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Notes Rectosigmoid Resection Using Transanal Endosocopic Microsurgery (Tem) with Transgastric Flexible Endoscopic Assistance: a Pilot Study in Swine
Patricia Sylla*1, Field F. Willingham2, Denise W. Gee1, William R. Brugge2, David W. Rattner1
1Surgery, Massachusetts General Hospital, Boston, MA; 2Medicine, GI unit, Massachusetts General Hospital, Boston, MA
Background: Transcolonic access has been used as an alternative to transgastric and transvaginal access for NOTES. Direct access to the rectosigmoid and specialized equipment makes TEM an ideal platform for transanal colorectal resection.
Purpose: To determine the feasibility of transanal segmental colectomy in a porcine model.
Methods: Procedures were performed in 7 swine cadavers ranging 30-40 kg. After occluding the lumen of the proximal rectum with a pursestring suture, a full thickness incision was created through the posterior rectal wall to enter the presacral space. Circumferential dissection of the rectum and mesorectum was extended cephalad to the mid-sigmoid. A flexible therapeutic colonoscope inserted through a gastrotomy was used to assist with retraction and achieve more proximal colon dissection. Once mobilized, the rectosigmoid was extracted transanally, transected, and a stapled anastomosis was completed.
Results: Transanal rectosigmoid resection was successfully completed in all animals with an average procedure time of 157 mins (range,120-240). The average length of resected colon was 20.3 cm (range 10-27). Both procedure time and length of specimen improved with time and experience. The anastomoses were complete in 6 of 7 animals. In one animal, a posterior anastomotic defect was noted. The peritoneal cavity was entered in all animals. On post-procedure laparotomy, no leak or adjacent organ injury was observed.
Conclusions: Transanal colorectal resection with TEM is feasible in swine and allows resection of up to 27cm of rectosigmoid. The combination of TEM and transgastric endoscopic assistance is a promising technique for NOTES segmental colectomy.
