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Dear Editor, We welcome the interesting comments made by the French surgeons. The idea of the article was to show that the transvaginal route is a feasible alternative in Natural Orifice Translumenal Endoscopic Surgery (NOTES). The fact that it can only be applied in females is definitely a limiting factor. Until safer routes for NOTES are described, at least female patients can benefit. Several surgeons have used the transvaginal approach, and have found it viable [1–6]. I do not know if it is fair enough to say that all female patients do not prefer the transvaginal route based on a questionnaire answered by just 125 subjects. As the article states, the inherent danger of a potentially fatal gastric perforation is always present in the transgastric approach, especially since there is no foolproof method of gastrotomy closure as yet. Were the dangers of the transgastric approach clearly explained to these 125 subjects? In the transvaginal route, postoperative pain during sexual intercourse is an issue to contend with, but this was not a problem in any of our patients. Besides, only randomized controlled trials comparing the different routes can provide solid evidence, and I dare say that human trials would currently be premature. For now, we have to be satisfied with small case series. Yes, the debate continues. References

surgical endoscopy/surgical endoscopy and other interventional techniques

Reply to: Re: “NOTES: Where have we been and where are we going” (2008; 22(5):1143–1145) and “Transvaginal endoscopic appendectomy in humans: a unique approach to NOTES, world’s first” (2008; 22(5):1343–1347)