Transvaginal Hybrid Natural Orifice Transluminal Endoscopic Surgery Retroperitoneoscopy-The First Human Case Report

Background: Retroperitoneal and transabdominal laparoscopic access to retroperitoneal organs became the golden standard for treatment of most adrenal and renal diseases. Natural orifice surgery is a promising concept in the evolution of minimal access surgery. The possibility of a natural orifice transluminal endoscopic surgery (NOTES) transvaginal retroperitoneal access to diagnose and perform retroperitoneal surgery was developed in our institution, aiming an alternative natural orifice less-invasive approach. Methods: Institutional review board approval was obtained from the institution for clinical transvaginal NOTES. A 67-year-old woman (body mass index = 35.6 kg/m(2)) found to have a large renal cyst situated in the lower pole with compression symptoms was subjected to the technique. Transvaginal retroperitoneal access was obtained by direct vision open technique, the space was digitally dissected, and a flexible two-channel colonoscope progressed the dissection to the left kidney. The cyst was dissected using endoscopic instruments, and resection was completed with use of two laparoscopic instruments because of peritoneal tear with loss of retropneumoperitoneum. Results: NOTES transvaginal retroperitoneoscopy was performed, and anatomical landmarks, such as left ureter, inferior mesenteric artery (IMA), vena cava, and aorta, were identified. Insufflation and orientation were hazardous, because of constitutional fat, and operative time was 210 minutes. Postoperative course was complicated by postoperative face and neck enphysema, which disappeared after few days. Observation was maintained for 4 postoperative days, and the patient was discharged without other complications. Follow-up at 30 days was uneventful. Conclusion: This first human procedure using flexible transvaginal retroperitoneoscopy showed feasibility of the access, but inadequate instruments led to technical difficulties for therapeutical purposes. However, the new concept of minimally invasive NOTES retroperitoneoscopy may open new therapeutic indications in clinical practice in the near future.