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J Minim Invasive Gynecol. 2014 Sep-Oct;21(5):818-24. doi: 10.1016/j.jmig.2014.03.011. Epub 2014 Mar 25.

Hysterectomy by transvaginal natural orifice transluminal endoscopic surgery (NOTES): a series of 137 patients.

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  • 1Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital at Linkou and University College of Medicine, Taiwan, Republic of China.
  • 2Department of Obstetrics and Gynecology, Chung Shan Medical University Hospital, Taichung, Taiwan, Republic of China.
  • 3Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital at Linkou and University College of Medicine, Taiwan, Republic of China; Graduate Institute of Clinical Medical Sciences, Chang Gung University College of Medicine, Tao-Yuan, Taiwan, Republic of China. Electronic address:



To evaluate the feasibility and safety of hysterectomy in benign disease using transvaginal natural orifice transluminal endoscopic surgery (NOTES).


Prospective observational study (Canadian Task Force classification II-3).


Tertiary referral medical center.


From May 2010 to August 2011, consecutive patients who were scheduled to undergo laparoscopic hysterectomy and without virginity or suspected pelvic inflammation or cul-de-sac obliteration were included.


Total hysterectomy via transvaginal NOTES.


The study included 137 patients, with mean (SEM) age 46.0 (0.4) years and body mass index 24.7 (0.4). Transvaginal NOTES was successfully performed in 130 patients (94.9%). Fifteen patients underwent concurrent adhesiolysis, and 17 underwent adnexal procedures. Mean (SEM) uterine weight was 450.0 (24.1) g; in 45 patients (34.6%), uterine weight was >500 g, and in 7 (5.4%) it was >1000 g. Operative time was 88.2 (4.1) minutes, with blood loss of 257.7 (23.9) mL. In 2 patients there was intraoperative hemorrhage or unintended cystotomy, and in another 5 transvaginal colpotomy failed because of a narrow vagina, cul-de-sac obliteration by bowel adhesions, or mass obstruction. Complications in these 7 patients (5.1%) were successfully managed via transabdominal laparoscopy. Five patients (3.6%) experienced postoperative urinary retention or febrile morbidity, and recovered uneventfully with conservative treatment.


Transvaginal NOTES is a feasible technique for performance of hysterectomy and can be used in procedures that are difficult to complete via conventional vaginal surgery because posterior colpotomy is achievable. This procedure was not impeded by uterine volume, and had the advantage of no abdominal incision.

Copyright © 2014 AAGL. Published by Elsevier Inc. All rights reserved.


Hysterectomy; Laparoscopy; Natural orifice transluminal endoscopic surgery (NOTES); Vaginal surgery

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