The most reported NOTES procedure is cholecystectomy. Five different authors have published their experiences with transvaginal cholecystectomy [9–13]. The largest NOTES cholecystectomy series in Asia was reported by Niu et al. from China [13]. They retrospectively compared the clinical results of 43 transvaginal cholecystectomies with those of 48 conventional laparoscopic cholecystectomies. Transvaginal cholecystectomy was performed with a transvaginal flexible endoscope, a 5 mm laparoscopic grasper introduced through the vagina for retraction of the gallbladder, and a single umbilical trocar. The cystic duct and artery were clipped with laparoscopic clips through the umbilical trocar. Transvaginal cholecystectomies were successfully completed in all patients without conversion to conventional laparoscopic surgery, and there were no intra- or postoperative complications in any patients. The operation time for the NOTES cholecystectomies was longer than that of conventional laparoscopic cholecystectomies (87 vs. 60 min, P < 0.05). However, postoperative pain, hospital stay, and the cost of hospitalization with NOTES were less than those with the conventional laparoscopic operation. Sohn et al. from Korea applied a single-port access system with a wound retractor and a surgical glove at the vaginal port to improve operation efficiency [12]. Their mean operation time was 86 min.

All other series were performed in a hybrid fashion using laparoscopic assistance with one or two trocars, and no serious complications were reported. The additional trocar seems to be an optimal way to perform NOTES cholecystectomy safely and easily at the present time with the current lack of availability of NOTES-specific devices.

Rao and Reddy from India were the first in the world to perform a transgastric appendectomy [9]. Appendectomies were completed using a double-channel endoscopes without laparoscopic assistance. Transgastric access was achieved with a needle knife and balloon dilation. The mesoappendix was dissected using a hot biopsy forceps with monopolar coagulation current. The appendix was secured with an endoloop and then transected using a polypectomy snare. The gastric access site was closed with multiple endoscopic clips. Two out of ten cases required conversion to conventional laparoscopic operation. Postoperative ileus was noted in one patient and needle knife injury to the abdominal wall in one other.

Palanivelu et al. from India reported 6 attempts at pure NOTES appendectomy with two patients requiring laparoscopic assistance and three requiring conversion to conventional laparoscopic operation [14]. There were no complications, and the hospital stay averaged 1–2 days.

Kitano, Yasuda et al. performed transgastric peritoneoscopy for preoperative staging in a pancreatic cancer patient in 2008 [16]. This was the first case of NOTES performed in Japan. The submucosal tunneling technique was used in combination with ESD methods, after confirming the safety and feasibility of this technique in experimental studies [31–34]. After injection of normal saline solution into the gastric submucosal layer, a 2 cm incision of the mucosa into the submucosal cushion was created (Fig. 22.1a). Dissection of the submucosal layer was then carried out with an ESD knife to make a narrow longitudinal submucosal tunnel approximately 5 cm long (Fig. 22.1b). A small incision of the seromuscular layer was made at the end of the submucosal tunnel, and the opening was enlarged with an endoscopic dilation balloon. The endoscope was then advanced into the peritoneal cavity through the tunnel, which provided an excellent view. After we confirmed no hepatic or peritoneal metastasis, the patient underwent a standard open operation without complications. We have performed 14 cases of transgastric submucosal peritoneoscopy. In some cases, peritoneal or liver metastasis was able to be diagnosed with transgastric peritoneoscopy before operation (Fig. 22.1c–e).