title: Totally NOTES (T-NOTES) transvaginal cholecystectomy using two endoscopes: preliminary report.
abstract: BACKGROUND
  Clinical applications of transvaginal Natural Orifice Transluminal Endoscopic Surgery (NOTES) are still limited in the literature, mostly case reports performed by hybrid procedures with laparoscopic assistance. Avoiding complications from incisions is the main goal for natural orifice surgery. This study reports on a technique developed at our institution that uses two endoscopes inserted into the vagina to perform a Totally NOTES (T-NOTES) transvaginal cholecystectomy, and describes preliminary results.
  
  
  METHODS
  IRB approval was obtained at the institution for transvaginal NOTES clinical trials, and informed consent was obtained. The technique of T-NOTES transvaginal cholecystectomy was clinically applied in four female patients with symptomatic cholelithiasis, and data were prospectively documented. Transvaginal NOTES access was obtained by direct vaginal incision, and two endoscopes were simultaneously introduced in the abdominal cavity. Dissection was accomplished with available endoscopic instruments. Ligation of cystic duct and artery was performed using endoscopic clips. Vaginal closure was achieved using the direct-vision sutured technique.
  
  
  RESULTS
  The technique was successfully performed in the four patients. Insufflation and spatial orientation was of good quality. Mean operative time was 210 min. There were no complications during the 30-day follow-up. Postoperative course was uneventful, and patients were released from the hospital on the first postoperative day.
  
  
  CONCLUSIONS
  Tranvaginal T-NOTES using two endoscopes provides a feasible method for natural orifice cholecystectomy using available technology. Large-series studies are needed to evaluate the results with respect to safety of the approach.
authors.affiliation: Department of Surgery and Endoscopy, SOUSAGROUP Hospital Femina, Goiania Caixa postal 22812, CEP 74 850-970, Goiania, Brazil. drluizhs@terra.com.br
authors.forename: Luiz Henrique
authors.initials: LH
authors.lastname: de Sousa
authors.forename: José Américo Gomides
authors.initials: JA
authors.lastname: de Sousa
authors.forename: Luiz Henrique
authors.initials: LH
authors.lastname: de Sousa Filho
authors.forename: Murilo Miranda
authors.initials: MM
authors.lastname: de Sousa
authors.forename: Vitor Miranda
authors.initials: VM
authors.lastname: de Sousa
authors.forename: Ana Patricia Miranda
authors.initials: AP
authors.lastname: de Sousa
authors.forename: Ricardo
authors.initials: R
authors.lastname: Zorron