NOTES Colonic resection is difficult to perform because of the need for exposure, dissection, vascular control and anastomosis. The aim of the present study was to evaluate the feasibility and early results of combined transgastric-transrectal NOTES sigmoidectomy.
Materials and Methods:
A two-week survival study was undertaken to evaluate the combined trangastric-transrectal approach for sigmoidectomy in 5 mini-pigs. Under general anesthesia transgastric peritoneal access was achieved. The sigmoid colon was identified by tracing the rectum proximally. A PCEEAâ was introduced transrectally. The anvil was detached from the PCEEAâ and left in the descending colon with the assistance of a blunt tip Berci needle, in the left lower quadrant. A transrectal endoluminal retractor was introduced through the anus to provide exposure. The transgastric route was used to divide the sigmoid mesocolic vessels using a round tip electrode, endoscopic clips and scissors. Once the sigmoid colon was sufficiently mobilized, a 12 mm trocar was introduced transrectally and transfixed into the posterior rectal wall. The proximal sigmoid was divided using a laparoscopic articulating linear stapler passed transrectally. The distal sigmoid stump was delivered through the anus (pull-through technique) and divided externally with a linear stapler. To complete the anastomosis, a colotomy was performed adjacent to the proximal staple line using an endoscopic needle knife passed through the transgastric endoscope. The anvil, previously left in the desending colon, was identified, retrieved and transfixed through the colotomy. The PCEEAâ was reintroduced through the anus and an end-to-end colorectal anastomosis was performed and checked with air leak testing and rectoscopy. All animals were monitored daily for signs of distress or changes in the feeding habits. Post-operative follow-up included upper and lower endoscopy, laparoscopy and necropsy 2 weeks after the initial procedure.
All sigmoid resections were performed successfully with no intraoperative complications with a mean operative time of 45 minutes (30-45). Post-operative course was uneventful. A regular diet was resumed within 24 hours of the procedure. Two week follow-up endoscopy, laparoscopy and necropsy demonstrated good caliber vascularisation and healing of the anastomosis and no intraperitoneal complications.
Combined transgastric-transrectal sigmoidectomy is feasible and safe in the animal model and has the potential to become one of the next clinical application of NOTES for benign colorectal disease.
Session: Podium Presentation
Program Number: S032