image: The surgery team included Antonio Alcaraz, José Ribal, Lluís Peri, Alejandro Molina, Concepción Monsalve and Mercè Clapera. view more
Credit: Hospital Clínic de Barcelona
Successful surgery that leaves no scars has become the main objective of the most daring and innovative surgeons. Since conventional open surgery gave way to laparoscopy-assisted surgery, which requires 3, 4 or even 5 incisions, surgeons operating on the pelvic and abdominal cavity, together with experts in robotics, are investigating new ways of entering the body to explore structures, diagnose diseases and extract organs. Hospital Clínic, Barcelona is committed to minimally invasive surgery, particularly as the navel has now been shown to be a safe and effective single access route for extracting kidneys. The operation – the first of its kind to be performed in Spain – was carried out by the team of Dr. Alcaraz of the Hospital Clínic urology department on 17 February on an 85-year-old woman who had been diagnosed with cancer. Three days after the operation, the woman was discharged home with no symptoms.
Today is World Kidney Day, an initiative promoted by the International Society of Nephrology (ISN) and the National Kidney Foundation, which is focussing its message this year on early detection of chronic kidney cancer and arterial hypertension, one of the most important factors in developing this cancer. In this context, Hospital Clínic, Barcelona presents this innovative technique, which was made possible by the joint work of the medical team of Dr. Antoni Alcaraz, head of the urology department, Dr. María José Ribal, urology specialist, Dr. Lluís Peri, urology specialist and Dr. Alejandro Molina, urology resident. Also taking part in the operation were Dr. Concepción Monsalve, anesthesiologist, and Ms Mercè Clapera, operating theatre nurse. This is the same team that, a little less than a year ago, carried out the world's first transvaginal nephrectomy due to kidney cancer – also a minimally invasive technique; this technique made it possible to extract a tumorous kidney using only 2 small 1-cm incisions in the abdomen and another incision that cannot be seen, inside the vagina. Since then, Dr. Alcaraz and his team have carried out a total of 12 kidney extractions via the vagina – a route that is also being proposed as an alternative for transplants involving live organ donors.
But the star of today's new milestone operation is the navel, an embryonic legacy that paves the way to a new generation of minimally invasive surgery. This procedure is another step forward in laparoscopic surgery as, instead of using the natural orifices of the body to operate (the technique of the NOTES [Natural Orifice Transluminal Endoscopy Surgery] program), it uses the embryonic orifice to extract affected organs, such as the kidney in this case. This new port of entry presents several advantages besides the esthetic advantage of not leaving scars, as patient recovery times are cut by half, there is very little risk of hemorrhage as the area is poorly vascularized, and pain is minimal as there are few nerve endings in the surrounding area. Furthermore, it is a technique that can be used on both men and women, unlike transvaginal nephrectomy, which is only possible in women.
The single-port transumbilical nephrectomy (the technical name for this operation) was carried out using a single trocar made by the company Olympus. This laparoscopic instrument requires considerable control and precision to be used correctly, as the surgeon has to use 3 instruments through a single point in order to manipulate the organ remotely and extract it once it has been entrapped inside the body. Accessing the kidney via this route means no visible marks are left as the minimal incision made by the surgeons is hidden by the natural folds of the umbilical scar. Nevertheless, as with laparoscopic surgery or the NOTES approach, the transumbilical route is not completely risk-free and must always be performed by an experienced team of surgeons who are permanently trained in the use of the instruments.
The umbilical route currently represents a genuine revolution in minimally invasive surgery. Using this technique, surgeons from different specialties involving the pelvic and abdominal cavity (urology, gynecology, gastroenterology, etc.) can extract organs affected by cancer or other conditions, such as the prostate gland, uterus, ovarian tumors and cysts, and perform ligation of the ovarian tubes , etc. This embryonic legacy also stimulates the genius of the most seasoned researchers who see the future in the combination of the transumbilical route and robotics, where both human intervention and invasion of the body are reduced to a minimum. And all of this can be done without sacrificing either the efficacy of the surgery or the benefits to the patient.