwu | | Pain | 4.06 ± 1.13 | 3.96 ± 0.96 | 0.725 | mwu | | Total | 24.13 ± 3.11 | 24.43 ± 2.70 | 0.687 | mwu | | FSFI postoperative 6th month | |||| | Desire | 3.64 ± 1.15 | 3.94 ± 0.98 | 0.176 | mwu | | Arousal | 4.47 ± 0.94 | 4.45 ± 0.80 | 0.926 | mwu | | Lubrication | 4.25 ± 0.91 | 4.30 ± 0.77 | 0.537 | mwu | | Orgasm | 3.94 ± 1.00 | 4.02 ± 1.03 | 0.594 | mwu | | Satisfaction | 4.93 ± 1.05 | 4.85 ± 0.94 | 0.525 | mwu | | Pain | 3.61 ± 1.25 | 3.51 ± 1.06 | 0.781 | mwu | | Total | 24.85 ± 3.75 | 25.09 ± 3.03 | 0.602 | mwu | Note: Values are presented as mean 6 standard deviation or number (percentage). p value: Indicates statistical significance, with values < 0.05 considered significant. Bold values represent the domains are statistically significant p < 0.5. Abbreviations: χ 2, Chi‐square test; CL, conventional laparoscopy; FSFI, female sexual function index; mwu, Mann–Whitney U test; VAS, visual analog scale; vNOTES, vaginal natural orifice transluminal endoscopic surgery. The mean total operative time was 30.44 ± 7.06 min in the vNOTES group and 34.71 ± 13.57 min in the CL group, with no statistically significant difference (p = 0.194). In the vNOTES group, the mean time from colpotomy entry to completion of the tubal ligation procedure was 7.84 ± 2.33 min. The mean length of hospital stay was significantly shorter in the vNOTES group compared with the CL group (14.90 ± 7.27 vs. 20.10 ± 3.96 h, p < 0.001). Postoperative total amount of analgesic requirement was significantly lower in the vNOTES group compared with the CL group (1.72 ± 0.76 vs. 4.88 ± 1.63 doses, p < 0.001). Postoperative pain scores, assessed using the VAS, were also significantly lower in the vNOTES group at both the 6th postoperative hour (4.92 ± 1.53 vs. 7.12 ± 0.95, p < 0.001) and the 24th postoperative hour (1.56 ± 0.72 vs. 2.18 ± 0.83, p 0.999). In both vNOTES and CL groups, one patient (2.6%) developed urinary tract infection, while only one patient (2%) in the CL group had surgical site infection postoperatively. The majority of patients in both groups had no postoperative complications. Preoperative FSFI domain scores and total scores were comparable between the groups, with no statistically significant differences across all domains (all p > 0.05). At the first postoperative month, FSFI domain and total scores remained similar between the groups (total score: 24.13 vs. 24.43, p = 0.687). Likewise, at the sixth postoperative month, no significant differences were found in any FSFI domain or total score (total score: 24.85 vs. 25.09, p = 0.602). 4. Discussion In this study, the safety and feasibility of the vNOTES approach in patients seeking permanent contraception and undergoing interval tubal ligation were demonstrated. Patients who underwent the vNOTES procedure reported significantly lower postoperative pain, shorter hospital stays, and reduced postoperative total amount of analgesic requirements compared with those who underwent the CL procedure. Historically, vaginal tubal sterilization was a mainstay of permanent contraception; however, its clinical utility has been eclipsed by laparoscopic techniques over the last decade. This transition was primarily necessitated by the technical constraints of the vaginal route, specifically the restricted visualization of the pelvic cavity and the ergonomic difficulty of accessing adnexal structures in patients without preexisting uterine descensus [13]. The emergence of vNOTES addresses these limitations by integrating endoscopic precision with a natural orifice approach, effectively reconciling the benefits of both traditional vaginal and laparoscopic methodologies [14, 15]. Recent clinical evidence supports that vNOTES can offer distinct clinical benefits over traditional laparoscopy for adnexal and other gynecologic procedures, including in obese patients [16, 17]. The favorable profile of vNOTES—encompassing superior cosmetic outcomes, enhanced patient satisfaction, expedited postoperative recovery, and reduced postoperative pain—positions this technique as a considerable and significant advancement in the surgical armamentarium for interval tubal ligation in candidates seeking definitive sterilization. A primary concern addressed in current literature is whether the vNOTES approach impacts long‐term sexual activity and quality of life in women of reproductive age. Cumulative evidence drawn from published studies suggests that sexual activity is not adversely affected following vNOTES procedures due to transvaginal access and colpotomy [18, 19]. This finding applies to both elective and emergent settings, encompassing vNOTES hysterectomy and adnexal surgeries performed across a broad spectrum of clinical indications. Corroborating these observations, the existing literature further substantiates that sexual functioning remains uncompromised in the context of vNOTES‐assisted tubal ligation and opportunistic salpingectomy, reinforcing the broader evidence base supporting the sexual safety profile of this surgical approach [20, 21]. In this study, FSFI total scores were comparable between the vNOTES and CL groups at baseline, 1 month (24.13 vs. 24.43, p = 0.687), and 6 months postoperatively (24.85 vs. 25.09, p = 0.602), indicating that neither approach adversely affected sexual function throughout the follow‐up period. The preservation of sexual function across the entire follow‐up period among patients in the vNOTES group carries notable clinical significance, particularly considering that the transvaginal route necessarily involves creation of a posterior colpotomy. The fact that this preservation persisted through the six‐month postoperative assessment provides further supporting evidence for the procedural safety of the vNOTES approach within this patient population. Consistent with the literature, no intraoperative conversions were recorded in either group, reflecting the technical feasibility and procedural safety of both approaches [20, 21, 22]. The zero conversion rate observed in the vNOTES group is particularly noteworthy, as transvaginal access via posterior colpotomy allows direct entry into the pouch of Douglas, providing an ergonomic and unobstructed view of the pelvis without the need for abdominal trocar placement. Importantly, a history of previous cesarean section—which was prevalent in a considerable proportion of the study cohort—did not adversely affect surgical feasibility or increase intraoperative difficulty in the vNOTES group. This finding is clinically significant, as prior cesarean delivery is frequently cited as a relative concern for minimally invasive pelvic procedures due to the risk of anterior adhesions. The posterior colpotomy access inherent to vNOTES effectively circumvents anterior abdominal wall changes associated with prior uterine surgery. Moreover, the use of a 30‐degree laparoscopic optic enables direct visualization of pelvic anatomy and facilitates access to the fallopian tubes through the posterior colpotomy opening. Collectively, these factors suggest that a history of cesarean section should not be considered a contraindication to vNOTES tubal ligation in appropriately selected patients. Another concern in the literature is the triangulation of instruments during vNOTES surgery, due to the limited movement area in the pelvis caudally. Under the influence of gravity, the uterus and fallopian tubes naturally tend to rest on the sigmoid colon and bowel. Combined with the challenges of instrument triangulation and the restricted operative space, adnexal surgeries become particularly demanding. In an expert consensus published in 2021, performing vNOTES hysterectomy prior to adnexal surgery was initially recommended to address these limitations [23]. Drawing on our substantial experience with vNOTES cases, we identified a simple maneuver to overcome these challenges and eliminate the aforementioned negative circumstances: an atraumatic grasper is used to grasp the ampullary segment of the fallopian tube and apply countertraction, pulling the tube beneath the ipsilateral cornua of the uterus. This effectively displaces the adnexa away from the bowel, creating a safer operative field and significantly improving the available space for ligation. Furthermore, this maneuver compensates for the time lost during vNOTES port setup, bringing the overall operative time to an acceptable level that is comparable to CL tubal ligation. Several studies comparing vNOTES and conventional laparoscopy in women seeking permanent sterilization reported no significant difference in hospital stay between the two approaches, a finding that may be attributed to differences in institutional discharge protocols and temporal factors across study settings [20, 21, 22]. Conversely, our findings demonstrated that the vNOTES group has a significantly shorter mean hospital stay compared with the CL group (14.90 ± 7.27 vs. 20.10 ± 3.96 h, p < 0.001). Consistent with our institutional ambulatory protocol, discharge eligibility was assessed from the 6th postoperative hour based on clinical readiness; the longer mean stay in the CL group reflects later attainment of discharge criteria rather than a planned overnight admission. The relatively higher standard deviation in hospital stay for the vNOTES group (14.90 ± 7.27 h) compared to the CL group (20.10 ± 3.96 h) reflects greater inter‐individual variability in achieving discharge readiness. Some vNOTES patients met discharge criteria considerably earlier, approaching the 6th postoperative hour, while others required a longer observation period due to individual variation in analgesic response or recovery trajectory. This variability, rather than reflecting a clinical concern, underscores the favorable recovery profile of the vNOTES technique, which allows a proportion of patients to be discharged substantially earlier than the group mean. Several factors may account for the shorter hospital stay observed in the vNOTES group. The absence of abdominal incisions may contribute to reduced postoperative pain and analgesic usage, as the posterior vaginal fornix is predominantly innervated by visceral afferent fibers, which transmit diffuse and poorly localized pain sensations. In contrast, abdominal trocar sites involve the parietal peritoneum, fascia, and skin, all of which are richly supplied by somatic nociceptive fibers that produce sharper, well‐localized pain [24, 25]. In our cohort, postoperative pain scores and analgesic consumption until discharge were significantly lower in the vNOTES group (p < 0.001), supporting this hypothesis. Collectively, these factors likely facilitate earlier mobilization and faster achievement of discharge criteria, reinforcing the enhanced recovery profile associated with the vNOTES approach. 4.1. Study Limitations This study has several limitations that should be acknowledged. First, its retrospective design limits the ability to establish causal relationships between the surgical approach and outcomes. Second, the relatively small sample size may have reduced the statistical power to detect differences in less frequent outcomes, particularly complications and long‐term functional results. Third, the study was conducted at a single tertiary center, and all procedures were performed by a single high‐volume surgeon. Although this approach minimized operator‐related variability, it may limit the generalizability of the findings to other institutions or surgeons with different levels of experience. In addition, the nonrandomized, patient‐preference‐based allocation of surgical approach represents a potential source of selection bias. To mitigate this, baseline demographic and clinical characteristics were systematically compared between groups and found to be statistically comparable. Furthermore, vaginal wall adequacy was assessed during preoperative evaluation for all vNOTES candidates; patients deemed unsuitable for transvaginal access were counseled toward conventional laparoscopy. While these measures reduce but cannot eliminate selection bias, a randomized controlled trial would be required to definitively establish equivalence between the two approaches. The follow‐up period for sexual function outcomes was limited to 6 months, and longer‐term data are required to better assess sustained functional and quality‐of‐life effects. Finally, ambulation and time to first flatus could not be assessed, as these parameters were not routinely recorded as part of the standard hospital protocol. Despite these limitations, the study has several strengths. Sexual function was assessed using a validated instrument with defined subdomains, allowing a structured evaluation of postoperative outcomes. Moreover, the analysis focused on a well‐defined cohort of patients undergoing interval tubal ligation, and the findings contribute to the limited literature directly comparing vNOTES and CL in this specific clinical context. The vNOTES approach demonstrated a statistically significant reduction in postoperative pain intensity, analgesic requirements, and hospitalization duration relative to CL for interval bilateral tubal ligation, while yielding equivalent perioperative outcomes, complication profiles, and sexual function indices. Due to its minimally invasive, scarless approach and favorable recovery profile, vNOTES may represent the preferred surgical modality for interval tubal ligation in patients seeking permanent sterilization. Author Contributions Merve Akpınar: formal analysis, writing – review and editing, data curation, methodology, software, visualization. Gizem Nur Koyan Karadeniz: conceptualization, investigation, funding acquisition, writing – original draft, visualization, methodology, writing – review and editing, supervision, validation, formal analysis, data curation. Yunus Katırcı: conceptualization, investigation, writing – original draft, methodology, supervision, project administration. Turan Arda Demirag: software, writing – review and editing, formal analysis, project administration, data curation, supervision. Emre Kar: software, writing – review and editing, visualization, formal analysis, project administration, data curation, supervision, resources, methodology, validation. Ozan Karadeniz: conceptualization, investigation, funding acquisition, writing – original draft, methodology, validation, visualization, writing – review and editing, project administration, formal analysis, software, data curation, supervision, resources. Funding The authors have nothing to report. Disclosure The authors have nothing to report. Ethics Statement This study was approved by the Ethics Committee of Health Sciences University Basaksehir Cam and Sakura City Hospital (KAEK/22.10.2025.230), and all stages of the study adhered to the principles of the Declaration of Helsinki. Consent Informed consent was received from all participants. Conflicts of Interest The authors declare no conflicts of interest. Data Availability Statement The dataset analyzed in this study contains detailed patient‐level clinical and surgical records collected under approval from the Ethics Committee of Health Sciences University Başakşehir Çam and Sakura City Hospital (KAEK/22.10.2025.230). Patient consent obtained at enrollment covered use of these data for the purposes of this research and its publication in aggregate/de‐identified form, but did not extend to public deposition of the underlying patient‐level dataset, in accordance with Turkish Personal Data Protection Law No. 6698 (KVKK) and institutional confidentiality policies governing hospital records. Because the dataset includes variables that, in combination, could risk re‐identification of patients within this relatively small cohort, unrestricted public sharing was not authorized by the Ethics Committee. De‐identified data may be made available to qualified researchers for the purpose of replicating the findings reported here, subject to a formal data‐sharing request to the corresponding author and approval from the Ethics Committee of Health Sciences University Başakşehir Çam and Sakura City Hospital, in line with institutional data governance requirements.

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Patient consent obtained at enrollment covered use of these data for the purposes of this research and its publication in aggregate/de‐identified form, but did not extend to public deposition of the underlying patient‐level dataset, in accordance with Turkish Personal Data Protection Law No. 6698 (KVKK) and institutional confidentiality policies governing hospital records. Because the dataset includes variables that, in combination, could risk re‐identification of patients within this relatively small cohort, unrestricted public sharing was not authorized by the Ethics Committee. De‐identified data may be made available to qualified researchers for the purpose of replicating the findings reported here, subject to a formal data‐sharing request to the corresponding author and approval from the Ethics Committee of Health Sciences University Başakşehir Çam and Sakura City Hospital, in line with institutional data governance requirements.