Abstract
Background
The authors’ group has previously described successful transanal rectosigmoid resection via natural orifice translumenal endoscopic surgery (NOTES) in both porcine and cadaveric models using the transanal endoscopic microsurgery platform. This report describes the largest cadaveric series to date as optimization of this approach for clinical application continues.
Methods
Between December 2008 and September 2011, NOTES transanal rectosigmoid resection with total mesorectal excision (TME) was successfully performed in 32 fresh human cadavers using transanal dissection alone (n = 19), with transgastric endoscopic assistance (n = 5), or with laparoscopic assistance (n = 8). The variables recorded were gender, body mass index (BMI), operative time, length of the mobilized specimen, integrity of the mesorectum and the resected specimen, and complications. Univariate statistical analysis was performed.
Results
Of the 32 cadavers, 22 were male with a mean BMI of 24 kg/m2 (range 16.3–37 kg/m2). The mean operative time was 5.1 h (range 3–8 h), and the mean specimen length was 53 cm (range 15–91.5 cm). After the first five cadavers, specimen length significantly improved, and a trend toward decreased operative time was demonstrated. The mesorectum was intact in 100 % of the specimens. In nine cadavers, endoscopic dissection was complicated by organ injury. Evaluation by the operative approach demonstrated a significantly longer specimen with laparoscopic assistance (67.7 cm) than with transgastric assistance (45.4 cm) or transanal dissection alone (49.2 cm) (p = 0.013). Comparison of the technique used for inferior mesenteric pedicle division demonstrated both significantly decreased operative time (4.8 vs 6 h; p = 0.024) and increased specimen length (57.7 vs 39.6 cm; p = 0.025) when a stapler was used in lieu of a bipolar cautery device.
Conclusion
Transanal NOTES rectosigmoid resection with TME is feasible and demonstrates improvement in specimen length and operative time with experience. Transitioning to clinical application requires laparoscopic assistance to overcome limitations related to NOTES instrumentation, as well as procedural training with fresh human cadavers.
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References
Rattner D, Kaloo A (2006) The ASGE/SAGES working group on natural orifice translumenal endoscopic surgery. Surg Endosc 20:329–333
Rattner DW, Hawes R, Schwaitzberg S, Kochman M, Swanstrom L (2011) The second SAGES/ASGE white paper on natural orifice transluminal endoscopic surgery: 5 years of progress. Surg Endosc 25:2441–2448
Rao GV, Reddy DN, Banerjee R (2008) NOTES: human experience. Gastrointest Endosc Clin North Am 18:361–370
Zornig C, Mofid H, Emmermann S et al (2008) Scarless cholecystectomy with combined transvaginal and transumbilical approach in a series of 20 patients. Surg Endosc 22:1427–1429
Gee DW, Willingham FF, Lauwers GY, Brugge WR, Rattner DW (2008) Natural orifice transesophageal mediastinoscopy and thoracoscopy: a survival series in swine. Surg Endosc 22:2117–2122
Gee DW, Rattner DW (2011) Transmediastinal endoscopic intervention. J Gastrointest Surg 15:1303–1305
Sylla P, Sohn DK et al (2010) Survival study of natural orifice translumenal endoscopic surgery for rectosigmoid resection using transanal endoscopic microsurgery with or without transgastric endoscopic assistance in a swine model. Surg Endosc 24:2022–2030
Sylla P, Rattner DW, Delgado S, Lacy AM (2010) NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance. Surg Endosc 24:1205–1210
Sylla P, Willingham FF, Sohn DK, Gee D, Brugge WR, Rattner DW (2008) NOTES rectosigmoid resection using transanal endoscopic microsurgery (TEM) with transgastric endoscopic assistance: a pilot study in swine. J Gastrointest Surg 12:1717–1723
Denk PM, Swanström LL, Whiteford MH (2008) Transanal endoscopic microsurgical platform for natural orifice surgery. Gastrointest Endosc 68:954–959
Whiteford MH, Denk PM, Swanstrom LL (2007) Feasibility of radical sigmoid colectomy performed as natural orifice translumenal endoscopic surgery (NOTES) using transanal endoscopic microsurgery. Surg Endosc 21:1870–1874
Zorron R, Phillips HN, Coelho D, Flach L, Lemos F, Vassallo R (2011) Perirectal NOTES access: “down-to-up” total mesorectal excision for rectal cancer. Surg Innov 19:11–19
Tuech JJ, Bridoux B, Kianifard L, Schwartz B, Tsilividis E, Huet E, Michot F (2011) Natural orifice total mesorectal excision using transanal port and laparoscopic assistance. Eur J Surg Oncol 37:334–335
Rieder E, Whiteford MH (2011) Transrectal natural orifice translumenal endoscopic surgery (NOTES) for colorectal resection. Colorectal Dis 13:51–54
Acknowledgments
We acknowledge Katherine Briggs for her help and assistance with the experiments. This work was made possible through a grant from the Center for Integration of Medicine and Innovative Technology (CIMIT), DoD award W82XWH-07-02-0011.
Disclosures
Patricia Sylla has received an honorarium from Genzyme for consulting, and from Applied Medical for teaching. David W. Rattner is a consultant for Olympus. Dana A. Telem, Kyung Su Han, Min-Chan Kim, Ifode Ajari, Dae Kyung Sohn, Kevin Woods, Varun Kapur, Mohammad A. Sbeih, and Silvana Perretta have no conflicts of interest or financial ties to disclose.
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Podium presentation at the Scientific Session of the 15th World Congress of Endoscopic Surgery, 7–10 March, 2012, San Diego, CA, USA.
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Telem, D.A., Han, K.S., Kim, MC. et al. Transanal rectosigmoid resection via natural orifice translumenal endoscopic surgery (NOTES) with total mesorectal excision in a large human cadaver series. Surg Endosc 27, 74–80 (2013). https://doi.org/10.1007/s00464-012-2409-y
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DOI: https://doi.org/10.1007/s00464-012-2409-y