NOVEL SURGICAL DEVICES FOR LEFT–SIDED MINIMALLY INVASIVE COLORECTAL RESECTION WITH TRANSRECTAL SPECIMEN EXTRACTION AND INTRACORPOREAL ANASTOMOSIS

Eric M Haas, MD, FACS, FASCRS. 1) Department of Surgery, Division of Minimally Invasive Colon and Rectal Surgery, The University of Texas Medical School at Houston, Houston, Texas 2) Division of Colon and Rectal Surgery, Houston Methodist Hospital, Houston, Texas 3) South East Clinical Research Associates, Inc.

Objective: A major drawback of minimally invasive left-sided (LS) colorectal resection is the need for an abdominal wall incision to remove the specimen and perform portions of the anastomosis such as placement of the anvil of the circular stapler. This incision not only results in increased pain, risk of surgical site infection, hernia and poor cosmesis, but also disrupts the flow of the procedure with loss of pneumoperitoneum. Although the feasibility and merits of transrectal extraction of specimen and completion of an intracorporeal anastomosis (ICA) were first published over 20 years, minimally invasive devices have not been specifically designed for this approach and fewer that 1% of cases are accomplished in this fashion.

We present devices designed to simplify and standardize LS colorectal resection with natural orifice transrectal extraction of the specimen and formation of ICA without the need for the customary abdominal wall incision.

Description of the devices: A novel pursestring stapling device serves to divide the bowel at the proximal and distal level of resection as well as to place a pursestring suture to prepare the bowel for the ICA. The cartridge of the stapler features a tri-staple row of staples on one side and a novel pursestring staple row on the other side which is separated by the cutting knife blade (Figs. 1,2,3). The stapling device accomplishes two critical tasks by simultaneously stapling closed the specimen while applying a pursestring suture to the portion of the bowel to be used for an end-to-end circular stapled anastomosis. A second device is a self-expanding natural orifice extraction retractor, which serves to straighten and widen the rectum and provide a barrier to the rectal lining. This device is designed for transrectal insertion and removal (Figs. 4,5) and facilitates extraction of benign and malignant disease without concerns of contamination of the rectal mucosa. It will also facilitate the removal of large or bulky specimens that are otherwise not amenable to transrectal excision without risk of tearing and traumatizing the rectum.

The step-wise approach begins with division of the proximal and distal level of resection using the pursestring stapler device (Figs. 6,7,8,9). Next the rectal retractor is placed, and the specimen is extracted (Figs. 10,11). The retractor is removed, and a conventional circular stapler is inserted with the anvil to prepare for the ICA (Fig. 12). The pursestring suture placed on the proximal bowel is tightened to secure the anvil, whereas the pursestring suture placed around the distal bowel is tightened about the head of the circular stapler (Fig. 13). The anvil is mated to the head of the stapler and the ICA is formed.

Results: This is in the development stages

Conclusion: We provide inventions and methods designed to successfuly complete minimally invasive natural orifice left-sided colorectal resection with transrectal extraction of the specimen and formation of ICA. This approach will obviate the need for any abdominal wall incision other than the port-sites resulting in the least possible invasive approach with significant patient benefits. These devices are designed to help foster widespread adoption of this approach.