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SECTION 2 Current Clinical Applications and Techniques
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technical challenges of operating through a confi ned
opening, but generally retains the familiar tools and techniques of laparoscopic surgery.
LESS procedures are technically demanding due to multiple factors, including (i) internal and external confl icts
between operating instruments and the optic system (Figure
15.3), (ii) lack of triangulation for working instruments, (iii)
in-line view, and (iv) limited ability to retract and expose.
The size of bariatric patients amplifi es the aforementioned
challenges. One potential solution to the LESS challenge of
triangulation is to use double -curved instruments (S -PORTAL
by Leroy, Karl Storz Endoskope, Tuttlingen, Germany) that
enable surgeons to coordinate their hand to their visual
fi eld. Another solution is to cross angulated instruments
(Roticulator™, Covidien, Mansfi eld, MA) through the apex
of the single incision port. While creating maximal triangulation and range of movement, the counterintuitive nature
Table 15.1 Potential advantages and challenges of bariatric NOTES.
Advantages Challenges
Anesthesia Less pneumoperitoneum
Reduced anesthesia requirements
Cosmetic No scars After major weight loss plastic surgery is often desired,
Technical Use of upper GI translumenal access to form
necessary anastomosis
Postoperative risks Reduced incisional hernia
Reduced risk of incision -site infection
Reduced abdominal wall pain
Faster return to activity
of crossed instruments is diffi cult for the surgeon to resolve.
Robotics may offer a further solution to crossing instruments. A telemanipulation system can be programmed to
cross instruments, yet still allow the surgeon to manipulate
the instrument seen on the left side with the left hand [12].
The current robotic platform (da Vinci, Intuitive Surgical,
Sunnyvale, CA, USA) has an approved single -port crossed instrument system that is undergoing clinical evaluation.
A LESS approach to bariatric surgery began with gastric
banding [13] and sleeve gastrectomy [14,15] in 2008. It was
logical to start with these procedures since they require the
upsizing of a port site to insert the fi lling port system and to
extract the gastric specimen, respectively. The LESS incision
may be performed in the upper abdomen or at the umbilicus, which enables better cosmetic results and lower pain.
The fi rst LESS Roux -en-Y gastric bypass was reported by
Huang et al. in 2009 [16]. The authors used a 6 cm omega -
Prolonged procedure time
resulting in large scars
Secure access closure, particularly for the stomach and rectum
Prolonged procedure time could contribute to increased
postoperative DVT and hypercapnia
Figure 15.3 LESS operating system with external confl icts between operating instruments and the optic system.
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CHAPTER 15 Bariatric NOTES Procedures
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shaped umbilical incision and overcame the challenge of
liver retraction with a suspension tape passed through the
lateral ligament. Overall, the current worldwide experience
with LESS applied to bariatric surgery is limited. A recent
review of the literature carried out by Huang over the period
2008–2011 reported on 114 LESS bariatric procedures
(46 gastric bands, 27 sleeve gastrectomies, and 41 gastric
bypasses) [17].
Lack of widespread adoption of LESS techniques among
bariatric surgeons is likely due to the technical diffi culty
with the available instruments along with the unproven
benefi ts. Comparative studies between a LESS and a standard laparoscopic approach are under way. Whether LESS is
a step toward NOTES or a defi nite surgical technique depends
on further technological developments to enable the surgeon
to provide improved patient outcomes (Video 15.1).
Technical considerations for bariatric
NOTES
Access routes
The availability of natural orifi ces is limited. Transgastric
access is appealing as most bariatric procedures involve the
opening, anastomosis, and/or division of the stomach. The
downside of transgastric access is the need for a fl exible
operating platform and the need for safe and reliable gastric
closure.
The transvaginal route has gained the most popularity in
NOTES to date as colpotomy for abdominal access has a track
record of success in the gynecologic literature with a low
rate of infection and complications [18,19]. Additionally, the
transvaginal route provides a direct axis to the upper gastrointestinal (GI) tract, which affords the opportunity to use
standard rigid laparoscopic instruments. The downside of
transvaginal access is, of course, that it is only applicable to
the female population. Transrectal access affords the same
axis toward the upper GI tract, but contains a signifi cantly
higher bacterial load, with the potential for causing abdominal infection, and the need for safe and reliable closure.
To date, the transgastric and transvaginal routes are being
investigated for bariatric NOTES techniques, with only a
single experimental report of the transrectal route [20].
Bariatric NOTES cases remain rare, accounting for around
1% of reported NOTES cases in humans [19,21]. Interestingly, the general patient population has shown an acceptance of NOTES despite unknown risk profi les and a
preference toward the transgastric route despite the increased
technical challenge [22].
Operating platform
There are two fundamental platforms that have been utilized for NOTES applications, fl exible and rigid. Flexible platforms, that is, endoscopes, offer the ability to move freely
throughout the abdomen. However, they are limited by a
lack of robust instruments, poor triangulation of instruments, and diffi culty with orientation. Rigid instruments
offer the ability to utilize the robust tools currently available
to the laparoscopic bariatric surgeon, but are limited to
working along a straight axis. The future of NOTES will
likely require robotic platforms to generate triangulation
and force through a fl exible platform at a distance from the
operator.
Experimental results of NOTES for existing
bariatric procedures
To date, gastric bypass, sleeve gastrectomy, and gastric
banding have been performed in the experimental setting
using either animal models or cadavers. Sleeve gastrectomy
and gastric banding have seen limited hybrid NOTES
approaches in patients. Duodenal switch is a technically
challenging operation that has yet to be attempted with
NOTES techniques. Vertical banded gastroplasty is currently
considered less effective than other approaches, it is
rarely performed, and it has not been a focus of NOTES
development.
The tendency in translating bariatric NOTES to human use
has been to make a stepwise transition from currently standardized laparoscopic techniques. Step -by-step visualization
and manipulations that are performed through transabdominal ports have been transitioned to translumenal access
ports. Each step of a procedure is thus enabled in the hybrid
setting with the ultimate goal of pure NOTES approaches.
NOTES gastric bypass
Gastric bypass is the gold standard for weight loss surgery,
but remains technically challenging. It requires access to
both the stomach and the small bowel, division of the
stomach, and two anastomoses. Furthermore, the creation
of a small gastric pouch near the gastroesophageal (GE)
junction routinely requires liver retraction, which can be
diffi cult in the setting of fatty liver.
Kalloo et al. reported a technique for NOTES peritoneal
exploration and potential gastrojejunostomy, paving the
way for NOTES gastric bypass [23]. The same group reported
a survival study in pigs using a prototype suturing device
delivered through a fl exible endoscope [24]. The feasibility
of additional gastrojejunal anastomosis techniques has also
been reported [25]. There have been no animal studies on
NOTES gastric bypass to -date.
A single human cadaveric hybrid NOTES procedure has
been reported by Madan et al. in a fresh cadaver [26]. The
group used an abdominal port for visualization and insuffl ation, a gastric port with a working fl exible endoscope,
and two transvaginal ports for a working endoscope and
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SECTION 2 Current Clinical Applications and Techniques
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Table 15.2 Overview of NOTES gastric bypass experience.
Study Subjects ( n) Key techniques and contributions Limitations
Madan et al.
2008 [26]
Hagen et al.
2008 [27]
Cadaver (1) Feasible hybrid procedure
One transabdominal port for insuffl ation and visualization
Two transvaginal ports for rigid and fl exible instruments
One transgastric port for fl exible endoscopic platform
One transvaginal fl exible powered stapler
Cadaver (7) Feasible hybrid procedure
Two or three transabdominal ports for insuffl ation, visualization,
and instruments
One or two transvaginal ports for fl exible and rigid instruments
One transgastric port for fl exible platform
Laparoscopic -assisted anastomoses with standard linear and circular
systems
additional instruments. They additionally used a fl exible
computer -modulated stapling system (Power Medical, Langhorne, PA, USA). The gastrotomy for the fl exible endoscope
was used to form the gastrojejunal anastomosis. The limitations were that it was done in a normal size cadaver without
the need for liver retraction, the vaginal and gastric ports
were not closed, the mesenteric defects were not closed, and
the transabdominal port was used for visualization.
Hagen et al. soon after reported a series of eight human
cadaveric gastric bypass procedures [27]. The group was
successful in four out of seven cadavers that were either
thawed or preserved in long -term solution. Standard linear
and circular staplers were used but required two or three
laparoscopic ports for assistance. The cadaver size was not
reported and liver retraction was performed laparoscopically
when necessary (Table 15.2).
NOTES sleeve gastrectomy
Sleeve gastrectomy lends itself to NOTES techniques as it is
focused in a single quadrant of the abdomen, requires no
anastomosis, and requires no delivery of a large device such
as a band or circular stapler. Transvaginal sleeve gastrectomy
has been successfully performed in animal models [20,28]
and translated into the most human experience with NOTES
bariatric procedures. All reported cases to date have been
hybrid, relying on a laparoscope for visualization of the
colpotomy and vaginal trocar placement.
Ramos et al. fi rst reported transvaginal hybrid NOTES
sleeve gastrectomy [29]. In a series of four cases, the vaginal
access was used as an optical port and for specimen extraction, while stapling, suturing, and retraction were performed
with standard transabdominal ports. The female patients
ranged from 26 to 46 years with a BMI range from 32 kg/
2
m
to 45 kg/m2. The pneumoperitoneum was created with a
Hybrid using laparoscopic visualization
Non-obese cadaver without liver retraction
Unreported operative time
Hybrid with laparoscopic visualization and
manipulation
Unreported cadaver size
Liver retraction by laparoscopy
Completed 4/7 procedures
6–9 hour operative time
Veress needle and a laparoscope was used through a 10 mm
umbilical port. Under laparoscopic vision, a 12 mm transvaginal trocar was inserted. Two additional transabdominal
ports were used, a 5 mm one in the right upper quadrant
and a 2 mm one in the left upper quadrant. The stomach
was mobilized using a Harmonic
®
scalpel and was calibrated
with a 36 F bougie. Using linear staplers, the sleeve was
performed from the mid -antrum to the angle of His. The
staple line was then reinforced with suture. The stomach
was extracted transvaginally. The colpotomy was closed with
absorbable suture and the mean operative time was 95
minutes. No complications were reported.
Chouillard et al. reported the largest series of transvaginal
sleeve gastrectomies on 20 patients aged 21 –58 with a mean
BMI of 41.9 kg/m
2
[30]. The procedure was successfully
completed in 70% of patients with a 12 mm umbilical trocar
and an additional 5 mm abdominal trocar and transvaginal
removal of the specimen. Mean operating time was 116
minutes. The procedure was performed with the assistance
of a gynecologist to perform and close the colpotomy. The
group described a technique to elevate the stomach and liver
with gauze sponges in addressing the diffi culty of retraction
for NOTES techniques. No complications were reported at
2-week follow -up. The mean excess weight loss was 46.3%
and 56.9% at 6 and 12 months, respectively.
Horgan’s group reported the fi rst case of hybrid NOTES
sleeve gastrectomy in the United States [31]. A 12 mm
umbilical port and transabdominal Nathanson retractor
were used. The operative time was 171 minutes. The patient
had a 53% excess body weight loss at 6 months. The group
described a novel 15 mm, 15 cm long transvaginal trocar
with a dual cap (Applied Medical, Rancho Santa Margarita,
CA, USA), allowing access for both a fl exible endoscope and
a rigid laparoscopic instrument.
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CHAPTER 15 Bariatric NOTES Procedures
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(a)
Figure 15.4 The progression of hybrid NOTES approaches at our institution: transvaginal endoscope with (a) three abdominal ports, (b) replacement of
one abdominal port with a Berci needle, (c) reduction to two abdominal ports, and (d) single abdominal incision with two ports. © IRCAD.
copyright © IRCAD
(b)
copyright © IRCAD copyright © IRCAD copyright © IRCAD
Our institution has experience of 12 cases of transvaginal
NOTES. We successfully completed 11 cases using a variety
of hybrid techniques (Figure 15.4). In all cases, the transvaginal access was used for visualization with a fl exible
endoscope while dissection was performed through a combination of transvaginal and transabdominal access. In three
cases, we used three abdominal trocars. In fi ve cases, we
(c) (d)
performed through the abdominal port. The gastric band
was inserted through a 15 mm trocar at the side of subcutaneous port placement and no stitches were used to secure
the band. The series included a major complication of iatrogenic ureter damage requiring subsequent laparoscopic
repair. Mean weight loss was reported as 15 kg at 6 -month
follow-up.
were able to use just two abdominal trocars with a transabdominal Berci needle for retraction and manipulation. In
two cases, we were able to use only two abdominal trocars,
Intralumenal therapy
and fi nally in one case, we were able to use only two
abdominal trocars through a single incision [32]. We had no
signifi cant complications. Excess body weight losses at 6, 12,
and 18 months were 75%, 80%, and 94%, respectively
(Table 15.3).
In Video 15.2, a hybrid natural orifi ce translumenal endoscopic sleeve gastrectomy is performed using the vagina as
the natural orifi ce and only two operative 5 mm ports. This
In addition to translumenal bariatric procedures, there are
several intralumenal procedures that are emerging. While
not NOTES, in that the lumen is not crossed, these procedures are natural orifi ce surgery and worth considering as
they are aligned with the minimally invasive goals of NOTES
and can be considered in both staged approaches to weight
loss and long -term management of bariatric patients.
video includes an audio commentary.
Intragastric balloon
NOTES gastric banding
Gastric banding is suited to hybrid NOTES approaches as an
abdominal incision is ultimately required to place the subcutaneous port. By combined abdominal access through the
requisite incision and NOTES techniques, gastric banding is
conceivable with minimal abdominal trauma.
The fi rst three cases of transvaginal hybrid NOTES gastric
banding were reported by Michalik et al. [33]. Patients
ranged from 29 to 52 years old with a BMI from 35 kg/m
to 37 kg/m
potomy was made under direct laparoscopic vision and a
dual-channel working endoscope was inserted directly
without trocar through the vaginal wall. Dissection was
carried out using the endoscope and liver retraction was
2
. Mean operating time was 100 minutes. Col-
The concept of gastric restriction with an endolumenal
balloon has been around since the 1980s [34–36]. However,
despite several excellent randomized controlled trials with
various device modifi cations, the system has proven ineffective at long -term weight loss and is fraught with complications, including refl ex inhibition of gastric emptying, and
gastric ulceration and erosion [37,38]. The BioEnterics
Intragastric Balloon (Allergan, Irvine, CA, USA) is most
2
studied and has recently found some utility as a fi rst -stage
procedure for high -risk, super -obese patients [39].
Revisional gastric pouch surgery
The gastric pouch can dilate in the long term after gastric
bypass, decreasing the effi cacy of the restrictive aspect of the
167
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Table 15.3 Overview of NOTES sleeve gastrectomy experience.
Study Subject ( n) Key techniques and contributions Limitations
Ramos et al.
2008 [29]
Chouillard et al.
2011 [30]
Fischer et al.
2010 [31]
Vix 2011
(unpublished
series)
Human (4) Feasible hybrid NOTES procedure
12 mm vaginal trocar and three abdominal trocars
Transvaginal specimen extraction
Human (20) Feasible hybrid NOTES procedure
One transvaginal port and progression from two
transabdominal ports to single incision with two ports
Novel use of gauze to elevate/retract stomach and liver
Transvaginal specimen extraction
Human (1) Feasible hybrid NOTES procedure
12 mm umbilical port and transabdominal liver retractor
Unique 15 mm transvaginal port accommodating both a
fl exible endoscope and a rigid instrument
Transvaginal specimen extraction
Human (12) Feasible hybrid NOTES procedure
Stepwise progression with transvaginal visualization from three
abdominal trocars to single -incision two -trocar procedure
surgery. Revisional surgery to reduce the size of the
pouch has been shown to augment weight loss. However,
revisional weight loss surgery carries a higher risk of
complication then the initial procedure [40]. Endolumenal
techniques, termed ROSE (restorative obesity surgery
procedure endolumenally) have been shown safe and effective in performing pouch revision. The Incisionless Operating Platform (USGI Medical, San Clemente, CA, USA)
was fi rst reported by Swanstrom ’s group to be feasible for
intragastric manipulations and full -thickness plication
in animal studies [41,42]. The ROSE procedure with signifi cant pouch volume reduction was shown to be feasible
and safe in early human studies [43–45]. In a study of 116
patients with pouch dilation and weight regain after
gastric bypass, endolumenal volume reduction using this
device resulted in 18% re -loss of excess weight over 6
months and durable tissue anchors at one year [46].
The StomaphyX device (Endogastric Solutions, Redmond,
WA) was also shown to be technically feasible at reducing
the gastric pouch with a low complication rate [47]. The
system has also been reported in the management of gastric
leaks [48].
Hybrid using laparoscopic visualization and
manipulation
Vaginal access exclusively for visualization
hybrid with laparoscopic visualization and
manipulation
70% completion with two abdominal trocars
Rigid transvaginal laparoscope
Hybrid with laparoscopic visualization and
manipulation
Single case report
Hybrid with laparoscopic visualization and
manipulation
Limited endoscopic manipulation
excess weight loss at 6 months without any major complications reported [49,50].
Endolumenal duodenal sleeve
An endolumenal sleeve designed to block duodenal and
proximal jejunal absorption, EndoBarrier
®
(GI Dynamics,
Lexington, MA, USA), is currently under investigation
(Figure 15.6). Animal studies showed a 20% difference in
weight between treatment and control groups as well as
increased insulin sensitivity in the treatment group [51]. The
results of the fi rst human trial in 12 patients revealed diffi cult placement, with two sleeves removed early and
removal with two pharyngeal tears during explication. Ten
patients tolerated the sleeve for 12 weeks, during which
they achieved 24% excess weight loss [51]. A second trial
reported that the device was tolerated in 80% of patients
for 12 weeks and resulted in 22% excess weight loss [52].
Complications included upper GI bleeding, migration, and
obstruction.
Conclusion
Transoral gastric plication
Transoral gastroplasty has been proposed with the TOGA
system (Satiety, Inc., Palo Alto, CA). The system is capable
of transoral full -thickness gastric plication to reduce the
volume of the stomach (Figure 15.5). Human experience
with the device is limited, but results to date show feasibility
and safety. Initial trials have shown between 22% and 46%
168
Bariatric surgery offers a durable and low -risk treatment for
patients with morbid obesity and associated comorbidities.
Laparoscopic techniques have decreased surgical morbidity
and have become the gold standard approach to weight
loss surgery. Bariatric specifi c challenges must be carefully
addressed in the development of new technologies and
techniques to maximize the benefi t of this emerging fi eld
TOGA*
https://t.me/med1917
Sleeve Stapler
Flexible
camera
Figure 15.5 TOGA procedure for gastric plication.
Figure 15.6 Endolumenal duodenal -jejunal barrier sleeve.
for weight loss surgery. Early investigations into the application of LESS, NOTES, and endolumenal surgery in the
management of obesity are promising. Safe, effective,
and less -invasive techniques could have a positive impact
on incision -related morbidity, cosmetic outcome, anesthetic
risk, and overall peri -operative morbidity.
Chapter video clips
Video 15.1 LESS sleeve gastrectomy.
Video 15.2 NOTES hybrid sleeve gastrectomy.
CHAPTER 15 Bariatric NOTES Procedures
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16
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Urologic Applications of NOTES
Candace F. Granberg,1Mitchell R. Humphreys ,2& Matthew T. Gettman
1
Mayo Clinic, Rochester, MN, USA
2
Mayo Clinic Arizona, Phoenix, AZ, USA
Transvaginal NOTES
Laboratory studies
The fi rst pure NOTES procedure was a transvaginal laparoscopic nephrectomy in a porcine model described by Gettman
et al. [1]. Through a posterior colpotomy, modifi ed plastic
fascial dilators were placed for use as laparoscopic ports.
Standard as well as articulating instruments (Roticulator
Endo Dissect, Roticulator Endo Mini -shears, US Surgical,
Norwalk, CT, USA) were utilized for dissection, at times with
handles oriented 180 ° apart due to close port proximity. The
hilar vessels were controlled with an Endo -GIA stapler (US
Surgical) placed through the colpotomy without a trocar.
After removal of the kidney in an EndoCatch bag, the colpotomy was not closed and was found to have healed upon
follow-up vaginoscopy. The authors noted that the anatomic
constraints of the porcine urogenital sinus in combination
with the limitations of the then -available laparoscopic
instruments made the procedure cumbersome.
Since this feasibility study, a tremendous amount of
energy has been applied by surgeons, researchers, and
medical engineers to develop operating platforms and specialized instrumentation designed to overcome the inherent
limitations encountered with natural orifi ce surgery. One
such platform, the ShapeLock TransPort ™ Multi -Lumen
Operating Platform (USGI Medical, San Clemente, CA,
USA), was used by Clayman et al. [2] for porcine transvaginal nephrectomy. Upon advancement to the desired surgical
location, the fl exible device can be locked, thus creating
a rigid platform through which two -handed dissection can
be carried out using instruments through its four ports.
Two specialized tissue -acquisition instruments, g -Prox™ and
g-Lix™ (USGI Medical), were used through the TransPort
device for retraction; however, throughout the procedure
1
other instruments were placed through a 12 mm abdominal
port to aid dissection and obtain hilar control. Limitations
noted with use of a single -port, multilumen platform include
diffi culty with triangulation as well as with dissection secondary to the orientation of the endoscope adjacent to and
in-line with the working instruments, which can lead to
instrument clashing.
Recognizing these limitations, a team led by Dr Jeffrey A.
Cadeddu employed their magnetic anchoring and guidance
system (MAGS) platform to perform complete transvaginal
NOTES nephrectomy in a porcine model as published by
Raman et al. [3]. This system relocates instruments away
from the transvaginal port, including a deployable customized camera and cautery dissector that were manipulated
along the anterior peritoneal surface via external magnets.
In this case, the hilar vessels were taken with an extra -long
articulating endovascular stapler placed through a 40 cm
prototype rigid transvaginal port. Although triangulation
was improved and instrument clashing was not problematic,
a drawback to the MAGS system was that the tethers from
the intracorporeal MAGS instruments are fed externally
through the trocar, resulting in leakage of CO
quent pneumoperitoneum reaching a maximum of only
7–10 mmHg during the case. Moreover, there is an exponential decay of the coupling strength of the magnets with
increasing abdominal wall thickness. This group has subsequently confi rmed a drop -off threshold of 3.64 ± 0.8 cm
using force -distance testing, thus the use of MAGS technology may be applied to a limited population [4].
Subsequently, Aron et al. described transvaginal nephrectomy in four human cadavers [5]. Through a 3 cm
posterior colpotomy, a self -retaining, four -channel QuadPort
(Advanced Surgical Concepts, Wicklow, Ireland) was introduced. Dissection was carried out using a combination of
straight and articulating instruments, metal clips were used
with subse-
2
Natural Orifi ce Translumenal Endoscopic Surgery (NOTES): Textbook and Video Atlas, First Edition. Edited by Anthony N. Kalloo, Jacques Marescaux,
Ricardo Zorron.
© 2012 John Wiley & Sons, Ltd. Published 2012 by John Wiley & Sons, Ltd.
172
CHAPTER 16 Urologic Applications of NOTES
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to control the renal artery, and an endovascular stapler was
used through the 15 mm channel of the QuadPort for control
of the renal vein. Diffi culties were noted with dissection of
the upper pole of the kidney, the length from introitus to
the upper pole requiring extra -long bariatric instruments,
and gas leak around the port in one cadaver with a retroverted uterus. Thus, the need for NOTES -specifi c platforms
and instrumentation was again emphasized.
Clinical applications
The animal and cadaver studies previously discussed lay the
groundwork for translation of transvaginal nephrectomy
from bench to bedside. In 2009, Kaouk et al. [6] reported
the fi rst clinical application of NOTES transvaginal nephrectomy for benign disease in a 57 -year -old female. Peri operative preparation included placement of a Foley catheter,
rectal pack, and self -retaining vaginal retractor. Initially, a
multichannel TriPort (Advanced Surgical Concepts) was
placed through the posterior colpotomy; however, signifi cant instrument clashing hindered progress and the port was
exchanged for a GelPort (Applied Medical, Rancho Santa
Margarita, CA). Through this port, one 12 mm and two
5 mm trocars were placed and the kidney was dissected
using articulating instruments. A 5 mm transumbilical port
was utilized to facilitate colon retraction prior to dividing the
hilar vessels with an endovascular stapler. Upon removal of
the kidney within a laparoscopic retrieval bag, the colpotomy was formally closed in a single layer of 2 -0 Vicryl. As
previously noted in the cadaver study, extra -long instruments were necessary for upper pole access. In all, the procedure proved challenging but feasible, with the patient
recovering well and dismissed from the hospital 23 hours
postoperatively.
This fi rst clinical case was not a pure NOTES procedure as
a single 5 mm transumbilical port was used initially for visualization for vaginal port placement due to the patient ’s prior
pelvic surgery and later in the case for colon retraction.
Expounding on their previous clinical application, Kaouk
et al. [7] reported the fi rst pure NOTES transvaginal nephrectomy, again for benign disease, in a 58 -year -old woman. In
this case, the TriPort and GelPort were interchanged throughout the case secondary to air leaks with the GelPort and
problems with dissection through the TriPort due to long
vaginal length. Visualization was provided using a 5 mm
defl ecting laparoscope (Olympus Surgical, Orangeburg, NJ,
USA) and dissection was carried out using 45 cm articulating
graspers and scissors (Novare Surgical, Cupertino, CA, USA)
and an extra -long (65 cm) monopolar J -hook. The hilum
was taken with an endovascular stapler, the kidney placed
in a laparoscopic retrieval bag and removed transvaginally,
and colpotomy was closed in a single layer. The entire procedure was performed transvaginally in 420 minutes with
estimated blood loss of 50 ml, and the patient was dismissed
from the hospital after 19 hours.
Although the prospect of pure NOTES transvaginal
nephrectomy is exciting, a lack of adequate NOTES - and
portal-specifi c instrumentation has precluded further clinical applications of this approach.
Hybrid NOTES
Since the inception of NOTES, a fl urry of reports of urologic
applications has been published describing use of more than
one NOTES portal or transabdominal port(s) in addition to
a single NOTES portal, termed hybrid NOTES. Here, a selection of laboratory and clinical works highlighting a variety
of urologic procedures are discussed.
Laboratory work
In 2007, Lima and colleagues [8] used a hybrid transgastric
and transvesical approach to perform nephrectomies in pigs.
Working instruments through both portals were used interchangeably throughout the procedures, which proved technically feasible. However, a signifi cant drawback to this
approach was the inability to retrieve the specimen through
either portal. Using a different combinational approach,
Isariyawongse et al. [9] utilized transgastric and transvaginal
access portals to complete pure NOTES nephrectomy in a
non-survival porcine model. Visualization for the procedure
was provided by a gastroscope through the transgastric site,
with retrofl exion imparting the correct surgical view. With
the exception of a retracting instrument placed transgastrically through the scope, all working instruments for dissection were placed transvaginally, allowing for improved
triangulation.
In an attempt to improve stability, traction, and triangulation, Box et al. [10] incorporated the da Vinci S robot (Intuitive Surgical, Sunnyvale, CA, USA) with transvaginal and
transcolonic ports to perform robotic -assisted NOTES
nephrectomy in a porcine model. In addition to the NOTES
portals, a 12 mm midline transabdominal port was used for
the robotic camera. The procedure was performed successfully and with the benefi t of 3D vision; however, frequent
robotic arm collisions occurred due to close port proximity.
Most of the initial descriptions of hybrid urologic NOTES
illustrated the feasibility of nephrectomy. Haber et al. [11]
expounded on the concept of robotic hybrid NOTES and
reported successful completion of pyeloplasty and partial
nephrectomy in addition to radical nephrectomy in a porcine
model. The approach taken by this group involved
placing the robotic scope and one robotic arm through a
transumbilical incision with the second robotic arm placed
transvaginally. All 30 procedures were performed without
complication using this hybrid approach. Notably, the mean
warm ischemia time in the partial nephrectomy cohort was
25.4 minutes. Authors noted that ease of intracorporeal
suturing was signifi cantly improved with robotic assistance;
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