Transplantation/Vascular Surgery

Single Port Transumbilical (E-NOTES) Donor NephrectomyInderbir S. Gill,* David Canes, Monish Aron, Georges-Pascal Haber, David A. Goldfarb,Stuart Flechner, Mahesh R. Desai, Jihad H. Kaouk and Mihir M. DesaiFrom the Center for Laparoscopic and Robotic Surgery, Department of Urology, Glickman Urological and Kidney Institute,Cleveland Clinic, Cleveland, Ohio

Purpose: We present the initial 4 patients undergoing single port transumbilical live donor nephrectomy. Scar-freeabdominal surgery via natural body orifices is called NOTES (natural orifice translumenal endoscopic surgery). In a similarmanner the umbilicus, an embryonic (E) natural orifice, permits abdominal access with hidden scar of entry. We propose theterm E-NOTES for embryonic natural orifice transumbilical endoscopic surgery.Materials and Methods: Through an intra-umbilical incision a novel single access tri-lumen R-port was inserted into theabdomen. No extra-umbilical skin incisions were made whatsoever. A 2 mm Veress needle port, inserted via skin needlepuncture to establish pneumoperitoneum, was used to selectively insert a needlescopic grasper for tissue retraction. Donorkidney was pre-entrapped and extracted transumbilically.Results: E-NOTES donor nephrectomy was successful in all 4 patients. Median operating time was 3.3 hours, blood loss was50 cc, warm ischemia time was 6.2 minutes and hospital stay was 3 days. Median length of harvested renal artery was 3.3cm, renal vein 4 cm and ureter 15 cm. No intraoperative complications occurred. Donor visual analog scores were 0/10 at 2weeks. Each allograft functioned immediately on transplantation.Conclusions: The initial experience with E-NOTES donor nephrectomy is encouraging. Excellent donor vascular and tissuedissection could be performed, and a quality donor kidney was retrieved transumbilically without any extra-umbilical skinincision. E-NOTES donor nephrectomy appears to have relevance and promise, especially for this typically younger, altruisticpopulation. Natural orifices present an unprecedented opportunity for scar-free surgery.

Key Words: laparoscopy; nephrectomy; surgical procedures, minimally invasive

Minimally invasive techniques have dramaticallychanged the surgical landscape within the last 2decades. Various substantial procedures, previ-

ously the exclusive domain of open surgery, are now rou-tinely performed minimally invasively. Multiple reports at-test to the comparable efficacy of laparoscopic techniques vstheir open surgical counterparts, albeit with decreased mor-bidity. This paradigm shift has been evident across virtuallyall surgical specialties including urology. Traditionally mul-tiple ports are a key prerequisite for laparoscopic surgery toallow optimal instrument triangulation. Due to the wide-spread acceptance of standard multiple port laparoscopicsurgery, currently ongoing efforts are focused on developingstrategies to further reduce incisional morbidity with im-proved cosmetic outcomes as a secondary benefit.

The concept of scar-free, pain-free surgery has been along-standing surgical fantasy, a chimera. Natural orificetranslumenal endoscopic surgery (NOTES), a recent innova-tion, implies intra-abdominal surgery via natural orifices(vagina, mouth/stomach, rectum).1 In a similar manner theumbilicus is an embryonic (E) natural orifice which, since itis a scar itself, conceals the intra-abdominal entry point forsurgical procedures. As such, we propose the term E-NOTES

Submitted for publication January 20, 2008.* Correspondence and requests for reprints: Center for Laparo-

scopic and Robotic Surgery, Cleveland Clinic Department of Urol-

ogy, 9500 Euclid Ave., A-100, Cleveland, Ohio 44195 (telephone:216-445-1530; FAX: 216-445-7031; e-mail: gilli@ccf.org).

0022-5347/08/1802-0637/0THE JOURNAL OF UROLOGY®

Copyright © 2008 by AMERICAN UROLOGICAL ASSOCIATION

637

(embryonic natural orifice transumbilical endoscopic sur-gery) for this surgical approach.

How may one best determine whether these surgicaladvances represent real substance or mere hype? Of thevarious abdominal procedures live donor nephrectomy is atechnically unforgiving, ultimate surgical yardstick forevaluating a new approach because a healthy, physiolog-ically pristine solid organ must be retrieved such that itcontinues to function long-term in the recipient after trans-plantation. No clinical scenario befits the dictum of primumnon nocere as profoundly as that of the altruistic, completelyhealthy donor. We developed the technique of virtually scar-free, single port E-NOTES donor nephrectomy and presentthe initial 4 clinical cases.

MATERIALS AND METHODS

After institutional review board waiver and informed pa-tient consent, E-NOTES donor nephrectomy was performedin 4 consecutive patients. The initial E-NOTES donor ne-phrectomy was performed on November 28, 2007.

R-PortThe R-port (Advanced Surgical Concepts, Dublin, Ireland) isa unique single access port with 3 inlet channels (1, 12 mmand 2, 5 mm) that allows simultaneous passage of a laparo-scope and 2 laparoscopic instruments. Inserted through a 2to 3 cm incision, the port is secured in position by 2 plastic

rings, 1 inserted within the peritoneum and the other re-

Vol. 180, 637-641, August 2008Printed in U.S.A.

DOI:10.1016/j.juro.2008.04.028

SINGLE PORT TRANSUMBILICAL DONOR NEPHRECTOMY638

maining outside the skin, both connected by a sliding plasticsleeve. Pulling up on the sleeve removes its slack, therebytightly approximating the 2 rings against each other andcreating an airtight seal for pneumoperitoneum. The fas-ciotomy between the 2 rings is effectively tented open by thetaut waist of the intervening plastic sleeve. Various stan-dard 5, 10 and 11/12 mm laparoscopic instruments, as wellas novel curved instruments, can be inserted through theR-port (fig. 1).

Left E-NOTES Donor Nephrectomy TechniqueWith the patient in a modified 45-degree flank positionpneumoperitoneum was obtained either by a 2 mm Veressneedle port inserted via skin puncture (without any skinincision) in the left subcostal area at the lateral edge of therectus abdominis or by the Hasson technique via the umbi-licus. A 2 cm completely intra-umbilical vertical skin inci-sion and 2 to 3 cm rectus fasciotomy were made to enter theperitoneal cavity and insert and secure the R-port. A rigid 5mm 30-degree digital laparoscope with integrated camerahead was used (EndoEye, Olympus, Orangeburg, NewYork). Standard laparoscopic instruments were used for themajority of the procedure and curved or bent instrumentswere used only selectively. The descending colon, spleen andpancreas were generously reflected medially using standardlaparoscopic J-hook or endoshears. Tissue countertractionwas achieved by either a specially designed curvedgrasper (Novare Surgical Systems, Cupertino, California)inserted through 1 of the 3 inlets of the R-port or with a 2mm needlescopic grasper inserted at the Veress needlesite (fig. 2).

The ureter and the intact gonadal vein were retractedlaterally, and dissection carried cephalad to expose the leftrenal vein. Lateral retraction of the kidney and the uretero-gonadal packet was achieved by 1 to 2 sutures passed be-tween the perirenal fat/fascia and the lateral abdominalwall, providing fixed internal retraction. The adrenal veinwas dissected, clipped with 11 mm metal clips and di-vided. The superior pole of the kidney was mobilized com-pletely. The renal vein and artery were individually dis-sected up to the interaortocaval area and the aorta,respectively (fig 3, A). The ureter was divided at the levelof the common iliac artery and adequate diuresis con-firmed. After freeing the kidney laterally it was pre-en-trapped in a 15 mm EndoCatch™ bag. The bag had beenpreviously detached from its metallic ring and insertedthrough the 12 mm inlet of the R-port. The kidney wasentrapped, and the mouth of the bag loosely cinched aroundthe intact renal artery and vein, taking care not to compro-mise renal perfusion (fig. 3, B). The renal artery was triple

FIG. 1. Computer rendered views of tri-port device (A), with inner and oulaparoscope and 5 mm instrument inserted (12 mm port not occupied).

clipped with 2 Hem-O-Lok clips (Teleflex Medical, ResearchTriangle Park, North Carolina) and 1, 11 mm metal clip anddivided. The renal vein was divided at its interaortocavallocation with a single fire of a 12 mm vascular Endo-GIA™stapler. The pre-entrapped kidney was extracted transum-bilically after generous cranial and caudal extension of therectus fascia incision, and appropriate extension of the skinincision commensurate with gentle atraumatic specimen ex-traction. After handing the donor kidney to the transplantsurgeon the rectus fascia was partially closed, the R-portreinserted and pneumoperitoneum reestablished to confirmhemostasis. Laparoscopic exit was completed.

RESULTS

E-NOTES donor nephrectomy was successful in each patientwithout need for any extra-umbilical skin incisions or con-version to standard laparoscopy. Perioperative data are pre-sented in the table. Median operating time was 3.3 hoursand median warm ischemia time was 6.2 minutes. Onepatient had 2 left renal arteries and each was controlledindividually. Median estimated blood loss was 50 cc andhospital stay was 3 days each. No intraoperative complica-tions occurred, although 1 patient was noted to have cornealabrasion unrelated to the surgical procedure.

On the bench table each kidney flushed normally. Medianlength of the harvested renal vein was 4 cm, the renal artery3.3 cm and ureter 15 cm (fig. 4). In 1 patient with an earlyrenal artery bifurcation at 1 cm from the aorta a commonarterial stem was preserved with the kidney. Each allograft

FIG. 2. Schematic diagram of single port tri-lumen device in umbi-licus. 2 mm needlescopic port inserted in left subcostal area withneedle puncture is used to selectively house 1.9 mm needlescopicgrasper as needed.

ter rings (B). Intraoperative view of device in use (C), showing 5 mm

nal a

SINGLE PORT TRANSUMBILICAL DONOR NEPHRECTOMY 639

functioned immediately upon transplantation, with appro-priate nadir recipient serum creatinine levels (see table).

Median donor VAS upon discharge home was 2/10. Con-valescence was complete at 2 weeks as reflected by VASscores of 0/10 at 2 weeks with no patient on any pain med-ication. Median umbilical incision length was 4 cm (fig. 5).

DISCUSSION

Natural orifices present a novel opportunity for scar-freemajor surgery. Natural orifices providing abdominal accessmay be categorized as existing or embryonic. Existing ab-dominal natural orifices include the mouth, vagina, urethraand anus. The umbilicus represents an embryonic naturalorifice. Natural orifice surgery performed indirectly via thestomach, vagina, urinary bladder or colon-rectum has beencalled NOTES (natural orifice translumenal endoscopic sur-gery).1,2 Alternatively natural orifice surgery can be per-formed directly via the umbilicus. We propose the termE-NOTES to describe embryonic natural orifice transumbili-cal endoscopic surgery.

Donor kidneys are in a critical shortage. The renal trans-plant waiting list in the United States is increasing annu-ally, having doubled in the last decade from 35,939 patientslisted in 1997 to 73,909 patients in 2007.3 Live donors mustweigh their altruism against the postoperative morbidity

FIG. 3. Intraoperative photograph after hilar dissection (A), with revessels pre-entrapped within 15 mm EndoCatch bag (B).

Pati

Pt No. 1

Age (yrs) 44Sex FemaleBody mass index 26.6Donor kidney LtDonor kidney vol on CT (cc) 130No. renal arteries 1 (early bifurcation)Operating room hrs 3Blood loss (cc) 50Warm ischemia time (mins) 4.5Umbilical incision length (cm) 4Vessel length (cm):

Renal artery 3Renal vein 4

Ureteral length (cm) 15Morphine equivalents (mg) 7VAS score:

At discharge home 2/10At 2 wks 0/10

Recipient nadir serum creatinine (mg/dl) 0.9

* 30 mg � 5 doses � 150 mg ketorolac.

and scarring conferred by open surgery. Since its initialreports in the laboratory4 and clinically,5 laparoscopic donornephrectomy has now become an established, even preferredalternative to open surgery, with equivalent allograft out-comes in the short, intermediate and long term.6 Addition-ally, by providing quicker recovery and superior cosmesis,important considerations in these younger, healthy, physi-cally active donors, laparoscopy decreases these disincen-tives to donation.7 Although E-NOTES might offer the po-tential to further decrease the morbidity associated withstandard laparoscopy, nevertheless, the preeminent issue inthis particular, high profile setting remains donor safety andremoval of a physiologically intact kidney.

Our initial experience with E-NOTES donor nephrectomyis encouraging. Each intraoperative step was accomplishedwith confidence, similar to standard multiport laparoscopy.Specifically the spleen, pancreas and descending colon couldbe mobilized medially, and the renal artery and vein indi-vidually skeletonized to achieve excellent length for trans-plant vascular anastomoses. In the first case preoperativeCT scanning documented early branching of the left renalartery 1 cm from its aortic origin. Nevertheless, we couldplace 3 clips proximally enough to provide a common arterialstump for the transplant surgeon. One technical nuanceinvolves maintaining intact the renogonadal vein junction,

rtery and vein skeletonized, and perfused kidney with intact hilar

ata

Pt No. 2 Pt No. 3 Pt No. 4

42 56 39Female Female Male

27.0 29.3 30.4Lt Lt LtNot available Not available 261

1 2 13.5 3 5

50 50 2008 4.7 7.64 4 5

3.5 4 2.44 4 3

13 15 150* 47.5 57

0/10 4/10 0/100/10 0/10 0/101.4 1.8 1.5

ent d

SINGLE PORT TRANSUMBILICAL DONOR NEPHRECTOMY640

without transecting the left gonadal vein. Thus, superolat-eral retraction of the intact gonadal vein provides superiorretraction of the renal vein and lateral retraction of thekidney in a single maneuver, facilitating exposure of theposteriorly located renal artery. Similar to our standardlaparoscopic technique the left renal vein was secured andtransected at its interaortocaval location in each instance.No visible vasospasm was evident and all 4 kidneys diuresedintraoperatively. To minimize warm ischemia, the kidneywas prebagged to allow expeditious extraction upon vasculartransection. However, in 1 case voluminous adherent peri-renal fat resulted in a large donor specimen, precludingprebagging. In this case the kidney was entrapped afterhilar transection, leading to a warm ischemia time of 7.6minutes. Kidney extraction was facilitated by incising therectus fascia generously. However, only a minimal extensionof the skin incision was necessary, to just beyond the supe-rior and inferior umbilical brim. The ultimate skin incisionwas concealed in the umbilicus. Each donor expressed grat-ified surprise with the cosmetic outcome (fig. 5). Each kidneydiuresed immediately after revascularization and no recipi-ent experienced delayed graft function.

We recently reported the initial clinical cases in the lit-erature with various single port E-NOTES procedures inurology.8–10 These include the initial cases of E-NOTESsingle port ablative nephrectomy, renal cryoablation, dis-membered Anderson-Hynes pyeloplasty (unilateral and sin-gle session bilateral), sacrocolpopexy, ileal ureter interposi-tion and psoas-hitch ureteroneocystostomy. Subsequentlywe have performed initial cases of single port E-NOTESradical prostatectomy, radical cystectomy with lymphade-nectomy and partial nephrectomy (unpublished data). Allprocedures were performed by the single port transumbilicalapproach, without any extra-umbilical skin incision, someeven without an adjunctive 2 mm needle port. However, wecontend that use of a 2 mm Veress needle port, initially forcreating pneumoperitoneum, and subsequently inserting a1.9 mm needlescopic grasper for instrument triangulation asnecessary adds security and technical facility. This 2 mmneedle port is inserted via a skin puncture without any

FIG. 4. Donor kidney on bench table demonstrating adequatelengths of renal artery (right), renal vein (middle) and ureter (farleft).

formal skin incision, does not require any closure and has no

obvious sequelae as regards cosmesis or patient morbidity.11

We are comfortable that selective ancillary use of 2 mm needleinstrumentation will expand the scope and efficacy of NOTESand E-NOTES, without conferring any discernable disadvan-tage. Recently, single incision transumbilical nephrectomy us-ing 3 separate ports was reported with good outcomes.12

NOTES and E-NOTES each provide the potential forvirtually scar-free surgery. However, we see fundamentaldifferences between these 2 approaches. Because NOTESinvolves access through the lumen of the stomach, vagina,urinary bladder or rectum, this approach requires the sur-geon to endoscopically open a normal organ to reach thetargeted diseased organ. E-NOTES does not. On completionof a NOTES procedure the viscus-of-entry must always berepaired endoscopically in a completely reliable, immedi-ately watertight manner to prevent contamination and infec-tion. Secure endoscopic closure of a viscerotomy is a dauntingtask, currently lacks the necessary devices and instruments,and has the potential for major complications. Spillage ofgastric, urinary or colonic contents within the abdomencould be catastrophic and the risk remains unquantified.This is a nonissue with E-NOTES. Since NOTES is per-formed translumenally, it typically requires flexible endo-scopes and coaxial flexible instrument accessories to negoti-ate the naturally existing contours of hollow organs. On theother hand, E-NOTES is performed extralumenally, withrigid instruments allowing triangulation. The flexible in-struments and endoscopes of NOTES are flimsier, introduc-ing an inherent, often counterintuitive, technical complex-ity. The sturdier rigid endoscopes and instrumentation ofE-NOTES, based on standard laparoscopic platforms, aremore intuitive and potentially present a shorter learningcurve. NOTES offers challenges in maintaining spatial ori-entation due to its indirect approach (transvaginal, trans-gastric, transcolonic or transvesical), rendering it techni-cally more difficult to perform. In contrast, E-NOTESprovides a familiar, direct approach from the umbilicus.Given the scar-free and minimally morbid nature of NOTESand E-NOTES at this writing it seems that E-NOTES mayoffer superior reliability which will likely translate into ear-lier and wider clinical acceptance and repertoire. In thefuture flexible robotic multitasking platforms will facilitateNOTES and E-NOTES.

FIG. 5. Abdomen 2 weeks postoperatively

SINGLE PORT TRANSUMBILICAL DONOR NEPHRECTOMY 641

Our report has limitations. An initial description of a noveltechnique in 4 cases is presented and considerable additionalexperience is necessary to demonstrate safety and broad appli-cability. A prospective matched pair comparison with tradi-tional laparoscopic donor nephrectomy is ongoing, to evaluatewhether E-NOTES further minimizes morbidity and cosmeticsequelae. Current issues with transumbilical single port sur-gery include crowding of instruments within the single accessport, with its attendant learning curve. The 5 mm digitalchip-on-a-stick endoscope provides excellent visualization andits built-in camera head minimizes clashing with adjacent in-struments. We believe that future advances in single porttechnology will increase the scope and application of E-NOTESin various surgical specialties such as general, colorectal, hepa-tobiliary and gynecologic surgery.

CONCLUSIONS

Natural orifices present an exciting opportunity for scar-freesurgery. As an embryonic natural orifice the umbilicus pre-sents a versatile, yet concealed access platform to variousintra-abdominal surgical targets. This initial experiencewith E-NOTES donor nephrectomy is encouraging. A qualitydonor kidney was retrieved transumbilically, without anyextra-umbilical skin incision. E-NOTES donor nephrectomyhas the potential to become a future standard. Live donorsare likely to welcome this development.

Abbreviations and Acronyms

CT � computerized tomographyE-NOTES � embryonic natural orifice

transumbilical endoscopic surgeryNOTES � natural orifice translumenal

endoscopic surgeryVAS � visual analog scale

REFERENCES

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3. The Organ Procurement and Transplantation Network(OPTN) data. Available at http://www.optn.org/latestData/step2.asp. Accessed December 12, 2007.

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EDITORIAL COMMENT

The authors should be commended in exploring the merits ofdonor nephrectomy via a single port laparoscopic technique.The hypothesis is that decreasing the number of incisionswill further decrease pain, shorten convalescence and im-prove cosmesis. Although this supposition may appear intu-itive, there is uncertainty regarding the true degree of ben-efit. There is a baseline morbidity related to the internalsurgical procedure. Indeed studies comparing the morbidityof conventional vs hand assisted laparoscopic renal surgeryhave failed to demonstrate a significant recuperative advan-tage with smaller incisions.1 In the current study the painVAS data are encouraging and reminiscent of the promise ofneedlescopic laparoscopy reported several years ago (refer-ence 11 in article). Since then there have been multiplerandomized trials comparing conventional laparoscopic andneedlescopic cholecystectomy with mixed results.2 As such,needlescopic cholecystectomy, while feasible, has not becomethe standard of care. Donors are a highly motivated groupnecessitating a true multi-institutional randomized compar-ison to objectively assess the potential advantages in mor-bidity as well as postoperative body image satisfaction.

This is a wonderful feasibility study. Readers must un-derstand that the equipment is evolving and limited at thistime. Moreover, the word NOTES in the title has an asteriskin front of it in the form of the letter “e.” The title would notbe as sexy without this acronym which has a specific conno-tation and a promise of something different. We laud theauthors for reaffirming the importance of aspiring to theideal.

Manish A. Vira andLouis R. Kavoussi

The Arthur Smith Institute for UrologyNorth Shore Long Island Jewish Health System

New Hyde Park, New York

1. Kocak B, Baker TB, Koffron AJ and Leventhal JR: Laparoscopicliving donor nephrectomy: a single-center sequential experi-ence comparing hand-assisted versus standard technique.Urology 2007; 70: 1060.

2. Novitsky YW, Kercher KW, Czerniach DR, Kaban GK, Khera S,Gallagher-Dorval KA et al: Advantages of mini-laparoscopicvs conventional laparoscopic cholecystectomy: results of a

prospective randomized trial. Arch Surg 2005; 140: 1178.