Transanal Completion Proctectomy Using Tem: Initial Patient Experience in Hybrid NOTES Procedure

Michelle K Savu, MD, Alicia Logue, MD, Joseph Love, MD. University of Texas Health Science Center /South Texas VA Heathcare System San Antonio

Abstract:
Objective: Transluminal surgery offers advantages to the patient by decreasing the morbidity of abdominal incisions. The rectum naturally lends itself to a NOTES procedure as the anus is a readily accessible orifice. The purpose of this study was to develop a transanal technique for excision of the rectum. We report our experimental work in sheep study followed by our initial clinical experience in a patient who underwent a hybrid NOTES combined procedure using the TEM (Wolf Medical InstrumentsR) device for a transanal completion proctectomy combined with a conventional sigmoid resection technique.
Methods: In an acute experimental model in four 50 ± 4 kg sheep, the TEM device was introduced transanally, transcolonic access to the mesorectum and further to the peritoneum was achieved and a circumferential dissection of the rectum was performed. The colorectal specimen was removed via the anus and transected and the specimens were immediately. (No anastomosis was attempted.) In the clinical experience, the patient was a 34 year old paraplegic male with a previous end colostomy and a long terminal Hartman’s pouch in need of a completion proctocolectomy for reconstructive surgery muscle flaps for chronic bilateral hip osteomyelitis and decubiti.
Results: The proctocolectomy was successfully completely performed via the TEM in all sheep with a mean operating time of 72 minutes (range: 45-130 min). The extracted specimens averaged 40 cm in length. In the patient, the rectum was dissected circumferentially using the TEM to the peritoneal reflection (without attempt to proceed farther). Operating time was 3 hours 40 minutes. There were no complications of bleeding or bowel wall injury. The remaining redundant sigmoid was resected by standard conventional technique. Postoperatively the patient developed a superficial perineal wound infection.
Conclusions/Expectations: Use of the TEM device for circumferential resection of the rectum is feasible and safe in both the experimental and clinical settings. The use of the TEM during dissection of the rectum offers the advantages of direct visualization, monitored rectal and peritoneal insufflation pressures and the ability of using current laparoscopic instrumentation. Future applications include development of a complete NOTES technique using the TEM for proctocolectomy for both benign and oncologic indications.