title: NOTES transvaginal cholecystectomy: preliminary clinical application.
abstract: BACKGROUND
  Natural orifice translumenal endoscopic surgery (NOTES) is an emerging concept in the recent literature that could lead to potential benefits in clinical applications. Restricted to animal experiments, however, human procedures have not yet been published. Because of the technical and ethical challenges involved in perforation and closure of a healthy organ-as is also seen in operating via the transgastric route-and because of the lack of understanding of the physiopathology and infection risk with these approaches, they have not been applied in the clinical setting. Thus the present study, based on previous animal experiments, describes preliminary clinical application in four cases of transvaginal NOTES cholecystectomy, and discusses safety, feasibility, and potential benefits of the method.
  
  
  METHODS
  Preliminary acute and survival animal experiments developed by the NOTES Research Group at our institution solved such technical problems for transvaginal NOTES as spatial orientation, insufflation, and instrumentation, making possible the introduction of NOTES as a clinical application. The trials were approved by ethics committee of our institution, and informed consent was obtained from all patients. Since 13 March 2007, four female patients with elective surgical indication for cholecystectomy have undergone transvaginal NOTES cholecystectomy. All intraoperative and postoperative parameters were documented. Vaginal access was achieved under direct vision with conventional instruments, and a 2-channel colonoscope was inserted into the abdominal cavity. After endoscopic insufflation to achieve pneumoperitoneum with CO(2), instruments were inserted through and alongside a colonoscope, allowing successful NOTES cholecystectomy in all patients, with vaginal extraction of the gallbladder. The vaginal wound was closed by direct vision using conventional instruments.
  
  
  RESULTS
  The procedure was successful in all patients, with operative time of 45-115 min. Patients experienced low need for postoperative analgesia. Free oral intake was permitted 2 h after the procedure. There were no postoperative complications, and patients were discharged, according to the study protocol, 48 h after the procedure.
  
  
  CONCLUSIONS
  Preliminary results showed the feasibility and safety of the transvaginal NOTES method in this small initial study population. The technique, developed in our institution, and not transgastric NOTES, may be the preferred approach to serve as the basis for clinical studies.
authors.affiliation: Department of Surgery, University Hospital Teresopolis HCTCO-FESO, Av. Américas 13554 BL.1 AP.207 Barra da Tijuca, Rio de Janeiro, Brazil. rzorron@terra.com.br
authors.forename: R
authors.initials: R
authors.lastname: Zorron
authors.forename: L C
authors.initials: LC
authors.lastname: Maggioni
authors.forename: L
authors.initials: L
authors.lastname: Pombo
authors.forename: A L
authors.initials: AL
authors.lastname: Oliveira
authors.forename: G L
authors.initials: GL
authors.lastname: Carvalho
authors.forename: M
authors.initials: M
authors.lastname: Filgueiras
mesh_terms: D000328:Adult; D002763:Cholecystectomy / Q000379:methods*; D002769:Cholelithiasis / Q000601:surgery*; D004724:Endoscopy / Q000379:methods*; D005260:Female; D006801:Humans; D014621:Vagina