Transrectal hybrid natural orifice transluminal endoscopic surgery (NOTES) nephrectomy in a porcine model

OBJECTIVE

To examine feasibility of transrectal hybrid natural orifice translumenal endoscopic surgery (NOTES) nephrectomy in the porcine model. NOTES uses ports of entry to the peritoneal cavity instead of abdominal wall incisions, thereby eliminating visible scar and also potentially reducing postoperative pain.

METHODS

After obtaining Institutional Animal Care and Use Committee approval, 3 female pigs (45 kg) underwent transrectal hybrid NOTES nephrectomy (2 right, 1 left). Pneumoperitoneum was created by a periumbilically-inserted 12-mm trocar, through which a laparoscope was advanced to obtain intraabdominal visualization. A horizontal incision was made 2 cm above the dentate line and a submucosal tunnel was created in the posterior rectal wall/presacral space. A dual-channel gastroscope was advanced through the submucosal tunnel and retroperitoneum to the level of the kidney using air insufflation. A window in the peritoneum was created and renal mobilization was completed. A transumbilically applied laparoscopic 45-mm stapler was used to transect the ureter and renal hilum. A specimen extraction bag was deployed transrectally and the specimen was delivered intact, followed by transrectal incision closure.

RESULTS

Transrectal hybrid NOTES nephrectomy was successfully performed in all cases. Mean operative time was 180 minutes (30 minutes for rectal access). Estimated blood loss was 50 mL. On necropsy, no intraabdominal injuries were noted.

CONCLUSIONS

In this initial report on feasibility of transrectal hybrid NOTES nephrectomy, we were able to perform the procedures with minimal blood loss and extract intact specimen. Survival studies are prerequisite to assess sterility and short- and long-term complications. This approach may be useful as an alternative to transvaginal access.

[Frey syndrome secondary to submaxillectomy and botulinic treatment]

A case of Frey syndrome (FS) secondary to submaxillar gland exeresis is presented and the results of the treatment with botulinum toxin (BTX) type A. FS is a condition of sweating cheek and preauricular area during realtime as a sequel detected in about 20-60% of patients after parotidectomy. The clinical symptoms include swelling, flushing and hyperhidrosis. The treatment choice for this condition is intracutaneous injection of BTX type A which blocks acetylcholine release at the sweat glands. A 30-year-old man, with thyroid medullar carcinoma diagnosed in 2002 received 6 cicles of cisplatin plus doxorubicin previous to the thyroidectomy with anterolateral neck dissection. During surgery the left ramus marginalis mandibulae was damaged. Two years later the patient referred sweating in submaxillar region during meals. CT scan demonstrated the absence of left submaxillar gland. Minor's test disclosed the affected area and BTX type A was injected (2.5 U/cm2/17 points). A twenty-one-day control showed a 95% reduction of the affected skin area. Persistent efficacy was observed up to one year follow-up time when he was reinjected. The FS, also known as "gustatory hyperhidrosis", was probably first reported by M. Duphenix in 1757. Lucja Frey considered its physiopathology as a disorder of both sympathetic and parasympathetic innervation. In our case the FS was caused by a misdirected regeneration of postganglionic parasympathetic nerve fibers that arrised from the nervus lingualis rami ganglionares of the nervus trigeminus. After nerve injury the colinergic parasympathetic fibers seek out colinergic receptors--sympathetic receptors of the skin--innervating sweat glands and small skin vessels. All previous cases were located at masseter region post-parotidectomy. We have not found any description of FS in the submaxillary region. The self-assessed efficacy of the treatment with a hyperhidrosis disease severity scale revealed a very satisfied patient at 20 months follow-up after being injected twice with BTX type A.