Transvaginal surgery has become one of the premier access sites for Natural Orifice Transluminal Endoscopic Surgery (NOTES). The transvaginal approach seems to be safe and cause only minimal postoperative pain while providing most favorable cosmetic results for patients. With approval of the Institutional Review Board, a pure transvaginal laparoscopic appendectomy was successfully performed at Yale-New Haven Hospital in November 2008.A 20-year-old female presented to the Emergency Room with right lower quadrant pain and was diagnosed with acute appendicitis. Consequently, she consented to undergo a transvaginal laparoscopic appendectomy. In steep Trendelenberg position, access to the abdominal cavity was accomplished with a 2cm incision thru the posterior fornix of the vagina. Once intraperitoneal access was established, a 14mm trocar was introduced to establish pneumoperitoneum up to 15mmHG. Then, a 5mm 30degree angled endoscope and a reticulating grasper for retraction were placed intraabdominal next to the trocar. After a nonperforated appendicitis was identified, the appendeceal base was taken with a 3.5mm stapler. Subsequently, a 2.5mm stapler was used to transect the mesoappendix and the appendix was removed thru the 14mm trocar. Finally, the posterior fornix of the vagina was closed with interrupted absorbable sutures. No transabdominal skin incisions or punctures were necessary throughout the entire case.Operative time was 59 min. No major or minor complications were observed. The patient was discharged home on postoperative day 1 with only minimal pain. Starting postoperative day 2, pain was easily controlled with Tylenol. Our case of a pure transvaginal appendectomy employs an easy to accomplish laparoscopic technique that seems to be safe for patients. It provides most favorable cosmetic results and appears to cause only minimal postoperative pain. The significant cosmetic advantage is obvious due to the elimination of abdominal incisions and subsequent scars. However, further studies are warranted to examine the possible advantage in regards to postoperative pain for the transvaginal approach.