Embryonic Natural Orifice Transumbilical Endoscopic Surgery (E-NOTES) for Advanced Reconstruction: Initial Experience

doi:10.1016/j.urology.2008.04.061

Urology

Volume 73, Issue 1, January 2009, Pages 182-187

https://doi.org/10.1016/j.urology.2008.04.061 Get rights and content

Objectives

Natural orifice transluminal endoscopic surgery comprises intraabdominal surgery performed by way of natural orifices (ie, vagina, mouth). In a similar manner, the umbilicus provides an embryonic natural orifice that permits intraabdominal access. We report on the feasibility of performing single-port advanced laparoscopic reconstructive surgery by way of the umbilicus in 6 patients. We propose the terminology embryonic-natural orifice transluminal endoscopic surgery (E-NOTES) for this novel surgical approach.

Methods

Through a single 1.5- to 3-cm intraumbilical incision and a novel, single-access port, we performed laparoscopic bilateral single-session Anderson-Hynes pyeloplasty (2 patients, 4 procedures), ileal ureter (n = 1), and ureteroneocystostomy with a psoas hitch (n = 1). No extraumbilical skin incisions were used. A 2-mm Veress needle port, inserted through a skin needle puncture, was used to create the pneumoperitoneum and to selectively insert a needlescopic grasper to assist in suturing.

Results

All procedures were successful without the need for any additional laparoscopic ports. For the 2 patients undergoing bilateral pyeloplasty (including patient repositioning) and the 1 patient each undergoing ileal ureter and psoas-hitch ureteroneocystostomy, the operating time was 4.5, 6, 5, and 3 hours, blood loss was 100, 50, 75, and 50 mL, and the hospital stay was 1, 2, 3, and 2 days, respectively. No intraoperative or postoperative complications developed.

Conclusions

To our knowledge, we present the initial experience with advanced laparoscopic reconstruction through a single intraumbilical port. Additional refinement of this technology could lead to wider incorporation of single-port laparoscopy in clinical practice. Embryonic-natural orifice transluminal endoscopic surgery appears to be a promising new approach for select indications.

Section snippets

Material and Methods

Laparoscopic single-session bilateral pyeloplasty (2 patients, 4 procedures), laparoscopic ileal ureter interposition (n = 1), and laparoscopic ureteroneocystostomy (n = 1) were performed exclusively through a single umbilical port. No extraumbilical skin incisions were used.

Results

All procedures were technically successful without the need for any extraumbilical skin incisions or additional ports. The perioperative data are outlined in Table 2. The operative time was 4.5 and 6 hours for the bilateral pyeloplasty, 5 hours for the ileal ureteral interposition, and 3 hours for the psoas hitch ureteroneocystostomy. No intraoperative or postoperative complications developed in any patient. The hospital stay was 1 and 2 days for the bilateral pyeloplasty, 3 days for the ileal

Comment

The past decade has witnessed increasing use of laparoscopic techniques for a variety of ablative and reconstructive procedures of the urinary tract.¹ With increasing comfort levels in the laparoscopic environment, a wide variety of complex reconstructive procedures requiring skill with intracorporeal suturing and knot tying have been performed with fair regularity at centers of excellence. With the firm establishment of laparoscopic surgery in current urologic practice, ongoing efforts are now

Conclusions

We report the initial experience with advanced laparoscopic reconstruction performed exclusively through a single transumbilical port. All procedures were completed successfully without complications or the need for any extraumbilical incisions. We believe that continuing advances in single-port technology will increase the scope and application of E-NOTES in the near future.

References (12)

J.H. Kaouk et al.
Laparoscopic reconstructive urology
J Urol.
(2003)
J.J. Soble et al.
Needlescopic urology: Incorporating 2-mm instruments in laparoscopic surgery
Urology
(1998)
E. Lima et al.
Third-generation nephrectomy by natural orifice transluminal endoscopic surgery
J Urol.
(2007)
O. Ates et al.
Single port laparoscopic appendectomy conducted intracorporeally with the aid of a transabdominal sling suture
J Pediatr Surg.
(2007)
J.D. Raman et al.
Laboratory and clinical development of single keyhole umbilical nephrectomy
Urology
(2007)
J. Marescaux et al.
Surgery without scars: Report of transluminal cholecystectomy in a human being
Arch Surg.
(2007)

There are more references available in the full text version of this article.

Cited by (118)

Kinematic and ergonomic assessment of laparoendoscopic single-site surgical instruments during simulator training tasks
2017, Applied Ergonomics
While laparoendoscopic single-site surgery (LESS) appears to be feasible and safe, instrument triangulation, tissue handling, and other bimanual tasks are difficult even for experienced surgeons. Novel technologies emerged to overcome LESS' procedural and ergonomic difficulties of “tunnel vision” and “instrument clashing.” Surgeon kinematics, self-reported workload and upper body discomfort were used to compare straight, bent and two articulating instruments while performing two basic surgical tasks in a LESS simulator. All instruments resulted in bilateral elevation and rotation of the shoulders, excessive forearm motion and flexion and ulnar deviation of wrists. Surgeons' adopted non-neutral upper extremity postures and performed excessive joint excursions to compensate for reduced freedom of movement at the single insertion site and to operate the instrument mechanisms. LESS' cosmetic benefits continue to impact laparoscopic surgery and by enabling performance through improved instruments, ergonomic improvement for LESS can reduce negative impact on surgeon well-being and patient safety.
Comparison of Laparoscopic Approaches for Dismembered Pyeloplasty in Children With Ureteropelvic Junction Obstruction: Critical Analysis of 11-Year Experiences in a Single Surgeon
2017, Urology
The choice of different laparoscopic approaches of laparoscopic pyeloplasty (LP) in children remains controversial. We present a comparison of different approaches of LP in children and a critical analysis of 11-year experiences in a single surgeon.
There were 1750 patients (1889 sides) who underwent LP between 2003 and 2014 reviewed. The diagnosis and outcomes of ureteropelvic junction obstruction (UPJO) were reviewed based on clinical and imaging data. Retroperitoneal laparoscopic pyeloplasty (RPLP) were performed in 451 cases (RPLP group), conventional transperitoneal laparoscopic pyeloplasty (CTLP) were performed in 311 cases (CTLP group), transumbilical single-site laparoscopic pyeloplasty (TSLP) were performed in 322 cases (TSLP group), and transumbilical multiport laparoscopic pyeloplasty (TMLP) were performed in 805 cases (TMLP group). We assessed preoperative clinical data and outcomes, and analyzed the transition experience. Data are expressed as medians for continuous variables.
The start of oral feeding, hospital stay, and the operative time of RPLP group were 1.10 ± 0.10 days, 5.22 ± 1.32 days, and 138.2 ± 20.1 minutes, respectively. Compared with the other 3 groups, the start of oral feeding was the soonest, hospital stay was the shortest, and the operative time was the longest in the RPLP group (P < .01 or .05). The cosmetic result of the TMLP group was 7.07 ± 1.20 scores, and there are significant differences in cosmetic results between the TMLP group and the other 3 groups (P < .05).
Although the 4 laparoscopic approaches for LP in children with UPJO are safe and efficient procedures with equivalent success rates, we recommend RPLP or TMLP as a treatment option for children with UPJO.
Robotic ileal ureter: A completely intracorporeal technique
2014, Urology
The first laparoscopic case of ileal interposition was reported in 2000, proving the feasibility of the procedure in a minimally invasive fashion by duplicating the principles of open surgery. Robotic applications in urology are expanding worldwide, given the unique features of the robotic platform, which facilitates more advanced laparoscopic procedures. In this study, we report a case of completely intracorporeal robotic ileal ureter and thoroughly describe our technique for this complex minimally invasive procedure.
A 50-year-old gentleman with a history of right renal stones underwent multiple right ureteroscopies and thereafter developed 2 proximal ureteral strictures of 5 mm. Preoperative estimated glomerular filtration rate was 71 mL/min/1.73 m². Renal scan showed preserved function. The treatment options were discussed, and the patient elected to undergo a robotic ileal ureter interposition. Total operative time was 7 hours, the estimated blood loss was approximately 50 mL, and the patient progressed to regular diet on postoperative day 4 without any problem, being discharged without complications. On the postoperative day 12, a cystogram demonstrated no extravasation, and the Foley catheter was removed. After 1 month, renal scan showed the left kidney with 60.1% and the right kidney with 39.9% of total renal function. At 2 years follow-up, his serum creatinine was 1.14 and estimated glomerular filtration rate was 70 mL/min/1.73 m².
Robot-assisted laparaoscopic ileal ureter with a completely intracorporeal technique is feasible and appears to be safe. A larger number of procedures using this technique and longer follow-up are needed to further define its role in the treatment of ureteral strictures.
Gallbladder-preserving polypectomy for gallbladder polyp by embryonic-natural orifice transumbilical endoscopic surgery with a gastric endoscopy
2022, BMC Gastroenterology
Laparoscopic totally intracorporeal ileal ureter replacement: a multi-institutional study
2022, Minimally Invasive Therapy and Allied Technologies
Minimally invasive ileal ureter replacement: Comparative analysis of robot-assisted laparoscopic versus conventional laparoscopic surgery
2021, International Journal of Medical Robotics and Computer Assisted Surgery

View all citing articles on Scopus

View full text

Technology and EngineeringEmbryonic Natural Orifice Transumbilical Endoscopic Surgery (E-NOTES) for Advanced Reconstruction: Initial Experience

Objectives

Methods

Results

Conclusions

Section snippets

Material and Methods

Results

Comment

Conclusions

J Urol.

Urology

J Urol.

J Pediatr Surg.

Urology

Surgery without scars: Report of transluminal cholecystectomy in a human being

Arch Surg.

Technology and Engineering
Embryonic Natural Orifice Transumbilical Endoscopic Surgery (E-NOTES) for Advanced Reconstruction: Initial Experience