True NOTES TME resection with splenic flexure release, high ligation of IMA, and end to side hand sewn coloanal anastomosis

Nicolas Lopez-Acevedo, MD, Grace A Montenegro, MD, Matthew N Johnson, BA, John H Marks, MD. Lankenau Medical Center

Background: Natural Orifice Transluminal Endoscopic Surgery (NOTES) represents the ultimate expression of minimally invasive surgery. Unlike in other areas where a healthy organ is perforated in order to address the diseased organ, in rectal surgery a natural orifice transanal approach allows for surgical access to perform a proper oncologic resection. We have developed and present here an initial feasibility and safety study of transanal total mesorectal excision (TME) with splenic flexure release, high ligation of the IMA and IMV and side to end coloanal anastomosis with temporary diverting ileostomy for rectal cancer.

Methods: As part of a prospective program of minimally invasive rectal cancer surgery, a program of NOTES TME resection was begun in December 2013 and four patients were treated until July 2014. Proctosigmoidectomy with release of the splenic flexure, high ligation of the IMA/IMV, with side to end coloanal anastomosis was performed transanally. Demographics, preoperative, perioperative, and postoperative data were prospectively obtained. Video documentation of all cases was recorded. The operative components of the operation were broken into TME excision, colonic mobilization, splenic flexure release, IMA/IMV transection, transanal extraction of specimen, and coloanal anastomosis for analysis of performance completion. All patients were diverted with a loop ileostomy. In cases in which the procedure could not be completed transanally, the component task was finished via a single port in the ileostomy site and time for completion was noted.

Results: Between December 2013 and July 2014 there were 3 women and 1 man operated on. Mean age was 56 years old (46-65). Mean BMI was 26 (23.8-30.2). Preoperative staging was T2N0, T2N1, T3N0, and T3N1. All cancers received chemoradiation (Xeloda; 5580 cGy (n=1), 5400 cGy (n=1) 5040 cGy (n=2)). All four patients had previous abdominal surgery. The operation was completed entirely transanally in 2 patients. Component completion of the operation was as follows: TME excision in 3 of 4; colonic mobilization in 4 of 4; splenic flexure release in 3 of 4; IMA/IMV transection in 3 of 4; transanal specimen extraction in 4 of 4; coloanal anastomosis in 4 of 4. The abdominal time for completion of the splenic flexure release took 4:53 (minutes; seconds), for transection of IMA/IMV took 19:43, and for completion of the TME took 13:41. Mean EBL was 194 cc (25-500). Outside of the stoma site, there were no abdominal incisions. There was no morbidity or mortality. The mesorectum was intact in all 4 patients and circumferential and distal margins were all negative. Mean LOS was 5 days (3-5) with median return of bowel function at 2 days (1-6).

Conclusion: This experience validates the feasibility and safety of a true NOTES TME. The critical anatomic views demonstrated on video confirm the potential of this approach for distal rectal cancer. Colorectal surgery represents the most logical application for NOTES. While highly promising, a great deal of work remains to develop the technique and applicability of NOTES colorectal surgery.

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