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151
11 Access: Transvesical
the widespread adoption of transvesical port in NOTES. This was the rationale for
this research group to report the usefulness of T-fasteners with a locking cinch sys-
tem [ 15 ] . They demonstrated the feasibility and safety of endoscopic closure of
vesical perforations with an endoscopic suturing kit (T-fasteners with a locking
cinch) in a survival porcine model. Three steps were involved in the endoscopic
closure of the perforation: (1) With the animals in the Trendelenburg position, the
needle punctured the edge of the perforation (the 19-gauge needle was loaded with
the metal T-tag attached to a 3.0 violet Monocryl 90-cm thread and was advanced
through the working channel of the cystoscope and placed through the full thickness
of one edge of the bladder wall). By advancing the stylet, the T-tag and thread were
released from the needle and left in the exterior part of the bladder; (2) needle punc-
ture of the opposite edge of the perforation, followed by release of the T-tag, which
was performed in a similar way; and (3) knot tying was then accomplished, fol-
lowed by suture cutting with a lock-and-cut combination device, which was
advanced to tie the threads together (Fig. 11.3 ). The defect was closed by pulling the
threads on either side of the incision together until they were snug against the lock,
and then by closing the lock and subsequently cutting the threads with the combina-
tion thread-locking and suture-cutting device. This resulted in a secure closure of
the perforation. No catheter was left in the bladder. All animals were evaluated
daily; the postmortem examination 15 days after surgery revealed complete healing
of the bladder wall incision. The authors concluded that these fi ndings provided
immediate support for clinical application of this method to close bladder perfora-
tions both in the management of bladder rupture and as a transvesical port in NOTES
procedures.
More recently, Metzelder et al. described another method for the closure of
bladder perforations in a porcine model. Five female piglets underwent right-sided
transurethral nephroureterectomy using a hybrid technique with one 15-mm trocar
placed umbilically and one 3-mm trocar placed transvesically. Hilar dissection was
performed with a 5-mm ligasure vessel-sealing device. After umbilical retrieval of
the resected kidney, the urinary bladder was closed by an endoloop via an umbilical
“two-in-one system” with the assistance of a 2-mm transurethrally placed endo-
scopic clamp [ 16 ] .
Fig. 11.3 Closure of bladder perforation with a pair of threads for a subsequent locking
152
E. Lima and J. Correia-Pinto
Transvesical port for abdominal morcellation of specimen
The morcellation was thought as a method to overcome the limitation of the size for
removing specimens, regardless of the diameter of the port accessed. One of the
limitations of the transvesical port was specimen retrieval, conditioned by the size
of the urethra. Recently using this concept, Lima et al reported pure transvesical
nephrectomy with kidney morcellation within the abdominal cavity [ 23 ] . In six
pigs, after a pure transvesical nephrectomy, the peritoneal cavity was emptied of
CO
2
and replaced with saline solution. Before emptying CO
2
, the kidney was fi xed
to the abdominal wall with a fi xing needle, created speci fi cally for this purpose.
Later, was introduced, through the working channel of the telescope, the morcella-
tor (Piranha-wolf morcellator
®
) in the peritoneal cavity and the kidney morcellation
began under saline solution. The morcellation proved to be effective, allowing exci-
sion of the entire kidney rapidly (median time: 15 minutes, range 10 to 20 minutes).
This study showed, for the fi rst time, the feasibility of morcellation of abdominal
organs through a natural ori fi ce, in porcine model.
Advantage and Limitations of Transvesical Port in Comparison
with Other Ports
Considering the natural ori fi ces that allow NOTES, in order to know which will be
the best port or the most suited to a particular procedure, some aspects should be
considered: ease of access, ease and safety of the otomy closure, potential infectious
complications related to the closure, maximum diameter and type of instruments
that the ori fi ces can tolerate, and if it allows specimen retrieval (Table 11.2 ).
The transgastric port has many limitations, such as the lack of sterility of
the digestive tract, being a long route—which implicates the use of fl exible
Table 11.2 Comparison among the transluminal ports
Transluminal port/features Transvesical Transvaginal Transcolonic Transgastric
Available in both genders Yes No Yes Yes
Possibility of using rigid
instruments
Yes Yes Yes No
Sterility Yes No No No
Limited size of access Yes No No No
Capability of closure —
a
Easy —
b
—
b
Specimen retrieval Yes Yes Yes —
c
Access to the abdominal
cavity
Inferior, anterior — Inferior, posterior Superior
a
If the otomy is up to 5 mm and with adequate bladder drainage, it is not necessary to close it up
b
Lack of an effective closure mechanism
c
Depends on the size of the specimen: small pieces can be extracted as opposed to larger pieces
153
11 Access: Transvesical
instruments—and the potential infectious and iatrogenic complications. Some limi-
tations are associated with gastroscopes, particularly the lack of triangulation and
traction, the need to work in retro fl exion with inverted images, and the dif fi culty in
controlling the pneumoperitoneum. The closure of the gastrotomy is also an impor-
tant limitation [
22 ] . In order to overcome these problems, some solutions were
launched, such as the design of new gastroscopes and transgastric instruments and
the combination of transgastric access with a transabdominal port (hybrid NOTES)
or with another natural ori fi ce (combined pure NOTES) [ 23 ] . Despite these attempts,
the application in humans depends on an effective gastrotomy closure method that
still does not exist.
In the transvaginal approach, the advantages include the possibility of using rigid
instruments and direct visualization of upper abdominal structures, without
retro fl exion and therefore with less dif fi culty in spatial orientation. Furthermore, it
has an easy method to access the peritoneal cavity through a simple incision at the
Douglas pouch. It is considered a good way for specimen retrieval, given its diam-
eter, and the port with the safest otomy closure to date. Nonetheless, being available
only in women is the limiting key factor. Other limitations are related to the patient’s
personal history (previous vaginal or pelvic surgery) that may not enable NOTES to
be performed. Still without a full understanding, but that should be taken into
account in future studies, are the effects on sexual function and quality of life of
female patients [ 23 ] .
The transcolonic port allows the introduction of rigid instruments and direct
visualization of the upper abdomen organs, is present in both sexes, and allows the
use of larger-diameter instruments and specimen retrieval due to the rectum’s com-
placency. However, it presents a high risk of infection because it is not sterile and
the transvisceral incision closure is not yet effective. It would take a colonic prepa-
ration and lumen sterilization to consider its implementation in humans [ 10 ] .
The transvesical port broke down some of the most feared complications in urol-
ogy: the perforation of the bladder wall that is requested by NOTES to access the
abdominal cavity. However, in 2006, Lima et al. saw this port as an advantageous
pathway, considering the following facts (Table 11.3 ): (1) The bladder and its
content are naturally sterile; (2) the bladder and the lower urinary tract allow the
passage of rigid instruments, which facilitates the structure’s retraction; (3) it is a
pathway present in both sexes; (4) it is the most anterior anatomical position in the
sagittal plane, allowing access to the upper abdominal organs above the bowel loops,
reducing the risk of damaging other organs, unlike the transvaginal and transcolonic
ports, in which the surgeon works through the bowel loops [ 23 ] . With practice arose
other advantages, among which are worth mentioning the simplicity of cystotomy
closure (which may not be necessary if the otomy is less than 5 mm with an ade-
quate bladder drainage), the ease and speed with which the pneumoperitoneum is
achieved and controlled, and the diminished complexity of spatial orientation given
the direct visualization of the upper abdomen organs. The disadvantage is related to
the diameter of the urethra, which limits the size of the instruments used and the
intact specimen retrieval.
154
E. Lima and J. Correia-Pinto
Potential Surgical Applications of the Transvesical Port
The transvesical port, because of its advantages (in particular, being naturally sterile
and anatomically the most anterior access to the abdominal cavity, allowing the
access to the upper abdominal organs above bowel loops), is appealing for both
urological and nonurological procedures. Thus, the transvesical port can potentially
be applied to several procedures such as peritoneoscopy, cancer staging, intraab-
dominal testes search, intraabdominal orchidectomy, varicocelectomy, ovarian
pathologies treatment, nephrectomy, cholecystectomy, and procedures in the dia-
phragm (Table
11.4 ).
Diagnostic procedures
Peritoneoscopy
Cancer staging
Endometriosis staging
Exploration intraabdominal testes
Ovarian pathologies
Interventional simple procedures
Intraabdominal orchidectomy
Oophorectomy
Tubal ligation
Diaphragmatic pacemakers
Accessory port for complex intraabdominal procedures
Nephrectomy
Cholecystectomy
Splenectomy
Table 11.4 Possible indications
for transvesical port
Table 11.3 Advantages and disadvantage of the transvesical port
Advantages
Naturally sterile
Located in most anterior portion of the pelvic cavity, allowing peritoneal access above the
bowel loops
Providing an en face orientation of the upper abdominal organs, allowing better visualization
and the ability to work straightforwardly
Visualization of all the intraperitoneal structures with a direct line of sight
The possibility to introduce rigid instruments by the working channels of the scopes, enhancing
the possibility to retract and grasping structures
Allows one to easily and quickly control and maintain the pneumoperitoneum with a standard
instrument
The ability to be performed in both genders
Easy endoscopic closure technique of the cystostomy tract although spontaneous healing is possible
Easy spatial orientation
Disadvantage
The diameter of the urethra limits the size of the devices and the intact specimen retrieval at the
end of the procedures
155
11 Access: Transvesical
Editorial Comment
Dr. Lima and colleagues pioneered the transvesical (transurethral) route as an option
for performing NOTES. While the bladder, like the vagina, may be a forgiving route
of entry compared to the bowel, the relatively small caliber of the urethra, especially
in males, and nonfamiliarity with nonurologist surgeons may limit its clinical use-
fulness. However, the transvesical route should be considered a potential access
route, especially in women.
References
1. Harrell AG, Heniford T. Minimally invasive abdominal surgery: Lux et veritas past, present,
and future. Am J Surg. 2005;190:239–43.
2. Autorino R, Cadeddu JA, Desai MM, et al. Laparoendoscopic single-site and natural ori fi ce
transluminal endoscopic surgery in urology: a critical analysis of the literature. Eur Urol.
2011;59(1):26.
3. Rattner D, Kalloo A. ASGE/SAGES Working Group on natural ori fi ce translumenal endo-
scopic surgery. Surg Endosc. 2006;20:329–33.
4. Kalloo AN, Singh VK, Jagannath SB, et al. Flexible transgastric peritoneoscopy: a novel
approach to diagnostic and therapeutic interventions in the peritoneal cavity. Gastrointest
Endosc. 2004;60:114–7.
5. Lima E, Rolanda C, Autorino R, Correia-Pinto J. Experimental foundation for NOTES and
hybrid NOTES. BJU Int. 2010;6:913–8.
6. Gettman MT, Lotan Y, Napper CA, Cadeddu JA. Transvaginal laparoscopic nephrectomy:
development and feasibility in the porcine model. Urology. 2002;59:446–50.
7. Autorino R, Stein RJ, Lima E, et al. Current status and future perspectives in laparoendoscopic
single-site and natural ori fi ce transluminal endoscopic urological surgery. Int J Urol. 2010;
17:410–31.
8. Lima E, Rolanda C, Pêgo JM, et al. Transvesical endoscopic peritoneoscopy: a novel 5 mm
port for intra-abdominal scarless surgery. J Urol. 2006;176:802–5.
9. Lima E, Henriques-Coelho T, Rolanda C, et al. Transvesical thoracoscopy: a natural ori fi ce
translumenal endoscopic approach for thoracic surgery. Surg Endosc. 2007;21:854–8.
10. Pai RD, Fong DG, Bundga ME, et al. Transcolonic endoscopic cholecystectomy: a NOTES
survival study in a porcine model (with video). Gastrointest Endosc. 2006;64:428–34.
11. Rolanda C, Lima E, Pêgo JM, et al. Third-generation cholecystectomy by natural ori fi ces:
transgastric and transvesical combined approach (with video). Gastrointest Endosc. 2007;65:
111–7.
12. Gettman MT, Blute ML. Transvesical peritoneoscopy: initial clinical evaluation of the bladder
as a portal for natural ori fi ce translumenal endoscopic surgery. Mayo Clin Proc. 2007;82:
843–5.
13. Lima E, Rolanda C, Pêgo JM, et al. Third-generation nephrectomy by natural ori fi ce translu-
minal endoscopic surgery. J Urol. 2007;178:2648–54.
14. Sawyer MD, Cherullo EE, Elmunzer BJ, et al. Pure natural ori fi ce translumenal endoscopic
surgery partial cystectomy: intravesical transurethral and extravesical transgastric techniques
in a porcine model. Urology. 2009;74:1049–53.
15. Lima E, Rolanda C, Osório L, et al. Endoscopic closure of transmural bladder wall perfora-
tions. Eur Urol. 2009;56:151–8.
156
E. Lima and J. Correia-Pinto
16. Metzelder M, Vieten G, Gosemann JH, et al. Endoloop closure of the urinary bladder is safe
and ef fi cient in female piglets undergoing transurethral NOTES nephrectomy. Eur J Pediatr
Surg. 2009;19:362–5.
17. Branco F, Pini F, Osório L, et al. Transvesical peritoneoscopy with rigid scope: feasibility
study in human male cadaver. Surg Endosc. 2011;25(6):2015–9.
18. Osório L, Silva D, Autorino R, Damiano R, Correia-Pinto J, Lima E. Pure NOTES transvesical
venous ligation: translational animal model of varicocelectomy. Urology 2011;78:1082–6.
19. Park PO, Bergstrom M, Ikeda K, et al. Experimental studies of transgastric gallbladder sur-
gery: cholecystectomy and cholecystogastric anastomosis (videos). Gastrointest Endosc.
2005;61:601–6.
20. Swanstrom LL, Kozarek R, Pasricha PJ, et al. Development of a new access device for trans-
gastric surgery. J Gastrointest Surg. 2005;9:1129–37.
21. McGee SM, Routh JC, Pereira CW, Gettman MT. Minimal contamination of the human peri-
toneum after transvesical incision. J Endourol. 2009;23:659–63.
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clips in an experimental model for varicocelectomy. Gastrointest Endosc. 2009;70:1137–45.
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157
A. Rane et al. (eds.), Scar-Less Surgery,
DOI 10.1007/978-1-84800-360-6_12, © Springer-Verlag London 2013
Keywords Access • Laproendoscopic single-site surgery • LESS • Transumbilical
Scarless • Single port • Technique
Introduction
Laparoscopic surgery typically uses a variable number of ports for a given proce-
dure to provide triangulation between instruments, allowing the surgeon adequate
intracorporeal working space for dissection and tissue manipulation [ 1 ] . While lap-
aroscopic surgery has evolved to be the reference standard for a number of extirpa-
tive and reconstructive procedures and is generally safe and effective, complications
related to port placement have also been well recognized in laparoscopy [ 2 ] .
Several urological groups initially used a variety of terms to describe the tech-
nique if it used a single-port or single-site access, now de fi ned as LESS (laparoen-
doscopic single-site) [ 3– 6 ] . LESS appears to offer the patient the potential bene fi ts
of decreased abdominal wall trauma, enhanced cosmesis, quicker recovery, and
increased patient satisfaction [ 7 ] .
A. Rane , M.D.
Department of Urology , East Surrey Hospital ,
Canada Avenue , Redhill, Surrey RH1 5RH , UK
e-mail: a.rane@btinternet.com
R. Autorino , M.D., Ph.D., FEBU (
*)
Urology Clinic, Second University of Naples ,
Piazza Miraglia, Naples 80138 , Italy
Center for Laparoscopic and Robotic Surgery , Glickman Urological and Kidney Institute,
Cleveland Clinic , 9500 Euclid Avenue Q10 , Cleveland , OH 44195 , USA
e-mail: autorir@ccf.org, ricautor@tin.it
Chapter 12
Access: Transumbilical
Abhay Rane and Riccardo Autorino
158
A. Rane and R. Autorino
Despite being regarded by some as an evolution of standard laparoscopic sur-
gery, LESS de fi es the most basic tenets of laparoscopy, including the triangulation
of working instruments and external spacing to decrease intra- and extracorporeal
clashing.
It may be postulated that when this access site is the umbilicus, which is a natural
scar, the cosmetic outcome will be optimal. According to the current nomenclature,
transumbilical LESS is more speci fi cally de fi ned as umbilical LESS (U-LESS), which
includes a variety of previous de fi nitions used by those who pioneered the technique
[ 5, 8– 13 ] (Table 12.1 ). Transumbilical LESS access can be obtained (Fig. 12.1 ).
By performing a single skin and fascial incision through which a single multi-•
channel access platform is placed ( single-port technique ) [ 9 ]
By placing several low-pro fi le ports through separate fascial incisions ( • single-
site technique ) [ 10 ]
Table 12.1 Umbilical LESS: nomenclature
Current terminology Previous terminology
Umbilical laparoendoscopic single-site
surgery (U-LESS) [
5 ]
One-port umbilical surgery (OPUS) [
9 ]
Keyhole umbilical surgery [
10 ]
Natural ori fi ce transumbilical surgery
(NOTUS) [
11 ]
Transumbilical endoscopic surgery (TUES)
[
12 ]
Embryonic natural ori fi ce transumbilical
endoscopic surgery (E-NOTES) [
13 ]
Single site accessSingle port access
Fascial incision
Skin incision
Fig. 12.1 Access
techniques in
laparoendoscopic single-site
surgery (LESS): single-port
and single-site
159
12 Access: Transumbilical
Technique and Devices
Single-Port Umbilical Access
Access devices for single-port surgery can be broadly categorized into two catego-
ries: industry-designed platforms and homemade ones [ 14, 15 ] . The clinical use of
several commercially available access devices has been reported so far (Fig. 12.2 ),
Fig. 12.2 Most commonly used purpose-built platforms for single-port surgery. ( a ) SILS port; ( b )
Endocone; ( c ) X-CONE; ( d ) single site laparoscopy ( SSL ) access system; ( e ) TriPort and QuadPort;
( f ) GelPOINT
160
A. Rane and R. Autorino
each with its own speci fi c feature. All devices utilize the principles of an open
Hassan technique for insertion, and therefore carry the advantages of safe access
under vision. The length of the incision may vary depending on the procedure to be
carried out.
One of the fi rst purpose-built devices described for single-port surgery [
16, 17 ] ,
the Uni-X™ Single Port System (Pnavel Systems, Inc., Morganville, NJ), was a
20-mm port with three separate fl exible instrumentation channels and a portal for
gas insuf fl ation. Once sited into the abdomen, the port was anchored in place using
fascial sutures. Despite being shown to be effective in the early clinical experience
with urologic LESS, this device is no longer available.
At around the same time, another company (Advanced Surgical Concepts,
Wicklow, Ireland) developed a different platform, known as the r-Port™. The device
had a body wall retractor component and a valve component composed of an elas-
tomeric material allowing instrument passage. Later versions (TriPort™) contained
one 12-mm valve, two 5-mm valves, and two additional valves for insuf fl ation and
smoke evacuation. The device can be inserted in incisions from 12 to 25 mm in
length, and the self-adjusting design allows usage in patients with varying abdomi-
nal wall thicknesses (up to 10 cm). The presence of valves as opposed to trocars
helps to diminish the external clashing of instruments. In the latest version of this
product (TriPort), currently marketed by Olympus Medical, there is a fourth 5-mm
lipseal valve, enabling the insertion of an additional instrument. Rane et al. reported
the fi rst clinical use of the r-Port [
9 ] . Later on, investigators from the Cleveland
Clinic also described the successful use of this device for a variety of urologic indi-
cations [ 18, 19 ] .
Except for its larger diameter, the QuadPort™ (Olympus Medical, Center Valley,
PA) is designed according to the same principle as the TriPort. It can be used for
incision lengths between 25 and 60 mm. Its larger diameter makes it more suitable
for the removal of biopsy samples and organs. This version has four lipseal valves
(one 5-mm valve, two 10-mm valves, and a 15-mm valve).
The GelPOINT™ (Applied Medical, Rancho Santa Margarita, CA) features a
GelSeal™ gel platform for port placement, an Alexis™ (Applied Medical, Rancho
Santa Margarita, CA) wound retractor for fi xation to the abdominal wall, self-
retaining, low-pro fi le trocars, and a built-in valve for insuf fl ation.
Although similar to the GelPort™ (Applied Medical, Rancho Santa Margarita,
CA), which is popular in hand-assisted laparoscopic surgery, the GelPOINT has
several important distinctions. It is smaller and does not contain a perforation within
the gel cap. An insuf fl ation port is located on the side of the device, and a suture
attached to the wound protection apparatus allows for easier platform removal. The
claimed potential advantages include adaptation to different trocar con fi gurations, a
larger outer working pro fi le providing less external clashing, and the ability to
accommodate different abdominal wall thicknesses. Recently, Gimenez et al.
reported their initial experience with LESS donor nephrectomy by using a single-
access GelPOINT™ device inserted into the abdomen through a 4–5-cm periumbil-
ical incision [
20 ] . No extra-umbilical incisions were needed, and the authors stated
that the device provided more space for triangulation.
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