Transperineal NOTES-Inspired Approach to the Total Mesorectal Excision (TME) in Patients with Rectal Neoplasia A preliminary experience

Elie K Chouillard, MD, PhD. Department of General Surgery, POISSY SAINT GERMAIN MEDICAL CENTER.

Background: Natural Orifice Transluminal Endoscopic Surgery (NOTES) is an emerging surgical approach. In humans, “pure” NOTES is still slowed down by technical hurdles. However, “Hybrid” variants have been increasingly reported. Total mesorectal excision (TME) is the best treatment for patients with resectable mid or low rectal neoplasia. However, TME is still technically demanding and associated with significant morbidity, mainly related to anastomotic failure and nerve injuries. We have developed a transanal, NOTES-inspired approach to TME (taTME) in patients with rectal neoplasia. The aim was to further reduce or even avoid the abdominal wall invasiveness of laparoscopy. Eventually, this approach could reduce post-operative pain, decrease overall morbidity, preserve the abdominal wall, and enhance cosmesis.

Methods: taTME was attempted in 16 patients with mid or low rectal neoplasia (i.e., lower edge of the tumor between 0 and 12 cm from the dentate line). Additional criteria included ASA status I to III and the absence of prior major abdominal surgery. The technique was performed using a transanal approach with or without single-incision laparoscopic abdominal assistance.

Results: taTME was completed in 14 patients (87.5 %). Conversion to conventional laparoscopy occurred in two patients. Mean operative time was 265 minutes (range, 155-440). Mortality rate was 0 %. Post-operative complication rate was 18.8 % (2 intestinal obstructions, 1 pelvic abscess). No anastomotic leakage occurred. Resection was complete in all the patients. An average of 18 nodes were retrieved (range, 12-81). Mean length of hospital stay was 10.4 days (range, 4-29).

Conclusion: taTME was found to be safe and feasible in this series of selected patients with mid or low rectal cancer. The short-term mortality and morbidity results seemed to be acceptable. There seemed to be no compromise in the oncological quality of resection occurred as based on the histological analysis of the specimen.