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The challenges with NOTES retroperitoneal access in humans.

E A Moran¹, J Bingener, F Murad

¹Division of General Surgery, Department of Surgery, Mayo Clinic College of Medicine, Rochester, MN, USA.

Surgical Endoscopy

|September 18, 2010

Summary

Natural orifice transluminal endoscopic surgery (NOTES) retroperitoneal access in humans is challenging due to abundant adipose tissue. Further research is needed to improve landmark identification for safe and effective procedures.

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Area of Science:

Minimally invasive surgery
Gastroenterology
Surgical anatomy

Background:

Animal studies suggest natural orifice transluminal endoscopic surgery (NOTES) is feasible for retroperitoneal access.
NOTES may offer unique retroperitoneal access in human patients.

Purpose of the Study:

To assess the feasibility of endoscopic transgastric and transrectal retroperitoneal access in a human cadaver model.
To compare NOTES retroperitoneal examination with endoscopic ultrasound (EUS) in prone and supine positions.

Main Methods:

A multidisciplinary team evaluated transgastric and transrectal retroperitoneal examination in six cadavers.
EUS retroperitoneal examination preceded NOTES access.
Transgastric access involved a needle knife gastrotomy; transrectal access used a posterior needle knife rectotomy.

Main Results:

Retroperitoneal access was successful at all sites.
Significant challenges were encountered in landmark identification, particularly with transrectal access and in the prone position.
Abundant retroperitoneal adipose tissue in human cadavers limited endoscopic visualization.

Conclusions:

Abundant human retroperitoneal adipose tissue hinders the translation of successful porcine NOTES research.
While access and dissection were feasible, identifying landmarks was difficult due to cadaveric tissue appearance and lack of blood flow.
Future research should focus on improving landmark identification through methods like pre-procedural anatomic marking or vascular perfusion.