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Background and study aims Natural orifice transluminal endoscopic surgery (NOTES) has been tested in the animal model for a multitude of procedures including cholecystectomy. Clinical experience using flexible endoscopes is, however, very limited. Transvaginal cholecystectomy has been shown to be the most feasible approach in which rigid instruments can be used. We report our experience in all patients treated over a 1-year period. Patients and methods Between June 2007 and June 2008, 68 patients (mean age 50 years) underwent transvaginal cholecystectomy with an additional 5-mm umbilical trocar using rigid laparoscopic instruments. Data about symptoms, operation, and postoperative course were prospectively collected, as were findings of a gynecological follow-up examination 1 week after surgery and the results of an interview at least 3 months after surgery. Results All 68 operations were finished successfully without conversion, with a mean operation time of 51 minutes; in three additional cases severe pelvic adhesions prevented further transvaginal progress. There were no intraoperative or immediately postoperative complications, but one patient presented with a Douglas pouch abscess 3 weeks after surgery. Gynecologic follow-up exams 1 week after surgery were unremarkable. All patients were interviewed 3-10 months after surgery and had no abdominal or gynecological complaints including in relation to sexual intercourse. Conclusion Transvaginal NOTES cholecystectomy with rigid instruments can be safely and effectively performed in daily routine.

Laparoscopic surgery has decreased trauma and improved results and natural orifice transluminal endoscopic surgery (NOTES) should be a further step in this direction. However the use of flexible gastroscopes in the abdomen is difficult and the generally chosen transgastric approach is not without risk. Therefore we have carried out a cholecystectomy with a combined transvaginal and transumbilical approach, using laparoscopic instruments. The optic and a dissector were inserted in the posterior fornix of the vagina, and a 5-mm trocar was inserted deep in the umbilicus. After dissection the gallbladder was removed through the vagina. The operation was done without problems within 85 minutes and left no visible scar. The postoperative course was uneventful. In NOTES the transvaginal approach has important advantages over the transgastric method (e. g. regarding sterilization and closure); standard laparoscopic instruments can be used whilst there are no flexible endoscopes that are easier to handle.