Skip to main content

Advertisement

SpringerLink
Log in

A novel single-port technique for transanal rectosigmoid resection and colorectal anastomosis on an ex vivo experimental model

  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

In the context of natural orifice translumenal endoscopic surgery (NOTES), we developed a new set of rigid instruments according to the principles of transanal endoscopic microsurgery (TEM).These instruments are long, curved, and steerable by rotating two wheels near its handle. Our success in transvaginal cholecystectomy in human with these instruments motivated us to explore the feasibility of rectosigmoid resection through the anus.

Methods

The young bovine large bowel with attached organs is collected en bloc and reintegrated into an anatomically designed trainer to reproduce the human anatomy. The technique comprises the following: (1) closure of the rectal lumen by an endolumenal pursestring suture; (2) transection of the rectal wall 1 cm distal to the pursestring suture and continuation of the dissection toward the fascia and upward excising the mesorectal tissue; (3) inferior mesenteric artery is divided near its origin; (4) the colon is mobilized up to the splenic flexure; (5) the mobilized colon is brought down to the pelvis, ligated twice at the intended proximal resection site, and divided between the ligatures; (6) specimen is delivered transanally; and (7) intestinal continuity is restored by stapled or hand-sutured anastomosis.

Results

Twelve rectosigmoid resections, 20 stapled, and 27 hand-sutured anastomoses were performed in two experimental setups. Mean operation time for the resection part was 78.6 min (standard deviation (SD) = 9.9). The average specimen length was 37.2 cm. During dissection in the pelvis, as the specimen was pushed upward and toward abdomen, an “empty pelvis” view of the working field was achieved, facilitating dissection. The mean operation time for hand-sutured and stapled anastomoses were 47.7 (SD = 6.9) and 43.3 (SD = 7.1) min, respectively. Both groups had one anastomotic leak.

Conclusions

Transanal rectosigmoid resection is feasible with TEM technology. The unobstructed “empty pelvis” view is likely to enhance the quality of mesorectal dissection.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 10
Fig. 11
Fig. 12
Fig. 13
Fig. 14
Fig. 15

Similar content being viewed by others

References

  1. Allaix ME, Arezzo A, Caldart M, Festa F, Morino M (2009) Transanal endoscopic microsurgery for rectal neoplasms: experience of 300 consecutive cases. Dis Colon Rectum 52:1831–1836

    Article  PubMed  Google Scholar 

  2. Guerrieri M, Baldarelli M, de Sanctis A, Campagnacci R, Rimini M, Lezoche E (2010) Treatment of rectal adenomas by transanal endoscopic microsurgery: 15 years’ experience. Surg Endosc 24:445–449

    Article  PubMed  Google Scholar 

  3. Baatrup G, Breum B, Qvist N, Wille-Jørgensen P, Elbrønd H, Møller P, Hesselfeldt P (2009) Transanal endoscopic microsurgery in 143 consecutive patients with rectal adenocarcinoma: results from a Danish multicenter study. Colorectal Dis 11:270–275

    Article  PubMed  CAS  Google Scholar 

  4. Buess G, Kipfmüller K, Ibald R, Heintz A, Hack D, Braunstein S, Gabbert H, Junginger T (1988) Clinical results of transanal endoscopic microsurgery. Surg Endosc 2:245–250

    Article  PubMed  CAS  Google Scholar 

  5. Gavagan JA, Whiteford MH, Swanstrom LL (2004) Full-thickness intraperitoneal excision by transanal endoscopic microsurgery does not increase short-term complications. Am J Surg 187:630–634

    Article  PubMed  Google Scholar 

  6. Baatrup G, Borschitz T, Cunningham C, Qvist N (2009) Perforation into the peritoneal cavity during transanal endoscopic microsurgery for rectal cancer is not associated with major complications or oncological compromise. Surg Endosc 23:2680–2683

    Article  Google Scholar 

  7. Whiteford MH, Denk PM, Swanström LL (2007) Feasibility of radical sigmoid colectomy performed as natural orifice translumenal endoscopic surgery (NOTES) using transanal endoscopic microsurgery. Surg Endosc 21:1870–1874

    Article  PubMed  CAS  Google Scholar 

  8. Sylla P, Willingham FF, Sohn DK, Gee D, Brugge WR, Rattner DW (2008) NOTES rectosigmoid resection using transanal endoscopic microsurgery (TEM) with transgastric endoscopic assistance: a pilot study in swine. J Gastrointest Surg 12:1717–1723

    Article  PubMed  Google Scholar 

  9. Buess G, Becerra-Garcia F, Misra MC (2008) Instruments for transluminal laparoscopic surgery or “NOTES”. Minim Invasive Ther Allied Technol 17:331–335

    Article  PubMed  Google Scholar 

  10. Becerra Garcia FC, Misra MC, Bhattacharjee HK, Buess G (2009) Experimental trial of transvaginal cholecystectomy: an ex vivo analysis of the learning process for a novel single-port technique. Surg Endosc 23:2242–2249

    Article  PubMed  CAS  Google Scholar 

  11. Waseda M, Inaki N, Mailaender L, Buess GF (2005) An innovative trainer for surgical procedures using animal organs. Minim Invasive Ther Allied Technol 14:262–266

    Article  PubMed  CAS  Google Scholar 

  12. Moreno M, Magos FJ, Arcovedo R, Olachea P, Palacios JA, Salazar A, Ramírez ME, Herrera JJ (2004) Comparison of the performance of the Gea extracorporeal knot with the Roeder extracorporeal knot and the classical knot. Surg Endosc 18:157–160

    Article  PubMed  CAS  Google Scholar 

  13. Buess G, Theiss R, Hutterer F, Pichlmaier H, Pelz C, Holfeld T, Said S, Isselhard W (1983) Transanal endoscopic surgery of the rectum—testing a new method in animal experiments [in German]. Leber Magen Darm 13:73–77

    PubMed  CAS  Google Scholar 

  14. Buess G, Frimberger E (2007) The dirty way to the gallbladder. Endoscopy 39:893–894

    Article  PubMed  CAS  Google Scholar 

  15. Gilbert JM, Trapnell JE (1988) Intraoperative testing of the integrity of left-sided colorectal anastomoses: a technique of value to the surgeon in training. Ann R Coll Surg Engl 70:158–160

    PubMed  CAS  Google Scholar 

  16. Ricciardi R, Roberts PL, Marcello PW, Hall JF, Read TE, Schoetz DJ (2009) Anastomotic leak testing after colorectal resection: what are the data? Arch Surg 144:407–411

    Article  PubMed  Google Scholar 

  17. Ito M, Sugito M, Kobayashi A, Nishizawa Y, Tsunoda Y, Saito N (2008) Relationship between multiple numbers of stapler firings during rectal division and anastomotic leakage after laparoscopic rectal resection. Int J Colorectal Dis 23:703–707

    Article  PubMed  Google Scholar 

  18. Kim JS, Cho SY, Min BS, Kim NK (2009) Risk factors for anastomotic leakage after laparoscopic intracorporeal colorectal anastomosis with a double stapling technique. J Am Coll Surg 209:694–701

    Article  PubMed  Google Scholar 

  19. Kuroyanagi H, Oya M, Ueno M, Fujimoto Y, Yamaguchi T, Muto T (2008) Standardized technique of laparoscopic intracorporeal rectal transection and anastomosis for low anterior resection. Surg Endosc 22:557–561

    Article  PubMed  Google Scholar 

  20. Neugebauer EA, Becker M, Buess GF, Cuschieri A, Dauben HP, Fingerhut A, Fuchs KH, Habermalz B, Lantsberg L, Morino M, Reiter-Theil S, Soskuty G, Wayand W, Welsch T; On behalf of the EAES (2010) EAES recommendations on methodology of innovation management in endoscopic surgery. Surg Endosc doi 10.1007/s00464-009-0818-3, Jan 7, 2010. [Epub ahead of print]

  21. Hermsen PE, Ayodeji ID, Hop WH, Tetteroo GW, de Graaf EJ (2009) Harmonic long shears further reduce operation time in transanal endoscopic microsurgery. Surg Endosc 23:2124–2130

    Article  PubMed  Google Scholar 

Download references

Acknowledgment

The first author acknowledges the MIO, Verein zur Forderung schonender OP Verfahren, Munich, Germany, from which he is receiving scholarship to pursue his doctorate studies in Germany.

Disclosures

G. F. Buess has shared patent rights with Richard Wolf GmbH, Knittlingen, Germany, for the long steerable instruments. H. K. Bhattacharjee, F. C. Becerra Garcia, P. Stortz, M. Sharma, S. Susanu, A. Kirschniak, and M. C. Misra have no conflicts of interest or financial ties to disclose.

Author information

Authors and Affiliations

  1. Section of Minimally Invasive Surgery, University Hospital Tuebingen, Waldhoernlestrasse 22, 72072, Tuebingen, Germany

    Hemanga K. Bhattacharjee, Gerhard F. Buess, Francisco Cesar Becerra Garcia, Pirmin Storz, Mousumi Sharma, Sidonia Susanu, Andreas Kirschniak & Mahesh C. Misra

  2. Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India

    Mahesh C. Misra

Authors
  1. Hemanga K. Bhattacharjee
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Gerhard F. Buess
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Francisco Cesar Becerra Garcia
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Pirmin Storz
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Mousumi Sharma
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Sidonia Susanu
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Andreas Kirschniak
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Mahesh C. Misra
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Hemanga K. Bhattacharjee.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Bhattacharjee, H.K., Buess, G.F., Becerra Garcia, F.C. et al. A novel single-port technique for transanal rectosigmoid resection and colorectal anastomosis on an ex vivo experimental model. Surg Endosc 25, 1844–1857 (2011). https://doi.org/10.1007/s00464-010-1476-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-010-1476-1

Keywords

Search

Navigation