Rigid NOTES: the transurethral approach in female piglets

Natural orifice transluminal endoscopic surgery (NOTES) was introduced to reduce scars and the surgical trauma. The feasibility of this technique in children is unknown. Our study was designed to determine the feasibility of various procedures via a transurethral-assisted approach in an animal model.

Specially designed Aesculap-Braun (Tuttlingen, Germany) instruments and Endo-Ligasure (Valleylab, Boulder, CO) were used in 12 female piglets (mean weight, 15.2 kg; range, 14-17). A modified 12-mm device, including a 0-degree optic and a working channel, was used for the umbilical approach and for CO(2) insufflation (8 mm Hg, flow 5L/min). A 3-mm trocar, including a 2-mm optic, was introduced via the urethra and the urinary bladder dome into the abdominal cavity. The end-point of the study was the feasibility of nephroureterectomy (n = 8) and bilateral tuboovariectomy (n = 4).

All nephroureterectomies and bilateral tuboovariectomies were performed successfully. Closure of the urinary bladder was safely performed with Endoloops (Ethicon Endosurgery, Cincinnati, OH) via the umbilical "two in one system." Intracorporal suturing, knotting, and placement of Endoclips (Ethicon Endosurgery) during nephrectomy were time-consuming due to the restricted motion of the two in one system. The use of a vessel-sealing device allowed a safe, fast, and easy nephroureterectomy.

Modifications of instruments and approaches are mandatory for NOTES and must be tested in animal models before being used in infants and children. We showed that nephroureterectomy and tuboovariectomy can be performed safely via a transurethral and umbilical approach in female piglets. The use of vessel-sealing devices is essential in two in one systems with limited view and range of motion.