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Asian J Endosc Surg ISSN 1758-5902
R E V I E W A RT I C L E
Advances in laparoscopic colorectal surgery: A review on NOTES and transanal extraction of specimen Alex Lik Hang Leung, Hester Yui Shan Cheung & Michael Ka Wah Li Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong SAR, China
Keywords Hybrid; natural orifice transluminal endoscopic surgery (NOTES); transanal extraction of specimen Correspondence Alex Lik Hang Leung, Department of Surgery, Pamela Youde Nethersole Eastern Hospital, 3 Lok Man Road, Chai Wan, Hong Kong SAR, China. Tel: +852 2595 6417 Fax: +852 2515 3195 Email: [email protected] Received: 31 August 2013; accepted 9 September 2013 DOI:10.1111/ases.12070
Abstract Laparoscopic colorectal surgery has rapidly developed since the 1980s. Relative to open surgery, it offers the benefits of less invasiveness and earlier recovery. However, when a mini-laparotomy wound is needed to retrieve the specimen, the benefits of minimally invasive surgery may be compromised as a result of pain- and wound-related complications. The introduction of natural orifice transluminal endoscopic surgery (NOTES) makes “scarless” surgery a possibility; pain- and wound-related complications are totally abolished. However, a number of technical issues need to be overcome before this technique can be used widely. The development of natural orifice specimen extraction surgery abandons the need for a specimen-retrieval incision and helps overcome the technical hurdles of NOTES. As a bridge between true “scarless” surgery and conventional laparoscopic surgery, hybrid procedures combining laparoscopic resection and natural orifice specimen extraction surgery currently play an important role in minimally invasive colorectal surgery.
Introduction
Application of NOTES in colorectal resection
Laparoscopic colectomy for colon cancer has improved postoperative patient recovery and outcomes in terms of postoperative pain, pain and wound-related complications, return of bowel function, and it provides oncological outcomes that are comparable to open colectomy (1–3). However, specimen retrieval requires a mini-laparotomy wound, which can cause postoperative pain, wound infection and incisional hernia. Thus, the benefits of minimally invasive surgery may be compromised.
Soon after Whiteford et al. had reported successful NOTES radical sigmoid colectomy in three cadavers in 2007 (6), Lacy et al. reported a case of radical sigmoid resection using transvaginal mini-laparoscopic-assisted natural orifice surgery for a patient with sigmoid adenocarcinoma (7). In 2010, Sylla et al. reported the first clinical case of mini-laparoscopic-assisted transanal endoscopic rectosigmoid resection using the transanal endoscopic microsurgery platform (Tables 1,2) (8,9). Zorron et al. performed “down-to-up” total mesorectal resection and rectosigmoidectomy with lymphadenectomy in two patients with rectal adenocarcinoma using the NOTES technique (10). Because NOTES still has many unresolved technical issues, it is currently not widely applied in colorectal pathologies.
NOTES Since Kalloo et al. described flexible transgastric peritoneoscopy in a swine model in 2000 (4), natural orifice transluminal endoscopic surgery (NOTES) has rapidly developed and been applied in different diagnostic and therapeutic procedures using various transvisceral accesses. NOTES can completely abolish pain and wound complications. It may be the next major revolution in minimally invasive surgery. A recent review of NOTES reported that the transcolonic route is the second most common route after the transgastric route (5).
NOSE Natural orifice specimen extraction (NOSE) is an important step in the evolution toward “scarless” surgery for colorectal diseases. A hybrid procedure combining
Asian J Endosc Surg 7 (2014) 11–16 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
11
A review on NOTES
ALH Leung et al.
Table 1 NOTES colorectal resection Indication and tumor size, procedure
Authors
Type of study
Whiteford et al. (6) Lacy et al. (7)
Case Thawed cadaver 3 (human 0 series model cadavers) Case Sigmoid 1 One report adenocarcinoma needle-scope
Patients (n)
Abdominal ports (n)
Route
Platform used for dissection Anastomosis
Operating time
Transanal
TEM platform
Double stapled
Mean Not 0 4.25 hours applicable 2.5 hours NA 0
TEM platform
Hand-sewn
4.5 hours
1. Flexible colonoscope
Transvaginal 0
Single stapled
Blood Loss (mL)
Conver-sion to open (n)
Two 2-mm ports Sylla et al. (8)
Case Rectal cancer 1 report with preoperative chemoirradiation Zorron et al. Case Rectal 2 (10) series adenocarcinoma
5 mm + two Transanal 2-mm ports to assist sigmoid mobilization 3 Transanal
NA
0
1.Single stapled 1. 350 min
1. 60
0
2. Hand-sewn 2. 360 min
2. 90
2. Rigid single-port device NA, not available; NOTES, natural orifice transluminal endoscopic surgery; TEM, transanal endoscopic microsurgery.
Table 2 Outcomes of NOTES colorectal resection Authors
Type of complication
VAS
Length of hospital stay (days)
Anal dysfunction
Lymph nodes reported (n)
Whiteford et al. (6) Lacy et al.(7) Sylla et al. (8) Zorron et al.(10)
Not applicable 0 NA 0
Not applicable NA NA NA
Not applicable 4 4 6
Not applicable NA NA NA
Not applicable 16 23 (negative) 1. 12 2. 11
NA, not available; NOTES, natural orifice transluminal endoscopic surgery; VAS, visual analog score.
laparoscopic surgery and NOSE can overcome the technical difficulty in NOTES colectomy. In this hybrid procedure, lymph node dissection, proximal and distal transection, and anastomosis are performed laparoscopically followed by transanal retrieval of specimen. This technique does not involve an abdominal incision for specimen retrieval, thus reducing pain- and wound-related complications. When NOSE is applied in colorectal surgery, the specimen can be retrieved transvaginally or through the anorectum. The transvaginal route may be complicated and is limited to female patients only (11). However, it may offer additional benefits, especially when performed at the same time as a gynecological procedure (12). Specimen extraction via the anorectum can be applied in both sexes and is widely reported in a number of studies (13–22). However, the technique is associated with risk of injury to the anorectum and potential intra-abdominal contamination.
Transanal removal of specimen Since Franklin et al. reported a series of patients who underwent laparoscopic sigmoid colon resection with
12
transanal specimen removal in 1993 (23), there have been a number of case series reporting laparoscopic colectomy with NOSE (13–22). However, only a few of these studies compared the outcomes of NOSE and conventional laparoscopic colectomy (22,24). A recent systematic review of the current literature was not able to show the superiority of left-sided laparoscopic colectomy with transrectal specimen extraction over conventional laparoscopic resection (25). The concept of NOSE even extends to single-site sigmoidectomy (26), laparoscopic total mesorectal excision (27), and robotic colorectal resection (28). NOSE is usually applied for left-sided colorectal pathologies. Tables 3 and 4 show recent case series or comparative studies using transanal specimen extraction for left-sided colorectal pathologies. (Those studies for mid- or low rectal pathologies, which required total mesorectal excision, are not discussed here) To avoid tumor seedling and injury to the anorectum, there are various kinds of techniques and devices that can be employed in transanal specimen retrieval, including a transanal endoscopic microsurgery rectoscope (29), a transanal endoscopic device (13,17), an Alexis wound retractor (Applied Medical, Rancho Santa Margarita,
Asian J Endosc Surg 7 (2014) 11–16 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Stage T3 tumor
Diverticular disease Small tumor (
Asian J Endosc Surg ISSN 1758-5902
R E V I E W A RT I C L E
Advances in laparoscopic colorectal surgery: A review on NOTES and transanal extraction of specimen Alex Lik Hang Leung, Hester Yui Shan Cheung & Michael Ka Wah Li Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong SAR, China
Keywords Hybrid; natural orifice transluminal endoscopic surgery (NOTES); transanal extraction of specimen Correspondence Alex Lik Hang Leung, Department of Surgery, Pamela Youde Nethersole Eastern Hospital, 3 Lok Man Road, Chai Wan, Hong Kong SAR, China. Tel: +852 2595 6417 Fax: +852 2515 3195 Email: [email protected] Received: 31 August 2013; accepted 9 September 2013 DOI:10.1111/ases.12070
Abstract Laparoscopic colorectal surgery has rapidly developed since the 1980s. Relative to open surgery, it offers the benefits of less invasiveness and earlier recovery. However, when a mini-laparotomy wound is needed to retrieve the specimen, the benefits of minimally invasive surgery may be compromised as a result of pain- and wound-related complications. The introduction of natural orifice transluminal endoscopic surgery (NOTES) makes “scarless” surgery a possibility; pain- and wound-related complications are totally abolished. However, a number of technical issues need to be overcome before this technique can be used widely. The development of natural orifice specimen extraction surgery abandons the need for a specimen-retrieval incision and helps overcome the technical hurdles of NOTES. As a bridge between true “scarless” surgery and conventional laparoscopic surgery, hybrid procedures combining laparoscopic resection and natural orifice specimen extraction surgery currently play an important role in minimally invasive colorectal surgery.
Introduction
Application of NOTES in colorectal resection
Laparoscopic colectomy for colon cancer has improved postoperative patient recovery and outcomes in terms of postoperative pain, pain and wound-related complications, return of bowel function, and it provides oncological outcomes that are comparable to open colectomy (1–3). However, specimen retrieval requires a mini-laparotomy wound, which can cause postoperative pain, wound infection and incisional hernia. Thus, the benefits of minimally invasive surgery may be compromised.
Soon after Whiteford et al. had reported successful NOTES radical sigmoid colectomy in three cadavers in 2007 (6), Lacy et al. reported a case of radical sigmoid resection using transvaginal mini-laparoscopic-assisted natural orifice surgery for a patient with sigmoid adenocarcinoma (7). In 2010, Sylla et al. reported the first clinical case of mini-laparoscopic-assisted transanal endoscopic rectosigmoid resection using the transanal endoscopic microsurgery platform (Tables 1,2) (8,9). Zorron et al. performed “down-to-up” total mesorectal resection and rectosigmoidectomy with lymphadenectomy in two patients with rectal adenocarcinoma using the NOTES technique (10). Because NOTES still has many unresolved technical issues, it is currently not widely applied in colorectal pathologies.
NOTES Since Kalloo et al. described flexible transgastric peritoneoscopy in a swine model in 2000 (4), natural orifice transluminal endoscopic surgery (NOTES) has rapidly developed and been applied in different diagnostic and therapeutic procedures using various transvisceral accesses. NOTES can completely abolish pain and wound complications. It may be the next major revolution in minimally invasive surgery. A recent review of NOTES reported that the transcolonic route is the second most common route after the transgastric route (5).
NOSE Natural orifice specimen extraction (NOSE) is an important step in the evolution toward “scarless” surgery for colorectal diseases. A hybrid procedure combining
Asian J Endosc Surg 7 (2014) 11–16 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
11
A review on NOTES
ALH Leung et al.
Table 1 NOTES colorectal resection Indication and tumor size, procedure
Authors
Type of study
Whiteford et al. (6) Lacy et al. (7)
Case Thawed cadaver 3 (human 0 series model cadavers) Case Sigmoid 1 One report adenocarcinoma needle-scope
Patients (n)
Abdominal ports (n)
Route
Platform used for dissection Anastomosis
Operating time
Transanal
TEM platform
Double stapled
Mean Not 0 4.25 hours applicable 2.5 hours NA 0
TEM platform
Hand-sewn
4.5 hours
1. Flexible colonoscope
Transvaginal 0
Single stapled
Blood Loss (mL)
Conver-sion to open (n)
Two 2-mm ports Sylla et al. (8)
Case Rectal cancer 1 report with preoperative chemoirradiation Zorron et al. Case Rectal 2 (10) series adenocarcinoma
5 mm + two Transanal 2-mm ports to assist sigmoid mobilization 3 Transanal
NA
0
1.Single stapled 1. 350 min
1. 60
0
2. Hand-sewn 2. 360 min
2. 90
2. Rigid single-port device NA, not available; NOTES, natural orifice transluminal endoscopic surgery; TEM, transanal endoscopic microsurgery.
Table 2 Outcomes of NOTES colorectal resection Authors
Type of complication
VAS
Length of hospital stay (days)
Anal dysfunction
Lymph nodes reported (n)
Whiteford et al. (6) Lacy et al.(7) Sylla et al. (8) Zorron et al.(10)
Not applicable 0 NA 0
Not applicable NA NA NA
Not applicable 4 4 6
Not applicable NA NA NA
Not applicable 16 23 (negative) 1. 12 2. 11
NA, not available; NOTES, natural orifice transluminal endoscopic surgery; VAS, visual analog score.
laparoscopic surgery and NOSE can overcome the technical difficulty in NOTES colectomy. In this hybrid procedure, lymph node dissection, proximal and distal transection, and anastomosis are performed laparoscopically followed by transanal retrieval of specimen. This technique does not involve an abdominal incision for specimen retrieval, thus reducing pain- and wound-related complications. When NOSE is applied in colorectal surgery, the specimen can be retrieved transvaginally or through the anorectum. The transvaginal route may be complicated and is limited to female patients only (11). However, it may offer additional benefits, especially when performed at the same time as a gynecological procedure (12). Specimen extraction via the anorectum can be applied in both sexes and is widely reported in a number of studies (13–22). However, the technique is associated with risk of injury to the anorectum and potential intra-abdominal contamination.
Transanal removal of specimen Since Franklin et al. reported a series of patients who underwent laparoscopic sigmoid colon resection with
12
transanal specimen removal in 1993 (23), there have been a number of case series reporting laparoscopic colectomy with NOSE (13–22). However, only a few of these studies compared the outcomes of NOSE and conventional laparoscopic colectomy (22,24). A recent systematic review of the current literature was not able to show the superiority of left-sided laparoscopic colectomy with transrectal specimen extraction over conventional laparoscopic resection (25). The concept of NOSE even extends to single-site sigmoidectomy (26), laparoscopic total mesorectal excision (27), and robotic colorectal resection (28). NOSE is usually applied for left-sided colorectal pathologies. Tables 3 and 4 show recent case series or comparative studies using transanal specimen extraction for left-sided colorectal pathologies. (Those studies for mid- or low rectal pathologies, which required total mesorectal excision, are not discussed here) To avoid tumor seedling and injury to the anorectum, there are various kinds of techniques and devices that can be employed in transanal specimen retrieval, including a transanal endoscopic microsurgery rectoscope (29), a transanal endoscopic device (13,17), an Alexis wound retractor (Applied Medical, Rancho Santa Margarita,
Asian J Endosc Surg 7 (2014) 11–16 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Stage T3 tumor
Diverticular disease Small tumor (
