Pure Retroperitoneal NOTES Transvaginal Nephrectomy Using Standard Laparoscopic Instruments:a Safety And Feasibility Study In A Porcine Model

The natural orifice translumenal endoscopic surgery(NOTES)technique allows the use of hollow organs(i.e.stomach,bladder,rectum,or vagina)to access the peritoneal cavity during abdominal surgery,which includes hybrid NOTES(HNOTES)and pure NOTES(PNOTES).There are some theoretical advantages of this technique,including avoidance of incision-related complications(wound infections,adhesions,and hernias),less postoperative pain,improved aesthetics,and a diminished immunologic impact.Potential access routes of NOTES include transgastric,transoral,transvaginal,transcolonic and transvesical.And the transvaginal approach may be the optimal choice because of a simple and secure closure of colpotomy site.Pure and hybrid NOTES transvaginal operations were routinely performed via transperitoneal access.Objective: To investigate the safety and feasibility of the retroperitoneal pure retroperitoneal NOTES transvaginal nephrectomy using standard laparoscopic instruments.Method: i.Four female pigs,weighing an average of 31 kg,were used in this study.Under general anesthesia.Posterolateral colpotomy was performed,and the incision was enlarged laterally using blunt dissection and pneumatic dilation.A single-port device(Tri Port)was inserted to construct the operative channel.The retroperitoneal space was created using sharp and blunt dissection under endoscopic guidance.Laparoscope was insert into the pelvic cavity to observe the anatomic structure of the pelvic cavity.All the pigs were observed 2 weeks postoperatively.ii.Six female pigs,weighing an average of 30 kg,were used in this study.Under general anesthesia,pure retroperitoneal NOTES transvaginal nephrectomy was conducted using standard laparoscopic instruments.Posterolateral colpotomy was performed,and the incision was enlarged laterally using blunt dissection and pneumatic dilation.A single-port device(self-designed multi-channel Tri Port)was inserted to construct the operative channel.The retroperitoneal space was created using sharp and blunt dissection under endoscopic guidance up to the level of the kidney.Dissection and removal of the kidney were performed according to standard surgical procedure,and the colpotomy site was closed using interrupted sutures.The survival and complications were observed 2 weeks postoperatively.Result: i.Colpotomy was completed in all cases.One case fail to implant and fixe the Tri Port on the skin to construct the operative channel.Tri Port was successful to implanted and fixed on the skin,retroperitoneal exploration were under went in 3 cases,however persistent gas leak occurred in these cases.In all cases,no intra-or postoperative complications were observed.ii.Two cases failed because of peritoneal rupture.One case was successful,but required the assistance of an extra 5 mm laparoscopic trocar inserted in the flank.Three cases of pure retroperitoneal NOTES transvaginal nephrectomy were completed,and survived 2 weeks after the operation.In these three cases,no intraor postoperative complications were observed.Conclusion: i.All findings confirmed the safety and feasibility of retroperitoneal transvaginal pure natural orifice translumenal endoscopic surgery(TVPNOTES)nephrectomy using standard laparoscopic instruments.ii.The self-designed multi-channel Tri Port can be used as operating platform for retroperitoneal transvaginal pure natural orifice translumenal endoscopic surgery (NOTES)in a porcine model.