title: Scarless cholecystectomy with combined transvaginal and transumbilical approach in a series of 20 patients.
abstract: BACKGROUND
  Laparoscopic surgery has dramatically improved surgical care of patients reducing postoperative pain, wound infection rate, hospital stay, inability to work, risk of hernia, and cosmetic result. Natural orifice transluminal endoscopic surgery (NOTES) is even less traumatic to the abdominal wall and might further improve minimal invasive surgery of patients, but might also increase surgical risk when used by a transgastric or transcolonic approach with flexible endoscopes. Therefore we decided to use a transvaginal approach using rigid laparoscopic instruments for cholecystectomies.
  
  
  METHODS
  Through a 5-mm incision deep in the umbilicus a pneumoperitoneum was created. The optic and a dissector were inserted through the posterior fornix of the vagina under laparoscopic control from the umbilicus and a transvaginal gallbladder removal was performed.
  
  
  RESULTS
  20 patients were successfully operated in a 4.5-month period. Operating time was 62 (35-100) min. No intra- or postoperative complications occurred in any patient. Gynecological examination after 8 days showed no negative findings and the cosmetic result was ideal with no visible scars.
  
  
  CONCLUSIONS
  In our series we showed that cholecystectomies can be routinely performed in a NOTES technique without visible scar. The transvaginal approach is the safe in NOTES and common laparoscopic instruments can be used as long as there are no better flexible endoscopes for this purpose.
authors.affiliation: Department of Surgery, Israelitisches Krankenhaus, Orchideenstieg 14, 22297, Hamburg, Germany. zornig@ik-h.de
authors.forename: C
authors.initials: C
authors.lastname: Zornig
authors.forename: H
authors.initials: H
authors.lastname: Mofid
authors.forename: A
authors.initials: A
authors.lastname: Emmermann
authors.forename: M
authors.initials: M
authors.lastname: Alm
authors.forename: H-A
authors.initials: HA
authors.lastname: von Waldenfels
authors.forename: C
authors.initials: C
authors.lastname: Felixmüller
mesh_terms: D017081:Cholecystectomy, Laparoscopic / Q000379:methods*; D002921:Cicatrix / Q000517:prevention & control*; D005260:Female; D005500:Follow-Up Studies; D005705:Gallbladder Diseases / Q000601:surgery*; D006801:Humans; D011183:Postoperative Complications / Q000517:prevention & control; D012189:Retrospective Studies; D016896:Treatment Outcome; D014472:Umbilicus; D014621:Vagina