Renal cancer. Contemporary management. Editor John A. Libertino. Springer New York, 2013
Natural orifice translumenal endoscopic surgery (NOTES)
Another avenue in exploration of minimally invasive surgery is incision-less surgery with natural orifice translumenal endoscopic surgery (NOTES). NOTES involves the use of an endoscopic camera into a hollow organ where a transvisceral incision is made to access the peritoneal cavity. Boylu et al. described a transgastric partial nephrectomy using thulium laser in a porcine model. This was a non-clamping technique. The specimen was retrieved using a wire loop and removed via the gastrotomy. Ideally a specimen sac would have been used to prevent possible tumor seeding; however, one was not available that could pass through the working port of the gastroscope. According to the authors, the most challenging aspect was manipulating the laser fiber within the gastroscope. Robotic NOTES partial nephrectomy through vaginal access was performed in the porcine model with no intraoperative complications. Besides the improved cosmetic effect, NOTES eliminates surgical site infections and incisional hernias. More study is needed, but the limits of NOTES are being explored and whether there will be more applications in the future is uncertain.