Embryonic Natural Orifice Transumbilical Endoscopic Surgery (E-NOTES) for Advanced Reconstruction: Initial Experience

OBJECTIVES Natural orifice transluminal endoscopic surgery comprises intraabdominal surgery performed by way of natural orifices (ie, vagina, mouth). In a similar manner, the umbilicus provides an embryonic natural orifice that permits intraabdominal access. We report on the feasibility of performing single-port advanced laparoscopic reconstructive surgery by way of the umbilicus in 6 patients. We propose the terminology embryonic-natural orifice transluminal endoscopic surgery (E-NOTES) for this novel surgical approach. METHODS Through a single 1.5- to 3-cm intraumbilical incision and a novel, single-access port, we performed laparoscopic bilateral single-session Anderson-Hynes pyeloplasty (2 patients, 4 procedures), ileal ureter (n = 1), and ureteroneocystostomy with a psoas hitch (n = 1). No extraumbilical skin incisions were used. A 2-mm Veress needle port, inserted through a skin needle puncture, was used to create the pneumoperitoneum and to selectively insert a needle-scopic grasper to assist in Suturing. RESULTS All procedures were successful without the need for any additional laparoscopic ports. For the 2 patients undergoing bilateral pyeloplasty (including patient repositioning) and the 1 patient each undergoing ileal ureter and psoas-hitch ureteroneocystostomy, the operating time was 4.5, 6, 5, and 3 hours, blood loss was 100, 50, 75, and 50 mL, and the hospital stay was 1, 2, 3, and 2 days, respectively. No intraoperative or postoperative complications developed. CONCLUSIONS To our knowledge, we present the initial experience with advanced laparoscopic reconstruction through a single intraumbilical port. Additional refinement of this technology could lead to wider incorporation of single-port laparoscopy in clinical practice. Embryonic-natural orifice transluminal endoscopic surgery appears to be a promising new approach for select indications. UROLOGY 73: 182-187, 2009. (C) 2009 Elsevier Inc.