Tech Coloproctol DOI 10.1007/s10151-014-1123-2
Natural orifice specimen extraction (NOSE) and transanal extracorporeal anvil placement during laparoscopic low anterior resection A. H. Alam • V. Soyer • M. Z. Sabuncuoglu E. Otan • C. Kayaalp
Received: 13 October 2013 / Accepted: 8 January 2014 Ó Springer-Verlag Italia 2014
Dear Sir, Natural orifice specimen extraction allows laparoscopic colorectal resections only through 5–12-mm trocar orifices on the abdominal wall without any additional incisions [1, 2]. Here, we describe a technique that facilitates laparoscopic coloanal anastomosis after retrieval of the colorectal specimen through the anus. A 62-year-old male presented with abdominal pain and rectal bleeding. He had no history of surgery and no severe comorbidity. His body mass index was less than 30 kg/m2. A mobile mass was palpated on digital rectal examination. Colonoscopy revealed an ulcerated vegetating tumor 5 cm in diameter located 10 cm from the anal verge. The pathologist reported adenocarcinoma. Computed tomography scanning showed a rectal tumor not invading surrounding tissues. No preoperative radiotherapy was planned. The patient was hospitalized for surgical treatment. Following preoperative mechanical bowel preparation and antibiotic prophylaxis, the patient was placed in the modified lithotomy position. A 10–12-mmHg pneumoperitoneum was established. We used a five-port technique: Two 5-mm ports were placed in the upper and lower left quadrants, and a 10-mm umbilical port and two 12-mm ports were placed in the upper and lower right quadrants. A. H. Alam Rabia Balkhi Hospital, Kabul, Afghanistan V. Soyer E. Otan C. Kayaalp (&) Department of General Surgery, Staff Surgeon of Gastrointestinal Surgery, Turgut Ozal Medical Center, Inonu University, Malatya 44315, Turkey e-mail: [email protected]
; [email protected]
M. Z. Sabuncuoglu Suleyman Demirel University, Isparta, Turkey
The peritoneum was incised on the promontory, and dissection extending to the inferior mesenteric artery and vein was commenced. These vascular structures were transected after clip placement. The left and sigmoid colons were mobilized with medial-to-lateral dissection. The rectum was suspended in the cranial direction, sharp dissection was extended along the avascular plane between the presacral fascia and mesorectum, and dissection with Ligasure TM (Covidien, Mansfield USA) was carried out laterally up to the levator ani muscle. Following mobilization, the rectum was transected at the rectosigmoid junction using a 60-mm laparoscopic stapler. The anus was dilated gently using two fingers, and the stapled stump was retracted transanally using an ovarian clamp (Figs. 1a, 2). The rectum was transected 5 cm distally from the mass (Fig. 1b). The proximal closed colonic segment in the abdomen was delivered transanally using an ovarian clamp under laparoscopic guidance. The closed end of the proximal bowel was opened, and following placement of the anvil, and fixation with 2–0 prolene sutures, it was returned to the abdomen (Fig. 1c). The rectum was closed using a stapler device (TA 60 mm, Covidien), and the closed stump was inverted back into the abdomen (Figs. 1d, 3). Using a transanally placed 28-mm circular stapler, anatomic continuity was provided under laparoscopic guidance (Fig. 1e). Intraoperative air leak testing of the anastomosis was negative. We created a diverting loop ileostomy for protection of the distal anastomosis. The patient’s postoperative course was uneventful except for urinary incontinence that was treated conservatively. He was discharged after 5 days. The histopathology findings were adenocarcinoma T2N0M0. The patient underwent two courses of postoperative chemotherapy and radiotherapy for 25 days. His ileostomy was reversed after 5 months, and there was no anal or urinary incontinence at 7-month follow-up.
Fig. 1 a Transected distal stump was retracted by grasping the staple line using an ovarian clamp and everted out. b Rectum was transected distally from the mass by using electrocautery. c The proximal closed colonic end in the abdomen was pulled out transanally using an ovarian clamp under guidance of the laparoscope. The closed end of the colon was opened. Anvil of end-to-end anastomotic stapler was
placed in and fixed with purse-string suture. Proximal colon with anvil was sent back into the abdomen. d Rectum was closed using a stapler device. e Anastomosis was done intracorporeally under laparoscopic guidance using a transanally placed end-to-end circular stapler
Fig. 3 Rectal stump was closed using a stapler device Fig. 2 Distal located rectal tumor was transected under direct vision by leaving a tumor free margin
Transanal extraction of the specimen and intracorporeal anastomosis using a double stapling technique has been described previously . However, this procedure has some limitations: (1) difficulty in determining the distal surgical margin during laparoscopy (2) difficulty in the transecting the rectum close to the anal sphincter (3) placement of the circular stapler anvil in the abdomen and fixation of it inside the proximal segment intracorporeally. Our technique eliminates all those drawbacks. The technique cannot be used for large circumferential tumors, which make rectal eversion impossible. We believe it is most suitable for pliable tumors close to the dentate line. Transection of the distal margin under direct vision, removal of the specimen through the anus and coloanal anastomosis without additional incision are the benefits of the technique.
In conclusion, surgeons who perform laparoscopic rectal surgery should keep this technique in mind as an alternative treatment option for selected cases to facilitate rectal resection and anvil placement and avoid additional abdominal incisions. Conflict of interest
References 1. Fu CG, Gao XH, Wang H et al (2013) Treatment for early ultralow rectal cancer: pull-through intersphincteric stapled transection and anastomosis (PISTA) versus low anterior resection. Tech Coloproctol 17:283–291 2. Ooi BS, Quah HM, Fu CW, Eu KW (2009) Laparoscopic high anterior resection with natural orifice specimen extraction (NOSE) for early rectal cancer. Tech Coloproctol 13:61–64