title: Transvaginal access for NOTES: a cohort study of microbiological colonization and contamination.
abstract: OBJECTIVE
  Animal data and limited clinical evidence suggest a low incidence of infection following transvaginal natural orifice transluminal endoscopic surgery (NOTES). However, a systematic microbiological evaluation has not yet been carried out. The aim of this prospective cohort study was to evaluate the extent of microbiological contamination of the peritoneal cavity caused by the transvaginal access for NOTES and the impact of preoperative vaginal disinfection on vaginal colonization.
  
  
  METHODS
  Consecutive female patients with symptomatic cholecystolithiasis were offered either transvaginal rigid-hybrid cholecystectomy (tvCCE) or conventional laparoscopic cholecystectomy. Patients who opted for tvCCE were prospectively evaluated between February and June 2010. Disinfection in patients undergoing tvCCE included hexetidine tablets and octenidine applied vaginally. All patients received a single dose of perioperative cefuroxime. Swabs were obtained from the posterior fornix and the peritoneal cavity at different intervals.
  
  
  RESULTS
  Of 32 patients, 27 (84 %) opted to undergo tvCCE. One patient (4 %; 95 % confidence interval [CI] 0.7 % - 18.3 %) had a positive bacterial culture in the Douglas pouch prior to transvaginal access compared with two patients (7 %; 95 %CI 2.1 % - 23.4 %) following colpotomy closure (P = 1.000). Vaginal disinfection significantly decreased vaginal bacterial load (P = 0.001) and bacterial growth in routine cultures (P < 0.001); in 16 patients (59 %; 95 %CI 40.7 % - 75.5 %) vaginal swabs were sterile after disinfection. No postoperative surgical site infections occurred (95 %CI 0 % - 12.5 %).
  
  
  CONCLUSIONS
  In selected patients and following vaginal antisepsis, transvaginal access for NOTES is associated with microbiological contamination of the peritoneal cavity in a minority of patients, indicating a low risk of peritoneal contamination caused by the transvaginal access.
authors.affiliation: Department of General, Visceral, and Transplant Surgery, University of Heidelberg, Im Neuenheimer Feld 110, Heidelberg, Germany. gelinke@web.de
authors.forename: G R
authors.initials: GR
authors.lastname: Linke
authors.forename: I
authors.initials: I
authors.lastname: Tarantino
authors.forename: T
authors.initials: T
authors.lastname: Bruderer
authors.forename: J
authors.initials: J
authors.lastname: Celeiro
authors.forename: R
authors.initials: R
authors.lastname: Warschkow
authors.forename: P E
authors.initials: PE
authors.lastname: Tarr
authors.forename: B P
authors.initials: BP
authors.lastname: Müller-Stich
authors.forename: A
authors.initials: A
authors.lastname: Zerz
mesh_terms: D000282:Administration, Intravaginal; D000328:Adult; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D000891:Anti-Infective Agents, Local / Q000627:therapeutic use; D019072:Antibiotic Prophylaxis / Q000379:methods*; D058491:Bacterial Load / Q000187:drug effects*; D002444:Cefuroxime / Q000627:therapeutic use; D002763:Cholecystectomy / Q000009:adverse effects / Q000379:methods; D017081:Cholecystectomy, Laparoscopic / Q000379:methods; D041761:Cholecystolithiasis / Q000601:surgery; D020884:Colpotomy / Q000009:adverse effects* / Q000379:methods; D016099:Endoscopy, Gastrointestinal / Q000009:adverse effects / Q000379:methods; D004866:Equipment Contamination / Q000517:prevention & control; D005260:Female; D006590:Hexetidine / Q000627:therapeutic use; D006801:Humans; D007097:Imines; D008875:Middle Aged; D010532:Peritoneal Diseases / Q000209:etiology / Q000382:microbiology / Q000517:prevention & control; D011183:Postoperative Complications / Q000382:microbiology / Q000517:prevention & control; D011446:Prospective Studies; D011725:Pyridines / Q000627:therapeutic use; D016896:Treatment Outcome; D014621:Vagina / Q000382:microbiology* / Q000601:surgery
chemical_list: D000900:Anti-Bacterial Agents; D000891:Anti-Infective Agents, Local; D007097:Imines; D011725:Pyridines; D006590:Hexetidine; D002444:Cefuroxime; C034213:octenidine