Surgical Endoscopy

, Volume 25, Issue 6, pp 1822–1826 | Cite as

NOTES cholecystectomy: matched-pair analysis comparing the transvaginal hybrid and conventional laparoscopic techniques in a series of 216 patients

  • Carsten ZornigEmail author
  • Linn Siemssen
  • Alice Emmermann
  • Margrit Alm
  • Hans A. von Waldenfels
  • Conrad Felixmüller
  • Hamid Mofid



Natural orifice transluminal endoscopic surgery (NOTES) is currently a very important topic for both gastroenterologists and surgeons. We have developed a technique of transvaginal hybrid NOTES cholecystectomy (TVC) that leaves no visible scar and is applicable to daily use. This technique is compared to the conventional laparoscopic cholecystectomy (CLC) in a matched-pair analysis.


From June 2007 until February 2009, 108 NOTES cholecystectomies were performed. For a matched-pair analysis we first selected a group of 192 female patients who had undergone CLC and who were operated on by the same group of surgeons in the same time period. Then 108 pairs who had TVC were matched according to the degree of inflammation of the gallbladder and age. We were able to contact 208 patients at least 3 months after surgery. Hence, the study analysis was performed with 100 complete pairs.


All 200 cholecystectomies were performed successfully without conversion. The TVC procedure was significantly longer than CLC (52 vs. 35 min, p < 0.001). There were no intraoperative complications in either group. There were no significant differences with respect to reoperations, wound infections, consumption of analgesic drugs, length of hospital stay, and sick leave. Seventy-five TVC and 73 CLC patients had sexual intercourse after the operation without any complaints.


We present here the largest series of NOTES for cholecystectomy published to date and the first comparative study with the gold standard. The TVC technique is as successful as the CLC, it causes no more complications than CLC, especially with respect to the vaginal approach, it is more time-consuming to perform, but has an ideal cosmetic result, i.e., no visible scar.


NOTES Transvaginal cholecystectomy Comparative study 



We thank Prof. Wegscheider and Dr. Treszl of the Institut für Biometrie und Epidemiologie, Universitätskrankenhaus Eppendorf, Hamburg, for their help in the statistical analysis of this study.


Prof. Zornig and Dres. Mofid, Siemssen, Emmermann, Alm, von Waldenfels, and Felixmüller have no conflicts of interest or financial ties to disclose.


  1. 1.
    Fong DG, Rai RD, Thompson CC (2007) Transcolonic endoscopic abdominal exploration: a NOTES survival study in a porcine model. Gastrointest Endosc 65:312–318PubMedCrossRefGoogle Scholar
  2. 2.
    Fong DG, Ryou M, Pai RD, Tavakkolizadeh A, Rattner DW, Thompson CC (2007) Transcolonic ventral hernia mesh fixation in a porcine model. Endoscopy 39:865–869PubMedCrossRefGoogle Scholar
  3. 3.
    Fritscher-Ravens A, Mosse CA, Ikeda K, Swain P (2006) Endoscopic transgastric lymphadenectomy by using EUS for selection and guidance. Gastrointest Endosc 63:302–306PubMedCrossRefGoogle Scholar
  4. 4.
    Jagannath SB, Kantesevoy SV, Vaughn CA, Chung SS, Cotton PB, Gostout CJ, Hawes RH, Pasricha PJ, Scorpio DG, Magee CA, Pipitone LJ, Kalloo AN (2005) Peroral transgastric endoscopic ligation of fallopian tubes with long-term survival in porcine model. Gastrointest Endosc 61:449–453PubMedCrossRefGoogle Scholar
  5. 5.
    Kantsevoy SV, Hu B, Jagannath SB, Vaughn CA, Beitler DM, Chung SS, Cotton PB, Gostout CJ, Hawes RH, Pasricha PJ, Magee CA, Pipitone LJ, Talamini MA, Kalloo AN (2006) Transgastric endoscopic splenectomy. Is it possible? Surg Endosc 20:522–525PubMedCrossRefGoogle Scholar
  6. 6.
    Kantsevoy SV, Jagannath SB, Niiyama H, Chung SS, Cotton PB, Gostout CJ, Hawes RH, Pasricha PJ, Magee CA, Vaughn CA, Barlow D, Shimonaka H, Kalloo AN (2005) Endoscopic gastrojejunostomy with survival in a porcine model. Gastrointest Endosc 62:287–292PubMedCrossRefGoogle Scholar
  7. 7.
    Lima E, Henriques-Coelho T, Rolanda C, Pêgo JM, Silva D, Carvalho JL, Correia-Pinto J (2007) Transvesical thoracoscopy: a natural orifice transluminal endoscopic approach for thoracic surgery. Surg Endosc 21:854–858PubMedCrossRefGoogle Scholar
  8. 8.
    Matthes K, Yusuf TE, Willingham FF, Mino-Kenudson M, Rattner DW, Brugge WR (2007) Feasibility of endoscopic transgastric distal pancreatectomy in the porcine animal model. Gastrointest Endosc 66:762–766PubMedCrossRefGoogle Scholar
  9. 9.
    Pai RD, Fong DG, Bundga ME, Odze RD, Rattner DW, Thompson CC (2006) Transcolonic endoscopic cholecystectomy: a NOTES survival study in a porcine model. Gastrointest Endosc 64:428–434PubMedCrossRefGoogle Scholar
  10. 10.
    Park PO, Bergström M, Ikeda K, Fritscher-Ravens A, Swain P (2005) Experimental studies of transgastric gallbladder surgery: cholecystectomy and cholecystogastric anastomosis. Gastrointest Endosc 61:601–606PubMedCrossRefGoogle Scholar
  11. 11.
    Wagh MS, Merrifield BF, Thompson CC (2006) Survival studies after endoscopic transgastric oophorectomy and tubectomy in a porcine model. Gastrointest Endosc 63:473–478PubMedCrossRefGoogle Scholar
  12. 12.
    Fritscher-Ravens A, Patel K, Ghanbari A, Kahle E, von Herbay A, Fritscher T, Niemann H, Koehler P (2007) Natural orifice transluminal endoscopic surgery (NOTES) in the mediastinum: long term survival animal experiments in transoesophageal access, including minor surgical procedures. Endoscopy 9:870–875CrossRefGoogle Scholar
  13. 13.
    Sanchez-Margallo FM, Asencio JM, Tejonero MC, Pérez FJ, Sánchez MA, Usón J, Pascual S (2008) Technical feasibility of totally natural orifice cholecystectomy in a swine model. Minim Invasive Ther Allied Technol 17:361–364PubMedCrossRefGoogle Scholar
  14. 14.
    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 66:1243–1245PubMedCrossRefGoogle Scholar
  15. 15.
    Marescaux J, Dallemagne B, Perretta S, Wattiez A, Mutter D, Coumaros D (2007) Surgery without scars: report of transluminal cholecystectomy in a human being. Arch Surg 142:823–826PubMedCrossRefGoogle Scholar
  16. 16.
    Zorrón R, Filgueiras M, Maggioni LC, Pombo L, Lopes Carvalho G, Lacerda Oliveira A (2007) NOTES. Transvaginal cholecystectomy: report of the first case. Surg Innov 14:279–283PubMedCrossRefGoogle Scholar
  17. 17.
    Branco AW, Branco Filho AJ, Kondo W, Noda RW, Kawahara N, Camargo AA, Stunitz LC, Valente J, Rangel M (2008) Hybrid transvaginal nephrectomy. Eur Urol 53:1290–1294PubMedCrossRefGoogle Scholar
  18. 18.
    Zorron R, Maggioni LC, Pombo L, Oliveira AL, Carvalho GL, Filgueiras M (2008) NOTES transvaginal cholecystectomy: preliminary clinical application. Surg Endosc 22:542–547PubMedCrossRefGoogle Scholar
  19. 19.
    Ramos AC, Zundel N, Neto MG, Maalouf M (2008) Human hybrid NOTES transvaginal sleeve gastrectomy: initial experience. Surg Obes Relat Dis 4:660–663PubMedCrossRefGoogle Scholar
  20. 20.
    Noguera JF, Dolz C, Cuadrado A, Olea JM, Vilella A (2008) Transvaginal liver resection (NOTES) combined with minilaparoscopy. Rev Esp Enferm Dig 100:411–415PubMedCrossRefGoogle Scholar
  21. 21.
    Lacy AM, Delgado S, Rojas OA, Almenara R, Blasi A, Llach J (2008) MA-NOS radical sigmoidectomy: report of a transvaginal resection in the human. Surg Endosc 22:1717–1723PubMedCrossRefGoogle Scholar
  22. 22.
    Bernhardt J, Gerber B, Schober HC, Kähler G, Ludwig K (2008) NOTES, case report of a unidirectional flexible appendectomy. Int J Colorectal Dis 23:547–550PubMedCrossRefGoogle Scholar
  23. 23.
    Zornig C, Emmermann A, von Waldenfels HA, Mofid H (2007) Laparoscopic cholecystectomy without visible scar: combined transvaginal and transumbilical approach. Endoscopy 39:913–915PubMedCrossRefGoogle Scholar
  24. 24.
    Zornig C, Mofid H, Emmermann A, Alm M, von Waldenfels HA, Felixmüller C (2008) Scarless cholecystectomy with combined transvaginal and transumbilical approach in a series of 20 patients. Surg Endosc 22:1427–1429PubMedCrossRefGoogle Scholar
  25. 25.
    Zornig C, Mofid H, Siemssen L, Emmermann A, Alm M, von Waldenfels HA, Felixmüller C (2009) Transvaginal NOTES hybrid cholecystectomy: feasibility results in 68 cases with mid-term follow-up. Endoscopy 41:391–394PubMedCrossRefGoogle Scholar
  26. 26.
    Johnson N, Barlow D, Lethaby A, Tavender E, Curr E, Garry R (2006) Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 2:CD003677PubMedGoogle Scholar
  27. 27.
    Voitk AJ, Tsao SG (2001) The umbilicus in laparoscopic surgery. Surg Endosc 15:878–881PubMedCrossRefGoogle Scholar
  28. 28.
    Rattner D, Kalloo A, ASGE/SAGES Working Group (2005) ASGE/SAGES Working Group on Natural Orifice Translumenal Endoscopic Surgery, October 2005. Surg Endosc 20:329–333CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Carsten Zornig
    • 1
    Email author
  • Linn Siemssen
    • 1
  • Alice Emmermann
    • 1
  • Margrit Alm
    • 1
  • Hans A. von Waldenfels
    • 2
  • Conrad Felixmüller
    • 2
  • Hamid Mofid
    • 1
  1. 1.Department of SurgeryIsraelitisches KrankenhausHamburgGermany
  2. 2.Praxisklinik Winterhude for Gynecology and ObstetricsHamburgGermany

Personalised recommendations