Recent technologic advances in endoscopic instrumentation and optics have allowed the development of a less invasive alternative to conventional laparoscopic surgery. During the past decade, natural orifice transluminal endoscopic surgery (NOTES) flourished in the field of general surgery, and it has emerged as a new concept of minimally invasive surgery. NOTES yields access to the abdominal cavity without any incisions on the abdominal wall (scarless surgery), and the natural orifices of the body surface, such as the mouth and the vagina, serve as the gateway to the peritoneal cavity. In gynecology, the vagina of a woman can be considered as an additional route for surgery. Recently, clinical application of transvaginal NOTES has broadened significantly in gynecology. Using transvaginal NOTES by applying the method of single-incision laparoscopic surgery via the vaginal route, not only adnexal surgery and hysterectomy, but also myomectomy and oncologic surgery could be performed safely and effectively in selected patients. In future, further studies should be conducted to evaluate the true clinical feasibility and safety of transvaginal NOTES.

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The aim of the present study was to investigate the expression and distribution patterns of inducible nitric oxide synthase (iNOS) in human non-pregnant and early pregnant endometrium using Northern blot analysis, reverse transcription-polymerase chain reaction (RT-PCR) and immunohistochemistry. Northern blot analysis revealed the expression of iNOS mRNA in human decidua and chorionic villi in the first trimester but not in the endometrium at any stage of the menstrual cycle. Nested RT-PCR, however, detected iNOS mRNA in human endometrium at all stages of the menstrual cycle. Immunohistochemical staining of the secretory endometrium using an anti-human iNOS polyclonal antibody revealed labelling specifically concentrated in glandular epithelial cells. Staining was absent in stromal cells. However, iNOS staining was positive in decidualized stromal cells in tissues obtained in the first trimester of pregnancy. Furthermore, extensive staining was observed in both syncytiotrophoblastic and cytotrophoblastic cells. The finding of a large amount of iNOS mRNA at the feto-maternal interface throughout the first trimester of pregnancy suggests that iNOS may play an important role in the maintenance of pregnancy.

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Hybrid transvaginal and transumbilical NOTES is feasible and safe in select patients, and it provides no visible scar.