Surgical Endoscopy

, Volume 27, Issue 1, pp 339–346 | Cite as

Minilaparoscopy-assisted transrectal low anterior resection (LAR): a preliminary study

  • Antonio M. LacyEmail author
  • Cedric Adelsdorfer
  • Salvadora Delgado
  • Patricia Sylla
  • David W. Rattner



Natural orifice translumenal endoscopic surgery (NOTES) represents the evolution of surgery towards less invasive procedures. The feasibility of NOTES transrectal approach has increased its clinical applicability. This report describes a first series of minilaparoscopy-assisted transrectal low anterior resection with double purse-string end-to-end circular stapler anastomoses.


Between March and April 2012 three selected patients underwent transrectal minilaparoscopy-assisted natural orifice surgery total mesorectal excision for rectal cancer. All the oncologic principles of open/laparoscopic low anterior resection for rectal cancer were strictly fulfilled. Two patients underwent neoadjuvant treatment. Laparoscopic visualization and assistance was provided through one 10-mm umbilical port and two ports, one of which was used as stoma site (5 mm) and the other as a drain site (2 mm needle port). The specimen was transected transanally followed by the confection of double purse-string lateral/end-to-end anastomoses. There were no intraoperative complications.


Mean operative time was 143 min. Oral intake was initiated on the second postoperative day. Patients were discharged home by day 5. The pathology unit confirmed that distal and circumferential margins were free of tumor invasion, and quality of mesorectum resection was reported satisfactory. One patient had to be readmitted because of severe dehydration due to increased ileostomy output. The patient was discharged at the third day after the readmission without renal failure.


In this preliminary report, transrectal minilaparoscopy-assisted low anterior resection was feasible and safe. Lateral/end-to-end anastomoses can be considered an interesting alternative to the double-stapling technique. However, it is necessary to further study and develop these procedures, along with careful patient selection, before transrectal low anterior resection may be considered for routine clinical use.


NOTES MA-NOS Minimally invasive surgery Transrectal Rectal cancer 



Dr. Antonio M. Lacy is a consultant for Covidien and for Olympus Medical. Dr. Cedric Adelsdorfer and Dr. Salvadora Delgado have no conflicts of interest or financial ties to disclose. Dr. Patricia Sylla is a consultant for Genzyme and for educational activities for Applied Medical. Dr. David W. Rattner is a consultant for educational conferences for Olympus Medical.


  1. 1.
    Rattner D, Kalloo A (2006) ASGE/SAGES Working Group on natural orifice translumenal endoscopic surgery. October 2005. Surg Endosc 20:329–333PubMedCrossRefGoogle Scholar
  2. 2.
    Pearl JP, Marks JM, Ponsky JL (2008) Hybrid surgery: combined laparoscopy and natural orifice surgery. Gastrointest Endosc Clin North Am 18:325–332CrossRefGoogle Scholar
  3. 3.
    Lacy AM, Delgado S, Rojas OA, Almenara R, Blasi A, Llach J (2008) MA-NOS radical sigmoidectomy: report of a transvaginal resection in the human. Surg Endosc 22:1717–1723PubMedCrossRefGoogle Scholar
  4. 4.
    Horgan S, Cullen JP, Talamini MA, Mintz Y, Ferreres A, Jacobsen GR, Sandler B, Bosia J, Savides T, Easter DW, Savu MK, Ramamoorthy SL, Whitcomb E, Agarwal S, Lukacz E, Dominguez G, Ferraina P (2009) Natural orifice surgery: initial clinical experience. Surg Endosc 23:1512–1518PubMedCrossRefGoogle Scholar
  5. 5.
    Rao GV (2006) Transgastric appendectomy results and followup (SAGES transgastric surgery panel). Presented at SAGES meeting, Dallas, TX, USAGoogle Scholar
  6. 6.
    Whiteford MH, Denk PM, Swamstrom LL (2007) Feasibility of radical sigmoid colectomy performed as natural orifice translumenal endoscopic surgery (NOTES) using transanal endoscopic microsurgery. Surg Endosc 21:1870–1874PubMedCrossRefGoogle Scholar
  7. 7.
    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 12:1717–1723PubMedCrossRefGoogle Scholar
  8. 8.
    Sylla P, Rattner DW, Delgado S, Lacy AM (2010) NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance. Surg Endosc 24:1205–1210PubMedCrossRefGoogle Scholar
  9. 9.
    Lacy AM, Saavedra-Perez D, Bravo R, Adelsdorfer C, Aceituno M, Balust J (2012) Minilaparoscopy-assisted natural orifice total colectomy: technical report of a minilaparoscopy-assisted transrectal resection. Surg Endosc. doi: 10.1007/s00464-011-2117-z Google Scholar
  10. 10.
    Kalloo AN, Singh VK, Jagannath SB, Niiyama H, Hill SL, Vaughn CA, Magee CA, Kantsevoy S (2004) Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity. Gastrointest Endosc 60:114–117PubMedCrossRefGoogle Scholar
  11. 11.
    Lacy AM, García-Valdecasas JC, Delgado S, Castells A, Taurá P, Piqué J, Visa J (2002) Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomised trial. Lancet 359:2224–2229PubMedCrossRefGoogle Scholar
  12. 12.
    Lacy AM, Delgado S, Castells A, Prins HA, Arroyo V, Ibarzabal A, Piqué JM (2008) The long-term results of a randomised clinical trial of laparoscopy assisted versus open surgery for colon cancer. Ann Surg 248:1–7PubMedCrossRefGoogle Scholar
  13. 13.
    Clinical Outcomes of Surgical Therapy Study Group (2004) A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med 350:2050–2059CrossRefGoogle Scholar
  14. 14.
    Guillou PJ, Quirke P, Thorpe H, Walker J, Jayne DG, Smith AM, Heath RM, Brown JM, MRC CLASICC trial group (2005) Short-term endpoints of conventional versus laparoscopic assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre randomised controlled trial. Lancet 365:1718–1726PubMedCrossRefGoogle Scholar
  15. 15.
    Delgado S, Momblan D, Salvador L, Bravo R, Castells A, Ibarzabal A, Pique JM, Lacy AM (2004) Laparoscopic-assisted approach in rectal cancer patients: lessons learned from 200 patients. Surg Endosc 18:1457–1462PubMedCrossRefGoogle Scholar
  16. 16.
    Eberl T, Jagoditsch M, Klingler A, Tschmelitsch J (2008) Risk factors for anastomotic leakage after resection for rectal cancer. Am J Surg 196:592–598PubMedCrossRefGoogle Scholar
  17. 17.
    Peeters KC, Tollenaar RA, Marijnen CA, Klein Kranenbarg E, Steup WH, Wiggers T, Rutten HJ, van de Velde CJ, Dutch Colorectal Cancer Group (2005) Risk factors for anastomotic failure after total mesorectal excision of rectal cancer. Br J Surg 92:211–216PubMedCrossRefGoogle Scholar
  18. 18.
    Milsom JW, de Oliveira O, Jr Trencheva KI, Pandey S, Lee SW, Sonoda T (2009) Long-term outcomes of patients undergoing curative laparoscopic surgery for mid and low rectal cancer. Dis Colon Rectum 52:1215–1222PubMedCrossRefGoogle Scholar
  19. 19.
    Leroy J, Jamali F, Forbes L, Smith M, Rubino F, Mutter D, Marescaux J (2004) Laparoscopic total mesorectal excision (TME) for rectal cancer surgery: long-term outcomes. Surg Endosc 18:281–289PubMedCrossRefGoogle Scholar
  20. 20.
    Bell SW, Walker KG, Rickard MJ, Sinclair G, Dent OF, Chapuis PH, Bokey EL (2003) Anastomotic leakage after curative anterior resection results in a higher prevalence of local recurrence. Br J Surg 90:1261–1266PubMedCrossRefGoogle Scholar
  21. 21.
    Jung SH, Yu CS, Choi PW et al (2008) Risk factors and oncologic impact of anastomotic leakage after rectal cancer surgery. Dis Colon Rectum 51:902–908PubMedCrossRefGoogle Scholar
  22. 22.
    Bruce J, Krukowski ZH, Al-Khairy G, Russell EM, Park KG (2001) Systematic review of the definition and measurement of anastomotic leak after gastrointestinal surgery. Br J Surg 88:1157–1168PubMedCrossRefGoogle Scholar
  23. 23.
    Kim JS, Cho SY, Min BS, Kim NK (2009) Risk factors for anastomotic leakage after laparoscopic intracorporeal colorectal anastomosis with a double stapling technique. J Am Coll Surg 209:694–701PubMedCrossRefGoogle Scholar
  24. 24.
    Ito M, Sugito M, Kobayashi A, Nishizawa Y, Tsunoda Y, Saito N (2008) Relationship between multiple numbers of stapler firings during rectal division and anastomotic leakage after laparoscopic rectal resection. Int J Colorectal Dis 23:703–707PubMedCrossRefGoogle Scholar
  25. 25.
    Scheidbach H, Schneider C, Konradt J, Bärlehner E, Köhler L, Wittekind CH, Köckerling F (2002) Laparoscopic abdominoperineal resection and anterior resection with curative intent for carcinoma of the rectum. Surg Endosc 16:7–13PubMedCrossRefGoogle Scholar
  26. 26.
    Lujan J, Valero G, Hernández Q, Sánchez A, Frutos MD, Parrilla P (2009) Randomized clinical trial comparing laparoscopic and open surgery in patients with rectal cancer. Br J Surg 96:982–989PubMedCrossRefGoogle Scholar
  27. 27.
    Strohlein MA, Grutzner KU, Jauch KW, Heiss MM (2008) Comparison of laparoscopic vs. open access surgery in patients with rectal cancer: a prospective analysis. Dis Colon Rectum 51:385–391PubMedCrossRefGoogle Scholar
  28. 28.
    Lelong B, Bege T, Esterni B, Guiramand J, Turrini O, Moutardier V, Magnin V, Monges G, Pernoud N, Blache JL, Giovannini M, Delpero JR (2007) Short-term outcome after laparoscopic or open restorative mesorectal excision for rectal cancer: a comparative cohort study. Dis Colon Rectum 50:176–183PubMedCrossRefGoogle Scholar
  29. 29.
    Kuroyanagi H, Oya M, Ueno M, Fujimoto Y, Yamaguchi T, Muto T (2008) Standardized technique of laparoscopic intracorporeal rectal transection and anastomosis for low anterior resection. Surg Endosc 22:557–561PubMedCrossRefGoogle Scholar
  30. 30.
    Fukunaga Y, Higashino M, Tanimura S, Takemura M, Fujiwara Y, Osugi H (2008) New technique for rectal division in laparoscopic anterior resection—with video. World J Surg 32:2095–2100PubMedCrossRefGoogle Scholar
  31. 31.
    Akiyoshi T, Ueno M, Fukunaga Y, Nagayama S, Fujimoto Y, Konishi T, Kuroyanagi H, Yamaguchi T (2011) Incidence of and risk factors for anastomotic leakage after laparoscopic anterior resection with intracorporeal rectal transection and double-stapling technique anastomosis for rectal cancer. Am J Surg 202(3):259–264PubMedCrossRefGoogle Scholar
  32. 32.
    Matthiessen P, Hallbook O, Rutegård J, Simert G, Sjödhal R (2007) Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial. Ann Surg 246:207–214PubMedCrossRefGoogle Scholar
  33. 33.
    Shah J, Buckley D, Frisby J, Darzi A (2003) Depth cue reliance in surgeons and medical students. Surg Endosc 17:1472–1474PubMedCrossRefGoogle Scholar
  34. 34.
    Rogers B (2009) Motion parallax as an independent cue for depth perception: a retrospective. Perception 38:907–911PubMedCrossRefGoogle Scholar
  35. 35.
    Wang HS, Lin JK, Yang SH, Jiang JK, Chen WS, Lin TC (2003) Prospective study of the functional results of transanal endoscopic microsurgery. Hepatogastroenterology 50(53):1376–1380PubMedGoogle Scholar
  36. 36.
    Kennedy ML, Lubowski DZ, King DW (2002) Transanal endoscopic microsurgery excision: is anorectal function compromised? Dis Colon Rectum 45(5):601–604PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • Antonio M. Lacy
    • 1
    Email author
  • Cedric Adelsdorfer
    • 1
  • Salvadora Delgado
    • 1
  • Patricia Sylla
    • 2
  • David W. Rattner
    • 2
  1. 1.Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases (ICMDM)Hospital Clínic, IDIBAPS, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Centro Esther Koplowitz, University of BarcelonaBarcelonaSpain
  2. 2.Division of Gastrointestinal SurgeryMassachusetts General HospitalBostonUSA

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