Allemann Pierre, Perretta Silvana, Asakuma Mitsuhiro, Dallemagne Bernard, Mutter Didier, Marescaux Jacques
IRCAD/EITS Institute, University hospital, 1 place de l'hôpital, 67091 Strasbourg, France.
Surg Endosc. 2009 Apr;23(4):882-3. doi: 10.1007/s00464-008-0297-y. Epub 2009 Jan 24.
The retroperitoneal approach preserves the peritoneal cavity and its envelope. The benefits of laparoscopic retroperitoneal approach to the kidney and the adrenal gland are well known. The pancreas may represent another potential target. Whereas NOTES transperitoneal distal pancreatectomy has been reported, the retroperitoneal approach, which may combine the advantages of peritoneal preservation with those of no scar surgery, has never been explored. We report the feasibility of NOTES transvaginal retroperitoneal pancreatectomy in a porcine model.
With the pig supine, under general anesthesia, a 10-mm posterior colpotomy was performed with a needle-knife operated through a flexible 12-mm, double-channel endoscope (Karl Storz). A retroperitoneal tunnel was created with blunt dissection up to the left kidney with progressive visualization of the left iliac vessels, ureter, and abdominal aorta. To reach the posterior aspect of the pancreas, a space was opened medial to the upper renal pole dividing the Gerota's fascia. The tail of pancreas was mobilized with blunt and sharp dissection, using monopolar cautery. Once the distal pancreas was dissected free, it was secured using a polypropylene endoscopic loop and then resected with an endoscopic snare (Olympus).
The procedure was successfully accomplished by a totally NOTES approach in five pigs, with a mean operative time of 118 (range, 105-185) minutes with no intraoperative complications and no injury to any retroperitoneal structure.
The pancreas is accessible by a transvaginal retroperitoneal NOTES approach. Human cadavers studies are necessary to confirm the validity of this model and to explore the need for specific technological developments, such as flexible stapling devices, to improve the safety of pancreatic resection.
腹膜后入路可保留腹膜腔及其包膜。腹腔镜腹膜后入路用于肾脏和肾上腺手术的益处已广为人知。胰腺可能是另一个潜在的手术目标。虽然已有经自然腔道内镜手术（NOTES）经腹腔行远端胰腺切除术的报道，但腹膜后入路可能兼具保留腹膜和无瘢痕手术的优点，却从未被探索过。我们报道了NOTES经阴道腹膜后胰腺切除术在猪模型中的可行性。
猪仰卧位，全身麻醉下，通过可弯曲的12毫米双通道内镜（Karl Storz）操作的针刀进行10毫米的后穹窿切开术。通过钝性分离建立腹膜后隧道直至左肾，逐步显露左髂血管、输尿管和腹主动脉。为到达胰腺后方，在肾上级内侧打开一个间隙，分开肾周筋膜。用单极电凝器钝性和锐性分离游离胰尾。一旦远端胰腺游离，用聚丙烯内镜圈套器固定，然后用内镜圈套器（奥林巴斯）切除。
五只猪通过完全NOTES入路成功完成手术，平均手术时间为118（范围105 - 185）分钟，术中无并发症，未损伤任何腹膜后结构。
经阴道腹膜后NOTES入路可到达胰腺。需要进行人体尸体研究以证实该模型的有效性，并探索是否需要特定的技术发展，如柔性吻合器械，以提高胰腺切除的安全性。
