NOTES Inspired Approach to the Mesorectum in Patients with Mid or Low Rectal Cancer: A preliminary experience

Elie K Chouillard, MD, Beatrice Vinson Bonnet, MD, Elias Chahine, MD, Abe L Fingerhut, MD, FACS

Paris Poissy Medical Center

Introduction: Natural Orifice Translumenal Endoscopic Surgery (NOTES) is an emerging surgical phenomenon. While the development of “pure” NOTES techniques in humans is still slowed by major technical hurdles, the “Hybrid” variants have been increasingly reported. Total mesorectum excision (TME) is the cornerstone of the treatment in patients with resectable mid or low rectal adenocarcinoma. Laparoscopic TME in such patients is feasible and sure. However, these procedures are still difficultly reproducible and associated to significant morbidities mainly related to ill-defined anatomy resulting in nerve injuries and anastomotic failure. We have developed a “Hybrid” NOTES variant of TME for patients with mid and low rectal cancer. By further reducing the invasiveness of the laparoscopic approach and enhancing the definition of the anatomy of the lower part of the mesorectum, we may reduce post-operative pain, decrease overall morbidity, preserve the abdominal wall, and enhance cosmesis.

Methods and procedures: “Hybrid” NOTES approach to TME was attempted in 22 patients. Inclusion criteria were proven adenocarcinoma of the mid or low rectum (inferior edge of the tumor between 0 and 12 cm from the dentate line), ASA I to III patients, and the absence of prior major abdominal surgery. The study was approved by the local Ethics Board. The written patient’ informed consent was always required. The technique was performed using a transanal approach with or without an umbilical assistance.

Results: The procedure was a success in 19 patients (86 %). In 3 patients, conversion to conventional laparoscopy occurred, with one or more abdominal ports added. The mean operative time was 184 minutes (121-288). The post-operative rate of complications was 9 % with 3 complications in 2 patients (1 pelvic abscess, 1 leak, 1 hematoma). The histological analysis showed that the margins were negative in all but one patient. The mean number of harvested lymph nodes was 21 (10-44). The median length of hospital stay was 6 days (4-21).

Conclusion: The “Hybrid” NOTES, transanal approach to TME was found to be sure and feasible in this series of selected patients with rectal cancer. No compromise in the oncological quality of the resection could be disclosed based on the histological analysis of the specimen.

Session: Poster Presentation

Program Number: P583