since its original description by mc burney in 1894 , appendectomy has been one of the most common surgical procedures performed by surgeons . in the last decades , laparoscopic appendectomy was an increasingly accepted treatment method for acute appendicitis , particularly for obese or female patients . natural orifice transluminal endoscopic surgery ( notes ) is a new approach that allows for minimal invasive surgery through the natural orifices such as mouth , anus , or vagina . less incision on the abdomen helps to reduce surgical pain , analgesic requirement , recovery time , hernia formation , intra - abdominal adhesion , and surgical site infection . however , notes has several disadvantages and limitations with the currently available instruments , including limited access and less familiar working angles and operative views . in the past few years this study aimed to summarize the recent clinical appraisals , feasibility , complications , and limitations of transvaginal appendectomy for humans and to outline techniques . electronic searches in december 2013 of the pubmed / medline , cochrane , google scholar , and ebscohost - academic search complete , including cinahl , used the key words [ ( vaginal or transvaginal ) and ( appendectomy or appendectomies or appendicectomy or appendicectomies ) ] . all the studies including congress proceedings and abstracts that describe the clinical course of patients were accepted for the analysis . two reviewers ( mehmet ali yagci and cuneyt kayaalp ) assessed the list of titles and/or abstracts of the scanned articles at pubmed / medline and cochrane using the key words in a function of [ all fields ] . if the articles met our inclusion criteria , full - text versions were obtained for assessment . if the articles were obviously irrelevant to the aim of this systematic review , they were excluded . additional studies were also excluded due to their content ( editorial letters , reviews , experimental studies , duplicated studies , technical notes not including patient data , and survey studies including questionnaires ) . after pubmed and cochrane searches , we scanned the ebscohost - academic search complete and google scholar databases with the same key words but using the [ title ] function . if any additional studies were found , they were added to the first search results . the unpublished , potentially relevant , trials at the registered trials database at https://www.clinicaltrials.gov/ were searched as well . the references of the selected relevant articles were cross checked to decrease the possibility of missing publications . transvaginal appendectomy was defined as a way of natural orifice translumenal endoscopic surgery for the appendix . all the patients were included , irrespective of age , region , race , obesity , comorbidities , or history of previous surgery . no restrictions were made on language , country , or journal . in cases of disagreement during the study selection and analysis data for affiliation , number of the patients , age , clinical findings , inclusion and exclusion criteria , body mass index , history of previous abdominal surgery , trocar sites ( pure or hybrid ) and types , scope site and types ( flexible or rigid ) , vaginal access and colpotomy closure techniques , intraoperative and postoperative complications , operating time , conversion to conventional laparoscopy or open surgery , postoperative pain , length of hospital stay , time off work , long term sexual function , and cosmetic satisfaction were recorded . a computer program including spreadsheet was used for records ( excel 2013 , microsoft windows ) . if there were any missing data , we tried to contact the authors via e - mail . data were tabulated in tables , and column sums were created with the numbers or the means  standard deviations , or the ranges of relevant parameters . when studies reported the median and range , we estimated the mean and standard deviation using the method described by hozo et al . . basic calculations were used for the total numbers of the dichotomous outcomes and weighted means with ranges for the continuous outcomes . chi - square test or the fisher exact test ( if expected values were less than 5 ) and student 's t - test were used for statistical analysis of both dichotomous and continuous variables ( spss 13.0 ) . a total of 154 articles were retrieved from the pubmed / medline database and no additional study was available in the cochrane library . after the elimination of the 96 irrelevant studies , google scholar , ebscohost - academic search complete , https://www.clinicaltrials.gov/ , and reference cross - checking defined 26 , 17 , 6 , and 2 studies , respectively ( figure 1 ) . after the elimination of repetitive studies in several databases or sources , seven studies were added to the previously selected 58 articles . studies including inadequate patient data , concomitant hysterectomy , experimental studies , and duplicated data were eliminated and finally 13 articles [ 315 ] were selected for the analysis ( figure 1 ) . two studies [ 10 , 11 ] belonged to the same clinical series and their data were complementary ( early and late results ) . as a result , we analyzed 12 clinical studies contained in 13 articles . some studies had duplicated results [ 1622 ] and their latest or the most comprehensive versions were accepted for the analysis [ 6 , 1013 ] . there were a total of 112 transvaginal appendectomies . studies originated in europe , north / south america , and asia , and two of them included international multicenter data [ 6 , 13 ] . publications were generally ( 11/13 ) in english but one was in german , and one was in japanese . the patients ' ages were generally in the mid - twenties or mid - thirties ; however , there was a large age range ( 1874 years ) . all the patients were in the american society of anesthesia ( asa ) i - ii scores . a diagnosis of complicated appendicitis ( perforation , abscess , and mass ) was usually an exclusion criterion . kg / m ) were also excluded , and the mean body mass index of the patients in this systematic review was 23.2  kg / m ( table 2 ) [ 4 , 79 , 13 , 14 ] . previous abdominal or pelvic surgery was not an exclusion criterion in all studies and 11% of the patients had a history of abdominal or pelvic surgery [ 9 , 15 ] . most of the cases ( 96% ) were of acute appendicitis , while others ( 4% ) were chronic appendicitis or incidental appendectomies . four of them were intraoperative complications : appendicular artery hemorrhage ( n : 3 ) and inability to sustain the pneumoperitoneum ( n : 1 ) . those cases required additional abdominal trocar access and were accepted as a conversion to conventional laparoscopy ( 3.6% ) , but no case required conversion to open surgery . postoperative complications occurred in five patients and all were treated by nonsurgical methods ( table 3 ) . intra - abdominal abscess , urinary retention , urinary infection , and dyspareunia were treated by percutaneous drainage plus antibiotics , foley catheter placement , antibiotics , and just waiting , respectively . the mean length of hospital stay was longer in the german series ( 3.4 days ) because of their national health system , [ 3 , 9 ] , and the mean length of hospital stay was 1.25 days for the rest of the studies . some studies used only the transvaginal access , called a pure or totally transvaginal appendectomy . others used an abdominal assistance ( usually a 5  mm umbilical trocar ) to the transvaginal access and are called a hybrid technique ( table 4 ) . pure transvaginal appendectomy was performed on only 22% of the cases and the remaining were hybrid procedures ( 78% ) . when we compared the operating time and the complications for both techniques , there were no differences . the operating times for pure [ 4 , 10 ] and hybrid [ 5 , 9 , 1215 ] techniques were 48.3  11.8 minutes and 49.6  25.5 minutes , respectively ( p = 0.83 ) . complication rates for pure [ 3 , 4 , 10 ] and hybrid [ 5 , 79 , 1215 ] techniques were 19.0% and 5.5% , respectively ( p = 0.09 ) . some authors used flexible endoscopes ( 20% ) and others preferred rigid laparoscopes ( 80% ) . operating times with flexible endoscopes [ 4 , 5 , 12 , 13 ] and rigid laparoscopes [ 9 , 10 , 1315 ] were 71.9  13.3 minutes and 45.2  21.6 minutes , respectively ( p = 0.0007 ) . complication rates for using flexible [ 35 , 8 , 12 , 13 ] and rigid [ 7 , 9 , 10 , 1315 ] scopes were 0% and 11.4% , respectively ( p = 0.33 ) . transvaginal appendectomy during vaginal hysterectomy was first described in 1949   and , at the time , was performed by the gynecologists with the aim of incidental appendectomy [ 6 , 23 ] . those studies did not include the acute appendicitis cases and their primary objectives were the treatment of gynecological pathologies , not the appendix . in 2008 , the first transvaginal appendectomy without vaginal hysterectomy was reported by palanivelu and coworkers from india   and after a short period of time three more cases were reported one from germany   and two from georgia . interestingly , these first three separate reports of transvaginal appendectomies all described the totally transvaginal ( pure ) technique using only an endoscope [ 3 , 4 , 22 ] . in those cases , there was no abdominal trocar for assistance , nor was there any other transvaginal equipment except endoscopes . transection of the appendixes was done with scissors [ 3 , 4 ] or snares   through the endoscopic channels . all the specimens were removed with the help of the endoscope and no extraction bags were used . reported that , before the first successful case , they experienced three prior conversions to conventional laparoscopic appendectomy due to technical difficulties with this pure endoscopic technique . bernhardt et al . used the same technique and reported that their case was not an acute appendicitis , but a recurring subacute appendicitis . we can conclude that , despite its minimal invasiveness , technical difficulties limit the application of the pure transvaginal technique to highly selected cases . but for now , this analysis revealed that this earliest described transvaginal appendectomy technique was the least commonly preferred one relative to others subsequently described . another technique for pure transvaginal appendectomy was reported using the placement of a single incision laparoscopic surgery ( sils ) port into the incised posterior vaginal fornix . the authors preferred a 5  mm 30 rigid telescope and two working ports ( 5  mm and 12  mm ) on the sils port . they divided the mesoappendix with a stapler or an energy device and the appendix was likewise divided with an endoscopic stapler . they reported almost half the operating time ( mean 44.4 minutes ) of the previously described endoscope - only pure transvaginal appendectomy . although this new technique seemed more adaptable to daily surgical practice , the authors warned that the sils port was inadequate as it was too short , which made placement difficult . they concluded that there was still room for innovation in the development of the technique . this analysis pointed out that hybrid procedures with umbilical port assistances were more common ( 72% ) than the pure transvaginal techniques . hybrid techniques had some advantages over pure ones , such as safer transvaginal introduction under direct vision , transumbilical view when necessary , and two directional working in the abdominal cavity . a hybrid procedure was started with pneumoperitoneum via a veress needle at the umbilicus and a 5  mm trocar was inserted via the umbilicus to inspect the abdominal cavity . after that a vaginal trocar ( 1015  mm ) was placed at the posterior fornix of the vagina . an additional working port was created in three different ways in the studies : ( i ) the channel of the laparoscope was used ; ( ii ) a second 5  mm trocar was inserted from the posterior fornix ; or ( iii ) a second 2.3  mm trocar was placed through the umbilicus . using a flexible endoscope instead of no clear benefits of flexible endoscopes over the rigid scopes were seen in this systematic analysis . transferring the surgeons from open surgery to laparoscopic surgery provided the patients with a more comfortable postoperative course and a more rapid recovery . however , its benefits on postoperative pain and patient recovery were not as amazing as in the previous transfer from open to laparoscopy . a recent meta - analysis found no difference on postoperative pain and length of hospital stay between the single port and the multiport laparoscopic appendectomies . natural orifice surgery is a novel technique that can have a positive influence on postoperative pain and recovery . an important drawback of this technique may be the unfamiliarity of the access to the abdomen for surgeons who are generally familiar with abdominal incisions or transanal surgeries . a second point that may keep surgeons away from this technique this systematic review demonstrated that , from the technical point of view , the equipment required for transvaginal appendectomy was not too distinct from the well - known existing conventional laparoscopic appendectomy equipment . there was no need for special equipment such as long trocars or flexible endoscopes . only two studies compared the results of transvaginal and conventional laparoscopic appendectomies [ 9 , 10 ] . despite the limited number of the patients in those studies , there was a trend towards shorter hospital stays [ 9 , 10 ] , quicker recovery , and less analgesic requirement   for the transvaginal groups ( table 5 ) . recent meta - analyses including thousands of conventional laparoscopic appendectomies demonstrated that the wound infection rate was 3.34% and the length of hospital stay was 1.92.9 days [ 24 , 25 ] . when compared to those results , this systematic review demonstrated that transvaginal appendectomy can be a rational alternative to conventional laparoscopic appendectomy in selected patients . it has very low wound infection rates ( zero in this study ) and short hospital stays ( mean 1.9 days ) . today first , there is not enough data of this technique for the morbidly obese patients . there is a considerable amount of obese people in the western countries and transvaginal appendectomy studies are necessary including morbid obese patients . we believe that minimal invasive surgeries like transvaginal appendectomy can have a place for the morbid obese patients in future . secondly , the risk of delving into the cultural sensitivity of using the vagina as an access point , particularly in third world countries can be a limitation . this can be a problem even in the most promiscuous cultures where virginity still runs some amount of the population . as a conclusion , appendectomy is one of the most common emergency visceral surgical procedures . the early results of transvaginal appendectomy in this systematic review show some promise for improved postoperative pain and patient recovery . using hybrid techniques with rigid laparoscopes may provide an easier adaptation for surgeons to this novel appendectomy method . for now , transvaginal appendectomy looks suitable for nonmorbid obese patients ( bmi < 35 ) and noncomplicated appendicitis . of course , its potential advantages and disadvantages will become clearer in the future with comparative studies . more studies are also necessary on the role of transvaginal appendectomy in some subgroups like morbidly obese patients or perforated appendicitis .
background . 
 natural orifice transluminal endoscopic surgery ( notes ) is a new approach that allows minimal invasive surgery through the mouth , anus , or vagina . objective . to summarize the recent clinical appraisal , feasibility , complications , and limitations of transvaginal appendectomy for humans and outline the techniques . 
 data sources . 
 pubmed / medline , cochrane , google - scholar , ebsco , clinicaltrials.gov and congress abstracts , were searched . 
 study selection . 
 all related reports were included , irrespective of age , region , race , obesity , comorbidities or history of previous surgery . 
 no restrictions were made in terms of language , country or journal . 
 main outcome measures . 
 patient selection criteria , surgical techniques , and results . results . 
 there were total 112 transvaginal appendectomies . 
 all the selected patients had uncomplicated appendicitis and there were no morbidly obese patients . 
 there was no standard surgical technique for transvaginal appendectomy . 
 mean operating time was 53.3 minutes ( 25130 minutes ) . 
 conversion and complication rates were 3.6% and 8.2% , respectively . 
 mean length of hospital stay was 1.9 days 
 . limitations . 
 there are a limited number of comparative studies and an absence of randomized studies . conclusions . for now , nonmorbidly obese females with noncomplicated appendicitis can be a candidate for transvaginal appendectomy . 
 it may decrease postoperative pain and enable the return to normal life and work off time . 
 more comparative studies including subgroups are necessary .