title: Multimedia manuscript. NOTES retroperitoneal transvaginal distal pancreatectomy.
abstract: BACKGROUND
  The retroperitoneal approach preserves the peritoneal cavity and its envelope. The benefits of laparoscopic retroperitoneal approach to the kidney and the adrenal gland are well known. The pancreas may represent another potential target. Whereas NOTES transperitoneal distal pancreatectomy has been reported, the retroperitoneal approach, which may combine the advantages of peritoneal preservation with those of no scar surgery, has never been explored. We report the feasibility of NOTES transvaginal retroperitoneal pancreatectomy in a porcine model.
  
  
  METHODS
  With the pig supine, under general anesthesia, a 10-mm posterior colpotomy was performed with a needle-knife operated through a flexible 12-mm, double-channel endoscope (Karl Storz). A retroperitoneal tunnel was created with blunt dissection up to the left kidney with progressive visualization of the left iliac vessels, ureter, and abdominal aorta. To reach the posterior aspect of the pancreas, a space was opened medial to the upper renal pole dividing the Gerota's fascia. The tail of pancreas was mobilized with blunt and sharp dissection, using monopolar cautery. Once the distal pancreas was dissected free, it was secured using a polypropylene endoscopic loop and then resected with an endoscopic snare (Olympus).
  
  
  RESULTS
  The procedure was successfully accomplished by a totally NOTES approach in five pigs, with a mean operative time of 118 (range, 105-185) minutes with no intraoperative complications and no injury to any retroperitoneal structure.
  
  
  CONCLUSIONS
  The pancreas is accessible by a transvaginal retroperitoneal NOTES approach. Human cadavers studies are necessary to confirm the validity of this model and to explore the need for specific technological developments, such as flexible stapling devices, to improve the safety of pancreatic resection.
authors.affiliation: IRCAD/EITS Institute, University hospital, 1 place de l'hôpital, 67091 Strasbourg, France. pierre.allemann@ircad.u-strasbg.fr
authors.forename: Pierre
authors.initials: P
authors.lastname: Allemann
authors.forename: Silvana
authors.initials: S
authors.lastname: Perretta
authors.forename: Mitsuhiro
authors.initials: M
authors.lastname: Asakuma
authors.forename: Bernard
authors.initials: B
authors.lastname: Dallemagne
authors.forename: Didier
authors.initials: D
authors.lastname: Mutter
authors.forename: Jacques
authors.initials: J
authors.lastname: Marescaux
mesh_terms: D000818:Animals; D020884:Colpotomy / Q000295:instrumentation*; D004195:Disease Models, Animal; D005260:Female; D010535:Laparoscopy / Q000379:methods*; D019212:Multimedia; D010180:Pancreatectomy / Q000379:methods*; D010182:Pancreatic Diseases / Q000601:surgery*; D012187:Retroperitoneal Space / Q000601:surgery*; D013552:Swine; D014621:Vagina