title: Transvaginal natural orifice translumenal endoscopic surgery cholecystectomy: early evolution of the technique.
abstract: BACKGROUND
  Initial excitement for Natural Orifice Transluminal Endoscopic Surgery (NOTES) has been partly tempered by the reality that a NOTES procedure without laparoscopic or needleoscopic-assistance has not been performed by most groups. After safely performing laparoscopically-assisted transvaginal cholecystectomy in an IACUC-approved porcine model, we embarked on an IRB-approved protocol to ultimately perform a pure NOTES cholecystectomy.
  
  
  METHODS
  We describe our experience with performing a true NOTES tansvaginal cholecystectomy after safely accomplishing 3 laparoscopically-assisted hybrid NOTES procedures in humans. To overcome the retracting limitations of currently available endoscopes, we used a 5-mm curved or articulating retractor that was placed into the abdomen via a separate colpotomy in the second and third patient. In a fourth patient, pneumoperitoneum to 15 torr was obtained via a transvaginal trocar placed through a colpotomy made under direct vision and endoscopically placed clips were used for both the cystic duct and artery, thus, obviating the need for any transabdominally placed instruments or needles.
  
  
  RESULTS
  This patient was the first patient to undergo a completely NOTES cholecystectomy at our institution and to our knowledge in the United States. She was discharged on the day of surgery and has not suffered any complication after 1 month of follow-up.
  
  
  CONCLUSIONS
  Pure NOTES transvaginal cholecystectomy without aid of laparoscopic or needleoscopic instruments is feasible and safe in humans. Additional experience with this technique will be required before comparative studies to standard laparoscopy and hybrid techniques are appropriate.
authors.affiliation: Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA.
authors.forename: Andrew A
authors.initials: AA
authors.lastname: Gumbs
authors.forename: Dennis
authors.initials: D
authors.lastname: Fowler
authors.forename: Luca
authors.initials: L
authors.lastname: Milone
authors.forename: John C
authors.initials: JC
authors.lastname: Evanko
authors.forename: Akuezunkpa O
authors.initials: AO
authors.lastname: Ude
authors.forename: Peter
authors.initials: P
authors.lastname: Stevens
authors.forename: Marc
authors.initials: M
authors.lastname: Bessler
mesh_terms: D002763:Cholecystectomy / Q000379:methods*; D015331:Cohort Studies; D020884:Colpotomy; D019723:Endoscopes; D004724:Endoscopy / Q000379:methods*; D005260:Female; D005705:Gallbladder Diseases / Q000601:surgery*; D006801:Humans; D016896:Treatment Outcome