title: Embryonic natural orifice transumbilical endoscopic surgery (E-NOTES) for advanced reconstruction: initial experience.
abstract: OBJECTIVE
  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.
authors.affiliation: Center for Laparoscopic and Robotic Surgery, Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA.
authors.forename: Mihir M
authors.initials: MM
authors.lastname: Desai
authors.forename: Robert
authors.initials: R
authors.lastname: Stein
authors.forename: Prashanth
authors.initials: P
authors.lastname: Rao
authors.forename: David
authors.initials: D
authors.lastname: Canes
authors.forename: Monish
authors.initials: M
authors.lastname: Aron
authors.forename: Pradeep P
authors.initials: PP
authors.lastname: Rao
authors.forename: Georges-Pascal
authors.initials: GP
authors.lastname: Haber
authors.forename: Amr
authors.initials: A
authors.lastname: Fergany
authors.forename: Jihad
authors.initials: J
authors.lastname: Kaouk
authors.forename: Inderbir S
authors.initials: IS
authors.lastname: Gill
mesh_terms: D000368:Aged; D004724:Endoscopy / Q000379:methods*; D005260:Female; D006801:Humans; D007682:Kidney Pelvis / Q000601:surgery*; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D014472:Umbilicus