Techniques of transvaginal access for NOTES

Vaginal access for natural orifice surgery has been successfully used for abdominal surgery since 2007. Various techniques of access have been developed for the purpose of introduction of endoscopes, specific vaginal ports, longer laparoscopic trocars, and for specimen extraction. This article discusses technical aspects, human casuistic, and rationale of natural orifice translumenal endoscopic surgery (NOTES) vaginal access. Vaginal access can be performed by direct vision using conventional instruments or by first introduction of an umbilical laparoscope to visualize the introduction of a transvaginal trocar. Insufflation through the endoscope's channel should be avoided and preferentially achieved by transvaginal insufflation, Veress needle, or laparoscopic trocar. Abdominal procedures may be approached transvaginally classified as Totally NOTES, Hybrid NOTES, NOTES-assisted laparoscopy, or using natural orifice only for specimen extraction (NOSE). Vaginal wound is usually closed with absorbable sutures under direct vision using conventional instruments. Vaginal gynecologic surgery has been used for more than a century, with low complication rates and good results. Initial clinical series of NOTES transvaginal surgery showed feasibility of the method, mostly still using hybrid techniques. The preliminary results of published clinical data showed feasibility and safety of the transvaginal NOTES method for a small initial study population. Different techniques for vaginal access still show prevalence of hybrid techniques with laparoscopy, thus claiming for new technology to allow pure NOTES techniques. Instead of transgastric or transcolonic NOTES accesses, transvaginal approach seems a logical solution for initial applications, as it avoids penetration in gastrointestinal lumen, has simple opening and closure, and has a historical low rate of issues for gynecologic applications.