title: Transvaginal Laparoscopically Assisted Endoscopic Appendectomy: a major Hybrid Natural Orifice Transluminal Endoscopic Surgery case series in Asia.
abstract: OBJECTIVE
  Evaluation of a Hybrid Approach to NOTES and its performance relative to conventional procedures.
  
  
  BACKGROUND
  Globally, numerous institutions have successfully implemented minimally invasive surgeries by applying natural orifice translumenal endoscopic surgery (NOTES) techniques and achieved decreased morbidity while performing incision-less surgery. However, these techniques are still not common in surgical practice in China and Pakistan. Documenting the experiences and challenges encountered in implementing NOTES in such environments can provide guidance for NOTES implementation elsewhere.
  
  
  METHODS
  From May 2010 to April 2012, 16 human transvaginal appendectomies were carried out applying a hybrid NOTES technique using a solo-umbilical trocar, which provided a safe access for laparoscopic assistance during surgical procedure. After removal of the appendix transvaginally, the colpotomy was sutured under direct vision with absorbable stitches. The outcomes of cases treated with hybrid NOTES techniques were compared to those of conventional laparoscopic appendectomy.
  
  
  RESULTS
  All patients underwent a successful surgical procedure with no intra- or post-operative complications and provided no specific complaints during the tenth day and a monthly follow-up for 2 years. The patients convalesced promptly with healthy and satisfactory cosmetic results. Compared to conventional laparoscopic appendectomy, the hybrid NOTES operation had less post-operative pain, lower cost, and shorter hospitalization.
  
  
  CONCLUSIONS
  Hybrid NOTES procedures can be performed safely using a solo-umbilical trocar. Our initial experience reveals that this hybrid technique is practically feasible and associated with minimal post-operative pain, reasonable convalescence time, and improved cosmetic outcomes.
authors.forename: Abdul Qadir
authors.initials: AQ
authors.lastname: Khan
authors.forename: Enyu
authors.initials: E
authors.lastname: Liu
authors.forename: Peng
authors.initials: P
authors.lastname: Li
authors.forename: Hazrat
authors.initials: H
authors.lastname: Gul
authors.forename: Jessica
authors.initials: J
authors.lastname: Fokeerchand
authors.affiliation: 1 Laparoscopic Minimally Invasive Surgery of Shandong University.
authors.forename: Jun
authors.initials: J
authors.lastname: Niu
authors.forename: Weibo
authors.initials: W
authors.lastname: Niu
keywords: Laparoscopy; appendectomy; endoscopy; natural orifice translumenal endoscopic surgery (NOTES); transvaginal