Hybrid NOTES laparoscopic anterior resection in women and men

Objective of the study: The NOTES hype of the last few years did not lead to any adoptions in daily routine with the exception of the hybrid NOTES cholecystectomy which has become a standard procedure in several institutions. In our opinion the rigid hybrid NOTES technique is the perfect tool to convert laparoscopically assisted operations into totally laparoscopic procedures, avoiding the need of a minilaparotomy.

Methods and procedures: Although, in standard laparoscopy, we can usually perform the operation with a few five millimetres incisions and one ten millimetre trocar (for insertion of the Endostapler), there remains the need for a minilaparotomy for specimen removal. This lead to the idea of removing specimen through natural orifices avoiding additional harm to the abdominal wall. As the transvaginal route is an old and well known surgical pathway since decades, it was obvious to develop the technique of transvaginal retrieval of colorectal specimens. When this technique was introduced, the proximal stapling of the specimen and the insertion of the anvil in the proximal lumen was performed extracorporally in the vagina. We advanced this technique and meanwhile we perform an intracorporal purse-string suture after insertion of the anvil in order to avoid any compromises concerning the length of the specimen. The transrectal pathway is a good alternative for retrieval of the specimen in men or in women with contraindications for a transvaginal route.

Results: In our experience after more than hundred transvaginal and transrectal laparoscopic anterior resections it is a safe and feasible method for daily routine.

Conclusions based on the results: In our opinion these techniques are the consequent evolution of the standard laparoscopic surgery in colorectal surgery. Combining standard laparoscopic operative techniques with specimen retrieval through natural orifices, eliminates the need for a minilaparotomy, allowing a totally laparoscopic operation with only small incisions. This significantly minimizes the risk of scar hernias, reduces postoperative pain and leads to quicker recovery of the patients. The transvaginal laparoscopic (rigid hybrid NOTES) anterior resection has become a routine procedure in our clinic. In near future, the transrectal laparoscopic resection will become our standard procedure in men. We demonstrate our technique of intracorporal purse-string suture combined with transvaginal removal and report a first series of transrectal laparoscopic anterior resection with operative video sequences.