title: Hybrid natural orifice transluminal endoscopic surgery for nephrectomy with standard laparoscopic instruments: experience in a canine model.
abstract: OBJECTIVE
  The aim of this study was to demonstrate the feasibility of hybrid natural orifice transluminal endoscopic surgery (NOTES) nephrectomy with standard laparoscopic instruments through a modified vaginal trocar in a canine model.
  
  
  METHODS
  Ten cross-bred adult female dogs were used for right (n = 4) and left (n = 6) transvaginal nephrectomy. After transumbilical peritoneoscopy, a laparoscopic transvaginal trocar was introduced through the posterior vaginal fornix under direct vision. Using a 10-mm working laparoscope lens with a 3-mm working channel as endovision via the umbilical port and the transvaginal port, triangulation and dissection of the kidney and its hilum were performed. The renal artery and vein were closed with Hem-o-lok clips transvaginally. At the end of the procedure, after snaring the kidney in an endobag, the specimen was retrieved through a colpotomy incision by extending the vaginal port site.
  
  
  RESULTS
  All procedures were completed without need for conversion. The mean operative time was 101 minutes (75-135 minutes). The mean preoperative/postoperative hemoglobin was 12.01/11.7 g/dL and intraoperative blood loss was minimal. The mean size of the removed kidneys was 9.1 x 5.1 cm and the mean weight was 98.5 g (90-115 g). Exploration of the abdomen and vagina after 1 month showed complete healing of the colpotomy incision with no visceral injury. There were no significant adhesions or fibrotic changes in the renal fossa.
  
  
  CONCLUSIONS
  Hybrid NOTES nephrectomy is technically feasible in canine model with a standard laparoscopic setup and instruments. This study may remove barriers for further investigational work with NOTES technique, especially with a view to adapting it for use in low-resource centers, while offering a strategy to help surgeons train with this novel technology.
authors.affiliation: Department of Urology, Shiraz Nephrology Urology Research Center and Comparative Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran. aminsharifi_ar@yahoo.com
authors.forename: Alireza
authors.initials: A
authors.lastname: Aminsharifi
authors.forename: Alireza
authors.initials: A
authors.lastname: Taddayun
authors.forename: Saeed
authors.initials: S
authors.lastname: Shakeri
authors.forename: Masoud
authors.initials: M
authors.lastname: Hashemi
authors.forename: Mahboobeh
authors.initials: M
authors.lastname: Abdi
mesh_terms: D000818:Animals; D020884:Colpotomy; D004285:Dogs; D005260:Female; D007668:Kidney / Q000098:blood supply; D020706:Laparoscopes; D023421:Models, Animal; D009392:Nephrectomy / Q000295:instrumentation*; D014621:Vagina / Q000601:surgery