Transvaginal laparoscopically assisted endoscopic cholecystectomy: preliminary clinical results for a series of 43 cases in China

Background  

Transvaginal cholecystectomy has been performed successfully at several research institutions worldwide using natural orifice transluminal endoscopic surgery (NOTES) techniques. However, it is a growing new surgical concept in China. Several technical challenges hinder the safe clinical application of NOTES. This study investigated transvaginal endoscopic cholecystectomy performed with the assistance of a single umbilical trocar and achieved helpful initial clinical experience.     

NOTES Hybrid Transvaginal Radical Nephrectomy for Tumor: Stepwise Progression Toward a First Successful Clinical Case

Background

Natural orifice translumenal endoscopic surgery (NOTES) has been used to perform nephrectomy in the laboratory; however, clinical reports to date have used multiple abdominal trocars to assist the transvaginal procedure.

Objective

To present our stepwise technique development and the first successful clinical case of NOTES transvaginal radical nephrectomy for tumor with umbilical assistance without extraumbilical skin incisions.

Design, setting, and participants

The four transvaginal NOTES procedures were performed at two institutions after obtaining institutional review board approval. Various operative steps were developed experimentally in three clinical cases, and on March 7, 2009, we performed the first successful case of NOTES hybrid transvaginal radical nephrectomy without any extraumbilical skin incisions. Using one multichannel access port in the vagina and one in the umbilicus, laparoscopic visualization, intraoperative tissue dissection, and hilar control were performed transvaginally and transumbilically. The intact specimen was extracted transvaginally.

Measurements

All perioperative data were accrued prospectively. A stepwise progression to the successful completion of the fourth case is systematically presented.

Results and limitations

Intraoperatively, at incrementally more advanced stages of the procedure, the first three NOTES clinical cases were electively converted to standard laparoscopy because of rectal injury during vaginal entry, of failure to progress, and of gradual bleeding during upper-pole dissection after transvaginal hilar control, respectively. The fourth case was successfully completed via transvaginal and umbilical access without conversion to standard laparoscopy. Operative time was 3.7 h, estimated blood loss was 150 cm³, and hospital stay was 1 d. Final pathology confirmed a 220-g, pT1b, 7-cm, grade 2, clear-cell renal cell carcinoma with negative margins. The patient was readmitted for an intraabdominal collection that responded to drainage and antibiotics.

Conclusions

We report our stepwise progression and the initial successful clinical case of NOTES hybrid transvaginal radical nephrectomy for tumor, assisted with only one umbilical trocar. Although transvaginal nephrectomy is feasible in the highly selected patient with favorable intraoperative circumstances, considerable refinements in technique and technology are necessary if this approach is to advance beyond mere anecdote.     

Transvaginal endoscopic partial gastrectomy in porcine models: the role of an extra endoscope for gastric control

Background  Transvaginal natural orifice translumenal endoscopic surgery (NOTES) gastrectomy is technically challenging, because wide perigastric dissection under appropriate tissue triangulation is unfeasible with current endoscopic instruments alone. The aim of this study was to investigate the feasibility of transvaginal NOTES gastrectomy with the use of an extra endoscope as a retracting device of the stomach. Methods  This acute in vivo feasibility study was performed under the approval of the Institutional Animal Care and Use Committee (IACUC). Four female 40-kg pigs received general anesthesia and underwent transvaginal endoscopic partial gastrectomy. Under laparoscopic guidance, the uterus was fixed anteriorly and transvaginal access was established in a standard fashion. The perigastric ligaments were dissected with needle knife/insulation-tipped electrosurgical knife (IT) via transvaginally placed double-channel endoscope. This step was assisted with the second, CO₂-insufflating endoscope advanced in the stomach (i.e., so-called endoscopic gastric control). A linear stapling device with a flexible shaft was then passed transvaginally, and the anterior gastric wall was partially resected. The specimen was isolated and retrieved through the vagina. Concluding endoscopy was carried out to confirm the absence of mucosal damage due to endoscopic gastric control. This was further confirmed at necropsy immediately after sacrifice. Results  All animals underwent successful transvaginal NOTES gastrectomy. Endoscopic gastric control greatly facilitated perigastric dissection by providing appropriate tissue countertraction on the ligaments. Use of transabdominal (laparoscopic) graspers was thus minimized. There were no intraoperative complications directly related to use of the primary (transvaginal) endoscope or the additional (gastric) endoscope. Distention of downstream bowel after gastric insufflation was minimal with CO₂. No major injuries were noted on gastric mucosa at postmortem investigations. Conclusions  Transvaginal NOTES partial gastrectomy is feasible in porcine models. Use of an extra endoscope to retract the stomach is effective to minimize transabdominal assistance. Further studies on human subjects are necessary to establish this as a safe and attractive ancillary technique in NOTES.     

Evaluation for transvaginal and transgastric NOTES cholecystectomy in human and animal natural orifice translumenal endoscopic surgery

Background/purpose  Natural orifice translumenal endoscopic surgery (NOTES) is a novel concept using an endoscope via a translumenal access for abdominal surgery. This study was designed to evaluate the feasibility and technical aspects of NOTES cholecystectomy from our experience on humans and animals. Methods  NOTES cholecystectomies were performed in 12 animal experiments, including 8 pigs (6 by transgastric and 2 by transvaginal accesses) and 4 dogs (4 transvaginal accesses), and a human female cadaver. Results  The entire gallbladder could be removed under direct vision in all experiments. The average time was 60 min by transgastric and 40 min by transvaginal in animals. It was 87 min for human transvaginal cholecystectomy. In all animal and human procedures, there was no major complication concerning the operation. Discussion  The transvaginal route may be the easiest route for abdominal NOTES. Percutaneous endoscopic gastrostomy (PEG) allowed the safe performance of a controlled gastric perforation and shortened the time. The hybrid method allowed performance of a safe procedure and shortened the time. Conclusions  Transvaginal and transgastric NOTES cholecystectomy is technically feasible and safe in both humans and animals. New instrumentation needs to be developed to perform a pure NOTES cholecystectomy without transabdominal assistance.     

Natural Orifice Translumenal Endoscopic Surgery (NOTES) Transvaginal Cholecystectomy in a Morbidly Obese Patient

Transvaginal natural orifice translumenal endoscopic surgery (NOTES) is a new diagnostic and potentially therapeutic method of surgical endoscopy. The first case of NOTES transvaginal cholecystectomy in a morbid obese patient in the literature is described. IRB approval was obtained at the institution for transvaginal NOTES clinical trials. A 58-year-old female patient with cholelithiasis, hypertension, and type II diabetes, and BMI of 35.8 kg/m(2) was submitted to the technique. After transvaginal access, a two-channel gastroscope was introduced into the abdominal cavity along with a laparoscopic trocar. There were 2 umbilical punctures for use of 3 mm laparoscopic equipment. Operative time was 85 min. There was no use of postoperative analgesia, and the patient was discharged on the third postoperative day. Transvaginal NOTES is a feasible alternative method for cholecystectomy in the morbidly obese, although available technology is limited for natural orifice surgery.     

Pure natural orifice transluminal endoscopic surgery (NOTES) cholecystectomy

Enthusiasm for natural orifice transluminal endoscopic surgery (NOTES) has been partly tempered by the reality that most NOTES procedures to date have been laparoscopically assisted. After safely performing transvaginal cholecystectomy in an IACUC-approved porcine model, the authors embarked on an institution review board (IRB)-approved protocol for ultimate performance of pure NOTES cholecystectomy in humans. They describe their experience performing a true NOTES transvaginal cholecystectomy after safely accomplishing three laparoscopically assisted or hybrid procedures in humans. One of the patients was a 35-year-old woman presenting with symptoms of biliary colic. Ultrasound confirmed gallstones, and her liver enzymes were normal. Pneumoperitoneum to 15 mmHg was obtained via a transvaginal trocar placed through a colpotomy made under direct vision. A double-channel endoscope then was advanced into the abdomen. To overcome the retracting limitations of currently available endoscopes, the authors used an extra-long 5-mm articulating retractor placed into the abdomen via a separate colpotomy made under direct vision using the flexible endoscope in a retroflexed position. Endoscopically placed clips were used for control of both the cystic duct and the artery. These techniques obviated the need for any transabdominally placed instruments or needles. This patient was the first to undergo a completely NOTES cholecystectomy at the authors’ institution, and to their knowledge, in the United States. She was discharged on the day of surgery and at this writing has not experienced any complication after 1 month of follow-up evaluation. Performance of NOTES transvaginal cholecystectomy without aid of laparoscopic or needleoscopic instruments is feasible and safe for humans. Additional experience with this technique are required before studies comparing it with standard laparoscopy and hybrid techniques are appropriate.     

Transvaginal endoscopic cholecystectomy in human beings: preliminary results

INTRODUCTION: The exciting concept of performing surgery in the peritoneal cavity without abdominal incisions by means of flexible endoscopes introduced through natural orifices-natural orifice transluminal endoscopic surgery (NOTES) has been widely investigated in recent years in experimental settings. However, experience with this procedure in human beings is still lacking. In this paper, we report the preliminary results of a small consecutive series of transvaginal endoscopic cholecystectomies. METHODS: A standard double-channel gastroscope introduced into the abdominal cavity through a posterior colpotomy was used to perform the cholecystectomy. The introduction of a 5-mm trocar in the left-upper abdominal quadrant was mandatory to create and monitor the pneumoperitoneum and allow the application of the standard laparoscopic clips. This port was also used to introduce a grasper that assisted in the exposure of the gallbladder. The gallbladder was removed through the vagina and was protected in a plastic bag. RESULTS: Since July 2007, 3 patients were successfully operated on by this approach, including 1 morbidly obese woman with a body mass index (BMI) of 45. The mean operative time was 136 minutes (range, 110-190). No postoperative complications occurred, and the patients did not complain of pain at both access sites. At the 1-month follow-up, none of the patients complained of dyspareunia. CONCLUSIONS: The transvaginal cholecystectomy is feasible, safe, and reproducible in women within a wide range of BMI. NOTES might dramatically change the way surgery will be conceived and performed in the future, as it holds the potential to abolish the historic association of surgery with pain and scars.     

Cholecystectomy by a combined transgastric and transparietal approach using two flexible endoscopes

Objective  This experimental study was designed to assess the technical feasibility and benefits of our novel approach for transgastric NOTES (natural orifice translumenal endoscopic surgery) cholecystectomy. Methods  Four pigs were subjected to NOTES cholecystectomy by the combined transgastric and transparietal approach using two flexible endoscopes. Under the guidance of a transparietal endoscope inserted through a trocar placed in the right upper abdomen, a gastrotomy was constructed, and a peroral endoscope was advanced into the peritoneal cavity through the gastrotomy and moved on retroflexion toward the gallbladder. Gallbladder excision with ligation of the cystic artery and duct using endoclips was performed using the peroral endoscope. After gastrotomy closure with endoclips inside the stomach, intraperitoneal lavage were carried out using the transparietal endoscope. Results  A complete gallbladder excision was carried out without major adverse events in all cases. The gastrotomies were successfully closed using endoclips (n = 3) or by the omentum-plug method (n = 1). Conclusion  This approach is technically feasible and makes transgastric NOTES cholecystectomy easier and safer.     

Natural orifice translumenal endoscopic surgery: critical appraisal of applications in clinical practice

Background  Natural orifice translumenal endoscopic surgery (NOTES), with its focus on eliminating incision-related complications, promises to revolutionize the way surgery is performed. This study aimed to summarize the clinical applications of NOTES for humans, outline the techniques used, and discuss the complications and limitations of current techniques. Methods  A literature search was performed using PubMed and Medline search tools to review the extent and outcomes of human procedures undertaken using the NOTES technique in its pure form or as a hybrid procedure reported until July 2008. The end points were the types of operation performed, the approach and technique used for each operation, and the procedure-related complications and technical limitations. Results  This review considered 16 publications reporting on 49 human subjects. All the studies except three used hybrid NOTES procedures, with varying amounts of transabdominal assistance. Three transvaginal cholecystectomies, one transvaginal appendectomy, and eight transgastric appendectomies have been performed using a pure NOTES technique. To date, 15 NOTES transvaginal cholecystectomies and 10 NOTES appendectomies (8 transgastric and 2 transvaginal) are reported. Other procedures including peritoneoscopy and sigmoid colectomy are described. Three cases of minor morbidity are reported and no mortality. Conclusions  Although initial human results seem encouraging, it is important that this research be conducted in a way that minimizes bad publicity and describes both favorable and adverse outcomes. Robust trials must be conducted at established centers with appropriate experience and institutional board ethical review to allow safe introduction of this novel technique, with adequate and expedient reporting of serious adverse events. The limitations of the current tools and methods are discussed, and suggestions are made for further improvements in the technology to facilitate NOTES operations.     

Transvaginal laparoscopic cholecystectomy: laparoscopically assisted

Natural orifice transluminal endoscopic surgery (NOTES) is considered the new frontier for minimally invasive surgery. NOTES procedures such as peritoneoscopy, splenectomy, and cholecystectomy in animal models have been described. The aim of our experiment was to determine the feasibility and technical aspects of a new endoluminal surgical procedure. After approval from Columbia’s IACUC, a transvaginal laparoscopically assisted endoscopic cholecystectomy was performed on four 30 kg Yorkshire pigs. The first step was to insert a 1.5 cm endoscope into the vagina under direct laparoscopic vision. Then the gallbladder was reached and, with the help of a laparoscopic grasper to hold up the gallbladder, the operation was performed. At the end of the procedure the gallbladder was snared out through the vagina attached to the endoscope. There were no intraoperative complications such as bleeding, common bile duct or endo-abdominal organ damage. Total operative time ranged between 110 and 155 min. Based on our experience in the porcine model, we believe that a transvaginal endoscopic cholecystectomy is feasible in humans. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Transvaginal natural orifice transluminal endoscopic surgery-assisted minilaparoscopic nephrectomy: a step towards scarless surgery

The feasibility of a transvaginal hybrid natural orifice transluminal endoscopic surgery (NOTES) nephrectomy has already been demonstrated using standard laparoscopic ports through the abdominal wall. We evaluated the feasibility of a transvaginal NOTES-assisted minilaparoscopic nephrectomy (mLN).The patient is positioned in a semilumbotomy position with legs separated to allow for vaginal access. A 3.5-mm port is placed at the umbilicus for a 30° laparoscope; two 3.5-mm ports are placed in the flank in the same location as for a standard transperitoneal nephrectomy; and a 12-mm port is placed through the vagina, perforating the vaginal wall. Kidney dissection is performed following the steps of a traditional nephrectomy. The renal pedicle is dissected and secured with Hem-o-Lok clips through the vaginal access port. The specimen is then extracted through an extended incision in the posterior wall of the vagina.We treated five patients. The average operative time was 120 min, blood loss was 160 ml, and no complications were recorded.Our initial experience suggests that transvaginal NOTES-assisted mLN is feasible and appears to be safe. It is simpler than a pure NOTES procedure and ensures excellent cosmetic results.     

Transvaginal NOTES Hybrid Cholecystectomy

Background. Initial reports confirm the safety and feasibility of natural orifice transluminal eendoscopic surgery (NOTES) transvaginal hybrid cholecystectomy (TVC). Benefits of TVC include no visible scars, less pain, and shorter recovery. The authors describe a single surgeon's initial experience with TVC through his first 20 cases. Method. Under direct visualization from a 5-mm umbilical trochar, a 12-mm trocar, or in 2 cases a SILS port was introduced through the posterior vagina into the cul-de-sac. The gallbladder was visualized using an endoscope introduced through the vaginal port. Using extracorporeal stay sutures for retraction, the cystic duct and artery were dissected free, clipped, and divided. The gallbladder was then removed through the vaginal port. Results. Twenty patients underwent a successful TVC. The average age was 34.9 years (21-55 years), average body mass index was 29.9 kg/m(2) (18.3-38.1 kg/m(2)), and the mean operative time was 71.4 minutes (42-116 minutes). Conclusion. TVC is a safe, feasible, and attractive alternative to traditional 4-port laparoscopic cholecystectomy.     

Transvaginal cholecystectomy without laparoscopic support using prototype flexible endoscopic instruments in a porcine model

Background

Transvaginal cholecystectomy with laparoscopic assistance has been performed safely in humans. The next goal was to develop a natural orifice transluminal endoscopic surgery (NOTES) technique to perform cholecystectomy without laparoscopic instruments using one flexible endoscope and flexible accessories. The aim of the study was to test the feasibility of the procedure in a survival porcine model.

Methods

Cholecystectomies were attempted in five 88–130-lb. pigs with a planned 2-week survival. Prototype flexible instruments (NOTES Toolbox, Ethicon Endo-Surgery, Inc.) were used to aid in access, dissection, and removal of the gallbladder via the transvaginal route.

Results

Cholecystectomy could be completed without abdominal incision using prototype instruments in four out of five pigs. The cystic duct could be exposed with a flexible hook knife and clips applied. The steerable trocar improved stability and the precision of the dissection. The critical view was established in all five pigs. Dissection of the gallbladder off the liver bed was imprecise resulting in gallbladder perforation in all pigs and liver hemorrhage in two. At necropsy, all clips on the cystic duct were secure and no bile leak, bowel injury, or adhesions were present.

Conclusions

NOTES cholecystectomy without laparoscopic support is feasible but challenging using prototype flexible endoscopic devices. A prototype clip applier was effective in controlling the cystic duct. Further improvements in instrument design to ensure precision and safety are needed before flexible devices should be used for pure NOTES procedures in humans.     

Natural Orifice Translumenal Endoscopic Surgery: A Critical Review

Natural orifice translumenal endoscopic surgery (NOTES) involves the intentional puncture of one of the viscera (e.g., stomach, rectum, vagina, urinary bladder) with an endoscope to access the abdominal cavity and perform an intraabdominal operation. Early laboratory work focused on feasibility studies, including such accomplishments as pure transgastric splenectomy and gastrojejunostomy. Contemporary laboratory work is investigating the infectious and immunologic implications of NOTES and honing the tools and techniques required for complex abdominal operations. Today NOTES has entered the clinical arena in a few cases: the first clinical series of transgastric peritoneoscopy has recently been published; multiple groups are accumulating patients in studies of NOTES cholecystectomy, either via the transgastric or transvaginal route; and a series of transgastric appendectomies has been well publicized, yet it remains unpublished. Although clinical NOTES is gaining momentum, the field should remain in check while rigorous laboratory work is performed and cogent clinical trials are undertaken. The zeal for NOTES should not take precedence over the welfare of the patient.     

经自然腔道内镜外科的发展趋势

Natural orifice translumenal endoscopic surgery(NOTES)is a surgical technique which is performed with an endoscope passed through a natural orifice,and then through an internal incision in the viscera(stomach,vagina or rectum)to perform intraabdominal operations.Since the first successful transgastric appendectomy performed by Dr.Rao and Reddy in 2004,NOTES is developing rapidly.The advantages of NOTES include no injury and scar in the body surface;lower anesthesia requirements;faster recovery and shorter hospital stays;avoidance of transabdominal wound infections.NOTES can also be applied to patients who are not suitable for open surgery and lapascopic surgery.NOTES has the potential to revolutionize the field of minimally invasive surgery by eliminating abdominal incisions,however,the safety and efficacy of NOTES still needs to be investigated in lhe future.     

Hybrid vaginal MA-NOS sleeve gastrectomy: technical note on the procedure in a patient

Background  Standard sleeve gastrectomy for the morbidly obese is feasible and safe using the hybrid transvaginal minilaparoscopic-assisted natural orifice surgery (MA-NOS) with available laparoscopic/endoscopic instruments and technology as illustrated by this technical report on a female patient. Methods  The intervention was a transvaginal sleeve gastrectomy in a 67-year-old woman who was hypertensive, noninsulin-dependent with diabetes with morbid obesity (BMI, 37). Operative field view was maintained at all times with a gastroscope introduced through a transvaginal trocar. The surgeon positioned himself at the right side of the patient using a 2-mm needle port/mini-grasper placed in the left upper quadrant for traction of the greater curvature of the stomach. A 12-mm umbilical trocar was used as the port for insertion of the LigaSure device used for division of the short gastric vessels and the Endo-GIA stapler for creation of the gastric tube. The first assistant used a second mini-grasper for liver retraction and stomach positioning. The resected stomach was retrieved through the vagina. There were no intraoperative complications. The operative time was 150 minutes. Results  The advantages of minimally invasive surgery seemed to be enhanced with this hybrid laparoscopic approach. Postoperative course was uneventful. All component steps of a laparoscopic sleeve gastrectomy (LSG) were reproduced. The patient was discharged on the third postoperative day. Conclusions  Transvaginal hybrid MA-NOS sleeve gastrectomy is both feasible and safe. The hybrid technique ensured safety during the performance of the procedure. MA-NOS is a potential option to avoid abdominal incisions and related complications for the laparoscopic resection of large intra-abdominal organs. Combined hybrid laparoscopic NOS for humans is currently a safe and reliable approach for major surgery through the NOS approach in female patients. Hybrid surgery allows controlled implementation of NOS techniques in clinical practice, providing a stepwise progression to the pure NOS approach once the appropriate technology has been developed. Additionally, it is the best way to stimulate the active development and evaluation of the underpinning technologies and instruments for these novel endoscopic surgical approaches. Appropriate clinical indications for these new procedures are yet to be defined. LSG is associated with short-term excess weight loss and resolution of comorbidities comparable to those obtained with other restrictive procedures. The performance of sleeve gastrectomy is an option in selected patients undergoing bariatric surgical treatment, particularly in the super obese and those who are considered high risk because of comorbid disease.     

Hybrid transvaginal cholecystectomy, NOTES, and minilaparoscopy: analysis of a prospective clinical series

Introduction  Natural orifice transluminal endoscopic surgery (NOTES) makes it possible to perform intraperitoneal surgical procedures with a minimal number of access points in the abdominal wall. It is not yet possible to perform these interventions without the help of abdominal wall entryways, so these procedures are hybrids, a fusion of minilaparoscopy and transluminal endoscopic surgery. In this paper we present a prospective clinical series of 15 patients who underwent transvaginal hybrid cholecystectomy for cholelithiasis. Methods  This was a prospective clinical series of 15 consecutive female patients, nonrandomly chosen and without a control group, who underwent a fusion transvaginal NOTES and minilaparoscopy procedure with two entryways for cholelithiasis. One was umbilical and measured 5 mm in diameter, and the other was in the right upper quadrant and measured 3 mm in diameter. Results  The scheduled surgical intervention was performed on the 15 patients in whom it had been indicated. There were no intraoperative complications. One patient had mild hematuria that resolved in less than 12 h; there were no other complications after average follow-up of 124 days. Nine patients were discharged in 24 h, and two were discharged less than 12 h after the procedure. Discussion  Hybrid transvaginal cholecystectomy is a good surgical model for minimally invasive surgery, a combination of NOTES and minilaparoscopy. It can be performed in surgical settings where laparoscopy is practised regularly, using the instruments normally used for endoscopy and laparoscopic surgery. Owing to the reproducibility of the intervention and the ease of vaginal closure, hybrid transvaginal cholecystectomy will permit further development of NOTES in the future.     

Partial gastrectomy using natural orifice translumenal endoscopic surgery (NOTES) for gastric submucosal tumors: early experience in humans

Background

Transvaginal endoscopic gastric surgery is one of the cutting edge procedures in the field of natural orifice translumenal endoscopic surgery (NOTES). Its feasibility has been shown sporadically in bariatric cases but not in oncologic conditions. The authors report their early experience with hybrid transvaginal NOTES gastrectomy for gastric submucosal tumors (SMTs).

Methods

Two female patients with SMTs in the distal stomach participated in this institutional review board (IRB)-approved study. Surgical indication was determined according to the National Comprehensive Cancer Network (NCCN) sarcoma guidelines, and the study adhered to the following oncologic principles: no direct handling of the lesion, full-thickness resection, and reasonable surgical margins. The study protocol required a minimum of two laparoscopic ports to ensure procedural safety and aforementioned oncologic appropriateness. Under laparoscopic guidance, a transvaginal route was created and secured with a 50-cm flexible overtube. A gastrointestinal endoscope was introduced, and the perigastric dissection was performed using an insulation-tipped diathermy knife (IT knife) and needle knife. This process was assisted with two laparoscopic graspers. After perigastric mobilization, the transvaginal endoscope was replaced with a digital stapling device, and partial gastrectomy was accomplished. The resected specimen was isolated and delivered through the vagina, and the vaginal wound was closed under direct vision. Outcomes measurements included surgical results, pain scoring, and clinical outcomes.

Results

Both operations were completed successfully in compliance with the aforementioned oncologic principles. The operating time was 365 and 170 min, respectively. The estimated blood loss was negligible. A minilaparotomy for specimen delivery was successfully avoided in both cases. A minimal vaginal incision was added for one patient at retrieval. Postoperatively, both patients reported no pain and recovered rapidly. The final diagnosis was hemorrhagic lipoma and gastrointestinal stromal tumor (GIST), respectively.

Conclusion

Our initial experience with human transvaginal NOTES gastrectomy showed it to be feasible and safe for gastric SMTs. It is a complex but promising surgical alternative for female oncologic patients undergoing partial gastric resection.     

Development of a feasible transrectal natural orifice transluminal endoscopic surgery (NOTES?) approach in a cadaveric appendectomy model: anterior is better

Background  

The transrectal natural orifice transluminal endoscopic surgery (NOTES) approach is a potentially promising alternative to transgastric or transvaginal approaches for intraperitoneal procedures. However, whether the optimal transrectal approach for intraperitoneal surgery is anterior or posterior remains unknown. To evaluate this, a prospective comparison of anterior and posterior transrectal NOTES approaches in a cadaveric appendectomy model was performed.