Introduction: Reducing parietal scars and their related pain and complications is one objective of minimal access surgery. Hybrid NOTES approach may be a valuable option to improve the surgical outcome in morbidly obese patient.

Methods: A sleeve gastrectomy (SG) and a cholecystectomy were performed in a 32 year old woman, BMI 40 kg/m2. Three ports were introduced, a 12mm 7cm above the umbilicus and two 5mm laterally at the same level: on the left side, a 30 degree laparoscope (Storz) was positioned, and on the right a liver retractor. A 15mm 15cm-long trocar was introduced through a posterior colpotomy. It provided a stable access for a 12mm dual-channel endoscope (Storz®). Division of the greater omentum began 6 cm proximal to the pylorus using fusion technology (Ligasure®-Covidien). A 36Fr gastric calibration tube was placed and the SG was carried out using staplers (EndoGIA®-Covidien) introduced through the midline port. An hemostatic suture covered the stapled line. A cholecystectomy completed the procedure. Resected tissues were retrieved transvaginally after introduction into a bag. Colpotomy site was closed with sutures (Endostitch®-Covidien).

Results: Procedure was completed through 4 accesses, 3 abdominal and one transvaginal trocars. Operative duration was 210 minutes. Postoperative course was uneventful. Postoperative pain (VAS) scored at 0. The patient was discharged the second day.

Conclusion: Usually laparoscopic SG needs 5 abdominal trocars (2x12mm, 3x5mm). Hybrid NOTES approach allows the suppression of two 12mm transparietal accesses, minimizing pain and hernia risks.