Combined Abdominal and Transanal Notes-inspired Approach to the Total Mesorectum Excision (TME): A Preliminary Study

Elie K Chouillard, MD PhD, Vincenzo J Greco, MD, Andrew Gumbs, MD FACS. On behalf of the Intercontinental Society of Natural Orifice, Endoscopic, and Laparoscopic Surgery (i-NOELS), Poissy, France


Aim: Natural Orifice Translumenal Endoscopic Surgery (NOTES) is an emerging concept in surgical ideology. Many variants have been described including « pure » NOTES, « Hybrid » NOTES, or even endoscopic surgery. Single Incision Laparoscopic Surgery (SILS) has been inspired by the potential advantages of NOTES including less abdominal wall complications, less postoperative pain, faster return to activity, and better cosmesis. This study analyzed the results of our combined, abdominal and transanal approach to total mesorectum excision (TME) in patients with low rectal cancer.
Methods: All patients were prospectively included after a written informed consent. The Ethical Board of the Hospital approved the study. Patients with resectable mid or low rectal cancer were considered candidates for a single incision approach to surgery. A single 25-mm diameter, umbilical incision was used. Three 5-mm ports were inserted through a special platform device. The lower part of the mesorectum was dissected through a transanal approach using a second type of platform device with laparoscopic instruments inserted through the anus (video).
Patients: From December 2009 to June 2011, this technique was attempted in 13 patients. Exclusion criteria comprised mainly prior open abdominal surgery, ASA III status, organ insufficiency, and hemostasis disorders.
Results: The success rate without conversion to laparotomy or additional port sites was 92.3 % (12 patients). Nine patients had rectal resection with sphincter preservation (coloanal anastomosis) and 4 patients had abdominoperineal resection. Mortality rate was nil. The overall morbidity rate (mainly minor complications) was 15.4 %. Pathological analysis of the specimen showed the margins were negative in all patients. Mean number of harvested lymph nodes was 17 (10-41).
Conclusions: SILS and NOTES procedures are safe and feasible in selected patients with rectal cancer. Advantages regarding postoperative pain and length of hospital stay could be demonstrated. However, larger scale studies are needed for further evidence-based analysis, especially regarding oncological outcome.

Session Number: Poster – Poster Presentations
Program Number: P120
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