IRCAD-EITS, University of Strasbourg , Strasbourg, France.
J Endourol. 2009 Nov;23(11):1887-92. doi: 10.1089/end.2008.0682.
Minimally invasive nephrectomy performed through a natural orifice such as the vagina could enhance cosmesis and improve patient acceptance of the procedure and postoperative recovery. As the vagina has already been proposed as a site of specimen extraction in patients undergoing laparoscopic nephrectomy, the aim of this study was to explore the feasibility of transvaginal, retroperitoneal natural orifice transluminal endoscopic surgery (NOTES) nephrectomy for both left- and right-sided kidneys initially in a porcine model and thereafter in a human cadaver model.
Ten female pigs underwent NOTES nephrectomy (five having a left nephrectomy and five having right nephrectomy). To do this, each pig was anesthetized and placed in a supine position. A retroperitoneal conduit was established by means of a posterior colpotomy and the retroperitoneal space then entered with a conventional double-channel endoscope (Storz). Thereafter, careful blunt dissection allowed a passage to be created up to the renal vessels and proximal ureter which were then dissected and divided separately after endoscopic clipping. We then attempted to reproduce the technique in two formaldehyde-preserved female cadavers.
All the porcine procedures were accomplished by a totally NOTES approach with a mean operative time of 50 minutes (range 45-60). No bleeding or injury to any of the retroperitoneal structures occurred. In the two cadavers, the retroperitoneal access was reproduced, but a complete dissection of the kidney was not possible because of the rigor of the surrounding tissues.
Transvaginal retroperitoneal NOTES right and left nephrectomy is certainly accomplishable in the porcine model, and the feasibility of the access was confirmed in two cadavers. As a retroperitoneal transvaginal dissection preserves the peritoneum and obviates bowel handling, this work should encourage further development of NOTES accesses for renal surgery.
通过阴道等自然腔道进行的微创肾切除术可以增强美容效果，并提高患者对手术和术后恢复的接受度。由于阴道已经被提议作为腹腔镜肾切除术患者标本提取的部位，本研究的目的是首先在猪模型中探索经阴道后腹膜自然腔道内镜手术（NOTES）左、右侧肾切除术的可行性，然后在人体尸体模型中探索其可行性。
10 只雌性猪接受了 NOTES 肾切除术（5 只进行左侧肾切除术，5 只进行右侧肾切除术）。为此，每只猪都接受麻醉并仰卧。通过后阴道切开术建立后腹膜管道，然后使用常规双通道内窥镜（STORZ）进入后腹膜腔。此后，通过仔细钝性分离，创建一条通往肾血管和近端输尿管的通道，然后使用内镜夹分别对其进行解剖和分离。我们随后试图在两个甲醛保存的女性尸体中重现该技术。
所有的猪手术均通过完全 NOTES 方法完成，平均手术时间为 50 分钟（45-60 分钟）。没有发生任何腹膜后结构的出血或损伤。在两具尸体中，均成功重现了后腹膜入路，但由于周围组织的僵硬，无法完成肾脏的完全解剖。
经阴道后腹膜 NOTES 右、左侧肾切除术在猪模型中肯定是可行的，并且在两具尸体中证实了入路的可行性。由于后腹膜经阴道分离术保留了腹膜并避免了肠处理，这项工作应该会鼓励进一步开发用于肾脏手术的 NOTES 入路。
