Because of the concerns over the operative platform, accidental
organ injury, and viscerotomy closure, natural orifice transluminal
endoscopic surgery (NOTES) currently remains an experimental technique.
Transanal NOTES for colorectal surgery overcomes all of these issues;
however, all of the reports to date have used hybrid laparoscopic
techniques. We demonstrate herein the first case, to our knowledge,
of pure transanal NOTES colorectal surgery.
The patient was a 56-year-old woman with a midrectal neoplasia.
Pure transanal NOTES total mesorectal excision with a coloanal
anastomosis and without a diverting stoma. Using a transanal endoscopic
operation device as a surgical platform, we created a viscerotomy
distal to an endoluminal purse-string suture. We performed a total
mesorectal excision using a “bottom-up” approach. The
sigmoid colon was mobilized by a posterior, retroperitoneal approach
and the colon was divided intraperitoneally. A hand-sewn, side-to-end,
coloanal anastomosis was performed. Because the viscerotomy was incorporated
into the anastomosis, the concerns of both accidental organ damage
and viscerotomy closure were abrogated.
The procedure was completed entirely by a transanal fashion.
We successfully mobilized the rectum, mesorectum, and sigmoid colon.
The specimen length was more than 20 cm. The patient required minimal
analgesia and her pain was nonabdominal.
To our knowledge, the first pure transanal NOTES total mesorectal
excision with retroperitoneal sigmoid mobilization and coloanal, side-to-end
anastomosis was successfully performed using what we called a Peri-Rectal
Oncologic Gateway for Retroperitoneal Endoscopic Single Site Surgery
(PROGRESSS). This monumental case could pave the way for a new era
in pure transanal NOTES for colorectal surgery.