• Dirk R Bulian, Georg Kaehler, Richard Magdeburg, Michael Butters, Jens Burghardt, Roland Albrecht, Joern Bernhardt, Markus M Heiss, Heinz J Buhr, and Kai S Lehmann.
• *Department of Abdominal, Vascular and Transplant Surgery, Cologne-Merheim Medical Center (CMMC), Witten/Herdecke University, Cologne, Germany †Central Interdisciplinary Endoscopy, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany ‡Surgical Department, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany §Department of Surgery, Krankenhaus Bietigheim, Bietigheim-Bissingen, Germany ¶Department of Surgery, Evangelisch-Freikirchliches Krankenhaus Rüdersdorf, Rüdersdorf, Germany ||Department of Visceral and Vascular Surgery, HELIOS Klinikum Aue, Germany **Department of Diagnostic und Interventional Endoscopy, Klinikum Suedstadt, Rostock, Germany ††German Society for General and Visceral Surgery, Berlin, Germany ‡‡Department of General, Visceral and Vascular Surgery, Charité University Medical Center Berlin, Campus Benjamin Franklin, Berlin, Germany.
• Ann. Surg. 2017 Mar 1; 265 (3): 534-538.

ObjectiveTo analyze the feasibility and safety of Natural Orifice Transluminal Endoscopic Surgery (NOTES) appendectomy, and to analyze separately the transvaginal appendectomy (TVAE) and the transgastric appendectomy (TGAE) procedures.BackgroundLaparoscopic appendectomy has rare but relevant complications, namely incisional hernias and neuralgia at the trocar sites, which can potentially be avoided by the NOTES techniques.MethodsThe first 217 data sets of the largest NOTES registry worldwide-the German NOTES registry-were analyzed with respect to demographic data, procedural data, and short-term outcomes. Furthermore, TVAEs were compared with TGAEs.ResultsAlmost all procedures were performed in hybrid technique (median of percutaneous trocars: 1). Median age (TVAE: 30.5 yrs vs TGAE: 25 yrs; P < 0.017), body mass index (TVAE: 22.8 kg/m vs TGAE: 24.1 kg/m; P < 0.016), and American Society of Anesthesiologists (ASA) classification (I/II/III; TVAE: 57.1%/41.8%/1.0% vs TGAE: 27.8%/69.4%/2.8%; P < 0.003) significantly differed between both access techniques. Whereas the median number of percutaneous trocars (TVAE: 1 vs TGAE: 1; P < 0.450), the need of additional trocars (TVAE: 6.6% vs TGAE: 13.9%; P < 0.156), the intra, and also postoperative rate of complications (TVAE: 0%/5.5% vs TGAE: 0%/11.1%; P < 1.000/0.258), and the median postoperative hospital stay (TVAE: 3 d vs TGAE: 3 d; P < 0.152) were comparable; the median procedural time (TVAE: 35 minutes vs TGAE: 96 minutes; P < 0.001) and conversion to laparotomy rate (TVAE: 0% vs TGAE: 5.6%; P < 0.023) were significantly less after TVAE.ConclusionsThe evaluation of the largest patient collective so far indicates that hybrid NOTES appendectomy is a safe procedure, with advantages for the transvaginal technique with respect to procedural time and conversion rate.

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