Transvaginal NOTES-assisted laparoscopic nephrectomy: a survival study in a sheep model.
BACKGROUND
This study aims to evaluate the feasibility and usefulness of an ovine model in order to perform natural orifice translumenal endoscopic surgery (NOTES) approach and laparoscopic nephrectomy for research and training purposes.


METHODS
Ten healthy female sheep were used to perform transvaginal NOTES-assisted right laparoscopic nephrectomy using a flexible 12-mm gastroscope through a vaginal access and two additional 5- and 10-mm trocars placed in the abdomen. The renal artery, the renal vein, and the ureter were dissected, and ligation was accomplished by using laparoscopic clips. The right kidney was retrieved transvaginally after enlarging the vaginal trocar incision. All data related with the surgical procedure, perioperative, and postoperative outcomes were recorded. The animals were monitored after surgery for a 30-day period with daily clinical follow-up.


RESULTS
We established a useful animal model of transvaginal NOTES-assisted laparoscopic nephrectomy, performing the transvaginal approach and the abdomen exploration with no complications in any animals. The renal artery, the renal vein, and the ureter were identified, clipped, and transected combining the 5-mm laparoscopic access and the endoscopic vision in the whole group. Mean operative time was 86 ± 14.49 min, estimated blood loss was less than 20 ml in all cases, and there was no bleeding or laceration of adjacent organs. The animals recovered successfully in all cases postoperatively. After 1 month, exploratory laparotomy did not show alterations in abdominal cavity, and the vaginotomy incision healed completely in every animal.


CONCLUSIONS
This experiment shows that transvaginal NOTES-assisted laparoscopic nephrectomy in ovine model is feasible and reproducible while offering an innovative possibility to help surgeons with this recent technology in the treatment of renal cancer. Well-managed experimental studies need to be carried out to determine the safety and efficacy of NOTES in the treatment of renal cancer.
Department of Scientific Direction, Minimally Invasive Surgery Centre Jesús Usón, Carretera N-521, km 41,8, 10071, Cáceres, Spain. msanchez@ccmijesususon.com
Francisco M
FM
Sánchez-Margallo
Francisco J
FJ
Pérez
Miguel A
MA
Sánchez
Jaime
J
Bachiller
Alvaro
A
Juárez
Alvaro
A
Serrano
María José
MJ
Ribal
Antonio
A
Alcaraz
D000818:Animals; D016063:Blood Loss, Surgical; D004210:Dissection / Q000379:methods; D005240:Feasibility Studies; D005260:Female; D007902:Length of Stay; D008026:Ligation / Q000379:methods; D057605:Natural Orifice Endoscopic Surgery / Q000295:instrumentation / Q000379:methods* / Q000401:mortality; D009392:Nephrectomy / Q000379:methods* / Q000401:mortality; D034561:Sheep, Domestic; D013525:Surgical Instruments; D014621:Vagina