Appendectomy is one of the more common surgical procedures that is performed throughout the United States each year despite decreasing in annual incidence. Open and laparoscopic appendectomy procedures are current standard treatments for non-complicated appendicitis, but advances in surgical techniques are continuing to emerge to further reduce postoperative pain and recovery time. One such procedure is natural orifice transluminal endoscopic surgery (NOTES) for performing transgastric appendectomy.

Transvaginal surgery is one component of NOTES that is gaining momentum for use in appendectomy and cholecystectomy. Transvaginal appendectomy (TVA) is a procedure performed via a single port that is inserted through the posterior vaginal fornix. The surgery is a type of NOTES that allows for appendectomy without visible scars. “NOTES has been at the forefront of minimally invasive surgery since it first emerged in 2004,” says Kurt E. Roberts, MD. “Some studies have described laparoscopic assisted TVAs for acute appendicitis in the surgical literature. However, pure TVAs have been limited to only one single-case report in Germany.”

Data on the Safety & Efficacy of TVA

Exploring the safety and efficacy of pure TVAs and comparing them with traditional laparoscopic appendectomy are important, according to Dr. Roberts. In the February 2012 Annals of Surgery, he and his colleagues published a study that compared a series of patients who underwent TVA with those who received conventional three-port laparoscopic appendectomy. TVA was offered to 42 women, 18 of whom agreed to undergo the surgery while two others declined it. The remaining 22 women were considered the control group, receiving three-port laparoscopic appendectomy.

Patients in the TVA arm required significantly less pain medication and returned to normal activities and work significantly sooner (Figures 1 and Figure 2, respectively), according to the study. The amount of patient controlled analgesia (PCA) used in the TVA group in the first 12 hours was 8 mg, compared with 23 mg for the control arm. The study also found that only one TVA case required a conversion to three-port appendectomy. Operative times were also similar between both patient groups, and complications were minor, occurring in two patients in each group. Dr. Roberts noted that there is a potential bias because the Annals of Surgery study is a cohort analysis. Further studies, including randomized controlled trials, are necessary to confirm these early promising results.

Learning Curve for Transvaginal NOTES

Only one incision is made for both single-incision laparoscopic surgery and transvaginal NOTES procedures, and the applied laparoscopic techniques are the same. “Because of these commonalities, it’s likely that the learning curve is similarly rapid,” says Dr. Roberts. He is one of the few surgeons in the world who has had a great deal of experience with TVA. Dr. Roberts has successfully performed more than 75 transvaginal cholecystectomies and appendectomies. He believes that both procedures will eventually become accepted alternatives to abdominal surgeries. “Women who declined to have TVA did so because the surgery was too new and experimental or because they were uncomfortable with having a procedure requiring vaginal access,” he added.

It’s likely that transvaginal NOTES will eventually become part of the repertoire of minimally invasive surgeons.

— Kurt E. Roberts, MD

While the feasibility of TVA was demonstrated in the analysis, Dr. Roberts says it is important to remember that patients were a part of a select group. Furthermore, TVA can be performed with existing laparoscopic instruments. “NOTES has been done previously by entering the stomach and rectum, but we’re still years away from having proper instrumentation for transgastric or transrectal surgery,” he says. “The hope is that instrumentation will improve and surgical techniques will be enhanced as more surgeons become familiar with NOTES. The transvaginal and single-port approaches should be considered important stepping stones in the evolution of minimally invasive surgery.”

 More to Come for Transvaginal Surgery

In light of their results, Dr. Roberts and colleagues have begun to offer transvaginal approaches to more women with appendicitis as well as to those requiring cholecystectomy and ventral hernia repair. “We’ve also been examining its application in sleeve gastrectomy,” he says. “Transvaginal surgery still requires investigational protocols and more randomized controlled trials, however. At the same time, it’s likely that transvaginal NOTES will eventually become part of the repertoire of minimally invasive surgeons.” On May 4, 2012, Dr. Roberts will be conducting a CME course at Yale University that addresses the NOTES procedure. He is also one of the program chairs of the 2012 International Natural Orifice Transluminal Endoscopic Surgery Annual meeting, which is being held in Chicago from July 12 to 14. For more information, go to