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Operative Laparoscopy 165

Fig. 5.21 Line drawing simulating the NOTES ovariectomy procedure
performed through a transgastric approach. From Freeman et al. (2009).
Reproduced with permission from Elsevier.

undergoing transgastric NOTES procedure for bilateral ovariectomy
(Fig. 5.21) have less pain than those undergoing open surgery (Freeman
et al., 2009, 2010). The technique requires operators skilled in endos-
copy and in laparoscopy to work together to perform these procedures,
the operative times are prolonged and instrumentation is currently still
in development. At present, human NOTES procedures are being per-
formed under Institutional Review Board protocols using both the trans-
gastric and transvaginal approaches for cholecystectomy, but it is not
known yet whether these techniques will prove to have a clinical benefit
over traditional laparoscopy.