Current experience and future directions of completely NOTES colorectal resection

Area of Science:

• Minimally Invasive Surgery
• Gastroenterology
• Surgical Innovation

Background:

• Clinical use of natural orifice translumenal surgery (NOTES) is limited by specialized equipment needs for complex procedures like colorectal resections.
• Transanal NOTES via transanal endoscopic microsurgery (TEM) offers a stable platform for translumenal access to the peritoneal cavity, particularly the colon and rectum.

Purpose of the Study:

• To evaluate the feasibility and safety of completely NOTES transanal rectosigmoid resection using TEM.
• To assess the utility of transgastric endoscopic assistance in enhancing NOTES transanal procedures.
• To establish the foundation for human clinical application of NOTES transanal surgery for colorectal diseases.

Main Methods:

• Demonstrated feasibility and safety in a swine survival model.
• Replicated technique in human cadavers using commercial TEM and combined endoscopic/laparoscopic tools.
• Performed complete rectal mobilization and total mesorectal excision transanally.
• Utilized transgastric and/or transanal endoscopic assistance to improve visualization and dissection.

Main Results:

• Completely NOTES transanal rectosigmoid resection was feasible and safe in a swine model.
• Successful replication in human cadavers, enabling complete rectal mobilization and total mesorectal excision.
• Endoscopic assistance improved visualization and dissection, overcoming TEM limitations.
• First human NOTES transanal rectal cancer excision using TEM and laparoscopic assistance was performed.

Conclusions:

• NOTES transanal approach using TEM is a promising, less morbid alternative for colorectal resections.
• Careful patient selection and improved instrumentation are crucial for widespread clinical adoption.
• This technique may enable completely NOTES transanal colorectal resection in the future.