Third-Generation Nephrectomy by Natural Orifice Transluminal Endoscopic Surgery

Abstract

Purpose:Recently there has been increasing enthusiasm for performing simple abdominal procedures by transgastric surgery. We previously reported the usefulness of a combined transgastric and transvesical approach to cholecystectomy. In this study we assessed the feasibility of combined transgastric and transvesical approach for performing a more complex surgical procedure, such as nephrectomy, in a porcine model. Materials and Methods: In a nonsurvival study combined transgastric and transvesical approaches were established in 6 female pigs. Under ureteroscope guidance we installed a transvesical 5 mm over tube into the peritoneal cavity and a flexible gastroscope was passed orally into the peritoneal cavity by a gastrotomy. We performed right or left nephrectomy with instruments introduced by the 2 devices that worked in the renal hilum, alternating device intervention for dissection and retraction procedures. Results: Four right and 2 left nephrectomies were performed. There were no complications during the creation of transvesical and transgastric access. In all animals we visualized the 2 kidneys. The renal vessels and ureter were reasonably individualized and ligated separately with ultrasonic scissors, which were introduced through the transvesical port. In 2 early cases mild hemorrhage occurred after ultrasonic ligation. To overcome this complication we applied clips successfully before ultrasonic ligation in the remaining animals. Thus, complete renal release and mobilization to the stomach were achieved in all animals. Conclusions: Nephrectomy by natural orifices using the combined transgastric and transvesical approach is technically feasible, although to our knowledge there is no reliable method for removing the specimen with current instruments.

Endoscopic Closure of Transmural Bladder Wall Perforations

“…In fact, after the description of the transvesical port and its usefulness to perform several intra-abdominal procedures (ie, cholecystectomy and nephrectomy), it would be advantageous to develop a reliable closure method for vesicotomy which avoids bladder catheterization [18,19]. We believe the observations presented here might be relevant to transluminal procedures performed during NOTES procedures using the transvesical approach.…”

Transvesical peritoneoscopy with rigid scope: feasibility study in human male cadaver

“…Transvesical access to the abdominal cavity either alone or in combination with transgastric access has been used for a broad range of procedures such as peritoneoscopy, liver biopsy, lung biopsy, cholecystectomy, nephrectomy, and partial cystectomy [7][8][9][10][11][12]. More recently, Gettman et al [13] reported the clinical feasibility of transvesical peritoneoscopy by using a flexible ureteroscope (DUR-8) during a case of robotic radical prostatectomy.…”

“…Soon it became apparent that this access was not only a major shift in how the bladder was seen, but also a safe and fast means of access to the peritoneal cavity, with an excellent view of all the upper peritoneal structures [7]. This same group of researchers also described the execution of complex surgical procedures, including nephrectomy [8] and cholecystectomy [9,10], which were carried out by an approach combining the transvesical port with the transgastric port. In both surgical procedures, the transvesical port represented not only a working port through which many instruments are used, but also a way of support and guidance in choosing the site of entry into the peritoneal cavity via the transgastric port [9,10].…”

Transvesical endoscopic peritoneoscopy: Intra-abdominal scarless surgery for urologic applications

“…These developments marked a new era in minimally invasive abdominal surgery, compelling novel, previously audacious goals, such as avoidance of incisions and pain. With the visceral wall no longer a barrier to endoscopic intervention, various authors described novel, complex abdominal procedures [6][7][8][9][10][11][12][13][14][15][16]. In 2006, such reports motivated researchers in this emerging field to organize the Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR), a joint initiative supported by the American Society for Gastrointestinal Endoscopy (AGES) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES).…”