Natural orifice total mesorectal excision using transanal port and laparoscopic assistance

Advancing mid-rectal cancer surgery: Unveiling the potential of natural orifice specimen extraction surgery in comparison to conventional laparoscopic-assisted resection

BACKGROUND

Mid-rectal cancer treatment traditionally involves conventional laparoscopic-assisted resection (CLAR). This study aimed to assess the clinical and therapeutic advantages of Natural Orifice Specimen Extraction Surgery (NOSES) over CLAR.

AIMS

To compare the clinical outcomes, intraoperative metrics, postoperative recovery, complications, and long-term prognosis between NOSES and CLAR groups.

MATERIALS & METHODS

A total of 136 patients were analyzed, with 92 undergoing CLAR and 44 undergoing NOSES. Clinical outcomes were evaluated, and propensity score matching (PSM) was employed to control potential biases.

RESULTS

The NOSES group exhibited significant improvements in postoperative recovery, including lower pain scores on days 1, 3, and 5 (p < .001), reduced need for additional analgesics (p = .02), shorter hospital stays (10.8 ± 2.3 vs. 14.2 ± 5.3 days; p < .001), and decreased intraoperative blood loss (48.1 ± 52.7 mL vs. 71.0 ± 55.0 mL; p = .03). Patients undergoing NOSES also reported enhanced satisfaction with postoperative abdominal appearance and better quality of life. Additionally, the NOSES approach resulted in fewer postoperative complications.

CONCLUSION

While long-term outcomes (overall survival, disease-free survival, and local recurrence rates) were comparable between the two methods, NOSES demonstrated superior postoperative outcomes compared to CLAR in mid-rectal cancer treatment, while maintaining similar long-term oncological safety. These findings suggest that NOSES could serve as an effective alternative to CLAR without compromising long-term results.

Precision functional sphincter-preserving surgery (PPS) for ultralow rectal cancer: a natural orifice specimen extraction (NOSE) surgery technique

BACKGROUND

In patients with ultralow rectal cancer, surgical resection of the tumor without impairing sphincter function remains a technical challenge. The purpose of this study was to describe a new technique of transanal natural orifice specimen extraction (NOSE) surgery using our independently developed devices, aiming to achieve precise cancer resection and preserve sphincter function in patients with ultralow rectal cancer.

METHODS

Precision functional sphincter-preserving surgery (PPS) was performed on nineteen patients with ultralow rectal cancer between June 2019 and April 2020. With the help of our independently developed devices, surgeons directly and accurately removed the lower edge of the tumor and retained healthy rectal tissue on the nontumorous side. Hand-sewn anastomosis with a mattress suture was used to achieve sturdy anastomosis. Preoperative baseline characteristics, operative details, 90-day postoperative complications, costs, and anal function score at 6 months after surgery were documented.

RESULTS

Nineteen ultralow rectal cancer patients with a median distance to the dentate line of 2.0 cm successfully underwent PPS without serious postoperative complications. Six out of nineteen patients (31.6%) received a prophylactic stoma. The average cost was 62164.1 yuan. At 6 months after surgery, the average Wexner anal function score and the average Vaizey score were both 3 points.

CONCLUSIONS

PPS can be employed to precisely resect rectal tumors and preserve sphincter function in ultralow rectal cancer patients. The use of our devices enhanced surgical efficiency, reduced the need for prophylactic stoma, reduced surgery-related costs, and prevented abdominal surgical incisions.

Neoadjuvant concurrent chemoradiotherapy followed by transanal total mesorectal excision assisted by single-port laparoscopic surgery for low-lying rectal adenocarcinoma: a single center study

Purpose

To assess the feasibility and short-term outcomes of neoadjuvant chemoradiotherapy (CCRT) followed by transanal total mesorectal excision assisted by single-port laparoscopic surgery (TaTME-SPLS) for low-lying rectal adenocarcinoma.

Methods and materials

A total of 23 patients with clinical stage II-III low-lying (from anal verge 0-8 cm) rectal adenocarcinoma who underwent neoadjuvant CCRT followed by TaTME-SPLS consecutively from December 2015 to December 2018, were enrolled into our study. Chi-squared testing and Student’s t testing were used to make parametric comparisons, and Fisher’s exact test or the Mann–Whitney U test were used to make nonparametric comparisons.

Results

Conversion rate in patients who underwent neoadjuvant CCRT followed by TaTME-SPLS was only 4%. The mean operation time was 366 min and the inter-sphincter resection (ISR) was done for 14 patients (60%). The mean number of lymph nodes harvested was 15. There was no surgical mortality, but the 30-day morbidity rate was 21% (5 patients were Clavien-Dindo I-II). Pathological complete response was 21.74% with 100% organ preservation and 100% clear distal margin after neoadjuvant CCRT followed by TaTME-SPLS.

Conclusion

TaTME-SPLS would be highly successful in lymph node negative and low T stage of low-lying rectal cancer patients who had pathological complete remission or high percentage of partial remission after neoadjuvant CCRT.

Glove single-port laparoscopy-assisted transanal total mesorectal excision for low rectal cancer: a preliminary report

PURPOSE

Glove single-port laparoscopy-assisted transanal total mesorectal excision (TaTME) has been successfully carried out in our medical center. The purpose of this study is to evaluate the feasibility of this emerging operation.

METHODS

This technique was performed by self-made glove single-port laparoscopic platform to radically resect low rectal cancer. Short-term postoperative results, including complications, length of hospital stay, and follow-up results were collected and analyzed statistically.

RESULTS

There are five consecutive patients (three males, two females) who underwent this surgery and included in this study. The mean distance from the tumor to the anal verge was 4.8 cm (range 4.0-6.0). The surgery was completed in all cases, and the rectal tumor was removed successfully without conversion; circumferential margins of all the excised specimens were negative. The mean time of operation was 338.00 min (range 280-400). The average number of lymph node dissection was 12.20. The average postoperative hospital stay was 8.60 days. During the follow-up (14.80 ± 1.92 months), all preventive ileostomies were successfully closed in about 3 months after the surgery, all patients had satisfactory anal function, and no tumor recurrence was found.

CONCLUSION

Glove single-port laparoscopy-assisted TaTME has a significant effect in specific patients with low rectal cancer, with rapid recovery and high safety. Prospective randomized studies involving more case counts and long-term follow-up results, especially oncologic outcomes, are needed to validate this technique.

Transanal total mesorectal excision for locally advanced middle-low rectal cancers

Background

This study investigated the results of transanal total mesorectal excision (TaTME) combined with laparoscopy for locally advanced mid–low rectal cancer.

Methods

Patients with mid–low locally advanced rectal cancer (T3 category or above and/or N+) who underwent rectal resection with TaTME technique were enrolled prospectively. Patients who had distant metastasis, multiple malignancies, intestinal obstruction or perforation, or a clinical complete response to chemoradiotherapy were excluded. Postoperative results, including morbidity, circumferential resection margin (CRM) assessment, short‐term survival and functional outcomes, were analysed.

Results

Thirty‐eight patients, with 25 mid and 13 low rectal tumours, who had elective resection by TaTME from March 2015 to September 2018 were included. There were 25 men and 13 women. Mean(s.d.) age was 58·2(16·4) years and mean(s.d.) BMI was 24·2(2·5) kg/m². Tumours were 3–9 cm from the anal verge. Mean(s.d.) duration of surgery was 210(42) min. All patients had hand‐sewn anastomoses and protective ileostomies. There were no conversions, abdominal perineal resections or postoperative deaths. Four patients had a complication, including three presacral abscesses, all managed by transanastomotic drainage. At 3 months after ileostomy closure, all patients had perfect continence. Apart from a greater tumour diameter in patients with low rectal cancers (6·0 cm versus 4·6 cm in those with mid rectal tumours; P = 0·035), clinical features were similar in the two groups. CRM positivity was greater for low than for mid rectal tumours (3 of 13 versus 0 of 25 respectively; P = 0·034), and more patients with a low tumour had TME grade 2 (4 of 13 versus 1 of 25; P = 0·038). There was no difference in oncological outcomes at 17 months.

Conclusion

Although this study cohort was small, special attention should be paid to bulky low rectal tumours to reduce the rate of CRM positivity.

Systematic review analysis of robotic and transanal approaches in TME surgery- A systematic review of the current literature in regard to challenges in rectal cancer surgery

Several patients' and pathological characteristics in rectal surgery can significantly complicate surgical loco regional tumor clearance. The main factors are obesity, short tumor distance from anal verge, bulky tumors, and narrow pelvis, which have been shown to be associated to poor surgical results in open and laparoscopic approaches. Minimally invasive surgery has the potential to reduce perioperative morbidity with equivalent short- and long-term oncological outcomes compared to conventional open approach. Achilles' heel of laparoscopic approaches is conversion to open surgery. High risk for conversion is evident for patients with bulky and low tumors as well as male gender and narrow pelvis. Hence, patient's characteristics represent challenges in rectal cancer surgery especially in minimally invasive approaches. The available surgical techniques increased remarkably with recently developed and implemented improvements of minimally invasive rectal cancer surgery. The controversial discussions about sense and purpose of these novel approaches are still ongoing in the literature. Herein, we evaluate, if latest technical advances like transanal approach or robotic assisted surgery have the potential to overcome known challenges and pitfalls in rectal cancer surgery in demanding surgical cases and highlight the role of current minimally invasive approaches in rectal cancer surgery.

Pure natural orifice transluminal endoscopic surgery for rectal cancer: Ta-TME and CME without abdominal assistance

AIM

To report our institution's experiences with pure transanal total mesorectal excision (TME) of rectal cancer using single-port equipment and to discuss the feasibility and safety of the technique.

METHODS

Between February and December 2017, 12 patients who were selected underwent NOTES TME in our institution. The preoperative assessment included blood analyses with carcinoembryonic antigen serum concentration, full colonoscopy, pelvic magnetic resonance imaging (MRI), and computed tomography (CT) of the abdomen and chest.

RESULTS

Ten patients (male:female, 6:4) treated with transanal TME with colorectal anastomosis in our institution were reviewed. Pure TME was performed without laparoscopic assistance in 6 of 10 patients. The mean operative time was 303.5 min. The median distal margin was 2.1 (0.2-4.2) cm. The median number of harvested lymph nodes is 17.5. Except one patient with anastomotic leak, most patients started dietary intake on postoperative day (POD) 3 and were discharged on POD 7. Anastomotic leak was the only postoperative complication.

CONCLUSION

This study showed that pure natural orifice transluminal endoscopic surgery (NOTES) TME with coloanal anastomosis for rectal cancer is safe and feasible in selected cases.

Natural orifice transluminal endoscopic surgery for colorectal cancer

Background

Natural orifice transluminal endoscopic surgery (NOTES) has theoretical advantages over other approaches.

Methods

This was a prospective cohort study of colorectal cancers operated on by NOTES (transanally for rectal tumours, transvaginally for sigmoid tumours) between December 2013 and December 2015, with a minimum follow‐up of 1 year. Eligibility criteria included ASA fitness grade I–III, BMI below 25 kg/m² and TNM stage T3 N0 M0. Exclusion criteria included pregnancy or distant metastasis. The anastomosis was either handsewn or performed mechanically.

Results

Sixteen patients were operated on by a transanal and four by a transvaginal approach. There were ten men and ten women, with a mean(s.d.) age of 55·6(12·1) years. Mean BMI was 22·4(2·6) kg/m². Four anterior, 11 low anterior and five intersphincteric resections were performed for 16 rectal and four low sigmoid tumours. The mean duration of surgery was 258(11) min. No conversion to laparotomy was needed, and there were no deaths. Five patients required additional ports, for intraoperative bleeding (1), suture of an intraoperative urethral injury with covering ileostomy (1) and difficulty in dissection (3). One patient had an anastomotic leak requiring transanal closure and ileostomy on day 7. Both ileostomies were closed after 2 months. The mean hospital stay was 6·4(1·8) days. All resections were R0.

Conclusion

In carefully selected patients NOTES for colorectal cancer resection was feasible and effective.

Study protocol for a multicenter prospective controlled and randomized trial of transanal total mesorectal excision versus laparoscopic low anterior resection in rectal cancer

PURPOSE

Compared with the open approach, laparoscopic total mesorectal excision (TME) achieves faster patient recovery, reduces morbidity rates, and shortens hospital stay. However, in laparoscopic low anterior resection (L-LAR), conversion to open surgery is required in almost 20% of cases. Transanal TME (Ta-TME) combined with laparoscopy, also called hybrid natural orifice transluminal endoscopic surgery (NOTES), is a less invasive procedure that can overcome some of the limitations of laparoscopic rectal surgery. In this study, we aim to determine whether Ta-TME has a lower rate of conversion to open surgery than L-LAR, and thus achieves faster patient recovery without altering the pathological, functional, or oncological results. The main objective is to compare the results for conversion to open surgery between Ta-TME and L-LAR.

METHODS

Multicenter, prospective randomized controlled study of patients diagnosed with rectal adenocarcinoma who will be randomly allocated to Ta-TME or L-LAR groups after the application of inclusion and exclusion criteria. The main endpoint is conversion to open surgery and the secondary endpoints are general morbidity and mortality and hospital stay. Demographic, surgical, and pathological variables will also be studied, along with quality of life and survival. A sample size of 53 patients per group is calculated. With an estimated loss of 10%, the final sample required will be 116 patients.

CONCLUSIONS

Ta-TME achieves a lower conversion rate to open surgery than L-LAR, thus improving patient recovery and reducing overall morbidity.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02550769. Registration no. Ethical and Clinical Research Committee, Parc Taulí University Hospital: ID 2014/064.

Minimally Invasive Surgery for Rectal Cancer: Current Status and Future Perspectives

Although laparoscopic resection for colon cancer has been proven safe and feasible when compared with open resection, currently no clear evidence is available regarding minimally invasive surgery for rectal cancer. This type of surgery may benefit patients by allowing fast recovery of normal dietary intake and bowel function, reduced postoperative pain, and shorter hospitalization. Therefore, minimally invasive surgeries such as laparoscopic or robot surgery have become the predominant treatment option for colon cancer. Specifically, the proportion of laparoscopic colorectal cancer surgery in Korea increased from 42.6 to 64.7% until 2013. However, laparoscopic surgery for rectal cancer is more difficult and technically demanding. In addition, the procedure requires a prolonged learning curve to achieve equivalent outcomes relative to open surgery. It is very challenging to approach the deep and narrow pelvis using laparoscopic instruments. However, robotic surgery provides better vision with a high definition three-dimensional view, exceptional ergonomics, Endowrist technology, enhanced dexterity of movement, and a lack of physiologic tremor, facilitated by the use of an assistant in the narrow and deep pelvis. Recently, an increasing number of reports have compared the outcomes of laparoscopic and open surgery for colon cancer. Such reports have prompted a discussion of the outcomes of minimally invasive surgery, including robotic surgery, for rectal cancer. The aim of this review is to summarize current data regarding the clinical outcomes, including oncologic outcomes, of minimally invasive surgery for rectal cancer.

A multicentre randomised controlled trial to evaluate the efficacy, morbidity and functional outcome of endoscopic transanal proctectomy versus laparoscopic proctectomy for low-lying rectal cancer (ETAP-GRECCAR 11 TRIAL): rationale and design

BACKGROUND

Total mesorectal excision is the standard surgical treatment for mid- and low-rectal cancer. Laparoscopy represents a clear leap forward in the management of rectal cancer patients, offering significant improvements in post-operative measures such as pain, first bowel movement, and hospital length of stay. However, there are still some limits to its applications, especially in difficult cases. Such cases may entail either conversion to an open procedure or positive resection margins. Transanal endoscopic proctectomy (ETAP) was recently described and could address the difficulties of approaching the lower third of the rectum. Early series and case-control studies have shown favourable short-term results, such as a low conversion rate, reduced hospital length of stay and oncological outcomes comparable to laparoscopic surgery. The aim of the proposed study is to compare the rate of positive resection margins (R1 resection) with ETAP versus laparoscopic proctectomy (LAP), with patients randomly assigned to each arm.

METHODS/DESIGN

The proposed study is a multicentre randomised trial using two parallel groups to compare ETAP and LAP. Patients with T3 lower-third rectal adenocarcinomas for whom conservative surgery with manual coloanal anastomosis is planned will be recruited. Randomisation will be performed immediately prior to surgery after ensuring that the patient meets the inclusion criteria and completing the baseline functional and quality of life tests. The study is designed as a non-inferiority trial with a main criterion of R0/R1 resection. Secondary endpoints will include the conversion rate, the minimal invasiveness of the abdominal approach, postoperative morbidity, the length of hospital stay, mesorectal macroscopic assessment, functional urologic and sexual results, faecal continence, global quality of life, stoma-free survival, and disease-free survival at 3 years. The inclusion period will be 3 years, and every patient will be followed for 3 years. The number of patients needed is 226.

DISCUSSION

There is a strong need for optimal evaluation of the ETAP because of substancial changes in the operative technique. Assessment of oncological safety and septic risk, as well as digestive and urological functional results, is particularily mandatory. Moreover, benefits of the ETAP technique could be demonstrated  in post-operative outcome.

TRIAL REGISTRATION

ClinicalTrial.gov: NCT02584985 . Date and version identifier: Version n°2 - 2015 July 6.

Transanal Total Mesorectal Excision: A Novel Approach to Rectal Surgery

Less invasive approaches continue to be explored and refined for diseases of the colon and rectum. The current gold standard for the surgical treatment of rectal cancer, total mesorectal excision (TME), is a technically precise yet demanding procedure with outcomes measured by both oncologic and functional outcomes (including bowel, urinary, and sexual). To date, the minimally invasive approach to rectal cancer has not yet been perfected, leaving ample opportunity for rectal surgeons to innovate. Transanal TME has recently emerged as a safe and effective technique for both benign and malignant diseases of the rectum. While widespread acceptance of this surgical approach remains tempered at this time due to lack of long-term oncologic outcome data, short-term outcomes are promising and there is great excitement surrounding the promise of this technique.

Transanal Total Mesorectal Excision With Single-Incision Laparoscopy for Rectal Cancer

Background and Objectives:

There has been great enthusiasm for the technique of transanal total mesorectal excision. Coupled with this procedure, we performed single-incision laparoscopic surgery for left colon mobilization. This is a description of our initial experience with the combined approach.

Methods:

Patients with distal or mid rectal cancer were included. The operation was performed by 2 teams: one team performed the single-incision mobilization of the left colon via the right lower quadrant ileostomy site, and the other team performed the total mesorectal excision with a transanal platform.

Results:

During the study period, 10 patients (5 men) with cancer of the rectum underwent the surgery. The mean age was 62.2 ± 11.1 years, and the mean body mass index was 23.4 ± 3.2 kg/m². The tumor's mean distance from the anal verge was 5.1 ± 2.5 cm. The median operating time was 247.5 minutes (range, 188–462 minutes). The mean estimated blood loss was 124 ± 126 mL (range, 10–188 mL). Conversion to multiport laparoscopy was needed in one case (10%). Postoperative pain, as reflected by the pain score, was minimal. The mean number of lymph nodes harvested was 15.6 ± 3.8. All specimens had clear distal and circumferential radial margins. The overall complication rate was 10%.

Conclusion:

Our experience showed transanal total mesorectal excision with single-incision laparoscopy to be a feasible option for rectal cancer. Patients reported minimal postoperative pain. Further studies on the long-term outcome are warranted.

Combined robotic transanal total mesorectal excision (R-taTME) and single-site plus one-port (R-SSPO) technique for ultra-low rectal surgery-initial experience with a new operation approach

OBJECTIVE

Robot-assisted rectal surgery is gaining popularity, and robotic single-site surgery is also being explored clinically. We report our initial experience with robotic transanal total mesorectal excision (R-taTME) and radical proctectomy using the robotic single-site plus one-port (R-SSPO) technique for low rectal surgery.

METHODS

Between July 2015 and March 2016, 15 consecutive patients with ultra-low rectal lesions underwent R-taTME followed by radical proctectomy using the R-SSPO technique by a single surgeon. The clinical and pathological results were retrospectively analyzed.

RESULTS

The median operative time was 473 (range, 335-569) min, and the estimated blood loss was 33 (range, 30-50) mL. The median number of lymph nodes harvested was 12 (range, 8-18). The median distal resection margin was 1.4 (range, 0.4-3.5) cm, and all patients had clear circumferential resection margins. We encountered a left ureteric transection intraoperatively in one patient, and another patient required reoperation for postoperative adhesive intestinal obstruction. There was no 30-day mortality.

CONCLUSION

R-taTME followed by radical proctectomy using the R-SSPO technique for patients with low rectal lesions is technically feasible and safe without compromising oncologic outcomes. However, there were considerable limitations and a steep learning curve using current robotic technology.

Pure Natural Orifice Transluminal Endoscopic Surgery (NOTES) with a new elongated, curved Transanal Endoscopic Operation (TEO) device for rectosigmoid resection: a survival study in a porcine model

BACKGROUND

Natural orifice transluminal endoscopic surgery (NOTES) has seen considerable new developments in its evolution to a platform for rectal and sigmoid resection, but to date no true single NOTES procedure has been convincing. This study investigates the safety and feasibility of a further developed transanal NOTES platform for single-access NOTES rectosigmoid resection.

METHODS

Ten large female pigs, mean weight 99.3 kg [standard deviation (SD) 7 kg, range 85.1-112.6 kg], underwent transanal rectosigmoid resection. Five animals were included in an acute study group with immediate postoperative euthanization. A second group included five animals in a survival study. Transanal rectosigmoid resections were performed with an elongated and curved transanal endoscopic operation (TEO) device. Coloanal anastomosis was performed using the transanal circular stapler technique. Survival follow-up was at 7 and 28 days via colonoscopy under sedation.

RESULTS

Single-access NOTES transanal rectosigmoid resection with coloanal anastomosis was performed in nine out of ten female pigs. Mean length of rectosigmoid specimens exteriorized was 18.7 cm (SD 2.9 cm, range 14-23 cm). Mean operating time was 124 min (SD 35.7 min, range 70-166 min). Within the survival group, no complications occurred during the monitoring phase. In one case, there was ascites and colitis at necropsy as well as fibrosis at the anastomosis site.

CONCLUSIONS

Pure transanal rectosigmoid resection is a feasible procedure. The approach via a single transanal access is demanding but viable with the elongated and curved TEO device. The newly developed scope offers an excellent view of the area cephalad to the promontory.

Transanal Minimally Invasive Surgery: State of the Art

The treatment for rectal cancer and benign rectal lesions continues to progress in the arena of minimally invasive surgery. While surgical excision of the primary mass remains essential for eradication of disease, there has been a paradigm shift towards less invasive resection methods. Local excision is increasing in popularity for its low morbidity and excellent functional results in select patients. Transanal minimally invasive surgery (TAMIS) is a new technology developed to elevate the practice of local excision to state-of-the-art resection. The goal of this article is to evaluate the history, short-term outcomes, and evolution of the TAMIS technique for excision of benign and malignant rectal neoplasia.

A systematic review of transanal total mesorectal excision: is this the future of rectal cancer surgery?

AIM

The surgical technique used for transanal total mesorectal excision (TaTME) was reviewed including the oncological quality of resection and the peri-operative outcome.

METHOD

A literature search of MEDLINE, Embase, Science Citation Index Expanded and Cochrane was performed in order to identify studies reporting on TaTME.

RESULTS

Thirty-six studies (eight case reports, 24 case series and four comparative studies) were identified, reporting 510 patients who underwent TaTME. The mean age ranged from 43 to 80 years and the mean body mass index from 21.7 to 31.8 kg/m(2) . The mean distance of the tumour from the anal verge ranged from 4 to 9.7 cm. The mean operation time ranged from 143 to 450 min and mean operative blood loss from 22 to 225 ml. The ratio of hand-sewn coloanal to stapled anastomoses performed was 2:1. One death was reported and the peri-operative morbidity rate was 35%. The anastomotic leakage rate was 6.1% and the reoperation rate was 3.7%. The mean hospital stay ranged from 4.3 to 16.6 days. The mesorectal excision was described as complete in 88% cases, nearly complete in 6% and incomplete in 6%. The circumferential resection margin was negative in 95% of cases and the distal resection margin was negative in 99.7%.

CONCLUSION

TaTME is a feasible and reproducible technique, with good quality of oncological resection. Standardization of the technique is required with formal training. Clear indications for this procedure need to be defined and its safety further assessed in future trials.

Transanal total mesorectal excision: A valid option for rectal cancer?

Low anterior resection can be a challenging operation, especially in obese male patients and in particular after radiotherapy. Transanal total mesorectal excision (TaTME) might offer technical advantages over laparoscopic or open approaches particularly for tumors in the distal third of the rectum. The aim of this article is to review the current experience with TaTME. The limits and future developments are also explored. Although the experience with TaTME is still limited, it might be a promising alternative to laparoscopic TME, especially for difficult cases where laparoscopy is too demanding. The preliminary data on complications and short-term oncological outcomes are good, but also emphasize the importance of careful patient selection. Finally, there is a need for large-scale trials focusing on long-term outcomes and oncological safety before widespread adoption can be recommended.

Shifting Paradigms in Minimally Invasive Surgery: Applications of Transanal Natural Orifice Transluminal Endoscopic Surgery in Colorectal Surgery

Since the advent of laparoscopy, minimally invasive techniques such as single port laparoscopy, robotics, endoscopically assisted laparoscopy, and transanal endoscopic surgery continue to revolutionize the field of colorectal surgery. Transanal natural orifice transluminal endoscopic surgery (NOTES) represents a further paradigm shift by combining the advantages of these earlier techniques to reduce the size and number of abdominal incisions and potentially optimize rectal dissection, especially with respect to performance of an oncologically adequate total mesorectal excision (TME) for rectal cancer. Since the first experimental report of transanal rectosigmoid resection in 2007, the potential impact of transanal NOTES in colorectal surgery has been extensively investigated in experimental models and recently transitioned to clinical application. There have been 14 clinical trials of transanal TME (taTME) for rectal cancer that have demonstrated the feasibility and preliminary oncologic safety of this approach in carefully selected patients, with results comparable to outcomes after laparoscopic and open TME, including cumulative intraoperative and postoperative complication rates of 5.5 and 35.5%, respectively, 97.3% rate of complete or near-complete specimens, and 93.6% rate of negative margins. Transanal NOTES has also been safely applied to proctectomy and colectomy for benign indications. The consensus among published series suggests that taTME is most safely performed with transabdominal assistance by surgeons experienced with laparoscopic TME, transanal endoscopic surgery, and sphincter-preserving techniques including intersphincteric resection. Future applications of transanal NOTES may include evolution to a pure endoscopic transanal approach for TME, colectomy, and sentinel lymph node biopsy for rectal cancer, with a potential role for robotic assistance.

Transanal total mesorectal excision assisted by single-port laparoscopic surgery for low rectal cancer

INTRODUCTION

We have combined the minimally invasive single-port laparoscopic surgery and the transanal total mesorectal excision (TaTME) for rectal cancer with the goal to standardize the approach and improve the quality of rectal cancer resection.

METHODS

By using two single-port platforms, selected patients were first operated by TaTME, and then a single-port laparoscopic surgery was introduced to assist and complete the abdominal portion. Short-term outcomes including perioperative outcome and pathologic results of these patients were evaluated.

RESULTS

Between July 2014 and March 2015, six patients with low rectal cancer (five males and one female) at a median age of 68 years were successfully operated in a median time of 360 min (range 310-420). The median estimated blood loss was 150 ml (range 50-800). In one patient, the spleen was removed because of a lesion identified preoperatively. Their postoperative recovery was uneventful except one acute myocardial infarction on postoperative day 3. Pathologic specimens showed negative margins and a complete excision of the mesorectum in all cases. The median number of harvested lymph nodes was 11.5 (range 4-12). At a median follow-up of 4 months (range 3-9), after ileostomy closure, none of the patients suffered from fecal incontinence.

CONCLUSION

TaTME assisted by abdominal single-port may be safely achieved in selected rectal cancer patients.

Transanal total mesorectal excision: a pure NOTES approach for selected patients

BACKGROUND

The concept of natural orifice transluminal endoscopic surgery (NOTES) has stimulated the development of various "incisionless" procedures. One of the most popular is the transanal approach for rectal lesions. The aims of this study were to report how we standardized NOTES technique for transanal mesorectal excision without abdominal assistance, discuss the difficulties and surgical outcomes of this technique and report its feasibility in a small group of selected patients.

METHODS

Three consecutive female patients underwent transanal NOTES rectal resection without transabdominal laparoscopic assistance for rectal lesions. Functional results were assessed with the Fecal Incontinence Quality of Life scale and the Wexner score.

RESULTS

The technical steps are described in details and complemented with a video. All procedures were completed without transabdominal laparoscopic help. The mesorectal plane was entirely dissected without any disruption, and distal and circumferential margins were tumor-free. No major complications were observed. Functional results show a significant impairment after surgery with improvement at 6 months to levels near those of the preoperative period.

CONCLUSIONS

The performance and publication of NOTES procedures are subject to much discussion. Despite the small number of patients, this procedure appears feasible and can be accomplished maintaining fecal continence and respecting oncologic principles.

Laparoscopic anterior resection with transanal total mesorectal excision for rectal cancer: preliminary experience and impact on postoperative bowel function

AIM

Transanal total mesorectal excision (TME) and the "down-to-up" mobilization concept might be possible alternatives to the standard TME, particularly in cases of narrow pelvis or bulky tumors in obese patients. Our aim was to test the feasibility and safety of transanal TME and to evaluate its impact on short-term functional outcome.

SUBJECTS AND METHODS

Six consecutive patients with histologically proven low/middle rectal adenocarcinoma were prospectively enrolled. All patients underwent laparoscopic anterior resection with transanal TME. Intraoperative complications, postoperative morbidity, and oncologic adequacy of the surgical specimen were evaluated in all patients. A bowel function questionnaire using information from the Wexner's score continence grading scale was administered to all patients 1 week before surgery and 6 months following operation.

RESULTS

Laparoscopically assisted transanal TME was successful in all patients. Mean operative time was 236 minutes (range, 200-270 minutes). There were no intraoperative complications. The anastomotic leak rate was 16.6%. Clear distal and circumferential margins and proper lymphadenectomy were obtained in all surgical specimens (mean number of nodes harvested, 32; range, 19-68). In no patients was a major incontinence observed; the median (range) Wexner score at 6 months after surgery was 3 (1-7).

CONCLUSIONS

Transanal TME is safe and feasible. Preliminary outcomes meet oncologic criteria. Moreover, the transanal approach does not have an adverse impact on functional outcome. Further long-term evaluation of results and clinical trials should be performed.

Transanal Total Mesorectal Excision for Rectal Cancer: Outcomes after 140 Patients

BACKGROUND

The anatomic difficulties that we have to deal with in open surgery for rectal cancer have not been overcome with the laparoscopic approach. In the search for a solution, a change of concept arose: approaching the rectum from below. The main objectives of this study were to show the potential advantages of the hybrid transabdominal-transanal total mesorectal excision (taTME). This approach may improve quality of the mesorectal specimens. Second, proctectomy can be technically easier and more safely performed "down to up," which would result in shorter surgical times, lower conversion rates, and less morbidity.

STUDY DESIGN

A prospective series of hybrid taTME was conducted from October 2011 to November 2014.

RESULTS

During the study period, 140 procedures were performed. Mean operative time was 166 minutes. There were no conversions or intraoperative complications. Macroscopic quality assessment of the resected specimen was complete in 97.1% and nearly complete in 2.1%. Thirty-day morbidity was minor (Clavien-Dindo I + II) in 24.2% and major (Clavien-Dindo III + IV) in 10 %. No patient died within the first 30 days postsurgery (Clavien-Dindo V). The mean follow-up was 15 months, with a 2.3% local recurrence rate and a 7.6% rate of systemic recurrence.

CONCLUSIONS

Pathologic analysis showed a very good macroscopic quality of TME specimens, which is the most important prognostic factor in rectal cancer. Intraoperative outcomes regarding conversion, surgical times, and intraoperative complications are very satisfactory. Short-term morbidity and oncologic outcomes are as good as in other laparoscopic TME series.

New approaches in laparoscopic surgery for colorectal diseases: The totally laparoscopic and single-incision approaches

More than 20 years have passed since the first report of laparoscopic colectomy in 1991. Thereafter, laparoscopic surgery for the management of colorectal diseases has been widely accepted as a prevailing option because of improved cosmetic outcomes, less postoperative pain, and shorter hospital stay in comparison with open surgery. To further the principle of minimally invasive surgery, two new approaches have been developed in this rapidly evolving field. The first is the totally laparoscopic approach. Currently most of standard techniques inevitably involve an abdominal incision for retrieval of the specimen and preparation for anastomosis, which might compromise the benefits of laparoscopic surgery. The totally laparoscopic approach dispenses with this incision by combining completely intraperitoneal anastomosis with retrieval of the specimen via a natural orifice, such as the anus or the vagina. Our new and reliable technique for intraperitoneal anastomosis is also described in detail in this article. The second is the single-incision approach. While three to six ports are needed in standard laparoscopic surgery, the single-incision approach uses the umbilicus as the sole access to the abdominal cavity. All of the laparoscopic procedures are performed entirely through the umbilicus, in which the surgical scar eventually becomes hidden, achieving virtually scarless surgery. This article reviews the current status of these two approaches and discusses the future of minimally invasive surgery for colorectal diseases.

Hybrid NOTES: TEO for transanal total mesorectal excision: intracorporeal resection and anastomosis

BACKGROUND

Laparoscopic surgery for rectal TME achieves better patient recovery, lower morbidity, and shorter hospital stay than open surgery. However, in laparoscopic rectal surgery, the overall conversion rate is nearly 20%. Transanal TME combined with laparoscopy, known as Hybrid NOTES, is a less invasive procedure that provides adequate solutions to some of the limitations of rectal laparoscopy. Transanal TME via TEO with technical variants (intracorporeal resection and anastomosis, TEO review of the anastomosis) attempts to standardize and simplify the procedure.

METHOD

Prospective observational study was used describe and assess the technique in terms of conversion to open surgery, overall morbidity, surgical site infection and hospital stay. The sample comprised consecutive patients diagnosed with rectal tumor less than 10 cm from the anal verge who were candidates for low anterior resection using TME (except T4). Demographic, surgical, postoperative, and pathological variables were analyzed, as well as morbidity rates.

RESULTS

From September 2012 to August 2014, 32 patients were included. The conversion rate was 0%. Overall morbidity was 31.3%, SSI rate was 9.4%, and mean hospital stay was 8 days. Oncological radical criteria were achieved with pathological parameters of 94% of complete TME and a median circumferential margin of 13 mm.

CONCLUSION

The introduction of technical variants of TEO for transanal resection can facilitate a procedure that requires extensive experience in transanal and laparoscopic surgery. Studies of sphincter function, quality of life, and long-term oncological outcome are now necessary.

A step toward NOTES total mesorectal excision for rectal cancer: endoscopic transanal proctectomy

BACKGROUND

Previous publications have suggested that endoscopic transanal proctectomy (ETAP) is a promising technique and may be an alternative to conventional low anterior resection for rectal cancer. The aim of this study was to evaluate the technical feasibility of ETAP, with a particular focus on postoperative and oncological results and on functional outcomes.

METHODS

This study was a multicenter prospective study of unselected consecutive patients with low rectal cancer requiring proctectomy and coloanal anastomosis. All patients underwent a standardized procedure. The study endpoints were the safety and adequacy of the oncological resection criteria. All patients were evaluated with the Wexner Fecal Incontinence Questionnaire after stoma closure.

RESULTS

Fifty-six consecutive patients (41 men) underwent ETAP between February 2010 and June 2012. The median age was 65 years (39-83), and the median body mass index was 27 (20-42). No intraoperative complications were encountered. There was no postoperative mortality, and the morbidity rate was 26%. The mesorectum was complete in 47 cases (84%) and nearly complete in 9 cases (16%). The median number of lymph nodes retrieved was 12 (range, 7-29) per patient. The median radial and distal margins were 8 mm (0-20) and 10 mm (3-40), respectively. R0 resection was achieved in 53 patients (94.6%). The median Wexner score was 4 (3-12). Thirteen (28%) patients reported stool fragmentation and difficult evacuation.

CONCLUSIONS

ETAP is a feasible alternative surgical option to conventional laparoscopy for rectal resection and may represent a promising step toward rectal natural orifice transluminal endoscopic surgery (NOTES).

Transanal total mesorectal excision in rectal cancer: short-term outcomes in comparison with laparoscopic surgery

OBJECTIVE

The aim of this study was to compare short-term results obtained with transanal total mesorectal excision (TME) and laparoscopic surgery.

BACKGROUND

Transanal TME appears as an alternative in the treatment of rectal cancer and other rectal disease. Natural orifices transluminal endoscopic surgery using the rectum as access in colorectal surgery is intuitively better suited than other access routes.

METHODS

All consecutive patients with middle or low rectal cancer submitted to surgery were included into a prospective cohort and treated by transanal TME assisted by laparoscopy. They were compared with a retrospective cohort of consecutive patients of identical characteristics treated by laparoscopic TME in the immediate chronological period.

RESULTS

Thirty-seven patients were included in both study groups. No differences were observed between them with respect to baseline characteristics, thus emphasizing the comparability of both cohorts. Surgical time was higher in the laparoscopy group (252 ± 50 minutes) than in the transanal group (215 ± 60 minutes) (P < 0.01). Moreover, coloanal anastomosis was performed less frequently (16% vs 43%, respectively; P = 0.01) and distal margin was lower (1.8 ± 1.2 mm vs 2.7 ± 1.7 mm, respectively; P = 0.05) in the laparoscopy group than in the transanal one. Although there was no significant difference in 30-day postoperative complication rate (laparoscopy, 51% vs transanal, 32%; P = 0.16), early readmissions were more frequent in the laparoscopy group than in the transanal one (22% vs 6%, respectively; P = 0.03).

CONCLUSIONS

Evaluation of short-term outcomes demonstrated that transanal TME is a feasible and safe technique associated with a shorter surgical time and a lower early readmission rate.

Perineal transanal approach: a new standard for laparoscopic sphincter-saving resection in low rectal cancer, a randomized trial

BACKGROUND

Laparoscopic sphincter preservation for low rectal cancer is challenging because of the high risk of positive circumferential resection margin. We hypothesized that perineal dissection of the distal rectum may improve quality of surgery, compared with the conventional abdominal dissection.

METHODS

Between 2008 and 2012, 100 patients with low rectal cancer (< 6 cm from the anal verge) suitable for sphincter preservation were randomized between perineal and abdominal low rectal dissection. Surgery included laparoscopic mobilization of the left colon with high rectal dissection. Distal rectal dissection was performed laparoscopically in the abdominal group and transanally in the perineal group. The primary endpoint was quality of surgery (circumferential resection margin, mesorectum grade, and lymph nodes). Secondary end points were morbidity and conversion.

RESULTS

The rate of positive circumferential resection margin decreased significantly after perineal compared with abdominal low rectal dissection, 4% versus 18% (P = 0.025). The mesorectum grade and the number of lymph nodes analyzed did not differ between the 2 groups. There was no difference in surgical morbidity (12% vs 14%; P = 0.766) and conversion (4% vs 10%; P = 0.436) between perineal and abdominal rectal dissection. Multivariate analysis showed that abdominal rectal dissection was the only independent factor of positive circumferential resection margin (odds ratio = 5.25; 95% confidence interval: 1.03-26.70; P = 0.046).

CONCLUSIONS

Perineal rectal dissection reduces the risk of positive circumferential resection margin, as compared with the conventional abdominal dissection in low rectal cancer. This suggests the perineal rectal dissection as a new standard in laparoscopic sphincter-saving resection for low rectal cancer.

Robotic-assisted laparoscopic transanal total mesorectal excision for rectal cancer: a prospective pilot study

BACKGROUND

We performed a prospective pilot study of robotic-assisted laparoscopic transanal proctectomy with total mesorectal excision for the surgical treatment of rectal cancer. This study was to assess the feasibility and safety of robotic-assisted laparoscopic transanal total mesorectal excision.

TECHNIQUE

All patients underwent robotic-assisted laparoscopic left colon mobilization, robotic-assisted laparoscopic transanal total mesorectal excision, ultralow mechanical colorectal or handsewn coloanal anastomosis, and a diverting loop ileostomy. Four patients with stage III disease received long-course preoperative chemoradiation before surgery.

MAIN OUTCOME MEASURES

Primary and secondary end points included the assessment of pathological examination and postoperative morbidity.

RESULTS

Between August 2013 and January 2014, 4 men and 1 woman underwent robotic-assisted laparoscopic transanal total mesorectal excision. Patient age and BMI were 57 ± 13.9 years and 25.8 ± 2,7 kg/m. Tumors were located an average of 5 ± 1 cm from the anal verge and were preoperatively staged as T2N0M0 (1 patient) and T2N1M0 (4 patients). Mean operative time was 398 ± 88 minutes with no intraoperative complications. Mean length of hospital stay was 6 ± 1 days. A Clavien II, grade B anastomotic leakage developed in 1 patient postoperatively. In all cases, pathological examination of the total mesorectal excision specimens showed complete mesorectal excision with negative proximal, distal, and circumferential margins. All patients were disease-free at their initial 3-month follow-up.

CONCLUSIONS

Robotic-assisted laparoscopic transanal total mesorectal excision is a feasible and safe option for the surgical management of early-stage rectal cancers. Robotic technology with endowristed instruments and 3-dimensional high-definition imaging are of great help in overcoming the limitations of traditional laparoscopic transanal surgery. Long-term functional and oncological assessments of outcome are needed.

Transanal total mesorectal excision: a systematic review of the experimental and clinical evidence

Achieving a clear distal or circumferential resection margins with laparoscopic total mesorectal excision (TME) may be laborious, especially in obese males and when operating on advanced distal rectal tumors with a poor response to neoadjuvant treatment. Transanal (TaTME) is a new natural orifice translumenal endoscopic surgery modality in which the rectum is mobilized transanally using endoscopic techniques with or without laparoscopic assistance. We conducted a comprehensive systematic review of publications on this new technique in PubMed and Embase databases from January, 2008, to July, 2014. Experimental and clinical studies written in English were included. Experimental research with TaTME was done on pigs with and without survival models and on human cadavers. In these studies, laparoscopic or transgastric assistance was frequently used resulting in an easier upper rectal dissection and in a longer rectal specimen. To date, 150 patients in 16 clinical studies have undergone TaTME. In all but 15 cases, transabdominal assistance was used. A rigid transanal endoscopic operations/transanal endoscopic microsurgery (TEO/TEM) platform was used in 37 patients. Rectal adenocarcinoma was the indication in all except for nine cases of benign diseases. Operative times ranged from 90 to 460 min. TME quality was deemed intact, satisfactory, or complete. Involvement in circumferential resection margins was detected in 16 (11.8 %) patients. The mean lymph node harvest was equal or greater than 12 in all studies. Regarding morbidity, pneumoretroperitoneum, damage to the urethra, and air embolism were reported intraoperatively. Mean hospital stay varied from 4 to 14 days. Postoperative complications occurred in 34 (22.7 %) patients. TaTME with TEM is feasible in selected cases. Oncologic safety parameters seem to be adequate although the evidence relies on small retrospective series conducted by highly trained surgeons. Further studies are expected.

Laparoscopic natural orifice specimen extraction-colectomy: A systematic review

Over the last 20 years, laparoscopic colorectal surgery has shown equal efficacy for benign and malignant colorectal diseases when compared to open surgery. However, a laparoscopic approach reduces postoperative morbidity and shortens hospital stay. In the quest to optimize outcomes after laparoscopic colorectal surgery, reduction of access trauma could be a way to improve recovery. To date, one method to reduce access trauma is natural orifice specimen extraction (NOSE). NOSE aims to reduce access trauma in laparoscopic colorectal surgery. The specimen is delivered via a natural orifice and the anastomosis is created intracorporeally. Different methods are used to extract the specimen and to create a bowel anastomosis. Currently, specimens are delivered transcolonically, transrectally, transanally, or transvaginally. Each of these NOSE-procedures raises specific issues with regard to operative technique and application. The presumed benefits of NOSE-procedures are less pain, lower analgesia requirements, faster recovery, shorter hospital stay, better cosmetic results, and lower incisional hernia rates. Avoidance of extraction site laparotomy is the most important characteristic of NOSE. Concerns associated with the NOSE-technique include bacterial contamination of the peritoneal cavity, inflammatory response, and postoperative outcomes, including postoperative pain and the functional and oncologic outcomes. These issues need to be studied in prospective randomized controlled trials. The aim of this systematic review is to describe the role of NOSE in minimally invasive colorectal surgery.

Robotic transanal total mesorectal excision for rectal cancer: experience with a first case

BACKGROUND

A transanal approach for total mesorectal excision (TME) using a single incision port is feasible. The disadvantages are technical difficulties associated with limited manoeuvrability.

METHODS

We present our first experience with robotic-assisted transanal total mesorectal excision. A 48 year-old woman with a tumour 8 cm from the anal verge was successfully operated using a transanal approach. A complete mesorectal excision was performed through a single incision port, using two robot arms.

RESULTS

TME was performed successfully and the patient recovered quickly without any complications. The histological report showed a complete mesorectal excision with free distal and circumferential margins. A sigmoidoscopy showed an intact anastomosis and the patient was planned for reversal of her ileostomy.

CONCLUSIONS

Transanal total mesorectal excision using the robot is feasible. Robotics may help to overcome technical difficulties associated with the single incision port.

A systematic review of transanal minimally invasive surgery (TAMIS) from 2010 to 2013

Transanal minimally invasive surgery (TAMIS) was introduced as an alternative to transanal endoscopic microsurgery in 2010. Over the past 4 years, considerable international experience has been gained with this approach. Most published reports focus on TAMIS for local excision of rectal neoplasia, but there are other important applications such as transanal mesorectal excision for rectal cancer. This comprehensive review details the progress with TAMIS since its inception. Robotic transanal surgery is a natural evolution of TAMIS still in its early infancy, which is also reviewed. A comprehensive search of PubMed, EMBASE, the Cochrane Library, and Web of Knowledge was performed. Since the inception of TAMIS in 2009, 33 retrospective studies and case reports, and 3 abstracts have been published on TAMIS for local excision of rectal neoplasms, which represents a combined n = 390 TAMIS procedures performed worldwide using eight different types of TAMIS platforms. A total of 152 lesions were excised for benign disease including adenomas and high-grade dysplasias (39 %), 209 for malignancy for carcinomas in situ and adenocarcinomas (53.5 %). Twenty-nine (7.5 %) of TAMIS resections were for other pathology, of which the majority (23/29) were neuroendocrine lesions. The remaining resections were for mucocele, gastrointestinal stromal tumor, melanoma, and fibrosis. Robotic-TAMIS has also been reported, however, data are extremely limited as there are only 7 case reports (combined n = 11) in the published literature. Success with Robotic-TAMIS has been demonstrated with various patient positions and by use of a special glove port. Transanal total mesorectal excision using the TAMIS platform has also been demonstrated is several small series, and the feasibility of performing pure transanal total mesorectal excision has also been reported. Combined, n = 78 cases of transanal total mesorectal excision have been performed using TAMIS. The advantages of TAMIS-assisted transanal total mesorectal excision are discussed.

A systematic review of transanal minimally invasive surgery (TAMIS) from 2010 to 2013

Transanal minimally invasive surgery (TAMIS) was introduced as an alternative to transanal endoscopic microsurgery in 2010. Over the past 4 years, considerable international experience has been gained with this approach. Most published reports focus on TAMIS for local excision of rectal neoplasia, but there are other important applications such as transanal mesorectal excision for rectal cancer. This comprehensive review details the progress with TAMIS since its inception. Robotic transanal surgery is a natural evolution of TAMIS still in its early infancy, which is also reviewed. A comprehensive search of PubMed, EMBASE, the Cochrane Library, and Web of Knowledge was performed. Since the inception of TAMIS in 2009, 33 retrospective studies and case reports, and 3 abstracts have been published on TAMIS for local excision of rectal neoplasms, which represents a combined n = 390 TAMIS procedures performed worldwide using eight different types of TAMIS platforms. A total of 152 lesions were excised for benign disease including adenomas and high-grade dysplasias (39 %), 209 for malignancy for carcinomas in situ and adenocarcinomas (53.5 %). Twenty-nine (7.5 %) of TAMIS resections were for other pathology, of which the majority (23/29) were neuroendocrine lesions. The remaining resections were for mucocele, gastrointestinal stromal tumor, melanoma, and fibrosis. Robotic-TAMIS has also been reported, however, data are extremely limited as there are only 7 case reports (combined n = 11) in the published literature. Success with Robotic-TAMIS has been demonstrated with various patient positions and by use of a special glove port. Transanal total mesorectal excision using the TAMIS platform has also been demonstrated is several small series, and the feasibility of performing pure transanal total mesorectal excision has also been reported. Combined, n = 78 cases of transanal total mesorectal excision have been performed using TAMIS. The advantages of TAMIS-assisted transanal total mesorectal excision are discussed.

Future directions in surgery for colorectal cancer: the evolving role of transanal endoscopic surgery

SUMMARY 

The morbidity associated with radical surgery for rectal cancer has launched a revolution in increasingly less-invasive methods of resection, including a recent resurgence in transanal endoscopic surgical approaches. The next evolution in transanal surgery for rectal cancer is natural orifice translumenal endoscopic surgery (NOTES). To date, 14 series of transanal NOTES total mesorectal excision (TME) for rectal cancer have been published (n = 76). Overall, the intraoperative and postoperative complication rates of 8 and 28%, respectively, compare favorably to those expected from laparoscopic and open TME. Short-term follow-up after NOTES TME has yielded no cancer recurrence in average-risk patients. High-risk patients have cancer recurrence rates similar to those after laparoscopic TME. Overall, these early data support transanal NOTES TME as a safe and viable alternative to conventional TME. Advances in instrumentation, surgical expertise and neoadjuvant treatment may expand current indications for NOTES even further.

Transanal endoscopic microsurgery: a review

Rectal adenomas and cancers occur frequently. Small adenomas can be removed colonoscopically, whereas larger polyps are removed via conventional transanal excision. Owing to technical difficulties, adenomas of the mid- and upper rectum require radical resection. Transanal endoscopic microsurgery (TEM) was first designed as an alternative treatment for these lesions. However, since its development TEM has been also used for a variety of rectal lesions, including carcinoids, rectal prolapse and diverticula, early stage carcinomas and palliative resection of rectal cancers. The objective of this review is to describe the current status of TEM in the treatment of rectal lesions. Since the 1980s, TEM has advanced substantially. With low recurrence rates, it is the method of choice for resection of endoscopically unresectable adenomas. Some studies have shown benefits to its use in treating early T1 rectal cancers compared with radical surgery in select patients. However, for more advanced rectal cancers TEM should be considered palliative or experimental. This technique has also been shown to be safe for the treatment of other uncommon rectal tumours, such as carcinoids. Transanal endoscopic microsurgery may allow for new strategies in the treatment of rectal pathology where technical limitations of transanal techniques have limited endoluminal surgical innovations.

Transanal minimal invasive surgery with the Endorec(TM) trocar: a low cost but effective technique

PURPOSE

Transanal endoscopic microsurgery (TEM) is a well-established surgical approach for local excision of benign adenomas and early-stage rectal cancer. This technique is expensive and associated with a long learning curve. To avoid these obstacles, we have developed an alternative approach using the Endorec(TM) trocar (Aspide, France), which combines the advantages of local transanal excision and single-port access. The aim of this study was to evaluate the feasibility of this technique.

PATIENTS AND METHODS

Fourteen consecutive patients underwent transanal resection using Endorec trocar and standard laparoscopic instruments. A retrospective evaluation of the outcome of this technique was performed.

RESULTS

Fourteen patients were successfully operated. Rectal lesions included adenoma in ten patients, T1 adenocarcinoma in three and one T2 adenocarcinoma not amenable for abdominal surgery. The average distal margin from the anal verge was 10 cm (range 5-17 cm), and the mean diameter was 3.5 cm (range 1-5 cm). Negative margins were obtained in 13 patients (92,8 %). Median operating time was 60 min (range 20-100). The excisional area was sutured in nine patients. Median postoperative stay was 4 days (range 1-13). Postoperative complications (21 %) included postoperative fever in one patient and two patients were readmitted with rectal blood loss 6 and 15 days postoperatively and were treated with conservative measures.

CONCLUSIONS

Our current data show that transanal surgery using Endorec trocar is feasible and safe. Although long-term outcomes and definite indications should be yet evaluated, we believe that this new technique offers a promising alternative to TEM.

Advanced laparoscopic surgery for colorectal disease: NOTES/NOSE or single port?

Laparoscopic surgery for colorectal disease is an evolving, dynamic subject undergoing constant adaptation. Hence there are significant ongoing advances in technique and technology as has been seen with the emergence of single port and Natural Orifice Transluminal Endoscopic operations with already considerable ramifications for many aspects of minimal access surgery. Most recently single port technologies and expertise have synergized with Transanal Endoscopic (TEM/TEO) experience to allow their convergence out of their respective niches so that pelvic surgery can be laparoendoscopically performed from both its abdominal and perineal aspects. Distinct from wound-related benefits, such capacity for high resolution and multi-dimensional imaging relates significant benefit to the operating team and patient. This state of the art review demonstrates the crucial perspective that advanced practices and performance capabilities are intrinsically complimentary rather than competitive. All surgeons need therefore to participate in adapting their practice styles to allow technical step-advance across the discipline.

Overview of single-port laparoscopic surgery for colorectal cancers: Past, present, and the future

Single-port laparoscopic surgery (SPLS) is implemented through a tailored minimal single incision through which a number of laparoscopic instruments access. Introduction of operation-customized port system, utilization of a camera without a separate external light, and instruments with different lengths has brought the favorable environment for SPLS. However, performing SPLS still creates several hardships compared to multiport laparoscopic surgery; a single-port system inevitably leads to clashing of surgical instruments due to crowding. To overcome such difficulties, investigators has developed novel concepts and maneuvers, including the concept of inverse triangulation and the maneuvers of pivoting, spreading out dissection, hanging suture, and transluminal traction. The final destination of SPLS is expected to be a completely seamless operation, maximizing the minimal invasiveness. Specimen extraction through the umbilicus can undermine cosmesis by inducing a larger incision. Therefore, hybrid laparoscopic technique, which combined laparoscopic surgical technique with natural orifice specimen extraction - i.e., transvaginal or transanal route-, has been developed. SPLS and NOSE seemed to be the best combination in pursuit of minimal invasiveness. In the near future, robotic SPLS with natural orifice transluminal endoscopic surgery’s way of specimen extraction seems to be pursued. It is expected to provide a completely or nearly complete seamless operation regardless of location of the lesion in the abdomen.

Dynamic article: transanal rectal excision: a pilot study

BACKGROUND

Laparoscopic total mesorectal excision can be difficult in a narrow pelvis. Transanal minimally invasive surgery allows the surgeon to mobilize the most distal part of the rectum by using a single port positioned in the anal canal.

OBJECTIVE

We aim to assess the safety and feasibility of transanal rectal excision.

DESIGN AND SETTING

This pilot study was conducted in a university hospital and tertiary colorectal referral center in Belgium.

PATIENTS

Over a 12-month period, all consecutive patients with benign disease and ASA grade 3 patients with a rectal carcinoma who required either intersphincteric proctectomy or coloanal anastomosis were included.

INTERVENTION

After intersphincteric dissection or sleeve mucosectomy, a single-access multichannel port was inserted into the anal canal. A transanal rectal excision was performed by using conventional laparoscopic instruments. The planes were developed as cephalad as possible, until the pouch of Douglas was opened. A laparoscopically assisted approach was used to gain bowel length and was used in patients who required proctectomy. In the case of a reconstruction, a handsewn coloanal anastomosis was made.

MAIN OUTCOME MEASURES

Intraoperative challenges, conversion rate, operating time, blood loss, morbidity, and length of stay were assessed.

RESULTS

Fourteen patients underwent a transanal rectal excision for both benign (9) and malignant (5) disease. In 11 patients (79%), laparoscopically assisted transanal minimally invasive rectal excision was performed. The median (range) transanal operating time was 55 (35-95) minutes. Intraoperative difficulties hindering dissection occurred in 5 patients and were due to inadequate exposure, rectal perforation, or fibrosis secondary to radiotherapy for prostate cancer. There was minimal postoperative morbidity, with a median follow-up of 6.3 (1.5-13.8) months. All patients were discharged within 14 days postoperatively, and there were no readmissions.

LIMITATIONS

The study was limited by the small number of patients.

CONCLUSION

Transanal rectal excision is safe and feasible and could be a promising technique to facilitate distal rectal mobilization (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A125).

Transanal colorectal resection using natural orifice translumenal endoscopic surgery (NOTES)

The surgical management of rectal cancer has evolved over the past century, with total mesorectal excision (TME) emerging as standard of care. As a result of the morbidity associated with open TME, minimally invasive techniques have become popular. Natural orifice translumenal endoscopic surgery (NOTES) has been held as the next revolution in surgical techniques, offering the possibility of 'incisionless' TME. Early clinical series of transanal TME with laparoscopic assistance (n = 72) are promising, with overall intraoperative and postoperative complication rates of 8.3% and 27.8%, respectively, similar to laparoscopic TME. The mesorectal specimen was intact in all patients, and 94.4% had negative margins. There was no oncological recurrence in average-risk patients at short-term follow up, and 2-year survival rates in high-risk patients were comparable to that after laparoscopic TME. These preliminary studies demonstrate transanal NOTES TME with laparoscopic assistance to be clinically feasible and safe given careful patient selection, surgical expertise, and appropriate procedural training. We are hopeful that with optimization of transanal instruments and surgical techniques, pure transanal NOTES TME will become a viable alternative to open and laparoscopic TME in the future.

Collaboration between laparoscopic surgery and endoscopic resection: an evidence-based review

Developments in endoscopy and laparoscopy have made monumental changes to the way gastrointestinal diseases are being managed. Many diseases that were traditionally managed by open surgical resection could now be treated by endoscopy alone. However, there are still instances where endoscopic treatment alone is inadequate for disease control and laparoscopic surgery is required. In addition, the collaboration between laparoscopic surgery and endoscopic submucosal dissection or other endoscopic resectional techniques represents a new frontier for further research. The present manuscript aims to discuss the complementary role of laparoscopic surgery to endoscopic resection in the traditional context and also its future development.