title: Video. Repeated transvaginal notes: is it possible?
abstract: OBJECTIVE
  Transvaginal surgery has been performed by gynecologists for decades with abundant literature supporting its efficacy and safety. Recently, several groups reported on the NOTES transvaginal (TV) approach for extrapelvic disease. Nevertheless, repeated TV access for NOTES has never been reported to date. Two cases of "repeated" TV access for NOTES cholecystectomy after TV hybrid sleeve gastrectomy are described.
  
  
  METHODS
  Two women, aged 57 and 32 years, developed symptomatic cholelithiasis respectively 6 and 8 months after TV sleeve gastrectomy for morbid obesity. Sleeve gastrectomy: a 2-cm posterior colpotomy was performed under laparoscopic control between the uterosacral ligaments. A double-channel endoscope and a 60-cm-long laparoscopic grasper were introduced transvaginally. Two abdominal ports were placed to allow the introduction of the stapling device and to assist during the procedure. An intragastric endoscope served to expose the stomach and to calibrate the gastric sleeve, which was performed in the standard fashion. Colpotomy was closed by separate 3/0 Vicryl stitches. At cholecystectomy, an exploratory laparoscopy ascertained the feasibility of a NOTES cholecystectomy. The posterior vaginal vault was carefully examined before regaining peritoneal access with the technique described above. Cholecystectomy was performed by using a double-channel endoscope introduced TV and a 5-mm transabdominal port. Follow-up consisted of 3 and 6 months pelvic examination and interview, which included sexual function assessment by sexual function questionnaire (SFQ31).
  
  
  RESULTS
  Both operations were performed successfully with no intraoperative or postoperative complications. At cholecystectomy, minimal pelvic adhesions were found with no vaginal scarring at the colpotomy site. No bleeding, pain, or vaginal infection occurred after both procedures. Patients resumed sexual activity 5.2 weeks postoperatively with a consistently normal SFQ31.
  
  
  CONCLUSIONS
  This report suggests that, in experienced hands, repeated TV access for extrapelvic surgery is possible and safe, putting forward the intriguing promises of less adhesions formation.
authors.affiliation: IRCAD, Department of Digestive and Endocrine Surgery, University of Strasbourg, Strasbourg, France. silvana.perretta@ircad.fr
authors.forename: S
authors.initials: S
authors.lastname: Perretta
authors.forename: M
authors.initials: M
authors.lastname: Vix
authors.forename: B
authors.initials: B
authors.lastname: Dallemagne
authors.forename: J
authors.initials: J
authors.lastname: Nassif
authors.forename: G
authors.initials: G
authors.lastname: Donatelli
authors.forename: J
authors.initials: J
authors.lastname: Marescaux
mesh_terms: D000328:Adult; D002763:Cholecystectomy / Q000379:methods*; D002769:Cholelithiasis / Q000601:surgery*; D003127:Colposcopy / Q000379:methods*; D005260:Female; D005743:Gastrectomy / Q000379:methods; D006801:Humans; D008875:Middle Aged; D057605:Natural Orifice Endoscopic Surgery / Q000379:methods*; D009767:Obesity, Morbid / Q000601:surgery; D024162:Second-Look Surgery / Q000379:methods; D016896:Treatment Outcome