Department of Surgery/Division of Urology, University of California, San Diego School of Medicine, La Jolla, CA 92093-0987, USA.
Urology. 2012 Sep;80(3):590-5. doi: 10.1016/j.urology.2012.06.026.
To examine feasibility of transrectal hybrid natural orifice transluminal endoscopic surgery (NOTES) nephrectomy in human cadavers in the evolution of this technique, as transrectal hybrid NOTES nephrectomy has been demonstrated in the porcine model.
Four hybrid transrectal NOTES nephrectomies were performed on 4 cadavers (3 female/1 male, 2 right/2 left). Pneumoperitoneum was created by periumbilical 12-mm trocar, through which a laparoscope was advanced to obtain intra-abdominal visualization. A 4-cm horizontal incision was made 2-cm above the dentate line and a submucosal tunnel was created in the posterior rectal wall/presacral space. A dual-channel gastroscope was advanced through the submucosal tunnel and retroperitoneum to the level of the kidney using air insufflation. A peritoneal window was created and renal mobilization was completed. A transumbilically applied laparoscopic 45-mm stapler was used to transect the ureter and renal hilum. A specimen entrapment bag was deployed transrectally for specimen extraction, followed by transrectal incision closure.
Transrectal NOTES nephrectomy was successfully performed in all cases, with intact specimen extraction. Median weight was 77 kg (range 74-85 kg); median body mass index (BMI) was 30.1 kg/m(2) (range 25.6-31.2 kg/m(2)). Mean operative time was 175 minutes (range 150-210 minutes). Median transrectal access time was 36 minutes (range 24-47 minutes). Median dimensions of removed kidneys were length 11.2 cm (range 10-12 cm), width 5 cm (range 4.5-6 cm), and thickness 3.8 cm (range 3-4.5 cm).
Transrectal hybrid NOTES nephrectomy in the cadaver model is feasible with intact specimen extraction and acceptable operative times. Preclinical survival studies are requisite to assess sterility and complications. This approach may be an alternative to transvaginal access.
在该技术的发展过程中，检查经直肠杂交自然腔道内镜手术（NOTES）肾切除术在人体尸体中的可行性，因为经直肠杂交NOTES 肾切除术已在猪模型中得到证实。
对 4 具尸体（3 名女性/1 名男性，2 个右侧/2 个左侧）进行了 4 例杂交经直肠NOTES 肾切除术。通过脐周 12mm 套管创建气腹，通过该套管推进腹腔镜以获得腹腔内可视化。在齿线上方 2cm 处做一个 4cm 长的水平切口，并在后直肠壁/骶前间隙创建黏膜下隧道。使用空气注入将双通道胃镜通过黏膜下隧道和后腹膜推进至肾脏水平。创建腹膜窗并完成肾脏游离。使用经脐应用的腹腔镜 45mm 吻合器横断输尿管和肾门。经直肠部署标本捕获袋以提取标本，然后经直肠切开闭合。
所有病例均成功完成经直肠NOTES 肾切除术，标本完整取出。中位体重为 77kg（范围 74-85kg）；中位体重指数（BMI）为 30.1kg/m2（范围 25.6-31.2kg/m2）。平均手术时间为 175 分钟（范围 150-210 分钟）。中位经直肠入路时间为 36 分钟（范围 24-47 分钟）。中位切除肾脏的尺寸为长度 11.2cm（范围 10-12cm），宽度 5cm（范围 4.5-6cm），厚度 3.8cm（范围 3-4.5cm）。
在尸体模型中，经直肠杂交NOTES 肾切除术具有完整的标本提取和可接受的手术时间，是可行的。需要进行临床前生存研究以评估无菌性和并发症。这种方法可能是经阴道入路的替代方法。
