JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES Volume 24, Number 7, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/lap.2014.0116
Technical Report
Journal of Laparoendoscopic & Advanced Surgical Techniques Downloaded from online.liebertpub.com by University Of Connecticut Healt Center on 06/13/14. For personal use only.
Intracorporeal Mesenteric Division of the Colon Can Make the Specimen More Suitable for Natural Orifice Extraction Mehmet Ali Yagci, MD,1 Cuneyt Kayaalp, MD,1 and Namiq Haydaroglu Novruzov, MD 2
Abstract
Laparoscopic surgery combined with natural orifice specimen extraction (NOSE) avoids extra incisions to the abdominal wall and causes less pain and fewer wound complications, together with a shorter recovery and reduced time off from work. However, the size of the specimen is a limiting factor for NOSE. We describe a novel method for natural orifice colorectal specimen extraction that reduces the diameter of the specimen and provides an easier extraction through the vagina. A totally laparoscopic right hemicolectomy for a cecal adenocarcinoma 5 cm in diameter was performed on a 62-year-old woman. Ileocolic anastomosis was done intracorporeally. Before transvaginal extraction, the largest width of the specimen was measured as 12 cm. The bulky mesentery of the cecum that limited the NOSE was divided partially along the bowel with a LigaSure (Covidien, Boulder, CO) device. The largest width of the specimen was reduced to 9 cm, and the specimen was extracted without difficulty through the vagina in a bag. The stage of the tumor was pT3pN1. There was no recurrence with a 7-month follow-up. Transvaginal specimen extraction may fail because of the size of the specimen. Reduction of the width of the specimen by partial division of the mesocolon provides a high success rate for NOSE. This novel technique should be in the repertoire of laparoscopic colorectal surgeons.
can be aborted because of specimen size. This challenge especially occurs for specimens that include larger mesenteries. We describe a novel method for natural orifice colorectal specimen extraction that reduces the diameter of the specimen and provides an easier extraction through the vagina.
Introduction
L
aparoscopic colectomy has been a more frequently preferred surgical method for malignant colorectal diseases since 2004.1 Current laparoscopic techniques for colorectal cancer require an abdominal incision for the removal of the resected specimen. This additional incision creates an additional risk of wound infection and incisional hernia. Natural orifice specimen extraction (NOSE) has been described as an alternative approach for delivering the resected specimen from the peritoneal cavity through an anatomic access, rather than an abdominal incision. The concept of NOSE is not new. Franklin et al.2 described in 1993 a totally laparoscopic colectomy with transanal specimen extraction. The vagina as an extraction site was first reported following laparoscopic cholecystectomy in 1993,3 and since then several authors have described standard laparoscopic colectomy with extraction of the specimen via the vagina or anus. NOSE minimizes surgical injury and involves no visible scar, low risk of incisional hernia and wound infection, faster recovery, and decreased postoperative pain.4–8 Although NOSE benefits from the minimal invasiveness of laparoscopic colorectal surgery, all natural orifices (anus, vagina, and mouth) have anatomic limitations, and the procedure 1 2
Case Report
A 62-year-old woman was admitted for hypochromic microcytic anemia. Medical history was significant for cerebrovascular accident, diabetes mellitus, and hypertension that were controlled by oral antidiabetic, antiaggregant, and antihypertensive agents. Her body mass index was 31 kg/m2, and the American Society of Anesthesiologists score was III. Physical examination revealed a palpable mass in the lower right quadrant. Her biochemical parameters were in the normal range. Colonoscopy showed a 5-cm ulcerous cecal mass with a histological diagnosis of adenocarcinoma. Computed tomography of the abdomen and pelvis was negative for metastatic disease (Fig. 1). The preoperative carcinoembryonic antigen level was 2.7 ng/mL (normal,
Technical Report
Journal of Laparoendoscopic & Advanced Surgical Techniques Downloaded from online.liebertpub.com by University Of Connecticut Healt Center on 06/13/14. For personal use only.
Intracorporeal Mesenteric Division of the Colon Can Make the Specimen More Suitable for Natural Orifice Extraction Mehmet Ali Yagci, MD,1 Cuneyt Kayaalp, MD,1 and Namiq Haydaroglu Novruzov, MD 2
Abstract
Laparoscopic surgery combined with natural orifice specimen extraction (NOSE) avoids extra incisions to the abdominal wall and causes less pain and fewer wound complications, together with a shorter recovery and reduced time off from work. However, the size of the specimen is a limiting factor for NOSE. We describe a novel method for natural orifice colorectal specimen extraction that reduces the diameter of the specimen and provides an easier extraction through the vagina. A totally laparoscopic right hemicolectomy for a cecal adenocarcinoma 5 cm in diameter was performed on a 62-year-old woman. Ileocolic anastomosis was done intracorporeally. Before transvaginal extraction, the largest width of the specimen was measured as 12 cm. The bulky mesentery of the cecum that limited the NOSE was divided partially along the bowel with a LigaSure (Covidien, Boulder, CO) device. The largest width of the specimen was reduced to 9 cm, and the specimen was extracted without difficulty through the vagina in a bag. The stage of the tumor was pT3pN1. There was no recurrence with a 7-month follow-up. Transvaginal specimen extraction may fail because of the size of the specimen. Reduction of the width of the specimen by partial division of the mesocolon provides a high success rate for NOSE. This novel technique should be in the repertoire of laparoscopic colorectal surgeons.
can be aborted because of specimen size. This challenge especially occurs for specimens that include larger mesenteries. We describe a novel method for natural orifice colorectal specimen extraction that reduces the diameter of the specimen and provides an easier extraction through the vagina.
Introduction
L
aparoscopic colectomy has been a more frequently preferred surgical method for malignant colorectal diseases since 2004.1 Current laparoscopic techniques for colorectal cancer require an abdominal incision for the removal of the resected specimen. This additional incision creates an additional risk of wound infection and incisional hernia. Natural orifice specimen extraction (NOSE) has been described as an alternative approach for delivering the resected specimen from the peritoneal cavity through an anatomic access, rather than an abdominal incision. The concept of NOSE is not new. Franklin et al.2 described in 1993 a totally laparoscopic colectomy with transanal specimen extraction. The vagina as an extraction site was first reported following laparoscopic cholecystectomy in 1993,3 and since then several authors have described standard laparoscopic colectomy with extraction of the specimen via the vagina or anus. NOSE minimizes surgical injury and involves no visible scar, low risk of incisional hernia and wound infection, faster recovery, and decreased postoperative pain.4–8 Although NOSE benefits from the minimal invasiveness of laparoscopic colorectal surgery, all natural orifices (anus, vagina, and mouth) have anatomic limitations, and the procedure 1 2
Case Report
A 62-year-old woman was admitted for hypochromic microcytic anemia. Medical history was significant for cerebrovascular accident, diabetes mellitus, and hypertension that were controlled by oral antidiabetic, antiaggregant, and antihypertensive agents. Her body mass index was 31 kg/m2, and the American Society of Anesthesiologists score was III. Physical examination revealed a palpable mass in the lower right quadrant. Her biochemical parameters were in the normal range. Colonoscopy showed a 5-cm ulcerous cecal mass with a histological diagnosis of adenocarcinoma. Computed tomography of the abdomen and pelvis was negative for metastatic disease (Fig. 1). The preoperative carcinoembryonic antigen level was 2.7 ng/mL (normal,
