Single Incision Laparoscopic Low Anterior Resection combined with Natural Orifice Surgery using prolapsing technique

Goutaro Katsuno, MD, PhD, Masaki Fukunaga, MD, PhD, Yoshifumi Lee, MD, PhD, Kunihiko Nagakari, MD, PhD, Masahiko Sugano, MD, PhD, Masaru Suda, MD, PhD, Yoshito Iida, MD, PhD, Seiichirou Yoshikawa, MD, PhD, Masakazu Ouchi, MD, PhD, Yoshitomo Itou, MD, PhD, Yoshinori Hirasaki, MD, PhD, Daisuke Azuma, MD, Shintaro Kohama, MD, Jun Nomoto, MD. Department of Surgery, Juntendo Urayasu Hospital, Juntendo University.

Introduction: It is often technically difficult to cut the lower rectum by endoscopic linear stapler in Single-incision Laparoscopic Low Anterior Resection (SILAR) because we need to insert some surgical devices through the same access platform. If we fail to cut the rectum correctly, it may cause anastomotic leakage.

Meanwhile, we have ever experienced 78 conventional laparoscopic low anterior resections using NOSE(Natural Orifice Specimen Extraction) with prolapsing technique for colo-rectal cancers. In these 78 cases, anastomotic leakage rate was very low (1/78: 1.28%). Using our experiences, we recently applied NOSE with prolapsing technique to overcome this technical difficulty in SILAR procedures for some selected patients.

Indications: SILAR is usually applied to cases that have relatively small tumor (less than 4cm) without peritonitis carcinomatosa. The patients with obesity (BMI >30) or extensive dilatation of the intestine are contraindicative for SILAR. Furthermore, the indications for prolapsing technique are as follows: (1) the extent of the primary tumor is below cT3; (2) tumor circumferential rate is below 50%; (3) anal stricture (-).

Surgical technique:

Single Incision Laparoscopic Low Anterior Resection (SILAR)
The access platform is placed in the small umbilical incision area. Recently, we usually use EZ accessTM as a Multi-access platform (MAP). SILAR is performed using a surgical technique similar to the conventional laparoscopic medial-to-lateral approach by standard straight laparoscopic instruments. We can usually divide the rectum using the flexible laparoscopic linear stapler inserted directly through the MAP. However, when we encounter some troubles where it might be technically difficult to divide the rectum at the lower level, NOSE (Natural Orifice Specimen Extraction) with prolapsing technique is very useful for dividing the rectum more confidently.

Natural Orifice Surgery using prolapsing technique
The proximal part of the tumor site is transected with laparoscopic staplers. Then, the tumor lesion and bowel are pulled out of the body through the anus by means of inversion, followed by cutting the distal side of the bowel with a stapler correctly and reinforcing the rectal stump by stich under direct vision. The distal side of the bowel is pushed back into the body. NOSE with prolapsing technique is complete. After that, the anvil is attached to the proximal part of the bowel at the umbilical incision site. Then, intra-corporeal anastomosis with Double Stapling Technique (DST) is performed.

Results: SILAR using NOSE with prolapsing technique was performed for 20 rectal cancer patients. All procedures were successful and were no anastomotic leakages in the series.

Conclusion: While the only drawback to this prolapsing technique is that it is limited to some selected patients, this technique enabled us to perform SILAR safely and reliably without spoiling the cosmetic advantage even in the cases where we needed to cut the lower rectum.

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