pelvic surgery. 4 Consequently, patients with previous pelvic surgery and history of major inflammatory pelvic disease or acute cholecys- tectomy were also excluded from the hybrid NOTES approach. So we started offering the hybrid NOTES approach to women over 40 years old with no previous pelvic surgery or history of inflam- matory pelvic disease. SILS was offered to male patients and women excluded from the hybrid NOTES approach being previous surgery in the upper right quadrant and gallbladder emphiema the main contraindications. At our department, nine female patients met the inclusion criteria to undergo hybrid transvaginal cholecystectomy. However, three preferred the SILS approach because of concerns about safety of the NOTES technique and potential for infectious complications related to the transvaginal approach. Peterson et al. 5 surveyed 100 women who were given a written description of MIS and NOTES surgery along with a 10-question survey exploring their concerns and opinions regarding transvaginal surgery. Women have a positive perception of transvaginal procedures and will want such procedures if they are found to be equivalent to laparoscopic surger- ies, but infectious were a major concern for women who would not want transvaginal surgery as showed in our limited experience. In conclusion, NOTES and SILS are promising techniques which need new and dedicated instrumentations to reduce technical limitations. References 1. Navarra G, Rando L, La Malfa G, Bartolotta G, Pracanica G. Hybrid transvaginal cholecystectomy: a novel approach. Am. J. Surg. 2009; 197: 69–72. 2. Navarra G, Pozza E, Occhionorelli S, Carcoforo P, Donini I. One-wound laparoscopic cholecystectomy. Br. J. Surg. 1997; 84: 695. 3. Long CY, Fang JH, Chen WC, Su JH, Hsu SC. Comparison of total laparoscopic hysterectomy and laparoscopically assisted vaginal hyster- ectomy. Gynecol. Obstet. Invest. 2002; 53: 214–9. 4. Chamberlain RS, Sakpal SV. A comprehensive review of single-incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) techniques for cholecystectomy. J. Gastrointest. Surg. 2009; 13: 1733–40. 5. Peterson CY, Ramamoorthy S, Andrews B, Horgan S, Talamini M, Chock A. Women’s positive perception of transvaginal NOTES surgery. Surg. Endosc. 2009; 23: 1770–4. Giuseppe Navarra, MD Giuseppe Currò, MD General and Oncologic Surgery Unit, Faculty of Medicine, University of Messina, G. Martino University Hospital, V. Cons. Valeria, Messina, Italy doi: 10.1111/j.1445-2197.2010.05499.x Post laryngectomy speech and voice rehabilitation: past, present and future Speech, as a form of communication, is a vital key to human exist- ence, giving meaning, colour and purpose to one’s life. In spite of major strides in the field of conservative laryngeal surgery and modalities of concurrent chemoradiation, total laryngectomy (TL) still remains the procedure of choice for advanced-stage (Stage T3-T4) laryngeal carcinoma around the world. 1 TL, although cura- tive, has its own set of consequences like loss of voice, olfactory and gustatory changes with psychosocial alterations affecting the overall quality of life of the patient. This demands comprehensive post- laryngectomy rehabilitation in order to bring the patient back to the mainstream of the society. Since the first laryngectomy more than 150 years ago, by The- odore Billroth our efforts to provide the laryngectomee with a near normal alaryngeal voice are still ongoing. In the past, many researchers have made attempts to make the laryngectomee speak ‘his own voice’ but, their efforts proved futile. The ‘artificial larynx’ devised by Billroth did not stood the test of time while Kaiser’s method of esophageal speech failed as it required a tremendous level of proficiency and training in order to learn the method. Although, esophageal speech was a hands-free speech and required no costly equipments, 40 to 74% of laryngectomees failed to acquire func- tional esophageal speech. 2 Intensity levels were 6–10 dB lower than laryngeal speech which made noisy environments problematic for esophageal speakers. 3 Next in succession was the electrolarynx, a handheld device which provided useful alaryngeal voice for a small number of laryngectomees, but here again, the significant limitations of the mechanical, robotic quality of the voice and the need to operate the device manually drastically limited its effectiveness. An interesting event is described by Gussenbauer of a laryngec- tomee who in a suicidal attempt stabbed his neck with an ice pick and miraculously could speak. 4 This event generated enthusiasm amongst the surgeons in the mid-1900s to provide surgical voice restoration using tracheoesophageal fistula. Surgeons such as Conley in the USA, Staffieri in Italy and Amatsu in Japan proposed reconstructive methods that incorporated shunts of planned fistulae to establish voice after total laryngectomy by attempting to mimic laryngeal voicing and restore pulmonary-driven speech. 4,5 Tragi- cally, all of these methods failed over time because the fistulae either allowed aspiration or became too patent or stenotic. To overcome these fistula-related problems, it was Professor Mozolewski of Poland who conceptualized the first useful voice prosthesis in 1972. The detailed description of the silicon one-way valve was given by Blom and Singer in 1980, which later revolutionized the field of post-laryngectomy voice rehabilitation. Surgical voice restoration using voice prosthesis is based on the concept of surgically creating a tracheoesophageal puncture which is maintained by the silicon one-way valve. The valve transfers the pulmonary driven air into the surgically created neo-glottis which is set into vibration. The sound generated by the mucosal vibrations in the neo-glottis is then articulated in the oral cavity (Fig. 1). 1,4 To date, numerous designs of voice prosthesis have been described viz: Blom-Singer, Provox 1 and 2, Provox Act-valve, Provox Vega, Groningen, VoiceMaster, Nijdam and Bordeaux voice prostheses. These prostheses mainly differ in the aspects of size, method of insertion and the pressure required in the effort to speak either low/high pressure. The non-indwelling devices developed earlier 770 Perspectives © 2010 The Authors ANZ Journal of Surgery © 2010 Royal Australasian College of Surgeons