Surgical Endoscopy

, Volume 24, Issue 10, pp 2424–2431 | Cite as

Transvaginal natural orifice translumenal endoscopic surgery (NOTES): a survey of women’s views on a new technique

  • Andrew D. Strickland
  • Michael G. A. Norwood
  • Fariba Behnia-Willison
  • Santosh A. Olakkengil
  • Peter J. Hewett



Laparoscopic and minimally invasive surgery has changed the surgical landscape irrevocably. Natural orifice translumenal endoscopic surgery (NOTES) offers the possibility of surgery without visible scars. Transvaginal entry offers potential benefits because it gains access to the peritoneal cavity without the need to open an abdominal viscus. Much of the discussion pertaining to NOTES focuses on technical and training issues, with little attention to date paid to the opinions of women. The perceptions of female health care workers and patients were sought in relation to their views on transvaginal NOTES.


This study surveyed 300 women using a 12-point questionnaire devised by a multidisciplinary group of surgeons interested in minimally invasive surgery. The questionnaire was designed to establish the opinions of women with respect to NOTES surgery versus standard laparoscopic procedures. Responses were de-identified.


Three-fourths of the women surveyed were neutral or unhappy about the prospect of a NOTES procedure, and this remained constant even when it was stipulated that laparoscopic cholecystectomy and NOTES had equivalent safety and efficacy. Younger nulliparous women were most concerned about the potential negative effect of NOTES on sexual function. A minority were concerned about the cosmetic effect of surgery, although surgical scars were perceived as more important to younger respondents.


Potentially, NOTES surgery offers women a scarless operation with the possibility of less pain than experienced in standard laparoscopic surgery. Few women, however, were troubled about the cosmetic effect of surgery. The effect of NOTES on sexual function was expressed as a particular concern by younger women. In all groups and across all ages, peritoneal access using the transvaginal route was met by significant scepticism. In Australia, women remain to be convinced about the potential advantages of the emerging NOTES technology.


NOTES Patient perceptions Questionnaire Transvaginal cholecystectomy 


  1. 1.
    Vigano l, Tayar C, Laurent A, Cherqui D (2009) Laparoscopic liver surgery: a systematic review. J Hepatobiliary Pancreat Surg 16:410–421CrossRefPubMedGoogle Scholar
  2. 2.
    Uranues S, Alimoglu O (2005) Laparoscopic surgery of the spleen. Surg Clin North Am 85:785–790CrossRefGoogle Scholar
  3. 3.
    Gurusamy K, Junnarkar S, Farouk M, Davidson BR (2008) Meta-analysis of randomized controlled trials and effectiveness of day-case laparoscopic cholecystectomy. Br J Surg 95:161–168CrossRefPubMedGoogle Scholar
  4. 4.
    Wattiez A, Cohen SB, Selvaggi L (2002) Laparoscopic hysterectomy. Curr Opin Obstet Gynecol 14:417–422CrossRefPubMedGoogle Scholar
  5. 5.
    Giger UF, Michel JM, Opitz I, Th Inderbitzin D, Kocher T, Krahenbuhl L (2006) Risk factors for perioperative complications in patients undergoing laparoscopic cholecystectomy: analysis of 22,953 consecutive cases from the Swiss Association of Laparoscopic and thoracoscopic Surgery database. J Am Coll Surg 203:723–728CrossRefPubMedGoogle Scholar
  6. 6.
    Kalloo AN, Singh VK, Jagannath SB, Niiyama H, Hill SL, Vaughn CA, Magee CA, Kantsevoy SV (2004) Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity. Gastrointest Endosc 60:114–117CrossRefPubMedGoogle Scholar
  7. 7.
    Bessler M, Stevens PD, Milone L, Parikh M, Fowler D (2007) Transvaginal laparoscopically assisted endoscopic cholecystectomy: a hybrid approach to natural orifice surgery. Gastrointest Endosc 66:1243–1245CrossRefPubMedGoogle Scholar
  8. 8.
    Palanivelu C, Rajan PS, Rangaranjan M, Parthasarathi R, Senthilnathan P, Prasad M (2008) Transvaginal endoscopic appendectomy in humans: a unique approach to NOTES: world’s first report. Surg Endosc 22:1343–1347CrossRefPubMedGoogle Scholar
  9. 9.
    Willingham FF, Brugge WR (2007) Taking NOTES: translumenal flexible endoscopy and endoscopic surgery. Curr Opin Gastroenterol 23:550–555CrossRefPubMedGoogle Scholar
  10. 10.
    Gumbs AA, Fowler D, Milone L, Evanko JC, Ude AO, Stevens P, Bessler M (2009) Transvaginal natural orifice translumenal endoscopic surgery cholecystectomy: early evolution of the technique. Ann Surg 249:908–912CrossRefPubMedGoogle Scholar
  11. 11.
    Yan SL, Thompson-Fawcett M (2009) NOTES: a new dimension of minimally invasive surgery. ANZ J Surg 79:583–602CrossRefGoogle Scholar
  12. 12.
    Boni L, Dionigi G, Rovera F (2009) Natural orifices transluminal endoscopic surgery (NOTES) and other allied “ultra” minimally invasive procedures: are we loosing the plot? Surg Endosc 23:927–929CrossRefPubMedGoogle Scholar
  13. 13.
    Maddern GJ (2009) NOTES: progress or marketing? ANZ J Surg 79:337–343CrossRefGoogle Scholar
  14. 14.
    Peterson CY, Ramamoorthy S, Andrews B, Horgan S, Talamini M, Chock A (2009) Women’s positive perception of transvaginal NOTES surgery. Surg Endosc 23:1770–1774CrossRefPubMedGoogle Scholar
  15. 15.
    Swanstrom LL, Volckmann E, Hungness E, Soper NJ (2009) Patient attitudes and expectations regarding natural orifice translumenal endoscopic surgery. Surg Endosc 23:1519–1525CrossRefPubMedGoogle Scholar
  16. 16.
    Varadarajulu S, Tamhane A, Drelichman ER (2008) Patient perception of natural orifice transluminal endoscopic surgery as a technique for cholecystectomy. Gastrointest Endosc 67:854–860CrossRefPubMedGoogle Scholar
  17. 17.
    El-Toukhy TA, Hefni MA, Davies AE, Mahadevan S (2004) The effect of different types of hysterectomy on urinary and sexual functions: a prospective study. J Obstet Gynaecol 24:420–425CrossRefPubMedGoogle Scholar
  18. 18.
    Dallenbach P, Kaelin-Gambirasio I, Jacob S, Dubuisson JB, Boulvain M (2008) Incidence rate and risk factors for vaginal vault prolapse after hysterectomy. Int Urogynecol J Pelvic Floor Dysfunct 19:1623–1629CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Andrew D. Strickland
    • 1
  • Michael G. A. Norwood
    • 1
  • Fariba Behnia-Willison
    • 1
  • Santosh A. Olakkengil
    • 1
  • Peter J. Hewett
    • 1
  1. 1.Department of SurgeryThe Queen Elizabeth Hospital, University of AdelaideAdelaideAustralia

Personalised recommendations