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224
P.-O. Park and M. Bergström
Technique
The abdominal cavity is entered through a NOTES access. For the purpose of anas-
tomoses, the access is created by cutting the stomach wall with a sphincterotome
instead of balloon dilation to reduce the risk of contraction of the stoma. After the
abdominal cavity is entered, a piece of small bowel is caught on a snare and brought
up into the stomach along with the double-channel gastroscope. Keeping the snare
in place, the fi rst four pairs of T-tags are placed around the bowel loop, attaching
it to the stomach. The snare then needs to come off and another two to four pairs
are placed to complete a suture line around the trapped loop of small bowel.
Eventually, the bowel is cut open and the gastrojejunostomy is ready and patent
(Fig. 17.4 ).
In a series of six nonsurvival pigs, we were able to create a gastrojejunostomy
that was patent and seemed robust at postmortem. These anastomoses were all
placed on the front side of the stomach at the mid-antrum. In a following series of
six survival animals, a gastrojejunostomy was performed with the same technique.
The small bowel was anastomosed to the stomach using T-tags and the pylorus was
left open. The pigs were allowed immediate intake of ordinary feed. They were
survived for 1 week. At the follow-up endoscopy, it was possible to identify the
openings of the gastrojejunostomy and to enter both of them with a standard (9-mm)
gastroscope. The pigs were sacri fi ced, and no signs of infection or leakage were
present postmortem.
Other methods for suturing have also been used for creating anastomoses in a
similar way. Kantsevoy et al. used the Eagle Claw suturing device to create sutured
gastrojejunostomies in pigs. The Eagle Claw is a suturing device that is mounted on
the outside of the endoscope and needs an overtube to protect the esophagus during
introduction. In their study, they present two survival animals with gastrojejunosto-
mies performed with pure NOTES technique, sutured in place using the Eagle Claw.
Both animals survived for 2 weeks and had patent robust anastomoses at postmor-
tem and no sign of leakage in the abdominal cavity [
21 ] .
Fig. 17.4 Six to eight pairs of T-tags are placed around the bowel loop attaching it to the stomach.
Eventually, the bowel is cut open and the gastrojejunostomy is ready and patent. At 1 week, an
endoscope can pass into the afferent end efferent loop of the gastroentero-anastomosis
225
17 NOTES Gastrojejunostomy
NOTES Compression Anastomoses
Compression anastomoses with NOTES techniques, entering the endoscope into the
abdominal cavity, have been performed in the same way as described above, but
with two balloons compressing the tissue instead of magnets [
31 ] . A device with
two separate balloons is brought down through the working channel of the endo-
scope. The distal balloon is introduced into a piece of small bowel and in fl ated. The
bowel is then brought up to the stomach’s serosal side and the proximal balloon is
in fl ated inside the stomach, creating both compression and fi xation. However, no
instant open stoma is created. The small fi stular tract between the joined organs is
dilated after 1 week and the stoma is ready. We explored this method in a series of
fi ve nonsurvival and four survival pigs, placing the device through a gastroscope
with a 6-mm working channel (Olympus GIF-XTQ160). In the survival pigs, the
device had fallen out and a fi stular tract was established at 5–10 days. After balloon
dilation, a 9-mm gastroscope could be passed down into both the afferent and effer-
ent limbs of small bowel [ 32 ] .
With the new technique called “smart self-assembling magnets for endoscopy”
(SAMSEN), Marvin Ryou et al. described a magnet compression anastomosis with
immediate gastrojejunostomy [ 33 ] . Four magnets form a 2.25 cm square frame, but
for delivery they are pinched in a linear shape. The magnets are made of neodym-
ium-iron-boron rare earth magnets (KJ Magnetics, Jamison, PA) covered by acrylo-
nitrile-butadienestyrene plastic. Through a gastrostomy, a gastroscope with an
overtube was introduced into the abdominal cavity to grab a loop of small bowel.
An enterotomy was performed and the SAMSEN magnet attached to two guide-
wires was introduced into the bowel to form the square frame around the entero-
tomy. The overtube was retracted into the stomach and a second SAMSEN magnet
was introduced over the guidewires to form the compression anastomosis under
fl uoroscopic guidance. The gastroscope was then passed through the anastomosis
into the small bowel to ensure the opening. These anastomoses have been tested in
animal and human cadaver studies and in acute animal studies and showed no leak-
age. The SAMSEN gastroentero-anastomosis is an interesting and promising tech-
nique. However, further studies, including survival studies, have to be presented
before conclusions can be drawn regarding the reliability and safety of this anasto-
motic technique.
Conclusions
There is an increasing interest in performing less invasive gastrojejunostomies, and
different types of devices and techniques have been developed during the last
decade. No pure NOTES techniques have been used in man. Only compression
anastomoses performed with a radiological or endoscopic technique have reached
beyond benchtop and animal experiments into clinical use. The limitation of the
226
P.-O. Park and M. Bergström
compression anastomoses with no instant formation of a gastrojejunostomy may
have been solved with the SAMSEN technique even if this technique has to be
simpli fi ed and proven safe in survival settings. However, there is a need to develop
an endoscopic stapling device to perform a fast, immediate, and reliable anastomo-
sis before the clinical use of NOTES gastrojejunostomies will become a standard
technique.
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4. Grif fi n SM, Chung SC, Leung JW, Li AK. Peptic pyloric stenosis treated by endoscopic bal-
loon dilatation. Br J Surg. 1989;76:1147–8.
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denal obstruction. J R Soc Med. 2003;96:494–6.
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625–33.
10. Murphy JB. Cholecysto-intestinal, gastro-intestinal, entero-intestinal anastomosis, and approx-
imation without sutures (original research). Med Rec NY. 1892;42:665–76.
11. Swain CP, Mills TN. Anastomosis at fl exible endoscopy: an experimental study of compres-
sion button gastrojejunostomy. Gastrointest Endosc. 1991;37:628–31.
12. Cope C. Creation of compression gastroenterostomy by means of the oral, percutaneous, or
surgical introduction of magnets: feasibility study in swine. J Vasc Interv Radiol. 1995;6:
539–45.
13. Cope C, Ginsberg GG. Long-term patency of experimental magnetic compression gastroen-
teric anastomoses achieved with covered stents. Gastrointest Endosc. 2001;53:780–4.
14. van Hooft JE, Vleggaar FP, Le Moine O, et al. Endoscopic magnetic gastroenteric anastomosis
for palliation of malignant gastric outlet obstruction: a prospective multicenter study.
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access anastomotic device for fl exible endoscopy. Gastrointest Endosc. 2003;58:585–91.
16. Kalloo AN, Singh VK, Jagannath SB, et al. Flexible transgastric peritoneoscopy: a novel
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17 NOTES Gastrojejunostomy
18. Park PO, Bergstrom M. Transgastric peritoneoscopy and appendectomy: thoughts on our fi rst
experience in humans. Endoscopy. 2010;42:81–4.
19. Park PO, Bergstrom M, Ikeda K, Swain P. Towards obesity surgery at fl exible endoscopy:
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patients (with videos). Gastrointest Endosc. 2008;68:981–7.
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development from bench to animal study (with video). Gastrointest Endosc. 2011;71:390–3.
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32. Bergstrom M, Swain CP, Lichtenborgen E, et al. Double balloon anastomsis: a new technique
to achieve transgastric gastro-jejunostomy. Gastrointest Endosc. 2006;63:AB79.
33. Ryou M, Cantillon-Murphy P, Azagury D, et al. Smart self-assembling magnets for endoscopy
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229
A. Rane et al. (eds.), Scar-Less Surgery,
DOI 10.1007/978-1-84800-360-6_18, © Springer-Verlag London 2013
Keywords NOTES • Scarless • Minimally invasive • Nephrectomy • Single-port
Transvaginal • Kidney
Introduction
Surgery is in a constant state of fl ux. In the last 20 years there has been a dramatic
shift from large, open incisions for surgical extirpation to ever-smaller incisions to
achieve the same surgical goals. Surgical removal of the kidney is a procedure that
dates back to 1869 and up until the 1990s necessitated a large, morbid incision, a
signi fi cant “surgical footprint” if you will. With technological advancement and
surgical ingenuity, this “surgical footprint” has diminished with time. First, with the
introduction of conventional laparoscopic nephrectomy [ 1 ] , followed by LESS
nephrectomy [ 2 ] , and fi nally with the advent of NOTES nephrectomy, this “surgical
footprint” has all but been abolished. Perhaps this is the fi nal chapter in the evolu-
tion of scarless surgery?
The bene fi ts of NOTES nephrectomy are more than simply cosmetic. Minimizing
pain, having a shorter convalescence, as well as eliminating abdominal wound com-
plications such as infection and hernias are other potential advantages of NOTES.
However, despite the appealing nature of NOTES nephrectomy, it has yet to receive
universal acceptance among urologists. The principal hurdle for widespread adop-
tion is the technical challenge NOTES nephrectomy presents. Although transvesi-
cal, transgastric, transureteric, and transcolonic NOTES nephrectomy have all been
described in animal models [ 3– 5 ] , only the transvaginal route has been performed
in humans. This technical necessity naturally eliminates 50 % of patients that would
S. Leslie , B.Sc., (Med), MB BS (Hons), FRACS (Urol) (*) • T. Gill , BS • M. M. Desai , M.D.
Department of Urology , Keck Medical Center,
University of Southern California Institute of Urology ,
1441 Eastlake Avenue, Suite 7416 , Los Angeles , CA 90033 , USA
e-mail: scottleslie@me.com ; adityadesai2003@gmail.com
Chapter 18
NOTES: Nephrectomy
Scott Leslie , Tania Gill , and Mihir M. Desai
230
S. Leslie et al.
otherwise be suitable for the procedure. In addition, approaching the kidney through
vaginal access presents the surgeon with unique obstacles. These include an unfa-
miliar view of the relevant anatomy and inadequate instrumentation that lacks the
appropriate triangulation. Despite the use of fl exible laparoscopes and extra-long
and articulated instruments in an attempt to overcome these hurdles, it is clear that
at this time the technology is not at the stage to facilitate a global acceptance of
NOTES nephrectomy.
In this chapter, we review the peer-reviewed literature of human cases of NOTES
nephrectomy that has been published over the last 5 years (Table
18.1 ).
NOTES Nephrectomy Terminology
As the clinical application of NOTES is in its infancy, there is as yet no agreed-upon
nomenclature de fi ning what constitutes NOTES. The precursor to NOTES nephre-
ctomy might be considered conventional laparoscopic nephrectomy with vaginal
extraction of the kidney. In 1993, Breda et al. described the fi rst case of laparoscopic
nephrectomy with removal of the specimen via the vagina [ 6 ] . Gill subsequently
reported the technical steps and outcomes of conventional laparoscopic nephrec-
tomy with vaginal extraction in a series of ten cases [ 7 ] . In these examples, where
the dissection is performed completely through transabdominal ports, but the speci-
men is removed via the natural ori fi ce, it is referred to as natural ori fi ce specimen
extraction (NOSE) [ 8 ] . Similarly, in instances where the natural ori fi ce is used for
the insertion of an endoscope for visualization, and the dissection is otherwise com-
pletely performed using conventional laparoscopic ports, this is referred to as natu-
ral ori fi ce visualization (NOV) [ 9, 10 ] .
The term “hybrid” NOTES de fi nes procedures in which one or more transab-
dominal ports assist the transvaginal dissection. In contrast, “pure” NOTES
refers to procedures where the whole case is performed entirely via the natural
ori fi ce. The literature demonstrates that hybrid procedures constitute over 90 %
of NOTES cases [ 11 ] . Indeed, in the case of nephrectomy, there is only one
published case of a pure transvaginal NOTES nephrectomy [ 12 ] . The ability to
safely access the peritoneum through the abdomen, as well as more effective
retraction and dissection, are reasons that hybrid NOTES is favored over pure
NOTES. Although additional abdominal ports are required for hybrid NOTES,
it preserves the main advantage of pure NOTES, which is avoidance of a large
abdominal incision to extract the specimen.
Indications and Patient Selection
NOTES nephrectomy has been performed for both benign and malignant conditions
of the kidney.
231
18 NOTES: Neph re ctomy
Table 18.1 Published NOTES nephrectomy series
Branco et al. [ 13 ] Kaouk et al. [ 12 ] Alcaraz et al. [ 17 ] Sotelo et al. [ 18 ] Kaouk et al. [ 12 ] Porpiglia et al. [ 16 ] Alcaraz et al. [ 15 ]
Patients 1 1 14 4 1 5 20
Pure vs. hybrid Hybrid Hybrid Hybrid Hybrid Pure Hybrid Hybrid
TVD
a
No Yes No Yes Yes Yes Yes
NOV
b
Yes Yes Yes Yes Yes No No
Optics Gastroscope EndoEYE EndoEYE EndoEYE EndoEYE 3-mm laparoscope Standard
laparoscope
Double-
channel,
fl exible
Specialized
instruments
– Graspers and
scissors
– – Graspers and
scissors
3-mm instruments –
45-cm 45-cm
Articulating
J-hook
Articulating
J-hook
65-cm 65-cm
Articulating Articulating
Abdominal
port(s)
X2 standard ports
(5 mm)
X1 standard port
(5 mm)
X2 standard ports
(5-mm,
12-mm)
TriPort Nil X3 mini-laparo-
scopic ports
(3.5-mm)
X3 standard ports
(10-, 10-,
5-mm)
Vaginal port No port TriPort and
GelPort
Bariatric port TriPort GelPort and
TriPort
Bariatric port Bariatric port
Operative time
(min)
170 307 133 222 420 120 117
EBL
c
350 100 111 150 50 160 215
Complications
and technical
dif fi culties
– Instrument
clashing with
the TriPort
Colon injury Colon injury
intraabdomi-
nal collection
Air leak with the
GelPort
– Postoperative
bleed
Hospital LOS
d
(h)
12 23 96 24 19 62 98
(continued)
232
S. Leslie et al.
Table 18.1 (continued)
Branco et al. [ 13 ] Kaouk et al. [ 12 ] Alcaraz et al. [ 17 ] Sotelo et al. [ 18 ] Kaouk et al. [ 12 ] Porpiglia et al. [ 16 ] Alcaraz et al. [ 15 ]
Pain VAS
e
(0–10)
– 1/10 – 3/10 0/10 – –
Pathology Benign Benign Malignant (10),
benign (4)
Malignant (3),
benign (1)
Benign Malignant (2),
benign (3)
Benign (donor
kidneys)
a
Transvaginal dissection
b
Natural ori fi ce visualization
c
Estimated blood loss
d
Length of stay
e
Visual analog score
233
18 NOTES: Neph re ctomy
Benign Conditions
NOTES nephrectomy was fi rst performed for atrophic, nonfunctioning kidneys
[
12– 14 ] . Recently Alcaraz et al. demonstrated the feasability of NOTES in the
setting of living-donor nephrectomy [ 15 ] . In this series, the outcomes of 20 patients
who underwent transvaginal NOTES donor nephrectomy were compared to a con-
temporaneous matched group who underwent conventional laparoscopic living-
donor nephrectomy. Although a longer warm ischemia time was associated with the
NOTES group (5 vs. 2.6 min), this did not translate into any difference between the
two groups in terms of graft function. They concluded that NOTES living-donor
nephrectomy was feasible; however, further randomized controlled trials with a lon-
ger follow-up were required.
Malignant Conditions
Three groups have described NOTES nephrectomy for renal cell carcinoma [ 16–
18 ] . Typically, these tumors are T1b, with the mean diameter being 5 cm. Given the
superior renal functional outcomes of partial nephrectomy over radical nephrec-
tomy, smaller tumors that are amenable to nephron-sparing surgery should be
excluded from NOTES nephrectomy.
NOTES nephrectomy has been performed for both upper pole and lower pole
tumors. However, dissecting around the upper pole is particularly challenging in
cases of NOTES given that the upper pole is farthest away from the ports. In addi-
tion, the inability to effectively retract an overlapping liver or spleen makes upper
pole dissection even more dif fi cult. For this reason, lower pole tumors may be better
suited to NOTES nephrectomy at this time.
Patient Factors
A history of prior abdominal surgery may complicate a NOTES nephrectomy pro-
cedure given the possibility of intraabdominal adhesions. This is particularly rele-
vant for pure transvaginal NOTES, where access to the peritoneal cavity is via the
posterior fornix of the vagina. An inability to recognize adherent bowel within the
pelvis during peritoneal access could result in inadvertent small bowel enterotomy.
As the kidney is removed via the vagina in NOTES nephrectomy, it is important
that the specimen can be safely extracted. Patients who have not had a previous
vaginal delivery, or whose vagina is not distensible on digital examination, are not
appropriate candidates for NOTES nephrectomy. Similarly, in obese patients, where
there may be a signi fi cant amount of perinephric fat, safe transvaginal extraction
may not be possible for such voluminous specimens.
234
S. Leslie et al.
Patient Positioning
As there is no one standard technique for NOTES nephrectomy, there are many
descriptions in the literature of how the patient should be positioned. Sotelo et al.
described having the patient in the supine lithotomy position initially for place-
ment of the umbilical and vaginal ports (Fig. 18.1 ). Once the ports are in position,
the table is rotated such that the patient is in a 45° lateral decubitus position [ 18 ] .
Similarly, in the case of pure NOTES nephrectomy described by Kaouk et al., the
patient is initially in lithotomy for the placement of the vaginal port [ 12 ] . A wedge
is placed on the side of the nephrectomy to accentuate the retroperitoneum, and
the operating table is tilted as required to facilitate re fl ection of the colon away
from the renal hilum. Porpiglia et al. described placing the patient in a lateral
decubitus position from the outset, with the legs separated to allow vaginal access
(Fig. 18.2 ) [ 16 ] .
As these procedures are often of long duration, irrespective of the way the patient
is positioned, it is important that pressure areas are padded and that appropriate
DVT prophylaxis is maintained throughout the procedure and in the immediate
postoperative period. A thorough vaginal and perineal scrub with iodine solution is
imperative to minimize postoperative infection. The addition of metronidazole to
the conventional cephazolin antibiotic regimen is important to cover for anaerobic
organisms that may reside in this area.
Fig. 18.1 Supine lithotomy position.
Transvaginal and transumbilical TriPort
(Advanced Surgical Concepts, Dublin,
Ireland) (Reprinted with permission from
Elsevier from Sotelo et al. [
18 ] )
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