Removal of the gall bladder has been at the forefront of new surgical approaches before - maybe because it's a fairly common procedure that is not usually done as an emergency, and lends itself to different approaches. Various surgical groups have considered the possibility of 'getting at' the gall bladder by different routes. First, it was using laparoscopy - 2 or 3 small incisions in the abdominal wall, using instruments guided by a laparoscope (a telescope view of the abdominal cavity). Then the idea of operating through the stomach was mooted. Instruments would be passed down the esophagus into the stomach, and out through the stomach wall into the abdominal cavity. This would avoid the disfiguring scars of laparoscopy (though these are infinitesimal compared with a regular cholecystectomy scar).

Now comes the ultimate (unless science fiction is invoked). Transvaginal cholecystectomy is claimed to be pain-free, scar-free, and without bleeding. This is based on a single procedure performed in France , and published in the Archives of Surgery. The technical term is colpotomy (through the cervical vault), and the approach is called NOTES (Natural Orifice Transluminal Endoscopic Surgery). A flexible videogastroscope and standard endoscopy instruments were used. The procedure took 3 hours. There was no postoperative pain, and the patient was sent hope on the 2nd postoperative day.

This approach will most probably catch on in this country; the NOTES enthusiasts are looking forward to offering 'invisible mending', although it will likely be more expensive than other approaches.