title: NOTES new frontier: Natural orifice approach to retroperitoneal disease.
abstract: OBJECTIVE
  To develop a pure transvaginal access to the retroperitoneum, that is simple, reproducible and uses endoscopic material available on the market.
  
  
  METHODS
  From February 2008 to April 2009, 31 pigs were operated on, with 17 as an acute experiment and 14 with a survival protocol. The animals were placed in a supine position and a 12-mm double-channel endoscope (Karl Storz™, Tuttlingen) was used for vision and dissection. During the same time period, the access experiment was reproduced on 3 human cadavers using material similar to that used in the animal model.
  
  
  RESULTS
  In the animal model, 37 interventions were done on the kidney, adrenal gland and pancreas. The mean time to fashion the access was 10 min (range 5 to 20 min). No intraoperative death was observed. Two major (5%) intraoperative complications occurred: one hemorrhage on the aorta and one tearing of the right renal vein. Peritoneal laceration was encountered in 5 cases without impairing the planned task. In the survival group, good clinical outcome was observed at a mean follow-up of 3 wk (range 2 to 6 wk). In the 3 cadavers, access was performed correctly. The mean time to fashion the access was 52 min (range 40 to 60 min). All the anatomical landmarks described in the pig model were clearly identified in the same sequence.
  
  
  CONCLUSIONS
  A retroperitoneal natural orifice translumenal surgical transvaginal approach is feasible in both animal and human models and allows performance of a large panel of interventions.
authors.affiliation: Pierre Allemann, Silvana Perretta, Mitsuhiro Asakuma, Bernard Dallemagne, Jacques Marescaux, IRCAD/EITS Institute, Strasbourg University Hospital, 1, place de l'hôpital, 67000 Strasbourg, France.
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: Jacques
authors.initials: J
authors.lastname: Marescaux