title: Robot-assisted transrectal hybrid natural orifice translumenal endoscopic surgery nephrectomy and adrenalectomy: initial investigation in a cadaver model.
abstract: OBJECTIVE
  To assess the feasibility of robotic transrectal hybrid natural orifice translumenal endoscopic surgery (NOTES) nephrectomy and adrenalectomy.
  
  
  METHODS
  A male cadaver was used for the present investigation and placed in lithotomy position. An 8- and 12-mm port was inserted through the same periumbilical skin incision. An incision was then created in the rectum 1 cm above the pectinate line, and a submucosal tunnel was developed, through which a robotic 8-mm port was inserted under vision. The cadaver was then placed in the right side up, flank position. The laparoscope and the right robot instrument were introduced through the umbilicus while the left robot instrument was introduced through the rectal port aiding the peri-umbilical ports in kidney and adrenal dissection. After completion of the nephrectomy, the kidney was placed in a specimen bag and extracted intact through the rectum. Closure of the rectal incision was accomplished extracorporeally using 2 suture layers.
  
  
  RESULTS
  Robotic transrectal hybrid NOTES nephrectomy and adrenalectomy were completed successfully. The total operative time was 145 minutes, of which the access and robotic docking required 20 minutes. Kidney dissection and hilar control was achieved within 60 minutes. Right adrenalectomy, specimen extraction, and rectal closure was completed in 15, 30, and 20 minutes, respectively.
  
  
  CONCLUSIONS
  We report the first investigation of a robot-assisted transrectal hybrid NOTES nephrectomy and adrenalectomy in a cadaver model to assess the range of motion and articulation of the robotic platform. Additional investigations in live animal model are needed to evaluate the safety of the transrectal approach.
authors.affiliation: Section of Laparoscopic and Robotic Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH 44195, USA.
authors.forename: Rémi
authors.initials: R
authors.lastname: Eyraud
authors.forename: Humberto
authors.initials: H
authors.lastname: Laydner
authors.forename: Riccardo
authors.initials: R
authors.lastname: Autorino
authors.forename: Shahab
authors.initials: S
authors.lastname: Hillyer
authors.forename: Jean-Alexandre
authors.initials: JA
authors.lastname: Long
authors.forename: Kamol
authors.initials: K
authors.lastname: Panumatrassamee
authors.forename: Ali
authors.initials: A
authors.lastname: Khalifeh
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Stein
authors.forename: Georges-Pascal
authors.initials: GP
authors.lastname: Haber
authors.forename: Jihad H
authors.initials: JH
authors.lastname: Kaouk
mesh_terms: D000315:Adrenalectomy / Q000379:methods*; D002102:Cadaver; D006801:Humans; D020706:Laparoscopes; D008297:Male; D057605:Natural Orifice Endoscopic Surgery / Q000379:methods*; D009392:Nephrectomy / Q000379:methods*; D012007:Rectum; D012371:Robotics / Q000379:methods*; D014472:Umbilicus