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432
J.-S. Trépanier et al.
Fig. 42.3 Rectotomy at the site of stenosis in the rectal
stump
Fig. 42.4 Rectotomy reaching the total mesorectal plane
(upper right corner)
decided to resect the proximal part of the rectum
beneath the previous Hartmann’s suture/staple
line, to avoid creating the anastomosis in a brotic
or narrowed rectal wall. If a longer segment of the
rectum has to be resected, one can close the rectal
lumen with a 0 polypropylene purse-string suture.
Subsequently, the rectotomy is performed, cutting
the rectal wall perpendicularly (Figs. 42.3 and
42.4). Once the perirectal mesorectum fat is
reached, dissection is directed cephalad toward the
desired point of rendezvous with the abdominal
team. Often, dissecting in the total mesorectal
plane will help to connect the abdominal and
transanal elds and will avoid having parallel
planes. In the process, the old staple line on the
rectal stump is completely resected and extracted
through the transanal platform. Next, a pursestring suture is placed on the open rectal stump
Fig. 42.5 Placement of a purse-string running suture on
the open rectal stump (from a transanal perspective)
Fig. 42.6 Another transanal view of the purse-string
suturing
using a 0 or 2–0 polypropylene suture (Figs.42.5
and 42.6). The proximal colon with the anvil in
place is pulled down into the pelvic inlet. The rectal stump purse string is tied around the anvil’s
long central spike, as is the case of PPH stapler.
Alternatively, a drain or a urinary catheter can be
used to guide the anvil if a standard EEA stapler is
employed. Then, a double purse-string single-stapled anastomosis is created after connecting the
anvil to the stapler (Figs.42.7 and 42.8). An endto-end or a side-to- end anastomosis can be performed according to the surgeon’s preference and
colon characteristics. Inspection of the anastomosis is achieved laparoscopically and transanally.
An air leak test is also performed. If there exists
concern about the appropriate vascularization of
the colon or rectum before completing the anastomosis, an intraoperative blood perfusion assessment is performed using indocyanine green (ICG)
uorescence imaging. A temporary diverting loop
42 Hartmann’s Reversal by a Combined Transanal-Transabdominal Approach
Conclusion
A combined laparoscopic abdominal and taHR is
a novel approach to achieve intestinal continuity
reconstruction. Further studies are needed to
prove the safety of the procedure and to clarify its
indications. However, in centers with expertise in
transanal surgery, in particular with taTME, it
was found to be a valuable additional tool to
accomplish Hartmann’s reversal by a minimally
invasive approach.
Acknowledgments We would like to thank www.ais-
Fig. 42.7 Creation of an end-to-end single-stapled double purse-string anastomosis (EEA anvil still in the proximal colon)
channel.com for the media support.
Support No source of funding to disclose.
References
1. Hartmann H. Nouveau procédé d’ablation des can-
cers de la partie terminale du colon pelvien. Congrès
Français Chir. 1921;30:411.
2. Schmelzer TM, Mostafa G, Norton HJ, Newcomb
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3. van de Wall BJM, Draaisma WA, Schouten ES,
Fig. 42.8 Final view of a completed anastomosis
ileostomy is created in the case of a low colorectal
anastomosis. A closed-suction drain is positioned
in the pelvis if deemed necessary by the surgeon,
and it is removed before hospital discharge.
Results
Preliminary results from a pilot study of ten
patients showed a 30% complication rate, with
no leak and no conversion to an open procedure
[27]. There was one conversion to a hand-
assisted procedure to help with the lysis of
adhesions. Three patients had complications:
one patient with surgical site infection (abdominal wall and pelvic) treated with antibiotics and
percutaneous drainage and two patients presented with ileus.
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JF. Avoiding or reversing Hartmann’s procedure
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12. Huynh H, Trottier DC, Soto CM, Moloo H, Poulin EC,
Mamazza J, et al. Laparoscopic colostomy reversal
after a Hartmann procedure: a prospective series, literature review and an argument against laparotomy as
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13. Haughn C, Ju B, Uchal M, Arnaud JP, Reed JF,
Bergamaschi R.Complication rates after Hartmannʼs
reversal: open vs. laparoscopic approach. Dis Colon
Rectum. 2008;51(8):1232–6.
14. Yang PF, Morgan MJ. Laparoscopic versus open
reversal of Hartmann’s procedure: a retrospective
review. ANZ J Surg. 2014;84(12):965–9.
15. de’Angelis N, Felli E, Azoulay D, Brunetti F.Roboticassisted reversal of Hartmann’s procedure for diverticulitis. J Robot Surg. 2014;8(4):381–3.
16. Arkenbosch J, Miyagaki H, Kumara HMCS, Yan X,
Cekic V, Whelan RL.Efcacy of laparoscopic- assisted
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database. Surg Endosc (Springer US). 2015;29(8):1–6.
17. Celentano V, Giglio MC, Bucci L.Laparoscopic versus open Hartmann’s reversal: a systematic review and
meta-analysis. Int J Color Dis. 2015;30(12):1603–15.
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H, Ben-Yaacov A, et al. Comparison between laparoscopic and open Hartmann’s reversal: results of a
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H. Endoscopic surgery in the rectum. Endoscopy.
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Braunstein S, etal. Clinical results of transanal endoscopic microsurgery. Surg Endosc. 1988;2(4):245–50.
21. Atallah S, Albert M, deBeche-Adams T, Larach
S. Transanal minimally invasive surgery (TAMIS):
applications beyond local excision. Tech Coloproctol
(Springer Milan). 2012;17(2):239–43.
22. Sylla P, Bordeianou LG, Berger D, Han KS, Lauwers
GY, Sahani DV, et al. A pilot study of natural orice transanal endoscopic total mesorectal excision
with laparoscopic assistance for rectal cancer. Surg
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23. Heald RJ. A new solution to some old problems:
transanal TME.Tech Coloproctol. 2013;17(3):257–8.
24. Adamina M, Buchs NC, Penna M, Hompes R,
St.Gallen Colorectal Consensus Expert Group.
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25. Bravo R, Fernández-Hevia M, Jiménez-Toscano M,
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27. Trépanier J-S, Arroyave MC, Bravo R, JiménezToscano M, DeLacy FB, Fernández-Hevia M, etal.
Transanal Hartmann’s colostomy reversal assisted by
laparoscopy: outcomes of the rst 10 patients. Surg
Endosc. 2017;142(12):598–4987.
Pure NOTES Transanal TME
Joel Leroy, Frédéric Bretagnol, Nguyen Ngoc Dan,
Hoa Nguyen Hoang, Truc Vu Trung,
and Chuc Phan Ngoc
43
Introduction
At the beginning of the twentieth century, Miles
(1906) [1] was the rst to propose an oncologic
resection in rectal cancer reducing local recurrence rate from 90% to 30%. He dened the benet to remove “en bloc” all the rectum and the
regional nodes with clear margin (R0 resection).
J. Leroy (*)
Hanoi High Tech & Digestive Center, St Paul
Hospital, Digestive Colorectal Department
of Minimally Invasive Surgery, Hanoi, Vietnam
F. Bretagnol
Digestive Surgery—University Louis Mourier
Hospital (APHP), Paris, France
N. N. Dan
Hanoi High Tech & Digestive Center, St Paul
Hospital, Hanoi, Vietnam
H. N. Hoang
Hanoi High Tech & Digestive Center, St Paul
Hospital, Digestive Colorectal Department of
Minimally Invasive Surgery, Hanoi, Vietnam
Thai Binh Medical University, Thai Binh, Vietnam
T. V. Trung
Hanoi Medical University, Hanoi, Vietnam
St Paul Hospital, Digestive Colorectal Department
of Minimally Invasive Surgery, Hanoi, Vietnam
C. P. Ngoc
Hanoi High Tech & Digestive Center, St Paul
Hospital, Digestive Colorectal Department
of Minimally Invasive Surgery, Hanoi, Vietnam
Hanoi Medical University, Hanoi, Vietnam
In 1982, Heald etal. published the concept of the
total mesorectal excision (TME) for rectal cancer
treatment [2]. This procedure remains the gold
standard worldwide in the surgical treatment of
advanced rectal cancer (Fig.43.1). Laparoscopic
resection has been shown to be oncologically
equivalent as compared to open resection in the
hands of experts, but TME is a challenging technique particularly for low rectal adenocarcinoma
managed by open or laparoscopy even with
robotic assistance, useful in obese patient [3].
Transanal TME (taTME) is not a completely
new concept [4] but, rather, a mixture of surgical
techniques developed during the end of the twentieth century [transanal endoscopy microsurgery
(TEM), transabdominal transanal (TATA), and
transanal minimally invasive surgery (TAMIS)].
Patricia Sylla and Antonio Lacy (2010) reported
their early experience, with transanal video assistance, showing encouraging results in terms of
safety and efcacy [5].
In the technique we describe below, oncologic
TME is performed exclusively via the pathway
using perirectal and retroperitoneal endoscopic
dissection. We described it in experimental and
clinical settings [6–9].
Rationale
In advanced rectal cancer, the surgical gold standard is TME performed either by (a) a minimally
invasive laparoscopic [without (90%) or with
© Springer Nature Switzerland AG 2019
S. Atallah (ed.), Transanal Minimally Invasive Surgery (TAMIS) and Transanal Total Mesorectal
Excision (taTME), https://doi.org/10.1007/978-3-030-11572-2_43
435
436
Fig. 43.1 TME principles for rectal cancer. Meso and its
tail are removed respecting fascial envelop
robotic assistance (10%)] resection or, alternatively, (b) by an open, abdominal procedure. To
perform a TME, Gerald Marks in the 1980s proposed transanal route for low rectal tumors after
radiochemotherapy (RCT) and in fragile patients
or patients with a difcult pelvic access (obesity),
i.e., narrow space. In the 1990s, his son John
Marks updated this approach by combining it
with laparoscopy [10]. All these techniques are
hybrid techniques that combine two approaches.
They called this technique the TATA (transanaltransabdominal) proctectomy [11].
The transanal route was used, by us and most
authors, to nish “up-to-down” TME using intersphincteric resection (ISR) in ultra-low rectal
tumors and for performing full-thickness resections with TEM platform. Recently surgeons have
proposed to begin transanally using video endoscopic platform to facilitate laparoscopic distal
step of the TME using the concept proposed by
Gerald and John Marks in the TATA. Zorron
(2014) named this approach down- to- up TME in
opposition of the up-to-down TME [12], but
authors performed only a distal or subtotal perirectal dissection, and it is more appropriate to say distal partial or total mesorectal dissection (TMD).
Both techniques use combined methods (transanal
and laparoscopic). They are well described in
other chapters of the book.
Our area of investigation focused on exploring
the possibility of performing a pure NOTES (natural orice transluminal endoscopic surgery)
J. Leroy et al.
Fig. 43.2 Gold standard of oncologic rectal resection for
cancer with lymphadenectomy
transanal procedure removing the rectum and the
mesorectum, dividing the inferior mesenteric vessels with en bloc lymphadenectomy (Fig. 43.2),
and doing a transanal colorectal or coloanal anastomosis after removing the specimen transanally.
Oncologic resection of the rectum must include
rectal resection, mesorectal resection respecting
propria fascia with free lateral and distal margin
(R0 resection), and en bloc vascular package
removal including inferior mesenteric vessels and
nodes (Fig.43.3). Most authors include the mobilization of splenic exure, but it is only for the
purpose of constructing a tension-free anastomosis, and not for any oncologic reason.
In early rectal cancer, different techniques
have been described. Local full-thickness
resection was introduced using a specically
designed operating apparatus (i.e., TEM) beginning in the early 1980s by Gerhard Buess with
success in selected cases [13]. The local recurrence rate was low but not nil. In our opinion,
oncologic, curative- intent local excision must
include analysis of the nodes in the mesorectum
43 Pure NOTES Transanal TME
437
Fig. 43.3 Mid-pelvis
cross-section view in
male. Anatomic
landmarks of fasciae
plane of dissection
Parietal fascia
Denonvillier fascia
Seminal vesicles
sacrum
Sacral vessels
to limit the risk of local recurrence treatment failure– and it is especially crucial to obtain staging
that is as accurate as possible, to avoid underestimation of the tumor’s true stage.
Our rst complete oncological resection of the
rectum together with its mesorectal envelope
using a purely transanal approach was performed
in June 2010. The patient was a 55-year-old male
(in fact, a family doctor) who developed a recurrent mid-rectal lesion after polypectomy with suspected invasive disease, based on morphology
(although biopsy revealed only benign neoplasia).
He refused standard of care, radical surgery (upto-down TME), because of the risk of bad functional results, and he preferred to have a transanal
local excision. Due to the characteristics of the
neoplasm, a pure NOTES transanal TME was performed. Finally pathologic examination revealed
invasive adenocarcinoma, pT2N1 (1/15 lymph
nodes positive for metastatic disease).
It was a pure NOTES taTME with a long operative time (about 6 h), but– except for diffuse
emphysema of the retroperitoneum, mediastinal,
and cervical spaces – the postoperative course
was uneventful with recovery that was quite
rapid. This patient subsequently received adju-
Superior Rectal Vessels
Superior
Hypogastric nerves
TOTAL
MESORECTAL
EXCISION
bladder
Sacral nerves
Middle
Rectal Artery
Inferior
Hypogastric nerves
vant RCT. On follow-up, 6months later, a liver
metastatic lesion was detected and promptly
resected. Today, the patient is disease-free with
good functional results.
For the next patient, we performed another
NOTES transanal TME for cancer, but, before
doing the anastomosis, a laparoscopic exploration through a single port introduced in the right
iliac fossa was performed so as to control the
quality of the vascular dissection and, in addition, to aid with bowel mobilization and for creating a diverting ileostomy, as the patient
received neoadjuvant radiotherapy. Analyzing
our initial experiences, we standardized the procedure that now seemed quite reproducible. As
this process improved, the operative time has
decreased markedly. Recently, a female (BMI
29) underwent the pure NOTES approach for
rectal cancer, she had no previous abdominal or
pelvic operations, who had a T2N0 mid-rectal
tumor (Figs.43.4 and 43.5). The operation was
completed in approximately 2h. Thus, we have
rened and standardized the steps of the procedure in a better way; consequently, indications
are limited in early- stage tumors for this technically demanding approach.
438
Fig. 43.4 CT-scan showing a long compliant sigmoid
loop (ideal case for pure NOTES taTME)
J. Leroy et al.
Patient Selection
Patient selection is paramount when considering
a pure NOTES taTME approach. After a thorough discussion concerning risks, benets, and
alternative approaches, consenting patients are
included in our prospective trial for pure NOTES
taTME.We select patients with mid-to-low early
rectal cancers (T1, T2) (Fig.43.6). Currently, we
exclude patients with locally advanced (T3, T4)
disease.
Surgical Technique
Armamentarium
Instrumentation is essential to the success of this
approach. We use the TEO® platform (Karl Storz,
Tuttlingen, Germany) which is a 4cm diameter
operating rectoscope tube (Fig. 43.7). The platform includes 4cm diameter tubes at the oblique
distal extremity (the superior border is the longest) and at the proximal orice, which allows the
connection of cups of different shapes and functions allowing for the introduction and use instruments of various diameters– including berscopes
up to 2cm in diameter (each instrument can maintain a seal with the aid of device- specic caps).
For the TEO® apparatus, there are three access
channel tube lengths (the “short” one which is
7.5cm long, the “medium” one is 15cm long, and
the “long” one is 20cm long). Once introduced
into the rectum (after dilating the sphincter with a
dilator), the tube is xed by an articulating support to the operating table. The TEO® can be
Fig. 43.5 CT-scan of T2 lateral mid-rectal cancer (same
patient, ideal case)
Fig. 43.6 Endoscopic view of the T2 mid-rectal cancer
43 Pure NOTES Transanal TME
Fig. 43.7 TEO® platform from Karl Storz
439
repositioned by adjusting the Martin arm which is
mounted to the operating table, and this allows
scope movement to more proximal portions of the
rectum, which is required during NOTES
taTME.This is important, as the working space is
a function of the size and length of the operating
tube and of the instruments size– since work is
done in the axis of the tube. The main advantage
of using the TEO® platform is in the concept of
circular retraction done by the shape of the tube. It
is exactly similar to the endoscopist when he performs a mucosectomy inside a cup exposing the
eld (Fig.43.8). Thus, TEO® is used to expose
the eld doing circular retraction leading to a
larger surgical eld to dissect safely in the middle
and for making a tunnel in the dissection plane
without an additional retractor. This allows one to
perform the operation autonomously.
Insufation is performed using CO
gas set
2
with continuous high ow (typically in the range
of 12–15 mmHg). The platform includes three
taps, or access points– two of them are a part of
the faceplate connected to the rectoscope (one for
the CO2 insufation, the other for cleaning the
Fig. 43.8 Endoscopic cap use for EMR at the extremity
of a berscope
camera’s lens), and the last tap, located in the
TEO® scope’s handle, is used for evacuating
plumes of smoke created during the process of
electrocautery dissection. It is very important to
have a specialized gas insufator, with continuous high ow of CO2, to clear the operative eld
and evacuate the smoke (ENDOFLATOR® 40
SCB, Karl Storz, Tuttlingen, Germany). To limit
440
J. Leroy et al.
Fig. 43.9 MedicalTek® (Taichung, Taiwan). Box for
2D–3D real video conversion (available in 2K and now in
4K)
the plumes of smoke, we use a low power (20
watts) setting and a modern electronic control
energy generator.
The platform includes a 4.5mm camera lens,
xed to the device, connected itself to a cold light
source by a ber-optic cable. The tip of the scope
is a Hopkins® angled 30° downward. There are
two camera lens scope lengths, the 21cm one is
adapted to the 7.5 and 15 cm platform and the
28cm one is for the 20cm length device. A full HD 2K video laparoscopic camera is connected
to the scope. Recently we used a 4K video camera (Olympus) and tested the 2K/4 K 3D video
convector (Fig.43.9).
For ergonomics, the liquid crystal display
(LCD) monitor (minimum 35′ diagonal) is positioned above the pubis. The TEO® is xed to the
operating table using a specic holding system,
U-shaped, autoclavable, with quick release coupling KSLOCK®, consisting of HR Rotation
Socket, to clamp to the OR table, for European
Fig. 43.10 U-shaped articulating arm xed to the operating table to maintain TEO® device
and US standard rails, with lateral clamp for
height and angle adjustment of the articulated
stand (Fig.43.10).
The TEO® faceplate is composed of three
channels (two 5mm and one 10mm) (Fig.43.11)
allowing introduction of operating instrumentation, which can include the same ones used for
conventional laparoscopic surgery, and in this
fashion, TEO® is similar to TAMIS.There exists
specic instrumentation developed for the TEO®
and the S-Portal® system (Karl Storz, Tuttlingen,
Germany), long instruments and double-curved
instruments with a rotating tip as developed by
S.Wexner and J.Leroy.
Monopolar electrosurgery can be connected to
any type of adapted laparoscopic instrument. In our
experience, the monopolar tool with optimal performance characteristics has been the 5 mm HF
monopolar spoon electrode with smoke evacuation
suction channel, designed by Olympus Company
(Tokyo, Japan) (Fig. 43.12). We also recommend
43 Pure NOTES Transanal TME
Fig. 43.11 Cap xed to the TEO®. Cap with three working channels and one for the camera
Fig. 43.12 Monopolar spatula with smoke evacuation
channel (Olympus™, Japan)
other energy devices (e.g., THUNDERBEAT™
platform or LigaSure Advance™ (Covidien, New
Haven, CT, USA) for the safe and durable sealing
of vessels. To control local bleeding, we use bipolar
coagulation, monopolar coagulation with spatula,
and, if necessary, the suction-irrigation-coagulation
cannula from Olympus Company designed by
J.Okuda (Fig.43.13).
441
Fig. 43.13 Suction, irrigation, and monopolar distal
coagulator (useful for pelvic bleeding control)
Setup
All patients were administered a standard preoperative bowel preparation. Specically, patients
received 3–8 days of a low residue diet, and,
upon admission 1 day prior to the operation,
cathartic enemas were administered. We have
since modied our protocol to include a full
mechanical bowel preparation combined with
oral antibiotics, based on evolving guidelines
supported by recent data [14].
The step-by-step procedure has been previously published and described in detail [28].
Under general anesthesia, the patient is placed
supine in a lithotomy/Lloyd-Davies position with
urinary catheter placement and padding required
around the calves to protect the common peroneal nerve in the lower leg. The patient’s buttocks
should extend slightly beyond the inferior edge
of the table. Thromboprophylaxis is initiated and
includes graded compression stockings, intermittent pneumatic compression devices, and venous
foot pumps. Operating table with remote control
changes in positioning is recommended.
The nal control monitoring screen is placed
above the pubis in the visual axis of the operator,
as described previously.
For safety reasons, the different control panel
elements (carbon dioxide pressure, carbon dioxide
output, insufated volume, power of used energies)
should be visually and rapidly accessible to the
team. The laparoscopic equipment should be prepared in the operating room in case of conversion
or should a hybrid technique be required. The
patient is draped for both approaches, as well, if the
event transabdominal access becomes necessary.