The advantages of NOTES are magnified in the morbidly obese. A 29-year-old female with a BMI of 44.9 kg/m2 is enrolled under IRB protocol for transvaginal sleeve gastrectomy. After exploration through a left upper quadrant port, a dual lumen vaginal trocar is placed. The short gastric vessels are taken with the harmonic shears. A gastric tube is sized with a 34 Fr Bougie, a sleeve created with a tissue stapler and oversewn with 2-0 silk suture. A closed suction drain is left in the gastric bed. The specimen was extracted through the colpotomy, which is then closed with absorbable suture. The diet was gradually advanced, with abdominal and vaginal incisions well healed at one month.