title: Natural orifice surgery: initial clinical experience.
abstract: BACKGROUND
  Natural orifice translumenal endoscopic surgery (NOTES) has moved quickly from preclinical investigation to clinical implementation. However, several major technical problems limit clinical NOTES including safe access, retraction and dissection of the gallbladder, and clipping of key structures. This study aimed to identify challenges and develop solutions for NOTES during the initial clinical experience.
  
  
  METHODS
  Under an Institutional Review Board (IRB)-approved protocol, patients consented to a natural orifice operation for removal of either the gallbladder or the appendix via either the vagina or the stomach using a single umbilical trocar for safety and assistance.
  
  
  RESULTS
  Nine transvaginal cholecystectomies, one transgastric appendectomy, and one transvaginal appendectomy have been completed to date. All but one patient were discharged on postoperative day 1 as per protocol. No complications occurred.
  
  
  CONCLUSIONS
  The limited initial evidence from this study demonstrates that NOTES is feasible and safe. The addition of an umbilical trocar is a bridge allowing safe performance of NOTES procedures until better instruments become available. The addition of a flexible long grasper through the vagina and a flexible operating platform through the stomach has enabled the performance of NOTES in a safe and easily reproducible manner. The use of a uterine manipulator has facilitated visualization of the cul de sac in women with a uterus to allow for safe transvaginal access.
authors.affiliation: Department of Surgery, University of California San Diego, San Diego, CA 92103, USA.
authors.forename: Santiago
authors.initials: S
authors.lastname: Horgan
authors.forename: John P
authors.initials: JP
authors.lastname: Cullen
authors.forename: Mark A
authors.initials: MA
authors.lastname: Talamini
authors.forename: Yoav
authors.initials: Y
authors.lastname: Mintz
authors.forename: Alberto
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authors.lastname: Ferreres
authors.forename: Garth R
authors.initials: GR
authors.lastname: Jacobsen
authors.forename: Bryan
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authors.lastname: Sandler
authors.forename: Julie
authors.initials: J
authors.lastname: Bosia
authors.forename: Thomas
authors.initials: T
authors.lastname: Savides
authors.forename: David W
authors.initials: DW
authors.lastname: Easter
authors.forename: Michelle K
authors.initials: MK
authors.lastname: Savu
authors.forename: Sonia L
authors.initials: SL
authors.lastname: Ramamoorthy
authors.forename: Emily
authors.initials: E
authors.lastname: Whitcomb
authors.forename: Sanjay
authors.initials: S
authors.lastname: Agarwal
authors.forename: Emily
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authors.lastname: Lukacz
authors.forename: Guillermo
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authors.lastname: Dominguez
authors.forename: Pedro
authors.initials: P
authors.lastname: Ferraina