Single Port Transumbilical (E-NOTES) Donor Nephrectomy

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Abstract
Purpose: We present the initial 4 patients undergoing single port transumbilical live donor nephrectomy. Scar-free abdominal surgery via natural body orifices is called NOTES (natural orifice translumenal endoscopic surgery). In a similar manner the umbilicus, an embryonic (E) natural orifice, permits abdominal access with hidden scar of entry. We propose the term 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 the abdomen. No extra-umbilical skin incisions were made whatsoever. A 2 mm Veress needle port, inserted via skin needle puncture to establish pneumoperitoneum, was used to selectively insert a needlescopic grasper for tissue retraction. Donor kidney 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 was 50 cc, warm ischemia time was 6.2 minutes and hospital stay was 3 days. Median length of harvested renal artery was 3.3 cm, renal vein 4 cm and ureter 15 cm. No intraoperative complications occurred. Donor visual analog scores were 0/10 at 2 weeks. Each allograft functioned immediately on transplantation. Conclusions: The initial experience with E-NOTES donor nephrectomy is encouraging. Excellent donor vascular and tissue dissection could be performed, and a quality donor kidney was retrieved transumbilically without any extra-umbilical skin incision. E-NOTES donor nephrectomy appears to have relevance and promise, especially for this typically younger, altruistic population. Natural orifices present an unprecedented opportunity for scar-free surgery.