Totally laparoscopic sigmoid colectomy: a simple and safe technique for intracorporeal anastomosis

Background

Current techniques of laparoscopic colectomy require an abdominal incision for extraction of the specimen. Although this incision is smaller than that for open laparotomy incision, it may reduce the advantages of laparoscopic surgery. In totally laparoscopic sigmoid colectomy, intracorporeal anastomosis is technically difficult. A safe and simple technique for circularly stapled intracorporeal anastomosis is described.

Methods

After mobilization of the colon and division of the mesentery, a semicircumferential colotomy is made at the anterior colonic wall just proximal to the transection site. The anvil of a circular stapling device, secured with a Prolene suture, is introduced via the colotomy. The suture is advanced anteriorly so that the center rod of the circular stapling device penetrates the colonic wall. The colon is staple-transected at this point to secure the anvil on the proximal colon. A grasping forceps is brought through the rectum, and the specimen is extracted through the colotomy made at the distal staple line. After the colotomy is reclosed with a linear stapler, anastomosis is established using a hemidouble stapling technique.

Results

Totally laparoscopic sigmoid colectomies were performed for 16 patients with colon cancers. All the patients were treated laparoscopically without any complications. The average operation time was 180 min. Although one patient experienced wound infection, no major complications occurred. There was no mortality in this series.

Conclusions

The procedure of totally intracorporeal anastomosis combined with transanal extraction of the specimen can be performed easily, enabling surgeons to achieve minimal invasiveness comparable with that of hybrid natural orifice translumenal endoscopic surgery (NOTES).     

A Stepwise Approach to Transanal Endoscopic Microsurgery for Rectal Cancer Using a Single-Incision Laparoscopic Port

Background

Radical rectal resection with total mesorectal excision is the current standard of care for the operative treatment of rectal cancer. Local excision is an acceptable alternative in selected patients with early disease (T_is0?T₁) and low-risk features, in whom radical resection may be associated with unacceptably high morbidity. With recent data demonstrating favorable results in well-selected patients, the role of local excision for rectal cancer is expanding.1 ^, 2 Transanal endoscopic microsurgery (TEM), which requires the use of an operating anoscope, has been used for the local excision of mid-upper rectal tumors. We describe an alternative approach to TEM for rectal cancer.

Methods

We present a stepwise technique for TEM using a single-incision laparoscopic (SILS) port. The patient is a 64 year-old male with a right anterolateral rectal polyp 7?cm from the anal verge, which on snare polypectomy demonstrated in-situ carcinoma with positive margins. Endoscopic ultrasound demonstrated uT₁ disease with no lymphadenopathy. He opted for local excision and underwent TEM. Our stepwise approach includes: (1) delineation of excision margins, (2) full thickness incision of the rectal wall, (3) circumferential dissection, and full thickness excision, and (4) suture repair.

Results

The procedure was performed without intraoperative or postoperative complications. Final pathology revealed in-situ carcinoma with widely negative margins. At 1- and 3-week follow-up visits, the patient was pain free with normal bowel activity and no rectal bleeding or genitourinary dysfunction.

Discussion

TEM using a SILS port is an effective technique for the local excision of mid-upper rectal cancer in well-selected patients.     

Laparoscopic Total Colectomy with Transvaginal Extraction of the Colon and Ileorectal Anastomosis

Background

The abdominal incision extraction site continues to be major source of morbidity after laparoscopic colectomy: mainly, incisional pain, wound infection, and incisional hernia. Also, in selected cases, it may delay initiating chemotherapy.

Methods

The video describes the technique of performing laparoscopic total colectomy, transvaginal removal of the entire colon, and intracorporeal ileorectal anastomosis in a 40-year-old woman with a sigmoid cancer and multiple endoscopically unresectable polyps throughout the colon. Computed tomography scan showed 2 liver lesions with carcinoembryonic antigen 138. Familial adenomatous polyposis gene analysis was negative. Six trocars (one 12 mm and five 5 mm) were used. The whole colon was removed through the transvaginal route. The anvil was introduced through the vagina, and circular stapled ileorectal anastomosis was done.

Results

There were no intraoperative complications. The operating time was 210 min. Blood loss was 20 mL. The patient was discharged home on postoperative day 2. Final pathology was T3N1bM1, and 2 of 23 lymph nodes were metastatic. All polyps were tubulovillous. She was commenced on chemotherapy 2 weeks after surgery. At 6-month follow-up, the patient was doing well, had no abdominal pain, and had no vaginal discharge or dyspareunia.

Conclusions

Natural orifice specimen extraction (NOSE) surgery can be added to the armamentarium of surgeons performing laparoscopic colon surgery. This technique may provide both an attractive way to reduce abdominal incision–related morbidity and a bridge to pure natural orifice transluminal endoscopic surgery (NOTES) colon surgery. Large-number patient data with long-term follow-up is needed.     

Impact of incision length on the short-term outcomes of laparoscopic colorectal surgery

Background

The recent introduction of hand-assist devices in laparoscopic colorectal surgery has renewed interest in the influence of incision length. This study aimed to define the impact of extraction incision length on the postoperative outcomes of laparoscopic left-sided colon and rectal resections.

Methods

Consecutive patients undergoing laparoscopic left-sided colorectal resection from 1991 to 2007 were retrieved from a prospectively collected database. The association between incision length and patient characteristics, diagnosis, and perioperative outcomes were analyzed using logistic regression, Spearman correlation, Wilcoxon test, and chi-square test.

Results

A total of 494 laparoscopic colorectal resections (left, sigmoid, anterior, and low anterior resections) were retrieved. Patients with conversions to open surgery (n = 59) and missing data (n = 53) were excluded. As a result, 382 cases were included in the study. A slight majority of the patients had malignant disease (n = 202, 53%). The median incision length was 5 cm (interquartile range, 4–6 cm). Increasing weight was positively correlated with incision length (p = 0.0001). Male patients had modestly larger mean incisions than female patients (5.5 vs. 5.0 cm; p = 0.0075). Age, previous surgery, diagnosis, days to resumption of normal diet, and days to discharge from hospital showed no significant relationship with incision length. No association was observed between the incision length and intraoperative or postoperative complications.

Conclusions

Patients undergoing laparoscopic colorectal surgery appear to achieve the same perioperative outcomes irrespective of their extraction incision lengths. To maintain the short-term benefits of laparoscopy, surgeons should consider pursuing a minimally invasive technique, even when a larger extraction incision will ultimately be required.     

Comparison of Peristomal Adhesion Formation Between Laparoscopic and Open Low Anterior Resection of Rectal Cancer

Background

Postoperative adhesions appear to be less common following laparoscopic surgery than after conventional open surgery. The purpose of this study was to compare the impact of laparoscopic and conventional open rectal surgery on peristomal adhesion formation.

Methods

We enrolled 97 subjects who were participants in a trial comparing open versus laparoscopic surgery for mid and low rectal cancer after neoadjuvant chemoradiotherapy. These patients had undergone rectal cancer surgery with ileostomy formation. Peristomal adhesions were assessed during ileostomy takedown using an adhesion grading system: (1) no adhesions or fine, filmy adhesions separable by blunt dissection; (2) dense adhesions, separable by sharp dissection; (3) very dense adhesions, resulting in enterotomy and/or requiring extension of the abdominal wall incision.

Results

A total of 57 patients underwent laparoscopic resection (group A) and 40 underwent open resection (group B). Operating time for ileostomy dissection was shorter in group A than in group B (14.6 vs. 19.8 min, respectively; p = 0.047). Dense adhesions (grades 2 and 3) were more common in group B (22/40, 55 %) than in group A (12/57, 21 %; p < 0.001). In particular, grade 3 adhesions were present only in group B (6/40).

Conclusions

The present findings suggest that laparoscopic rectal surgery results in less peristomal adhesion formation than does conventional open surgery.     

Feasibility of Single-Port Laparoscopic Surgery for Sigmoid Colon and Rectal Cancers and Preoperative Assessment of Operative Difficulty

Purpose

Single-port laparoscopic surgery is more difficult for sigmoid colon and rectal cancers than for right-sided colon cancer. We sought to analyze the feasibility of this procedure for sigmoid colon and rectal cancers and to estimate its difficulty.

Methods

We analyzed prospectively collected data from 63 consecutive patients with sigmoid colon or rectal cancers who underwent single-port laparoscopic surgery at our institution from June 2009 to December 2011. Patient and tumor characteristics, including patients’ pelvic anatomy which was assessed on CT scan imaging, were evaluated to elucidate what factors would affect the difficulty of the procedure and the necessity of using an additional trocar.

Results

Overall, the median operative duration was 190 min and blood loss was 20 ml, with no postoperative complications. The median number of lymph nodes harvested was 17 and the distal margin was 58 mm. The tumor was located significantly closer to the anus in cases in which an additional trocar was required in the right lower quadrant (9.5 vs 18 cm, p?<?0.0001). Procedural difficulty was significantly increased in cases in which the sacral promontory protruded ventrally (odds ratio 0.779 [95 % confidence interval 0.613 to 0.945], p?=?0.0236).

Conclusions

Depending on tumor location and sacral promontory shape, the introduction of an additional trocar might render single-port laparoscopic surgery feasible for sigmoid colon and rectal cancer resection.     

Laparoscopic resection for gastrointestinal stromal tumors in the stomach

Purpose

Gastrointestinal stromal tumors (GISTs) should be surgically resected, even those smaller than 5?cm in size, which is the threshold of clinical malignancy for submucosal tumors (SMTs) in the gastrointestinal tract. This study reviewed the use of laparoscopic surgery for gastric partial resection of GISTs or SMTs that were suspected to be GISTs.

Methods

Eighteen patients underwent laparoscopic partial resection of the stomach for GISTs or SMTs. The tumor location was confirmed by intraluminal endoscopy. One-half of the circumference around the tumor was dissected, and the tumor was turned toward the abdominal cavity. The nonresected part of the tumor and the edge of the incision line was lifted up using forceps, and the incision line was closed using laparoscopic stapling devices.

Results

Two cases were diagnosed as GIST by endoscopic biopsy. Six patients underwent endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB) examinations, which diagnosed five GISTs. There were 18 tumors smaller than 5?cm, including 10 GISTs, 4 leiomyomas, 3 schwannomas, and one heterotopic pancreas.

Conclusions

Endoscopic ultrasound-guided FNAB is recommended for definite preoperative diagnosis of histopathologically unknown SMTs to determine the indications for surgery. The laparoscopic approach with the assistance of endoscopy is useful for improving the curability, with minimal invasiveness for the partial resection of GISTs.     

Transvaginal Specimen Extraction After Laparoscopic Colectomy

Background

Despite the advantages of laparoscopic colon surgery, the need for an incision in the abdominal wall to remove the surgical specimen is a morbidity factor. The objective of this article is to introduce transvaginal specimen extraction after laparoscopic colectomy, in order to avoid an abdominal incision.

Methods

Between 2008 and 2011, 21 selected women with benign and malignant colorectal pathologies underwent laparoscopic colectomy and the extraction of the surgical specimen was done through a transvaginal access route. Of these patients, 12 had symptomatic diverticular disease, four had rectal villous adenomas, two had severe chronic constipation, and three had adenocarcinomas. We describe the surgical technique and the short-term outcomes related to the transvaginal specimen extraction.

Results

The procedure was successful in all cases. There were no immediate complications or mortality. At follow-up, between 2 and 34?months, there were no functional disorders associated with the transvaginal specimen extraction.

Conclusion

Specimen removal of laparoscopic colectomies via the transvaginal route avoids the abdominal wall incision and its potential complications. It is feasible, safe, and simple to perform, with no additional costs, and provides excellent cosmetic results.     

A novel approach for the treatment of pelvic abscess: transrectal endoscopic drainage facilitated by transanal endoscopic microsurgery access

Background

Postoperative pelvic abscesses in patients submitted to colorectal surgery are challenging. The surgical approach may be too risky, and image-guided drainage often is difficult due to the complex anatomy of the pelvis. This article describes novel access for drainage of a pelvic collection using a minimally invasive natural orifice approach.

Methods

A 37?year-old man presented with sepsis due to a pelvic abscess during the second postoperative week after a Hartmann procedure due to perforated rectal cancer. Percutaneous drainage was determined by computed tomography to be unsuccessful, and another operation was considered to be hazardous. Because the pelvic fluid was very close to the rectal stump, transrectal drainage was planned. The rectal stump was opened using transanal endoscopic microsurgery (TEM) instruments. The endoscope was advanced through the TEM working channel and the rectal stump opening, accessing the abdominal cavity and pelvic collection.

Results

The pelvic collection was endoscopically drained and the local cavity washed with saline through the scope channel. A Foley catheter was placed in the rectal stump. The patient’s recovery after the procedure was successful, without the need for further intervention.

Conclusions

Transrectal endoscopic drainage may be an option for selected cases of pelvic fluid collection in patients submitted to Hartmann’s procedure. The technique allows not only fluid drainage but also visualization of the local cavity, cleavage of multiloculated abscesses, and saline irrigation if necessary. The use of TEM instrumentation allows safe access to the peritoneal cavity.     

Laparoscopic TME with APPEAR (Anterior and Perineal PlanE for ultra-low Anterior Resection of the Rectum) technique for distal rectal cancer

Background

Laparoscopic sphincter saving rectal resection for low rectal cancer is hampered by narrow pelvis and limitations of current stapling devices [1]. The APPEAR (Anterior Perineal PlanE for Ultra-low Anterior Resection of the Rectum) was proposed by Williams et al. [2, 3] as an alternative to the abdominal-perineal resection to perform very low rectal resection and anastomosis through a perineal wound. We adapted the original technique to the laparoscopic approach, avoiding any other abdominal incision.

Methods

Between December 2011 and April 2012, five patients (2 females; median age 72 years (range 60–78)) with rectal cancer not involving the sphincters underwent laparoscopic total mesorectal excision (TME) with APPEAR. Mean distance of the tumor from anal verge was 3.2 ± 1.1 cm (range 2–5).

Results

All of the procedures were completed laparoscopically. All of the anastomoses were stapled, and a protective stoma was always constructed. The surgical specimens were retrieved from the perineal wound, and the stoma performed through one of the port sites, without any further abdominal incision. Mean operative time was 333 ± 47 min (range 295–405), postoperative stay 12 ± 5 days (range 6–17). Perineal wound infection was observed in three patients, two of whom also had anastomotic fistula, and was treated conservatively with prolonged suction drainage. Histological examination showed three pT3N+, one T2N0, and one complete response after neoadjuvant radiochemotherapy, with a mean distal clear margin of 1.27 ± 0.5 cm (range 0.5–1.7). After a median follow-up of 9 months (range 8–12), one stoma reversal has been performed and the patient is fully continent.

Conclusions

Our experience shows the feasibility of the APPEAR technique with laparoscopic TME, without any other abdominal incision. This technique offers advantage over the limitations of current laparoscopic stapling devices and their scanty maneuverability in the pelvis, allowing resection and anastomosis under direct vision, with adequate distal clearance, while sparing the anal sphincters.     

Transanal Endoscopic Microsurgery (TEM) Facilitated by Video-Assistance and Anal Insertion of a Single-Incision Laparoscopic Surgery (SILS®)-Port: Preliminary Experience

Objective

Transanal endoscopic microsurgery (TEM) is an established method for the resection of benign and early malignant rectal lesions. Very recently, TEM via an anally inserted single incision laparoscopic surgery (SILS^®)-port has been proposed to overcome remaining obstacles of the classical TEM equipment.

Methods

Nine patients with a total of 12 benign or early stage malignant rectal polyps were operated using the SILS^®-port for TEM. Patients’ and polyps’ characteristics, perioperative and postoperative complications, as well as operating and hospitalization time were recorded.

Results

All 12 polyps (ten low-grade adenoma, one high-grade adenoma, one pT₂ carcinoma [preoperatively staged as T₁]) were resected. Local full-thickness bowel wall resection was performed for three lesions and submucosal resection for nine lesions. Median operating time was 64 (range 30–180) min. No conversion to laparoscopic or open techniques was necessary. The median maximum diameter of the specimen was 25 (range 3–60) mm, fragmentation of polyps was avoidable in 11 of 12 (92 %) lesions, and resection margins were histologically clear in 11 of 12 (92 %) polyps. Only one patient, in whom three lesions were resected, experienced a complication as postoperative hemorrhage. No mortality occurred. Median hospitalization time was four (range 1–14) days.

Conclusions

SILS^®-TEM is a feasible and safe method, providing numerous advantages in application, handling, and economy compared with the classical TEM technique. SILS^®-TEM might become a promising alternative to classical TEM. Randomized, controlled trials comparing safety and efficacy of both instrumental settings will be needed in the future.     

Endoscopic identification of the jejunum facilitates minimally invasive jejunostomy tube insertion in selected cases

Background

Percutaneous endoscopic gastrostomy (PEG), direct percutaneous endoscopic jejunostomy, and laparoscopic feeding tube insertion are established techniques for placing a feeding tube. However, these techniques may be difficult or contraindicated after previous gastric or upper abdominal surgery.

Methods

A total of 10 patients underwent minimally invasive jejunostomy tube insertion via endoscopic identification of the jejunum. The indications for the procedure were dysphagia, poor nutritional status, prolonged intensive care unit (ICU) admission, and gastroparesis. Eight of the patients had undergone previous upper abdominal surgeries and were rejected for either PEG or direct percutaneous jejunostomy. With the patients under general anesthesia, esophagogastroduodenoscopy was performed. The jejunum was identified and intubated. A small abdominal incision (1 in.) was made. The proximal jejunum was identified easily by the light and digital palpation of the endoscope. The jejunum was delivered in the wound, and the jejunostomy tube was inserted using Witzel’s technique. The wound was closed.

Results

All the patients tolerated the procedure well. The mean time for the procedure was 29 ± 13 min. There was no mortality related to the procedure and no complications. Jejunal feeding started on the first postoperative day.

Conclusion

The use of intraoperative endoscopy facilitated identification of the jejunum. Easy, safe, and quick, the procedure saved the patient a formal laparotomy and extensive manipulation.     

Prospective randomized comparison of laparoscopic peritoneal vaginoplasty with laparoscopic sigmoid vaginoplasty for treating congenital vaginal agenesis

Introduction and hypothesis

The aim of this study was to compare the effectiveness and long-term anatomic and functional results of laparoscopic peritoneal vaginoplasty and laparoscopic sigmoid vaginoplasty.

Methods

From January 2002 to December 2010, 40 patients with congenital vaginal agenesis were prospectively randomized to undergo either laparoscopic peritoneal vaginoplasty (26 cases) or laparoscopic sigmoid vaginoplasty (14 cases) in 2:1 ratio. Pre- and postoperative examination findings, Female Sexual Function Index (FSFI) questionnaire responses, and sexual satisfaction rates are reported.

Results

All surgical procedures were performed successfully, with no intraoperative complications. The laparoscopic peritoneal vaginoplasty group had significantly less blood loss and a surgery shorter on average than the laparoscopic sigmoid colovaginoplasty group. Postoperative course was uneventful for all patients in both groups, though postoperative retention time and hospital stay were less for peritoneal vaginoplasty patients than for sigmoid vaginoplasty patients. Mean neovaginal length, excessive mucous production, sexual life initiation time, and sexual satisfaction rate were similar between groups. Patient complaints of abdominal discomfort, unusual odor from vaginal secretions, and vaginal contraction during intercourse were higher in the sigmoid colovaginoplasty group (p < 0.005 vs. peritoneal vaginoplasty). Postoperative FSFI scores did not differ significantly between groups.

Conclusions

Relative to laparoscopic sigmoid colovaginoplasty, laparoscopic peritoneal vaginoplasty provides good anatomic and functional results and excellent patient satisfaction.     

Transanal Endoscopic Microsurgery vs. Laparoscopic Total Mesorectal Excision for T2N0 Rectal Cancer

Objective

The aim was to compare transanal endoscopic microsurgery (TEM) and laparoscopic resection (LR) in terms of short-term and oncologic outcomes in patients with a preoperatively diagnosed T2N0 extraperitoneal rectal cancer.

Methods

We conducted a retrospective analysis of a prospective database. All patients with a preoperatively staged T2N0 extraperitoneal rectal adenocarcinoma were considered for LR. Patients refusing LR or medically unfit for LR were considered for TEM, which was associated with neoadjuvant RT in the last cases. Only patients with a minimum follow-up of 36?months were included.

Results

Seventy-eight patients were included. TEM was indicated or preferred in 43 patients; of these, 11 underwent neoadjuvant RT. Morbidity was significantly lower after TEM (p?<?0.001). The median follow-up was 70 (36?C140) months. A higher local recurrence rate was noted after TEM (26?%), compared to neoadjuvant RT + TEM (0?%) and LR (9?%) (p?=?0.070). Overall, 5-year survival rate was 76?% after TEM, 77.8?% after RT + TEM, and 96?% after LR, respectively (p?=?0.134).

Conclusions

While TEM alone may only be considered a palliative treatment, it might allow similar oncologic results to abdominal resection in responders to neoadjuvant RT. Large prospective randomized trials are awaited to confirm these findings.     

Management of benign ovarian cysts by a novel, gasless, single-incision laparoscopic technique: keyless abdominal rope-lifting surgery (KARS)

Background

To find the most efficacious method to minimize the side effects and maximize the advantages of laparoscopic surgery, this study aimed to define and document a gasless, single-incision abdominal access technique for the management of benign ovarian cysts.

Methods

During a 1½ year period, 55 women underwent surgery for a benign ovarian cyst. Conventional carbon dioxide (CO₂) laparoscopy was used for 33 of the women, and 22 of the women underwent a novel, gasless, single-incision laparoscopic surgery. An abdominal access pathway through a single intraabdominal incision was used to place transabdominal sutures that elevated the abdominal wall, and the operations were performed through the intra-umbilical entry without the use of trocars. Thus, the new technique was called keyless abdominal rope-lifting surgery (KARS). Two operative groups were compared to assess the feasibility of the new technique.

Results

All the operations could be performed by KARS without conversion to CO₂ laparoscopy or laparotomy. However, for two patients in the conventional laparoscopy group, minilaparotomy had to be performed for tissue retrieval. Although the two techniques had many similar results, the total operative times and the abdominal access times in the KARS group were significantly longer than in the conventional laparoscopy group (p < 0.05). Simple oral analgesics were adequate for postoperative pain relief in both groups.

Conclusions

The KARS technique is a gasless, single-incision laparoscopic procedure that can be performed safely and effectively in terms of cosmesis, postoperative pain, and fertility preservation for the management of benign adnexal pathologies.     

Transanal endoscopic resection with peritoneal entry: a word of caution

Background

Peritoneal entry during transanal endoscopic microsurgery (TEM) can usually be managed transanally with full-thickness suture closure by experienced operators. The preliminary safety of transanal minimally invasive surgery (TAMIS) has been demonstrated, but the reported experience with upper rectal tumors is limited. The incidence and management of peritoneal entry during transanal endoscopic surgery across various platforms have not been previously evaluated.

Methods

Retrospective analysis of a prospectively maintained database of all transanal endoscopic resections performed at a single institution between January 2008 and December 2014 was conducted. Cases with and without peritoneal entry were evaluated with respect to transanal platform used, surgical indication, size, location and distance from the anal verge, and incidence of postoperative complications.

Results

A total of 78 transanal endoscopic procedures were performed on 76 patients using the rigid transanal endoscopic operation (TEO, 65.4 %), TEM (26.9 %), and TAMIS platform (7.7 %). The most common surgical indication included endoscopically unresectable adenomas (50 %). The average distance of lesions from the anal verge (AV) was 9.6 cm (range 4–20 cm). Peritoneal entry occurred in 22 cases (28.2 %). Platform used (TAMIS vs. rigid, p < 0.05), mean distance from the AV (p < 0.0001), location along the rectum (p = 0.01), and mean specimen size (p = 0.01) were associated with a higher likelihood of peritoneal entry. All rectal defects associated with peritoneal entry were successfully closed transanally except for two (TEM and TEO) cases that required conversion to laparoscopic low anterior resection and laparoscopic Hartmann’s, respectively. There were four TAMIS cases that required conversion to TEO platforms.

Conclusion

In this high-risk TEM, TEO, and TAMIS series (one-third of rectal lesions located in the upper rectum), 91 % of all peritoneal entries were managed transanally without increased morbidity. TAMIS for upper rectal lesions was associated with a high risk of complicated peritoneal entry requiring conversion to a rigid platform.

     

Paradigm-Shifting New Evidence for Treatment of Rectal Cancer

Background

Treatment of rectal cancer has dramatically evolved during the last three decades shifting toward a tailored approach based on preoperative staging and response to neoadjuvant combined modality therapy (CMT).

Methods

A literature search was performed using PubMed/Medline electronic databases.

Results

Selected patients with T1 N0 rectal cancer are best treated with local excision by transanal endoscopic microsurgery (TEM). Satisfactory results have been reported after CMT and TEM for the treatment of highly selected T2 N0 rectal cancers. CMT followed by rectal resection and total mesorectal excision is considered the standard of care for the treatment of locally advanced rectal cancer. However, a subset of stage II and III patients may not require neoadjuvant radiation treatment. Finally, there are mounting data supporting a “watch and wait” approach or local excision in patients with complete clinical response after neoadjuvant CMT.

Conclusions

Current evidence shows that selected T1 N0 rectal cancers can be managed by TEM alone, while locally advanced cancers should be treated by CMT followed by radical surgery. Studies are underway to identify patients that do not benefit from neoadjuvant radiation therapy. A non-operative approach in case of complete clinical response must be validated by large prospective studies.     

Transrectal robotic natural orifice translumenal endoscopic surgery (NOTES) applied to intestinal anastomosis in a porcine intestine model

Background

Natural orifice translumenal endoscopic surgery (NOTES) is a minimally invasive operation using devices such as flexible endoscopes and linear or circular staplers. Nevertheless, hand-sewn anastomosis in NOTES remains challenging. This study aimed to investigate the feasibility of transrectal robotic NOTES requiring intracorporeal small intestinal anastomosis and closure of the rectal anterior wall incision in a relevant human model.

Methods

The authors developed a flexible rectal proctoscope with a diameter of 43 mm for transrectal robotic NOTES. Small intestinal anastomosis was performed in a porcine intestinal transrectal NOTES model using two robotic arms and a camera inserted through the proctoscope and a rectal anterior wall incision. The quality of transrectal small intestinal anastomosis using the da Vinci surgical system (transrectal robotic NOTES group) was compared with that of transabdominal anastomosis using the da Vinci surgical system (transabdominal robot-assisted surgery group) and transrectal anastomosis using traditional transanal endoscopic microsurgery (TEM) instruments (TEM NOTES group). The quality of transrectal rectal anterior wall suturing in the transrectal robotic NOTES group was compared with that of the TEM NOTES group and the open surgical instruments group (open group).

Results

Robotic intracorporeal suturing was performed successfully in the porcine intestine model. During small intestinal anastomosis, burst pressure in the transrectal robotic NOTES group (67.7 ± 29.3 mmHg) was similar to that in the transabdominal robot-assisted surgery group (73.3 ± 18.2 mmHg) but significantly higher than in the TEM NOTES group (20.3 ± 24.0 mmHg; p < 0.01). During rectal anterior wall suturing, the burst pressure did not differ significantly between the transrectal robotic NOTES group (149.9 ± 81.1 mmHg) and the open group (195.0 ± 60.5 mmHg).

Conclusions

The preliminary safety and efficacy of transrectal robotic NOTES was established. Further studies are required to determine the practical feasibility of this procedure.     

Transvaginal cholecystectomy without laparoscopic support using prototype flexible endoscopic instruments in a porcine model

Background

Transvaginal cholecystectomy with laparoscopic assistance has been performed safely in humans. The next goal was to develop a natural orifice transluminal endoscopic surgery (NOTES) technique to perform cholecystectomy without laparoscopic instruments using one flexible endoscope and flexible accessories. The aim of the study was to test the feasibility of the procedure in a survival porcine model.

Methods

Cholecystectomies were attempted in five 88–130-lb. pigs with a planned 2-week survival. Prototype flexible instruments (NOTES Toolbox, Ethicon Endo-Surgery, Inc.) were used to aid in access, dissection, and removal of the gallbladder via the transvaginal route.

Results

Cholecystectomy could be completed without abdominal incision using prototype instruments in four out of five pigs. The cystic duct could be exposed with a flexible hook knife and clips applied. The steerable trocar improved stability and the precision of the dissection. The critical view was established in all five pigs. Dissection of the gallbladder off the liver bed was imprecise resulting in gallbladder perforation in all pigs and liver hemorrhage in two. At necropsy, all clips on the cystic duct were secure and no bile leak, bowel injury, or adhesions were present.

Conclusions

NOTES cholecystectomy without laparoscopic support is feasible but challenging using prototype flexible endoscopic devices. A prototype clip applier was effective in controlling the cystic duct. Further improvements in instrument design to ensure precision and safety are needed before flexible devices should be used for pure NOTES procedures in humans.