How do gynecologists feel about transvaginal NOTES surgery?

Background: Natural-orifice transluminal endoscopic surgery (NOTES) is regarded as safer and less invasive than laparoscopic surgery. However, there has been no documentation of the opinions of surgically active, experienced gynecologists about the indications, contra indications, risks, and complications of transvaginal access. Methods: A two-page questionnaire was distributed to the heads of the gynecological departments at 181 university and major teaching hospitals across Germany, Austria, and Switzerland. Fifty-two questionnaires (28.7%) were returned and evaluated. The questionnaire contained ten questions, four of which were yes/no questions and another five of which allowed between four and seven answers. The questionnaire contained one additional open question. Results: Of the respondents, 69.2% classified transvaginal access for extrapelvic abdominal surgery as ethical; the remaining 30.8% described it as experimental. Only 28.8% would re-commend NOTES to their patients if NOTES presented the same surgical risks as the laparoscopic approach. When asked about NOTES-associated complications, 73.1% mentioned the risk of infection, 61.5% visceral lesions, 44.2% infertility, and 34.6% adhesions. In terms of long-term problems, gynecologists are concerned about dyspareunia and infertility. Adopting their patients' point of view, 17.3% voted the lack of scarring compared to laparoscopy as important and 57.6% as unimportant. Conclusions: While transvaginal NOTES is argued to be a promising access for scarless surgery, gynecologists mention postoperative infection, visceral lesions, infertility, and adhesions as conceivable complications. Since long-term experience has not yet been achieved, potential problems such as dyspareunia, infertility, and the spread of pre-existing endometriosis remain definitely conceivable complications.