Transvaginal extraperitoneal lymphadenectomy by Natural Orifices Transluminal Endoscopic Surgery (NOTES) technique in porcine model: Feasibility and survival study

ObjectiveRetroperitoneal pelvic and lomboartic lymphadenectomy is widely used as a staging and/or prognostic procedure in gynecologic malignancies. Associated morbidity ranges from 2 to 13% of cases. This study assesses the feasibility of extraperitoneal lymphadenectomy using Natural Orifices Transluminal Endoscopic Surgery (NOTES) in porcine survival model.MethodsSix female pigs weighing 25 to 30 kg were used. Using a transvaginal access to the retroperitoneum, we performed three pelvic lymph node excision and three others in the laterocaval, interaorticocaval and lateroaortic regions. Colpotomy was closed with interrupted absorbable sutures.ResultsRetroperitoneal lymphadenectomies were performed successfully in all six pigs. We experienced one accidental peritoneal perforation, one diffuse anterior abdominal wall emphysema, one abdominal wall bleeding secondary to electrical muscle stimulation and two pneumoperitoneums evacuated by Veress needle insertion. All animals thrived until three weeks after the initial intervention. On laparoscopic second look there were no abscess, no infection and no adhesions even with the accidental peritoneal perforation. On laparotomy, no retroperitoneal abscess was found, but there was a small amount of fibrosis at the lymphadenectomy sites. All colpotomies were inspected and showed good healing.ConclusionsThis study demonstrated the technical feasibility and safety of extraperitoneal lymphadenectomy by totally NOTES technique and provided the first report on survival porcine model. Cadaver experiments would test its feasibility in humans. Sentinel lymph node could be an application of NOTES lymphadenectomy in humans. NOTES endoscopic instruments are urgently needed for further advances in the technique. Further studies are mandatory to evaluate its future indications.