Perretta Silvana, Allemann Pierre, Asakuma Mitsuhiro, Dallemagne Bernard, Marescaux Jacques
IRCAD/EITS Institute, Strasbourg Cedex, France.
Surg Endosc. 2009 Jun;23(6):1390. doi: 10.1007/s00464-009-0367-9. Epub 2009 Mar 5.
Endoscopic adrenalectomy currently is performed using either a retroperitoneal or transperitoneal approach. The retroperitoneal approach is ideal for patients with small lesions who have undergone previous intraabdominal surgery. This study aimed to explore transvaginal retroperitoneal right and left adrenalectomies in porcine and cadaver models.
Right and left adrenalectomies were performed for two female pigs. With the pig supine under general anaesthesia, the retroperitoneal space was entered with a double-channel endoscope (Storz) through a posterior colpotomy. A retroperitoneal tunnel was fashioned using blunt dissection with the assistance of low carbon dioxide insufflation up to the inferior pole of the kidney. Dissection of the upper renal pole allowed access to the adrenal gland. Using blunt dissection, a plane was created between the aorta on the left and the adrenal gland and inferior vena cava on the right. The left main middle vascular pedicle was identified and taken between clips, whereas an endoloop was used on the right side. The specimen was retrieved intact with a polypectomy snare. The same access then was reproduced with two female cadavers.
Transvaginal retroperitoneal adrenalectomies were successfully accomplished with a transvaginal approach using natural orifice translumenal endoscopic surgery (NOTES). The operative time was 70 min, and there was no injury to the retroperitoneal structures. The access was effectively reproduced in the cadaver model, with prompt identification of the retroperitoneal anatomic landmarks.
Transvaginal retroperitoneal NOTES adrenalectomy is feasible in the porcine model. It reaches the adrenal proper anatomic plane with no need for dissection or retraction of the surrounding organs. This technique might be especially valuable for patients with multiple previous abdominal operations and obese patients in that allows direct access to the adrenal gland and minimizes the cardiovascular and pulmonary risk related to carbon dioxide pneumoperitoneum. Although the operation was successfully validated with cadavers, further experiments and better tools are needed before NOTES transvaginal retroperitoneal access is considered for humans.
目前内镜下肾上腺切除术可采用后腹腔镜或经腹腔途径进行。后腹腔镜途径对于曾接受过腹腔内手术且肾上腺病变较小的患者是理想的选择。本研究旨在探索在猪和尸体模型中经阴道后腹腔镜下左右肾上腺切除术。
对两只雌性猪进行左右肾上腺切除术。猪在全身麻醉下仰卧，通过后穹窿切开术，使用双通道内镜（史托斯）进入后腹膜腔。在低二氧化碳气腹辅助下，用钝性分离法构建一条通向肾下极的后腹膜隧道。对上极肾进行分离以便显露肾上腺。通过钝性分离，在左侧的主动脉与肾上腺以及右侧的肾上腺与下腔静脉之间创建一个平面。识别并夹闭左侧主要中间血管蒂，而右侧则使用圈套器。用息肉切除圈套器完整取出标本。然后在两具女性尸体上重复相同的入路操作。
通过经自然腔道内镜手术（NOTES）经阴道途径成功完成了经阴道后腹腔镜肾上腺切除术。手术时间为70分钟，未对后腹膜结构造成损伤。在尸体模型中有效重现了该入路，能迅速识别后腹膜解剖标志。
经阴道后腹腔镜NOTES肾上腺切除术在猪模型中是可行的。它能到达肾上腺的正常解剖平面，无需对周围器官进行分离或牵拉。该技术对于有多次腹部手术史的患者和肥胖患者可能特别有价值，因为它可以直接进入肾上腺，并将与二氧化碳气腹相关的心血管和肺部风险降至最低。尽管该手术在尸体上已成功验证，但在考虑将NOTES经阴道后腹腔镜入路应用于人体之前，还需要进一步的实验和更好的工具。
