title: Natural orifice translumenal endoscopic surgery (NOTES) renal cryoablation in a porcine model.
abstract: OBJECTIVE
  To present our laboratory experience with natural orifice translumenal endoscopic surgery (NOTES) renal cryoablation.
  
  
  METHODS
  In two female farm pigs, we performed four procedures of NOTES renal cryoablation. In each pig, NOTES was performed through a transgastric approach and a transvaginal approach for each kidney, respectively. The pig was placed in the flank position and pneumoperitoneum obtained using a transabdominal Veress needle. In the first pig, we started with the left kidney with a transgastric approach: a dual-channel video gastroscope (Olympus, Tokyo, Japan) was used, the stomach wall was punctured using a needle-knife, a guidewire was passed into the abdominal cavity and the access dilated using a controlled radial expansion balloon. The bowel was mobilized medially and the Gerota's fascia overlying the upper pole was dissected. Under direct endoscopic vision, a cryoablation probe was introduced percutaneously into the anterior upper pole of the kidney. The pig was then flipped to the right flank position and a transvaginal approach was used: the gastroscope was introduced through the posterior fornix of the vagina. For the second pig, we performed initially a transgastric right-side cryoablation then a transvaginal left-side cryoablation as described for the first pig.
  
  
  RESULTS
  All four procedures were performed successfully, with no intraoperative complications. No additional laparoscopic ports or open conversions were necessary. The vision of the kidney and the ice-ball was adequate for all cases. The mean operative duration was 83 min. Stomach closure was tested watertight, and there were no abdominal or pelvic injuries found at autopsy.
  
  
  CONCLUSIONS
  NOTES can provide adequate minimal surgical dissection for safe and effective percutaneous renal cryoablation under direct videoscopic monitoring at kidney locations otherwise not accessible percutaneously. Both transgastric and transvaginal approaches can be used effectively for renal cryoablation providing a minimally invasive scar-less surgery.
authors.affiliation: Section of Laparoscopic and Robotic Surgery, Glickman Urological Institute, The Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
authors.forename: Sebastien
authors.initials: S
authors.lastname: Crouzet
authors.forename: Georges-Pascal
authors.initials: GP
authors.lastname: Haber
authors.forename: Kazumi
authors.initials: K
authors.lastname: Kamoi
authors.forename: Andre
authors.initials: A
authors.lastname: Berger
authors.forename: Stacy
authors.initials: S
authors.lastname: Brethauer
authors.forename: Patrick
authors.initials: P
authors.lastname: Gatmaitan
authors.forename: Inderbir S
authors.initials: IS
authors.lastname: Gill
authors.forename: Jihad H
authors.initials: JH
authors.lastname: Kaouk
mesh_terms: D000818:Animals; D003452:Cryosurgery / Q000295:instrumentation / Q000379:methods*; D004724:Endoscopy / Q000379:methods*; D005260:Female; D007680:Kidney Neoplasms / Q000601:surgery*; D009392:Nephrectomy / Q000295:instrumentation / Q000379:methods*; D013270:Stomach; D013552:Swine; D014621:Vagina