NOTES in the management of colorectal diseases: Current experience and future directions

Abstract

Clinical implementation and widespread application of natural orifice translumenal surgery (NOTES) has been limited by the lack of specialized endoscopic equipment, which has prevented the ability to perform complex procedures including colorectal resections. Relative to other types of translumenal access, transanal NOTES using transanal endoscopic microsurgery (TEM) provides a stable platform for endolumenal and direct translu menal access to the peritoneal cavity, and specifically to the colon and rectum. Completely NOTES transanal rectosigmoid resection using TEM, with or without transgastric endoscopic assistance, was demonstrated to be feasible and safe in a swine survival model. The same technique was successfully replicated in human cadavers using commercially available TEM, with end oscopic and laparoscopic instrumentation. This approach also permitted complete rectal mobilization with total mesorectal excision to be performed completely tra nsanally. As in the swine model, transgastric and/or transanal endoscopic assistance extended the length of proximal colon mobilized and overcame some of the difficulties with TEM dissection including limited end oscopic visualization and maladapted instrumentation. This extensive laboratory experience with NOTES tra nsanal rectosigmoid resection served as the basis for the first human NOTES transanal rectal cancer excision using TEM and laparoscopic assistance. Based on this early clinical experience, NOTES transanal approach using TEM holds significant promise as a safe and substantially less morbid alternative to conventional colorectal resection in the management of benign and malignant colorectal diseases. Careful patient selection and substantial impr ovement in NOTES instrumentation are critical to optimize this approach prior to widespread clinical application, and may ultimately permit completely NOTES transanal colorectal resection.

Transanal endoscopic microsurgery: what indications in 2013?

“…TEM has been proposed as a platform for NOTES, since it is a well-established technique that allows both full-thickness resection and suture of the rectal wall defect. The feasibility of some transrectal NOTES procedures (diagnostic peritoneoscopy, liver biopsy, sigmoid resection) using TEM instrumentation, suggesting TEM as a portal for NOTES, has been recently demonstrated in experimental studies [ 76 ].…”

TAMIS-assisted laparoscopic low anterior resection with total mesorectal excision in a cadaveric series

“…10–12 Investigative activity as escalated in the evaluation of proctectomy and left colectomy via a completely trans-anal approach. 13 The feasibility and safety of trans-anal proctectomy and trans-rectal rectosigmoid resection has been demonstrated in human cadavers and porcine survival models using the rigid trans anal endoscopic platform. 14–22 The first clinical case utilizing a rigid trans anal endoscopic platform to perform trans-anal total mesorectal excision with laparoscopic assistance in a 76 year old woman with rectal cancer (pre-operative clinical stage T2N2M0) was published in 2010.…”

3-Port incisionless laparoscopic surgery for rectal cancer with a transrectal assistance

“…In 2007, Whiteford et al described the first transanal NOTES radical sigmoidectomy in human cadavers [7]. However, the progress continues to be hampered by always needing for expensive specialized equipment as well as safety concerns regarding NOTES translumenal access, particularly regarding access closure [8]. To some extent, it has hindered the widespread acceptance of this approach.…”