Best Practice & Research Clinical Gastroenterology 28 (2014) 81–96

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Best Practice & Research Clinical Gastroenterology

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Advanced laparoscopic surgery for colorectal disease: NOTES/NOSE or single port? Rishabh Sehgal, MD, MRCSI, Registrar in Surgery, Ronan A. Cahill, MD, FRCS, Consultant Colorectal Surgeon * Department of Colorectal Surgery, Beaumont Hospital, Dublin 9, Ireland

a b s t r a c t Keywords: Laparoscopy Colorectal surgery Single port laparoscopic surgery Single incision laparoscopic surgery Natural Orifice Transluminal Endoscopic Surgery (NOTES) Natural Orifice Specimen Extraction (NOSE) Transanal Minimal Access Surgery (TAMIS) Endoscopic proctectomy

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. Ó 2013 Elsevier Ltd. All rights reserved.

Introduction Colorectal surgery remains a dynamic discipline that constantly evolves as new technologies and expertise develop concurrent to advances in disease understanding, detection and imaging which themselves impact on the stage of pathology presentation [1]. Over a relatively short time period, minimal * Corresponding author. Tel.: þ353 (0) 1 809 3092. E-mail address: [email protected] (R.A. Cahill). 1521-6918/$ – see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bpg.2013.11.010

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Practice points  Operative innovation is a crucial and intrinsic aspect to developing colorectal surgery.  Access approaches are not competitive or antagonistic but in fact are complimentary.  Single port and transanal endoscopic practice has synergized with Natural Orifice operative concepts to suggest new ways to address currently challenging issues.

Research agenda  Novel instrumentation that can be used across a variety of operative approaches in order to minimize the compromises that are inherent in confined access techniques are needed. Specialized instruments can also be valuable but may lack widespread utility.  Surgeon practice style issues require specific research as a barrier to innovation implementation as (if not more) important as the device cost and operative time implications often associated with new or adapted surgical techniques. access techniques have already greatly impacted on clinical practice and indeed also on patient perception regarding operative intervention [2]. Central to the concept of accelerating evolution in surgical technique is the realization that step-changes work in tandem as the discipline strives towards technique perfection rather than in parallel streams in isolation and reciprocal exclusion. Specifically therefore the stepadvances in operative access that relate to the most recent vogue in surgical technical experience, namely single port laparoscopy and Natural Orifice Transluminal Endoscopic Surgery (NOTES) for instrument access and specimen exit, should be seen as adjunctive to both each other as well as mainstream contemporary practice and that their impact on practitioner behaviour and the evolution direction of colorectal surgery will be more than just their short-term impact on individual patients (see Fig. 1) [3]. While reduced and even single port laparoscopic access has been in existence for a considerably longer time than NOTES, the emergence of the latter concept seems to have markedly encouraged acceptance of confined access laparoscopy from the perspective of both surgical practitioner and device manufacturer (perhaps even by simply shifting perspectives of what seems extreme within the spectrum of minimal access surgery). In turn, both the practice and devices associated with single port laparoscopy has encouraged appreciation of Transanal Endoscopic Microsurgery (TEM) and Operation (TEO) practitioners whose experience and equipment had hitherfore seemed to be predominantly developing in parallel rather than in concert with mainstream laparoscopic development. As the performance of narrow access manipulation of grouped instruments around a set and common fulcrum point becomes more common and the access devices more available, transanal and transrectal endoscopic surgery has recently been realized taking advantage of precedence in the feasibility and

Fig. 1. Schematic to illustrate that complimentary nature and directional alignment of ancillary operative accesses all directed towards evolving surgery towards its ultimate perfection.

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safety associated with NOTES research in conjunction with established experience and standardization of multiport laparoscopic techniques and flexible and rigid intraluminal endoscopic practice [4,5]. NOTES was itself first espoused as a specific entity in 2006 and quickly led to consensus panels and groups working in tandem to explore and realize the possibilities of transparietal endoscopic working via natural orifices [6–10]. The concept certainly focused attention on the access potential of the extended body wall surface and encouraged additional adjunctive approaches other than transabdominal, transperitoneal access. In addition its research has led to clinical practice that demonstrated safety associated with temporary, controlled breaches of the alimentary tract and the peritoneal and systemic tolerability of minimal contamination as opposed to uncontrolled luminal spillage and infection [11]. After initial focus on transgastric working and thereafter transvaginal approaches, NOTES practice for the most part is now progressing most compellingly in the realm of colorectal surgery at present via transrectal or transanal/perineal routes [12]. This state of the art review aims to summarize the experience, principles and development underlying both these technical advances and illustrate how their synergism will pave the way for what seems likely the next step-change in colorectal access, that is laparoendoscopic operating from below either alone or in tandem with a trans-abdominal/transperitoneal approach. Multiport laparoscopy for colorectal disease Multiport laparoscopy is of course now well established as an operative access approach for colorectal resection aside from its other diagnostic and therapeutic interventions in this speciality [13]. Laparoscopic colorectal resectional procedures inevitably require a site for specimen extraction which reflects the diameter of the bowel and disease process being excised. Currently this is most often performed via an extended trocar wound or separate incision sited for optimum cosmetic and reparative advantage either of which in some way increases body wall trauma and risks adverse consequence [14,15]. While the morbidity due to 5 mm ports is generally stated to be negligible it is worth reflecting that the quoted dimension refers only to the internal diameter of the trocar and different brands vary in external diameter by up to 2 mm. In addition, the port needs perfect placement to ensure minimum risk and any oblique/imperfect placement can lead to an entry site considerably larger than that intended (due to radial forces exerted by arc of movement at the fulcrum point) [16]. These points means that even small ports can include considerable morbidity resulting in pain and cost to both patient and health-care provider even if on a somewhat exceptional basis (with incidence rates reported between 1 and 6%) [17,18]. Laparoscopic resectional surgery at present also of course usually involves one or more ports of at least 10 mm internal diameter in addition for the purposes of vessel management or bowel transection and trocars of this size are known to risk complication to a greater degree even if perfectly placed. Given these perspectives, it has been perhaps only natural that colorectal surgeons have continued to evolve operative access towards its minimized optimum along two main avenues. The first has been to avoid any additional port site/abdominal wall wounds other than that predicted as being anyway required for the purposes of specimen extraction and perform the entire laparoscopic operation (with or without extra-corporeal anastomosis) via this wound alone made preemptively at the initiation of the procedure (single port laparoscopy). The second has been to try alternative routes to extract the specimen other than through the abdominal wall taking advantage of the fact that the colorectum has a direct exit channel at its distal end (the anus) and another adjacent to it within the pelvis (the vagina) and that many specialty surgeons have long been expert at endoluminal approaches whether by flexible endoscopy or rigid operative instruments. While both accesses have their proponents, it is unclear yet whether either will ultimately be proven better or whether both techniques will be supplanted themselves in the colorectal armamentarium by another, disruptive access that takes neither for its precedent. Single port laparoscopy in colorectal surgery Technical aspects Single port laparoscopy for colorectal operation has been proposed and practiced for quite some time even before its recent acceptance as a defined entity [19–21]. Its proponents have demonstrated

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that the procedure is certainly feasible and in keeping with safe oncological and surgical practice. [22– 24] Its potential advantages lie in its obviation of any wound other than that needed to facilitate specimen extraction alone and, in this regard, it seems more suited to colorectal surgery (see Fig. 2) than other procedures such a cholecystectomy or appendicectomy where the avoidance of a couple of 5 mm ports may be less of an advantage given the 3–4 cm incision needed to site the single access device (which requires a wound dimension larger than that usually needed simply for specimen extraction in the latter operative examples). Colorectal surgery of course often employs 10–12 mm ports for instruments other than camera placement for both vessel clipping/stapling and specimen cross-stapling for transection as well as smaller 5 mm ports and many procedures involve a temporary or permanent stoma site which anyway approximates the diameter needed for both single port placement and specimen extraction. In this way, Single Port Access should avoid port site complications which, although unusual in terms in incidence, can produce high morbidity in patients and undermine any other advantage provided by the use of a minimally invasive approach for the index procedure [25,26]. While the cosmetic aspect may be less important in the usually more elderly cohort presenting for cancer surgery, body image is a high priority among younger patients and perhaps especially in those with inflammatory bowel disease [27–29]. Many of this latter group often have negative connotations of surgery (as ‘failure’) and carer interest in minimizing abdominal wounding (also beneficial in terms of preservation of abdominal wall surfaces given the likelihood in future of re-intervention either for disease recurrence or restoration of gastrointestinal continuity) is intuitively beneficial. In this way, studies have shown patient benefit associated with this operative effort but interestingly also in terms of overall hospital stay despite the arguable relatively marginal physical benefit incurred. This seems to be particularly the case for total colectomy with end ileostomy for medical refractory colitis in both the

Fig. 2. Intraoperative photographs related to single port laparoscopic access for resectional colorectal surgery (a) A commercial device (Quadport, ACS, Ireland, distributed Olympus Corp, Japan) sited in the right iliac fossa at the place intended for end ileostomy formation in a patient undergoing urgent total colectomy with stoma for ulcerative colitis. (b) The intraoperative view early in the same procedure as (a) which commences with rectosigmoid transection. (c) The extracted specimen removed via the single port access/end ileostomy site (same patient as (a) and (b)). (d) A non-commercial access device (the ‘surgical glove port’) in situ in a 3 cm transumbilical wound in a patient undergoing redo ileocolic resection and anastomosis for recurrent Crohn’s disease (prior ileocaecal resection). (e) The interior aspect of the same procedure as (d), here a predominantly lateral to medial approach is used as the stricture is seen to be densely adherent to the lateral abdominal wall. (f) The exteriorized specimen via the same 3 cm wound thereby facilitating an extra-corporeal anastomosis in the usual fashion. Note in figures (b) and (e) that the view is along the two parallel instrument shafts as all instruments are coming from the same surgical access site. A 30 degree camera lens allows greater perspective and reduced instrument clashing but concedes a somewhat off-centred view for the same reason.

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elective and urgent setting (wherein the whole operation can often be performed safely through the ileostomy site alone) [30,31] and primary and even redo ileocolic resection for Crohn’s Disease of the terminal ileum [28,29]. The perceived disadvantages of the single port techniques include access device cost and more practically their inherent tendency for instrument clash and suboptimal viewing during operations. These issues can of course be neutralized by jucidious practice and focused interest. Cost is always related to volume and surgical device manufacturers often have a portfolio of products that can reflect institutional and cross-institutional usage. Furthermore, innovations including the surgical glove port can make such access in fact cheaper than the equivalent multiport technique [32]. Instrument clutter can be reduced considerably by both streamlined operator/camera-assistant choreography that develops with time and experience and also by instrument selection and skill including expertise with 30 degree camera sets and perhaps fixed curve and roticulated instrumentation [33]. Any disadvantage is off-set too by care in patient selection and low threshold to conversion to include additional access sites in case of the access not easily facilitating the specifics of the patient’s body morphology and anatomy or the stage of the disease. Natural Orifice Transluminal Endoscopic Surgery (NOTES) and Specimen Extraction (NOSE) in colorectal surgery Technical aspects There has long been interest in the employment of natural orifices for the purposes of specimen extraction at least for selected indications in order to avoid the need for abdominal wounding simply for this purpose both to maximize cosmetic advantage and also to avoid any potential complications related to abdominal wounds (including wound pain, infection, haematoma and dehiscence/hernia) [34]. The fact that the colorectum is already being divided as part of any laparoscopic resectional operation raise the obvious concept of whether specimens can be extracted transanally and the facilitatory qualities of the vagina towards operative intervention (clean nature, easy access, elasticity, excellent wound healing and lack of septic calamity as consequence of imperfection of closure healing) as well as its adjacency to the colon and rectum equally suggested similar opportunity. This is especially the case if the anastomosis is performed completely laparoscopically leaving a separate segment of colon for extraction without other need for abdominal wall incision for the purpose of preparing and performing the anastomosis. The description and proof of concept of Natural Orifice Transluminal Endoscopic Surgery (NOTES) really focused attention on this area although initial work rather focused on transgastric and even transvesical access routes over transrectal operating (due mostly to concerns re septic implications). Over time however, transrectal and transvaginal access have in fact proved more practical than the former routes and it is now accepted that modern care and technology (incorporating antibiotic prophylaxis, rectal washout and modern energy and closure devices) seem capable of minimizing the clinical consequences of controlled colorectal enterotomy during the relatively prolonged period needed to facilitate specimen extraction. There have been many clinical reports of transrectal and transvaginal operative techniques (see Table 1) but common among them all (and holding up NOTES advance as a routine approach among colorectal surgery) has been the difficulties in and complexity associated with secure placement of the stapler anvil within the proximal portion awaiting anastomosis. All Natural Orifice techniques at present therefore need considerable revision and reformatting of the step-wise approach to laparoscopic surgery which itself has only relatively recently become standardized across the specialty as the necessary anastomotic preparation prior to resectional effort [35,36]. Unless this can be not only performed efficiently and safely but also compellingly communicated, the majority of surgeons will likely still prefer to continue with extraction through the abdominal wall wherein the quality of the bowel and its perfusion can be (albeit subjectively) assessed for perfusion and pliability and the stapler anvil can be easily securely placed by means of a purse-string without excessive effort. Certainly several innovative ways of locating the anvil proximal to the resection area have been proposed and proved valid including colonoscopic placement, magneting anchoring and percutaneous wire guidance [37– 40]. However none have yet proven completely persuasive to a wide audience of practitioners. So

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Table 1 a. Publications relating to transvaginal access/specimen extraction for resectional colorectal surgery. b. Publications relating to transrectal access/specimen extraction for left sided resectional colorectal surgery. (a) Year

1st Author

N

Mean Age

Approach

Indications

Access platform

Mean procedure time (mins)

Outcome

No. of lymph nodes

Mean blood loss (ml)

Mean postop LOS (days)

[62]

2013

Franklin ME

26

69.9

Lap/Transvaginal

Lap/NOSE

159

83.5

5.5

2011

Karahasanoglu T

29

Hybrid Lap

140

NA

20

4

[64] [65]

2009 2008

Sanchez JE Ghezzi F

1 33

63 33.4

Single port/ Transvaginal Lap/Transvaginal Lap/Transvaginal

Two intraop injuries to sigmoid and rectum Uneventful

NA

[63]

Various colorectal diseases: cancer, diverticulitis, other. Crohn’s disease Rectal prolapse Endometriosis of rectosigmoid

NA NA

NA 290

NA NA

NA 300

3 6.7

[66] [67]

2008 2007

Lacy AM Boni L

1 11

78 45

Lap/Transvaginal Lap/Transvaginal

Sigmoid Cancer Endometriosis involving sigmoid colon, mid-rectum or low rectum

Hybrid Lap Hybrid Lap

150 240

16 NA

NA NA

4 5

1

Uneventful One intraop bleeding from IMA One postop pelvic seroma One postop urinary retention Uneventful Uneventful

(b) Ref. Year

1st Author

N

Gender Mean Approach (M/F) age (yrs)

Indication

Access platform

Outcome Mean procedure time (mins)

[61] 2013 Leroy J

1 F

56

Transanal alone

Rectal Polyp

TEO device

190

[68] 2013 Zhang H

1 F

48

Rectal cancer

277 NA

Single port with PPH anoscope Lap/NOSE

300

[62] 2013 Franklin ME

Transanal alone Transanal alone

[69] 2012 Cheung TP

1 F

65.3

42

Lap/ Transanal

Various colorectal diseases: cancer, diverticulitis, other.

Cancer of appendix TEO device stump

164.7

120

LOS Specimen No. of Mean (days) length (cm) lymph blood nodes loss (ml)

20 Pelvic haematoma requiring CT guided drainage Uneventful >10 cm One Bowel Obstruction Six fecal incontinence Three anastomotic leaks Uneventful

16

Minimal NA

12

50

NA

NA

NA

87.5

6.9

NA

NA

30

5

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Ref.

1 M

36

[71] 2012 Awad ZT

1 F

27

[72] 2012 Zorron R

2 1/1

63.5

[73] 2011 Tuech JJ [11] 2011 Leroy J

1 F 16 4/12

45 61.2

Lap/ Transrectal Lap/ Transanal Transanal alone Lap/Transanal Lap/Transanal

[74] 2010 Sylla P [75] 2010 Lamade W

1 F 5 0/5

76 43

[76] 2009 Cheung HY

10 4/6

66

Lap/Transanal Hybrid Lap/ NOS Lap/Transanal

[77] 2009 Akamatsu H [78] 2009 Ooi BS

16 n/a 1 M

n/a 51

Lap/Transanal Lap/Transanal

Ulcerative Colitis

Lap/TOE device

240

Colonic inertia/ Biliary dyskinesia Rectal cancer

NA

180

Rectal cancer Sigmoid Diverticulitis Rectal cancer Diverticulitis and Rectal prolapse Left colon and Rectal Cancer Sigmoid Cancer Rectal Polyp

Rigid transrectal 355 single port device Endorec Trocar 300 Open rectal stump 120.9

Postop fever, settled on abx. Uneventful

NA

NA

NA

14

NA

NA

10

4

Uneventful

NA

11.5

75

6

NA 27.7

15 NA

NA NA

NA 6.1

NA NA

23 NA

NA NA

4 7

PPH/needle ports Tri-Port-NOS-SIG

270 155.9

Uneventful Two postop fever, normal CT Uneventful Uneventful

TOE

127.5

Uneventful

NA

11

20

7

Uneventful Uneventful

NA NA

NA NA

NA NA

11 6

Open rectal stump 180 Open rectal stump NA

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[70] 2012 Lacy AM

87

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too transvaginal extraction has been limited predominantly to upper rectum/sigmoid resections and for benign disease in order to prevent excessive traction of the segment necessary for uncomplicated anastomotic healing. Innovative staplers and other anastomotic devices may provide solutions to these practical, technical difficulties [41,42] but will obviously need considerable testing to ensure equivalence of anastomotic safety over current standard levels (especially important in colorectal surgery given the potential catastrophic consequences of postoperative intestinal breakdown). Clinical experience Transvaginal colorectal surgery To date, over 150 patients have now been described in clinical reports involving colorectal surgery with a specific focus on transvaginal extraction and Table 1 is intended to supplement the excellent review by Diana et al. on this specific topic (this review detailed 130 patients described in 23 publications including 49 right sided resections and 81 left sided resections all with transvaginal extraction in association with a laparoscopic mobilization) [43]. The most common indications to date have been resections for cancer and endometriosis (together accounting for over 90% of such cases) and a joint gynaecological procedure operation is encompassed in approximately 17% of patients. Patients with Body Mass Index up to 28 kg/m [2] have been included and the rate of ‘severe’ complications is reported by be approximately 2% and 3.7% for right and left sided colorectal resections respectively. There have been many more cases performed wherein the route of extraction has not been the main focus of the publication and of course there have been many additional non-colorectal procedures where the interior aspect of the vagina has been used either as the sole access point or indeed as a contributing access point as part of a hybrid general surgical technique (‘concept of total parietal surface) that paved the way for this route to be used for non-gynaecological specimen extraction. In tandem with this has been the very broad experience of many gynaecological surgeons in addition to the well established track record of the vagina as a well vascularized site that tends to heal excellently after incision. Again, and in contra-distinctions to other specialities wherein the vagina access site is simply required as site for specimen extraction, resectional colorectal surgery contains the need to place the stapler anvil within the proximal colonic conduit add complexity and requires considerable reformatting of the operative steps of the entire laparoscopic procedure (see above). Transrectal colorectal surgery The transrectal route was perhaps the slowest NOTES route to gain appreciation as a natural orifice extraction (indeed initially more endeavour focused on transvesical surgery in preference) mostly due to obvious concerns regarding bacterial contamination. Important experimental and clinical work in this specific area now supports the concept however that controlled exposure of the lumen of the colon is very different in clinical consequence to uncontrolled perforation and that careful preoperative preparation and expert technique can make the colorectum permissible as an entry/exit site for instrumentation ingress and even specimen egress. Further advantage for this route this that the enterotomy site can be included in the specimen for resection thereby eliminating an extra intracorporeal site for closure and obviating any potential for its breakdown and resulting complication. The simplest (and most obvious) use of this concept is in transanal extraction for patients undergoing proctectomy or panproctocolectomy and clearly the same principles can advance to include subsequent hand-sewn colo-anal anastomosis in patients suitable for such restoration of gastrointestinal continuity. Most procedures in the literature relate to left sided resections although there have been experiences reported of transanal specimen extraction for right sided resections using a colonoscope to extract the specimen transanal before laparoscopic intracorporeal anastomosis (see Fig. 3) [44,45]. Again however the main difficulty in this approach for anything other than ultralow rectal resections is the means of setting up for anastomotic construction in advance of the resectional component of surgery and in determining the optimum means for its performance as well as the current continuing need for transparietal placement which encourages exteriorization of a bowel segment for anvil placement as the natural option. While specific published clinical experience is

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Fig. 3. Intraoperative photographs showing the technique described by Prof Joel Leroy at IRACD/EITS, Strasbourg, France for Natural Orifice Specimen Extraction in combination with fully laparoscopic sigmoidectomy colectomy [11]. (a) After full mobilization of the sigmoid colonic segment for resection, a purse-string suture is placed just proximal to the intended site of distal transection. After rectal washout, a colotomy is made just below this with a suction device in close proximity to contain any luminal spillage. (b)The anvil of the stapler to be used to make the colorectal anastomosis is passed into the peritoneal cavity through the colostomy and (c) is placed into the proximal colonic segment just above the level planned for proximal transection. There is a suture tied to the pike of the anvil which will allow its capture within the proximal staple line and allow its subsequent delivery through and snug capture in a precise colotomy made near this staple line. (e) A specimen bag is delivered via the opening at the top of the rectal stump allowing (f) exteriorization of the specimen via the anorectum. The top of the rectum is then cross-stapled to close it (the small transected segment being extracted via the 12 mm laparoscopic port site). A standard transanal stapled anastomosis can then be performed by mating the circular stapler head passed into the rectum with the anvil already sited in the proximal colon.

limited (see Table 1), proponents definitely have shown that this route can be used for the performance of complex resectional surgery with anastomosis whether in combination with standard or mini-port laparoscopy or alone as the sole means of surgical access. While not all reports include complete data for compilation, experiences have included patients of body mass index upto 29 kg/m [2] and lesions a median of 30 cm proximal to the anal verge. Transanal minimal access surgery Many colorectal surgeons already employ transanal techniques in their operative repertoire at least for proctological disease. The selective practice associated with Transanal Endoscopic Microsurgery or Operation (see Fig. 4) has also been long established as a robust means for address of mid-rectal benign lesions and increasingly for local excision for rectal cancers either for palliation or cure and the indications for such intervention is increasing [46]. The obvious similarities in device shape and access confinement has led many practices to use single port devices as a means of providing hermetic transanal endoscopy using standard laparoscopic instruments and reported clinical results have been very good (see Fig. 5) [47,48]. While single port devices used transanally lack in some degree the stability associated with TEM (in addition to the potential for difficulties in placement/security of position, both TEO and single port devices use standard laparoscopic pressuretriggerred, gas-sufflation to provide the pneumorectum which may provide less consistent filling) and the single port system of course requires an expert camera-operator in close adjacency to the operator, they possess the advantage of being more widely accessible but also have enhanced technical capacity in the address of the lateral rectal wall with the patient in standard lithothomy position (and so tolerate less strict patient positioning) and may facilitate precise movements as are needed for example in suturing due to the intrinsic flexibility of nodal distance between trocar sites [49]. More recently, and excitingly, the precedent of Natural Orifice experience in combination with TEMTEO/Single port laparoscopy has encouraged surgeons to undertake full-thickness circumferential

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Fig. 4. Photographs showing the Transanal Endoscopic Operation Set (Karl Storz) both outside of and in position in a patient. The long rigid rectoscope is attached to the operating table and contains a camera slot within its upper portion. It is supplied with specialized instrumentation and obviates the need for a assistant as camera-operator.

incision of the rectum and therefore perform segmental resection of the rectum and even partial colon either predominantly or even entirely from a perineal approach (see Table 2). Low anastomosis can also be performed by this route by either direct suture placement or anvil placement into the exteriorized residual segment on the perineal aspect and thereafter stapler firing. While obviously very applicable for benign cases, this route of approach can also be easily be used to accompany a trans-abdominal component (including laparotomy) as its particular advantage (the excellent view obtained for precise dissection anteriorly around the very low and mid-rectum up to the level of the seminal vesicles) dovetails well to compliment any approach from above (which due to the anatomical configuration of the mid and low rectum within the pelvis most easily addresses the posterior aspect of the dissection, see Figs. 6 and 7). The potential benefits range from shortened operative time (dual team-combined operating) to greater precision in fascial and nerve appreciation (due to enhanced high definition of salient mesodermal, neurological and vascular structures). Concluding comments ‘Standard’ should not ever imply ‘status’ or ‘perfection’ where surgical technique is concerned and laparoscopic colorectal surgery is undergoing constant evolution as is the hallmark of any contemporary surgical specialty. At present, perhaps the most important advantage of laparoendoscopic capability still relates to the view and image quality so obtained and the advantages this imparts for

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Fig. 5. Photographs (a) and (b) show multi-instrumentation in operation via a single port device placed in the abdominal wall illustrating similarities in operating positions between this access and that of TEO/TEM systems as shown in Fig. 5(c) and (d) show both a commercial device (SILS Port, Covidien) and the surgical Glove Port used in a transanal position to facilitate intraluminal and also even transluminal (see Fig. 7) procedures of the rectum.

operative precision as well as theatre team co-operation and choreography are separate even to the benefits related to reduced wound size alone. As visualization technology advances further (including but not limited to routine video capture and archiving as well as 3D and extended energy spectrum analysis [50,51]) the case for video-assisted surgery strengthens incrementally. Therefore it is natural that endoscopic operative access continues to evolve. As always, when innovation happens to push the edge of the spectrum of care forward, improvement in the median is often a much more important consequence then the exceptional case achieved. Therefore it is essential that all colorectal surgeons follow advances in their field and consider closely how to take advantage of the concepts being demonstrated by pioneering units. Table 2 Tabulated summary of publications relating to transanal proctectomy and Total Mesorectal Excision (TME) experience. 1st author

n

Platform Method Pathology

Dumont F [56] 4 Gelpoint Bremers A [57] 9 TEM Rouanet P [58] 30 TEO Sylla P [59] 5 TEO Lacy A [60] 20 Gelpoint Leroy J [61] 1 TEO

TME CRD TME TME TME TME

Malignant Benign Malignant Malignant Malignant Benign

Trans-abdominal Operative LOS (days) assistance: n duration (min)

Morbidity Positive CRM

No of lymph nodes

360a 161 304a 275 235 190

25% 22% 30% 60% 5% Yes

16 NA 13a 33 16 16

13 12 14a 5.2 6.5 –

Laparoscopy: 4 Laparotomy: 1 Laparotomy: 2 Laparoscopy: 5 Laparoscopy: 20 No

0% n/a 13.3% 0% 0% No

Abbreviations: TEM: transanal endoscopic microsurgery, TEO: transanal endoscopic operation, CRD: close rectal dissection, TME: total mesorectal excision, CRM: circumferential margin, n/a: not applicable. a Median.

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Fig. 6. Magnetic Resonance Images (MRI) of the pelvis in both (a) a male and (b) a female patient with rectal pathology requiring anterior resection as primary therapy. The position of the patient is familiar to any colorectal surgery as being in the same orientation as the anaesthesied patient placed in lithothomy. The lower rectum occupies herein a horizontal plane that lies at almost 90 degrees to the sigmoid colon. Its position in the bony pelvis is directly aligned therefore with an endoscopic platform directed towards the anorectum from below while it is relatively inaccessible to any straight, rigid instrumentation (including a camera) attempting to approach it from the trans-abdominal aspect (whether via laparoscopy or laparotomy).

Fig. 7. Intraoperative photographs taking from an endoscopic proctectomy in a patient needing completion proctectomy following on from an urgent single port laparoscopic total colectomy for ulcerative colitis refractory to medical therapy. The surgery is performed from the perineal side but with an additional laparoscope placed subumbilically in order to monitor the intraperitoneal aspect of the rectal stump in case of any adhesions and to ensure entry into the peritoneum from below is safely performed. (a) The Gelpath port device (Applied Medical) which has been positioned into the perineum following intersphincteric circumferential mobilization of the anal canal with purse-string closure of the mobilized anus. (b) and (c) show the excellent views obtained and the preservation of the fascia around the mesorectum. The purse-stringed stump is retracted and an energy device (here a Ligasure, Covidien) is used to provide haemostatic dissection. (d) and (e) show the excellent visualization of the seminal vesicles and complete preservation of Denonviller’s fascia (f) shows entry from below into the peritoneal cavity (as indicated by the shine-through of the laparoscopic light from the peritoneal aspect).

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While many also decry the limitations of standard operating equipment, it is compelling that many of the innovative procedures described recently have used very conventional instrumentation reinforcing the point that minimally invasive surgeons most often require familiarity and confidence in their equipment perhaps most especially when performing unfamiliar procedures. Although much of the more rarefied endeavour undertaken in NOTES research and innovation laboratories may in future return to impact clinical practice [52,53], at present it is clear that the greatest impact on contemporary colorectal surgery has been when laparoscopic (predominantly straight, rigid) instrumentation has been used rather than flexible equipment. The huge amount of device innovation that centred around NOTES elucidation can be expected to return into the clinical domain once such procedures have started to become more accepted and standardized. Undoubtedly technology will have a considerable role in the roll-out of any such techniques and help markedly in moving their performance firmly into the sphere of the busy surgeon in routine practice (by whom the majority of the case service is performed worldwide). Natural Orifice Specimen Extractions techniques have paved the route for NOTES to enter clinical practice at least in a highly selected practice. Commentators who decry transvaginal access routes as only being applicable to half the population seem to underestimate the fact that this represents a potential audience of 3.5 billion (albeit lower if the access route is confined further to sexually active adults or further still to those post-partum or post-menopausal) but the point is well made that early innovation experience requires consistency over a critical number and frequency of procedural caseload is essential in the adoption and acceptance of new techniques. Clearly occasional practice is no basis for complex or technique early adoption. More conceptually, the practice of specimen extraction via an extended abdominal wall incision also by itself facilitates a spectrum of surgical access under the broad term of ‘laparoscopic-assistance’ from near-pure laparoscopic surgery to ‘mini-laparotomy’. This is especially true in the instance of right hemicolectomy where the need for specimen extraction along with the current impracticality of transanal stapled anastomosis permits many surgeons to continue to employ extra-corporeal techniques for ileocolonic re-connection following disease segment resection. While of course this is proven safe in routine, general practice, the need for specimen extraction does mitigate against widespread progress with regard to intra-abdominal technical perfection in and uptake of intracorporeal stapling [54]. The hybrid-type procedure it permits may mitigate towards a bigger wound that needed for specimen extraction alone in instances of inadequate proximal or distal mobilization and furthermore in someway contribute to the relatively higher rates of ileus/delayed gastric emptying seen in right-sided procedures even within enhanced recovery programmes. In contra-distinction, left sided procedures include stapler anvil placement in the proximal colon at the time of specimen removal (following intrabdominal distal transection) and the use of transanal stapler placement permits intracorporeal anastomosis with in situ assessment of anastomotic mechanical integrity (and perhaps in future dynamic control of perfusion sufficiency [55]) at the time of its construction and therefore keeps full focus on pure laparoscopic operating and drives skill-set acquisition and technical evolution in a greater way. The emergence of TAMIS for full-thickness resection of either part of or the entire rectum and mesorectum has been a very exciting and potentially very important recent innovation that should markedly demonstrate the advance of complimentary technologies into clinical practice. It clearly may address a very real and challenging area in colorectal surgery namely the efficient and precise dissection of the low and mid-rectum in combination with access from above (whether this is performed laparoscopically or by laparotomy). The excellent views provided in an hithero obscured area (especially in male and obese patients) may significant improve our ability to teach and train a new generation of surgeons as much as provide safer and potentially oncologically more robust operations for our patients with reduced short-term and long-term morbidity (certainly in terms of anorectal and sexual functioning). If proven so, its evolution should provide a case-study in why colorectal surgeons should resist their predjucidices regarding new concepts such as NOTES and ensure that specifics of practice style and point-in-time concerns don’t mitigate into failure to evolve service over a career for the benefit of future patients and departmental standards. Conflict of interests None to declare by either author.

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