Hybrid natural orifice transluminal endoscopic surgery for nephrectomy with standard laparoscopic instruments: Experience in a canine model

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. Materials and 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 × 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. Conclusion: 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.