Gill IS et al. (2008) Single port transumbilical (E-NOTES) donor nephrectomy. J Urol 180: 637–641

Natural body orifices such as the vagina and rectum offer concealed access points for potentially scar-free laparoscopic surgery (so-called 'natural orifice translumenal endoscopic surgery'). Gill and colleagues from the Cleveland Clinic, Cleveland, OH, have developed a related technique, whereby access is obtained via the umbilicus. They recently presented the first four cases of donor nephrectomy performed by use of this approach.

The first procedure was carried out on 28 November 2007. A single-access R-port was inserted into the abdomen via a 2 cm vertical intraumbilical incision and a 2–3 cm rectus fasciotomy, to enable entry of the laparoscope and instruments. After being freed, the kidney was enclosed in a polyurethane pouch and removed transumbilically, with extension of the rectus fascia incision and the skin incision as necessary.

The technique was successful in all cases; no extraumbilical incisions were required (median umbilical incision length was 4 cm) and no intraoperative complications occurred. Surgery lasted a median of 3.3 h and kidneys were exposed to a median warm ischemia time of 6.2 min. All kidneys functioned immediately upon implantation. Each donor remained in hospital for 3 days.

Scar-free surgery is likely to appeal to living kidney donors. The authors contend that their technique might be preferable to the original translumenal approach because the transumbilical technique is less technically challenging and does not require opening a healthy organ to access a diseased organ. A prospective study comparing single-port transumbilical donor nephrectomy with the conventional laparoscopic procedure is currently underway.