title: Safety of transvaginal hybrid NOTES cholecystectomy: a systematic review and meta-analysis.
abstract: BACKGROUND
  Despite increasing data regarding clinical outcomes following transvaginal hybrid NOTES cholecystectomy (TVC), a consensus regarding safety based on comparative studies has yet to be reached. The aim of this systematic review and meta-analysis was to compare safety and clinical outcomes of TVC with conventional laparoscopic cholecystectomy (CLC) for the treatment of benign gallstone disease.
  
  
  METHODS
  A comprehensive search for published studies comparing TVC and CLC was performed. Review of each study was conducted and data were extracted. All pooled outcome measures were determined using random-effects models.
  
  
  RESULTS
  Data were retrieved from 14 studies describing 1,145 patients. There was no difference in total complications (POR = 0.68; 95 % CI 0.40-1.14; P = 0.14), incidence of bile duct injury (POR = 1.33; 95 % CI 0.31-5.66; P = 0.70), Clavien-Dindo Grade II (POR = 0.48; 95 % CI 0.14-1.60; P = 0.23) or Grade III (POR = 0.63; 95 % CI 0.24-1.65; P = 0.34) complications between TCV and CLC. Time of return to normal activities was significantly reduced in the TVC group (WMD = -4.86 days; 95 % CI -9.33 to -0.39; P = 0.03), and there was a non-significant reduction in postoperative pain on days 1 (WMD = -0.80; 95 % CI -1.60 to 0.01; P = 0.05) and 3 (WMD = -0.89; 95 % CI -1.77 to -0.01; P = 0.05).
  
  
  CONCLUSIONS
  TVC is safe when performed by appropriately trained surgeons and may be associated with a faster return to normal activities and decreased postoperative pain.
authors.affiliation: Department of Surgery and Cancer, St Mary's Hospital, Imperial College London, London 10th Floor QEQM Building, St. Mary's Hospital South Wharf Road, London, W2 1NY, UK, m.sodergren@imperial.ac.uk.
authors.forename: Mikael H
authors.initials: MH
authors.lastname: Sodergren
authors.forename: Sheraz
authors.initials: S
authors.lastname: Markar
authors.forename: Philip H
authors.initials: PH
authors.lastname: Pucher
authors.forename: Ismail A
authors.initials: IA
authors.lastname: Badran
authors.forename: Long R
authors.initials: LR
authors.lastname: Jiao
authors.forename: Ara
authors.initials: A
authors.lastname: Darzi
mesh_terms: D017081:Cholecystectomy, Laparoscopic / Q000009:adverse effects / Q000592:standards*; D002769:Cholelithiasis / Q000601:surgery*; D005260:Female; D006801:Humans; D057605:Natural Orifice Endoscopic Surgery / Q000009:adverse effects / Q000592:standards*; D017063:Outcome Assessment, Health Care; D010149:Postoperative Pain; D061214:Patient Safety; D014621:Vagina