title: Transvaginal liver resection (NOTES) combined with minilaparoscopy.
abstract: OBJECTIVE
  to report on the first liver resection performed on a human being by a transvaginal NOTES approach combined with minilaparoscopy.
  
  
  METHODS
  a sixty-one-year-old woman with a history of Wertheim s hysterectomy for endometrial carcinoma 10 years ago, and malignant melanoma correctly treated in 2006, had suspected segment-V liver metastasis near the gallbladder by CT-scan and MRI. The indication for a laparoscopic approach was made, and a combined transvaginal and minilaparoscopic resection was offered and accepted by the patient. The procedure was performed by a multidisciplinary team composed of surgeons and gastroenterologists. It involved creating a pneumoperitoneum by placing a Veres needle in the umbilical fundus, followed by the insertion of a 5-mm trocar. A second, 3-mm trocar was placed in the right upper quadrant. A lot of pelvic adhesions were found in the major pelvis, and it was necessary to place a third, 5-mm trocar in the left abdominal side. It was employed only for the adhesions, not for liver resection. Adhesions were removed to reveal the minor pelvis and the vaginal fornix. A colpotomy was performed with a 12-mm trocar placed inside the vagina, which allowed the insertion of the videogastroscope as far as the liver hilum.
  
  
  RESULTS
  liver resection (segment-V partial resection) and cholecystectomy were performed by using a combination of working tools inserted through the entry port for the minilaparoscopy and the videogastroscope. The en bloc resection was removed transvaginally through the videogastroscope. There were no postoperative complications, and the patient was discharged after 48 hours.
  
  
  CONCLUSIONS
  transvaginal liver resection is possible and safe when performed by a multidisciplinary team. Natural orifice transluminal endoscopic surgery (NOTES) is an emerging modality that seeks to be less invasive, better tolerated, and more respectful of esthetics. It will probably open the way for very important medical and technological innovations.
authors.affiliation: Surgery and Gastroenterology Departments, Son Llàtzer Hospital. Palma de Mallorca, Spain. jnoguera@hsll.es
authors.forename: J F
authors.initials: JF
authors.lastname: Noguera
authors.forename: C
authors.initials: C
authors.lastname: Dolz
authors.forename: A
authors.initials: A
authors.lastname: Cuadrado
authors.forename: J M
authors.initials: JM
authors.lastname: Olea
authors.forename: A
authors.initials: A
authors.lastname: Vilella
mesh_terms: D005260:Female; D006498:Hepatectomy / Q000379:methods*; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008875:Middle Aged; D014621:Vagina