Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1127_Библиотеки_им_академика_М_И_Перельмана
.pdf
SECTION 2 Current Clinical Applications and Techniques
https://t.me/med1917
(a)
(b)
Figure 14.1 NOTES transanal rectosigmoid resection using the TEM platform with or without transgastric endoscopic assistance in swine. (a) The
rectum is occluded with a purse string suture. (b) The TEM platform is inserted and positioned transanally. (c) Following endoscopic mobilization, the
rectosigmoid is exteriorized transanally in preparation for transection.
that the swine pelvis is too narrow to accommodate full length insertion of the TEM proctoscope for optimal exposure. This obstacle was in part overcome by combining
transgastric access with a double -channel colonoscope to
provide additional visualization and assist with endoscopic
mobilization of the sigmoid colon.
A two -week survival comparative study of transanal
versus combined transanal and transgastric endoscopic rectosigmoid resection (TA +TG) was performed in 20 animals
(see Video 14.1). Transanal dissection of the rectosigmoid
was fi rst performed through the TEM platform (Figure
14.1). In the TA +TG group, additional rectosigmoid colon
was performed transgastrically using a colonoscope. The
specimen was then exteriorized transanally, measured, and
transected, and stapled colorectal anastomosis was performed transanally followed by gastrotomy closure in the
TA +TG group using endoscopic T -tags (Figure 14.2). This
study confi rmed the feasibility and reproducibility of
transanal rectosigmoid resection with TEM, and demonstrated the safety of this approach [44]. There were no
mortalities in either group, and two complications were
noted in the TA +TG group, one abdominal hematoma and
one abdominal wall abscess resulting from a T -tag misfi re
(c)
during endoscopic gastrotomy closure [44]. The peritoneal
cavity was entered transanally in every case, and all resected
specimens and stapled anastomoses were intact. The length
of sigmoid colon that could be mobilized transanally was
limited by the reach of the TEM platform above the sacral
promontory. Transgastric access provided visualization and
endoscopic access to residual attachments of the rectosigmoid colon, which extended the average length of overall
colon mobilized transanally by 54% relative to a pure
transanal approach (15.6 versus 10.5 cm), at the cost of
signifi cantly longer operative time (254.5 versus 97.5
minutes). Sohn et al. reported similar fi ndings in a 1 -week
survival study comparing NOTES TA +TG rectosigmoid resec-
tion with single -port laparoscopic rectosigmoid resection in
22 animals [61]. Combined TA +TG procedures required sig-
nifi cantly longer operative time (mean, 239 versus 103
minutes). In the TA +TG group, four abscesses at the gas-
trotomy closure site, and two perisplenic hematomas were
found at necropsy versus two abdominal wound infections
in the laparoscopic group. Overall, complications did not
differ statistically between the groups, and the morbidity of
the NOTES procedures was again due to transgastric access
and closure [61].
154
CHAPTER 14 NOTES Applied for Rectal Surgery
https://t.me/med1917
(a)
Figure 14.2 NOTES transanal rectosigmoid resection using the TEM platform with or without transgastric endoscopic assistance in swine. (a) The
rectosigmoid is transected transanally and stapled colorectal anastomosis is performed. (b) The anastomotic rings are examined. (c) The animals survive
for 2 weeks and necropsy is performed.
(a)
Figure 14.3 NOTES transanal rectosigmoid resection using the TEM platform in a human cadaver. (a) The rectum is occluded above the anal sphincter
complex with a purse string suture. (b) The TEM platform is inserted and positioned transanally. (c) Transanal endoscopic mobilization of the rectosigmoid
is performed using TEM, laparoscopic, and endoscopic instruments.
(b)
(b) (c)
(c)
NOTES transanal rectosigmoid resection:
human cadaver experience
When evaluating potential clinical application of this technique, a major limitation of swine as a model for transanal
endoscopic rectosigmoid resection is the fact that the swine
mesorectum is considerably attenuated relative to the
human counterpart, such that TME cannot be accurately
replicated in swine. The technique was therefore extensively
evaluated in human cadavers. The steps of the procedure
were similar to that described in swine, with additional
sigmoid dissection performed endoscopically through the
TEM platform, using long and fl exible -tip laparoscopic
instruments as well as endoscopic tools.
Procedural steps
The technique of NOTES transanal rectosigmoid resection
was evaluated in human cadavers (see Video 14.2). Using
an anoscope, a circumferential purse string suture is placed
approximately 3.5 –4 cm from the anal verge, above the anal
sphincter muscle complex, and tied to occlude the rectal
lumen (Figure 14.3). The short -length TEM proctoscope is
inserted transanally and secured onto the operating table.
The faceplate is locked onto the platform and CO
fl ated to a pressure of 8 –10 mm Hg. The TEM scope is
inserted through the platform and connected to the camera
head and to a standard laparoscopic video tower (Figure
14.3). The rectal dissection is initiated by scoring the rectal
mucosa with cautery starting just distal to the purse string.
This dissection is extended full -thickness through the entire
is insuf-
2
155
SECTION 2 Current Clinical Applications and Techniques
https://t.me/med1917
(a)
Figure 14.4 NOTES transanal rectosigmoid resection using the TEM platform in a human female cadaver. (a) Full -thickness rectal transection is
performed through the TEM platform. Anteriorly, the rectal wall is mobilized off the posterior wall of the vagina. (b) Posteriorly, the presacral plane is
entered, and total mesorectal excision is performed transanally through the TEM platform. (c) The peritoneal refl ection is divided anteriorly and the
abdominal cavity is entered.
rectal wall, which is greatly facilitated by CO
Posteriorly, the presacral space is entered and TME is completed (Figure 14.4). This dissection is extended laterally on
either side and anteriorly. The anterior rectal wall is dissected sharply off the posterior wall of the prostate or vagina.
As the rectal dissection is extended more proximally toward
the rectosigmoid junction, the short -length proctoscope is
replaced with the longer proctoscope. As the anterior rectal
dissection is extended more cephalad, the peritoneal refl ection is reached and divided and the peritoneal cavity is
entered (Figure 14.4). The rectosigmoid is mobilized as
far cephalad as possible above the sacral promontory,
which is achieved using long straight and fl exible -tip instruments (Figure 14.5). The inferior mesenteric artery
(IMA) pedicle is identifi ed and transected using a stapling
device inserted transanally. When dissection using standard
laparoscopic and TEM instruments cannot be extended any
more proximally due to diffi culties with length and reach,
additional mobilization is carried out using a gastroscope
inserted transanally through one of the TEM ports. Following maximal mobilization, the specimen is exteriorized
transanally and transected (Figure 14.5). On close inspection
of the specimen, an intact mesorectum and sigmoid mesentery and intact colon and rectum are noted. Standard stapled
or handsewn coloanal can then be performed.
(b) (c)
insuffl ation.
2
the instrumentation required for the procedure, (v) the
ability to standardize the steps of the procedure, and (vi) any
factors associated with diffi cult dissection.
In a preliminary series of seven male and female cadavers
weighing an average of 80 kg (range, 63.6 –113.6kg),
transanal rectal mobilization with TME could be performed
in all cases with grossly intact rectum and complete mesorectum [62]. The peritoneal cavity was entered transanally
in all cases, and more cephalad colon mobilization became
limited by diffi culties visualizing and reaching above the
sacral promontory and providing effective bowel retraction
with the short length and rigid platform and dissecting
instruments. In three cadavers, additional sigmoid mobilization was achieved using transgastric endoscopic assistance,
and in the other four cadavers, a single -channel gastroscope
was inserted transanally to assist with proximal dissection
using standard and novel endoscopic tools. Overall, the
mean length of rectosigmoid mobilized transanally was
38.5 cm (range, 15 –75 cm), and operative time was 5.8 hours
(range 4 –8 hours) [62]. In three cadavers, the IMA could be
transected transanally through the TEM platform using a
laparoscopic stapler, and in the remaining four cadavers, this
could not be achieved due to diffi culties with exposure and
retraction. In two cadavers, proximal sigmoid mobilization
was complicated by a focal tear. Procedures were performed
using standard -length laparoscopic tools, longer -length
Experience in human cadavers
The feasibility of NOTES transanal rectosigmoid resection
using the TEM platform was evaluated in male and female
human cadavers to identify potential obstacles prior to transitioning to clinical application. Specifi cally evaluated were
(i) the completeness of TME and integrity of the resected
specimen, (ii) the ease and safety of transanal peritoneal
entry, (iii) the ability to transect the IMA transanally, (iv)
laparoscopic tools with fl exible tips, TEM instrumentation,
and standard endoscopes. Based on this preliminary experience, we concluded that transanal endoscopic rectal and
mesorectal dissection could be standardized using commercially available instrumentation, with relatively steep
learning curve, especially if performed by surgeons with
experience with laparoscopic colorectal surgery and TEM.
Rieder et al. recently compared pure transanal radical
156
(a)
https://t.me/med1917
CHAPTER 14 NOTES Applied for Rectal Surgery
(b)
Figure 14.5 NOTES transanal rectosigmoid resection using the TEM platform in a human cadaver. Following peritoneal entry, the sigmoid colon is
dissected medially (a) and laterally (b) transanally using TEM, laparoscopic, and endoscopic instruments. (c) Following maximal transanal endoscopic
mobilization, the rectosigmoid is exteriorized.
rectosigmoidectomy using the TEM platform ( N = 4) to
conventional laparoscopic -assisted rectosigmoid dissection
(N = 2) with stapled colorectal anastomosis [63]. Transanal
procedures required signifi cantly longer operative time
(mean, 247 versus 110 minutes) with signifi cantly less
length of rectosigmoid mobilized than with the laparoscopic
approach (mean, 16 cm versus 31 cm). One pure transanal
(c)
fective to retract the bowel. Transgastric and/or transanal
endoscopic tools can facilitate mobilization of additional
colon, but in the majority of cadavers, this can only extend
colon mobilization to the level of the proximal left colon.
Splenic fl exure takedown could not be performed using a
pure endoscopic technique and would require transabdomi-
nal laparoscopic assistance.
case was converted to a hybrid procedure due to diffi culty
mobilizing the sigmoid colon transanally, and one anastomotic defect was noted in the transanal group. Pathologic
evaluation of resected specimens demonstrated comparable
NOTES transanal rectosigmoid resection:
clinical experience
number of lymph nodes in both groups (median, 5 versus
4.5 nodes) [63].
In conclusion, as noted in swine, the main limitation of
NOTES transanal rectosigmoid resection in human cadavers
is to gain deeper access and exposure of the upper pelvis and
effectively manipulate the sigmoid and proximal colon
transanally. These limitations are magnifi ed in cadavers with
an acute angle at the sacral promontory, visceral obesity, and
pelvic adhesions. Currently available instrumentation is
maladapted for this purpose, and endoscopic tools are inef-
The fi rst clinical case of a NOTES transanal resection for
rectal cancer using TEM and laparoscopic assistance was
recently performed at the Hospital Clinic in Barcelona [64].
After obtaining Institutional Review Board approval,
transanal endoscopic rectal resection with TME using the
TEM platform was performed in a 76 -year -old female with
a pre -operatively staged T2N1 moderately differentiated
adenocarcinoma of the anterior rectum located 6 cm from
the anal verge, for which she was treated with standard
157
SECTION 2 Current Clinical Applications and Techniques
https://t.me/med1917
(a)
Figure 14.6 NOTES transanal rectosigmoid resection with laparoscopic assistance in a female patient with a mid -rectal cancer. (a) Posterior rectal and
mesorectal dissection is performed through the TEM platform along the presacral plane. (b) Anterior dissection of the rectum from the posterior vagina
is complete and the peritoneal refl ection is dissected with peritoneal entry. (c) Following rectosigmoid mobilization and division of the IMA pedicle,
the specimen is exteriorized and transected transanally in preparation for coloanal anastomosis.
long-course pre -operative chemoradiation. The patient was
an ideal surgical candidate in that she had no prior major
abdominal or pelvic surgery, was in excellent heath with a
BMI of 20 and excellent continence at baseline. Diagnostic
laparoscopy through a 5 -mm trocar at the planned ileos-
(b)
(c)
tichannel trocar through which the mesorectal and rectal
dissection were extended into the peritoneal cavity using
laparoscopic instruments [65]. The procedure was also performed with an intact specimen and complete mesorectal
excision.
tomy site was fi rst performed to ensure that there were no
factors precluding safe transanal endoscopic access such as
pelvic adhesions. The rectum was occluded with a purse
string 2 cm below the tumor and transanal endoscopic rectal
The future of NOTES transanal
rectosigmoid resection
dissection with TME was completed using the same steps
and instruments as described in human cadavers (Figure
14.6). The peritoneal cavity was entered anteriorly under
direct laparoscopic visualization, and laparoscopic assistance
was provided using two 2 mm needle ports at the umbilicus
and in the suprapubic area. Transabdominal assistance was
used to help retract the sigmoid colon, expose and divide
the left peritoneal attachments, identify the left ureter, and
dissect and retract the IMA in preparation for transaction,
which was completed transanally using a laparoscopic
stapler. The rectosigmoid colon was subsequent extracted
transanally followed by handsewn coloanal anastomosis
(Figure 14.6). The total procedure time was under 5 hours,
the patient ’s recovery was uneventful, and she was discharged on the fi fth postoperative day. The fi nal pathology
demonstrated a ypT1N0 tumor with intact mesorectum that
included 23 negative lymph nodes and negative proximal,
distal, and radial margins [64].
Since this original report, one additional report of transanal
rectal dissection with TME and laparoscopic assistance was
published, in a patient with a low T1 rectal cancer (3 cm
from the dentate line) [65]. In this report, the authors fi rst
performed transanal mucosectomy and full -thickness circumferential rectal resection using a transanal technique,
followed by introduction of a 4 cm wide disposable mul-
There is a growing number of reports on laparoscopic colorectal resections for benign and malignant disease with
natural orifi ce specimen extraction (NOSE), where transrectal [50,66–73] or transvaginal [74–79] access is used for
specimen extraction and/or assistance during dissection.
These early reports suggest potential benefi ts with regards
to postoperative pain, recovery, and incisional -related morbidity. At the far end of natural orifi ce surgery, pure transanal
endoscopic colorectal surgery, and specifi cally rectosigmoid
resection, remains an area of active investigation, but is currently unachievable clinically due to limitations with current
instrumentation. Until better platforms and endoscopic tools
come along, based on the encouraging preliminary clinical
experience, a hybrid NOTES approach that combines
transanal endoscopic access and laparoscopic assistance is
safe and feasible in carefully selected patients. This approach
has the potential to reduce the morbidity of radical rectal
cancer resections and the technical diffi culties of total mesorectal excision, particularly in morbidly obese patients. The
procedural and oncologic safety of NOTES transanal rectosigmoid resection with laparoscopic assistance for rectal
cancer needs to be investigated in the setting of IRB -approved
clinical trials. Critical factors for the success of this approach
include careful patient selection and extensive endoscopic,
158
CHAPTER 14 NOTES Applied for Rectal Surgery
https://t.me/med1917
TEM, and laparoscopic experience. The procedure involves
full-thickness circumferential rectal dissection starting just
above the anorectal ring in order to facilitate performance
of a safe coloanal or low colorectal anastomosis. Hence,
eligibility for the procedure should include low - and mid rectal tumors that would otherwise require low anterior
resection with TME and a diverting loop ileostomy. Until the
oncologic adequacy and safety of this approach is demonstrated in larger phase I and phase II studies, eligibility
criteria should exclude large, nearly obstructing, and T4
tumors, node -positive and metastatic disease, and any other
factors that might compromise the adequacy of the mesorectal excision. Morbid obesity and prior pelvic surgery are also
contraindications to the procedure, particularly during the
learning curve required for the procedure.
Chapter video clips
Video 14.1 NOTES transanal rectosigmoid resection using the
TEM platform with transgastric endoscopic assistance in swine.
Video 14.2 NOTES transanal rectosigmoid resection using the
TEM platform in a human male cadaver.
References
1 Påhlman L, Bohe M, Cedermark B, et al. The Swedish rectal
cancer registry . Br J Surg 2007;94:1285–92.
2 Jayne DG, Brown JM, Thorpe H, et al. Bladder and sexual func-
tion following resection for rectal cancer in a randomized clinical
trial of laparoscopic versus open technique . Br J Surg 2005;92:
1124–32.
3 Breukink SO, van der Zaag-Loonen HJ, Bouma EM, et al.
Prospective evaluation of quality of life and sexual functioning
after laparoscopic total mesorectal excision . Dis Colon Rectum
2007;50:147–55.
4 Lacy AM, García-Valdecasas JC, Delgado S, et al. Laparoscopy-
assisted colectomy versus open colectomy for treatment of non metastatic colon cancer: a randomised trial . Lancet 2002;359:
2224–9.
5 Colon Cancer Laparoscopic or Open Resection Study Group
(COLOR). Laparoscopic surgery versus open surgery for colon
cancer: short -term outcomes of a randomised trial . Lancet Oncol
2005;6:477–84.
6 Clinical Outcomes of Surgical Therapy Study Group . A compari-
son of laparoscopically assisted and open colectomy for colon
cancer . N Engl J Med 2004;350:2050–9.
7 MRC CLASICC trial group. Short -term endpoints of conven-
tional versus laparoscopic -assisted surgery in patients with
colorectal cancer (MRC CLASICC trial): multicentre, randomised
controlled trial . Lancet 2005;365:1718–26.
8 Leung KL, Kwok SP , Lam SC, Lee JF , et al. Laparoscopic resec-
tion of rectosigmoid carcinoma: prospective randomised trial .
Lancet 2004;363:1187–92.
9 MRC CLASICC trial group. Randomized trial of laparoscopic -
assisted resection of colorectal carcinoma: 3 -year results of the
UK MRC CLASICC Trial Group . J Clin Oncol 2007;25:3061–8.
10 Ng SS, Leung KL, Lee JF , et al. Long-term morbidity and onco-
logic outcomes of laparoscopic -assisted anterior resection for
upper rectal cancer: ten -year results of a prospective, randomized trial . Dis Colon Rectum 2009;52:558–66.
11 Nascimbeni R, Nivatvongs S, Larson DR, et al. Long-term sur-
vival after local excision for T1 carcinoma of the rectum . Dis
Colon Rectum 2004;47:1773–9.
12 Paty PB, Nash GM, Baron P, et al. Long-term results of local
excision for rectal cancer . Ann Surg 2002;236:522–9.
13 Heintz A, Mörschel M, Junginger T. Comparison of results after
transanal endoscopic microsurgery and radical resection for T1
carcinoma of the rectum . Surg Endosc 1998;2:1145–8.
14 Nascimbeni R, Burgart LJ, Nivatvongs S, et al. Risk of lymph
node metastasis in T1 carcinoma of the colon and rectum . Dis
Colon Rectum 2002;45:200–206.
15 Moore JS, Cataldo PA , Osler T, et al. Transanal endoscopic
microsurgery is more effective than traditional transanal excision for resection of rectal masses . Dis Colon Rectum 2008;51:
1026–30.
16 de Graaf EJ, Burger JW , van Ijsseldijk AL, et al. Transanal endo-
scopic microsurgery is superior to transanal excision of rectal
adenomas. Colorectal Dis 2011;13:762–7.
17 Tsai BM, Finne CO, Nordenstam JF , et al. Transanal endoscopic
microsurgery resection of rectal tumors: outcomes and recommendations. Dis Colon Rectum 2010;53:16–23.
18 Kreissler -Haag D, Schuld J, Lindemann W, et al. Complications
after transanal endoscopic microsurgical resection correlate with
location of rectal neoplasms . Surg Endosc 2008;22:612–6.
19 Allaix ME, Arezzo A, Caldart M, et al. Transanal endoscopic
microsurgery for rectal neoplasms: experience of 300 consecutive cases . Dis Colon Rectum 2009;52:1831–6.
20 Smith LE, Ko ST , Saclarides T, et al. Transanal Endoscopic
Microsurgery. Initial registry results . Dis Colon Rectum 1996;39:
S79–S84.
21 Baatrup G, Breum B, Qvist N, et al. Transanal endoscopic micro-
surgery in 143 consecutive patients with rectal adenocarcinoma:
results from a Danish multicenter study . Colorectal Dis 2009;11:
270–75.
22 Lee W, Lee D, Choi S, et al. Transanal endoscopic microsurgery
and radical surgery for T1 and T2 rectal cancer . Surg Endosc
2003;17:1283–7.
23 Winde G, Nottberg H, Keller R, et al. Surgical cure for early rectal
carcinomas (T1). Transanal endoscopic microsurgery vs. anterior
resection. Dis Colon Rectum 1996;39:969–76.
24 Tytherleigh MG, Warren BF , Mortensen NJ. Management of
early rectal cancer . Br J Surg 2008;95:409–23.
25 Weiser MR, Landmann RG, Wong WD, et al. Surgical salvage of
recurrent rectal cancer after transanal excision . Dis Colon Rectum
2005;48:1169–75.
26 The German Rectal Cancer Study Group. Preoperative versus
postoperative chemoradiotherapy for rectal cancer . N Engl J Med
2004;351:1731–40.
27 Hartley A, Ho KF , McConkey C, et al. Pathological complete
response following pre -operative chemoradiotherapy in rectal
cancer: analysis of phase II/III trials . Br J Radiol 2005;78:
934–8.
159
SECTION 2 Current Clinical Applications and Techniques
https://t.me/med1917
28 Lezoche G, Baldarelli M, Guerrieri M, et al. A prospective ran-
domized study with a 5 -year minimum follow -up evaluation
of transanal endoscopic microsurgery versus laparoscopic total
mesorectal excision after neoadjuvant therapy . Surg Endosc
2008;22:352–8.
29 Baatrup G, Endreseth BH, Isaksen V, et al. Preoperative staging
and treatment options in T1 rectal adenocarcinoma . Acta Oncol
2009;48:328–42.
30 ASGE/SAGES. ASGE/SAGES Working Group on Natural Orifi ce
Translumenal Endoscopic Surgery White Paper . Gastrointest
Endosc 2006;63:199–203.
31 Marescaux J, Dallemagne B, Perretta S, et al. Surgery without
scars: report of translumenal cholecystectomy in a human being .
Arch Surg 2007;142:823–6.
32 Isariyawongse JP , McGee MF , Rosen MJ et al. Pure natural
orifi ce transluminal endoscopic surgery (NOTES) nephrectomy
using standard laparoscopic instruments in the porcine model .
J Endourol 2008;22:1087–91.
33 Ramos AC, Zundel N, Neto MG, et al. Human hybrid NOTES
transvaginal sleeve gastrectomy: initial experience . Surg Obes
Relat Dis 2008;4:660–63.
34 Peterson CY , Ramamoorthy S, Andrews B, et al. Women ’s posi-
tive perception of transvaginal NOTES surgery . Surg Endosc
2009;23:1770–74.
35 Bucher P, Ostermann S, Pugin F, et al. Female population per-
ception of conventional laparoscopy, transumbilical LESS, and
transvaginal NOTES for cholecystectomy . Surg Endosc 2011;25:
2308–15.
36 Wilhelm D, Meining A, von Delius S, et al. An innovative, safe
and sterile sigmoid access (ISSA) for NOTES . Endoscopy 2007;39:
401–6.
37 Dubcenco E, Grantcharov T, Streutker CJ, et al. The develop-
ment of a novel intracolonic occlusion balloon for transcolonic
natural orifi ce transluminal endoscopic surgery: description of
the technique and early experience in a porcine model . Gastroin-
test Endosc 2008;68:760–66.
38 Ryou M, Fong DG, Pai RD, et al. Evaluation of a novel access
and closure device for NOTES applications: a transcolonic survival study in the porcine model . Gastrointest Endosc 2008;67:
964–9.
39 Fong DG, Pai RD, Thompson CC. Transcolonic endoscopic
abdominal exploration: a NOTES survival study in a porcine
model. Gastrointest Endosc 2007;65:312–18.
40 Mathews JC, Chin MS, Fernandez-Esparrach G, et al. Early
healing of transcolonic and transgastric natural orifi ce transluminal endoscopic surgery access sites . J Am Coll Surg 2010;210:
480–90.
41 Fan JK, Tong DK, Law WL, et al. Transrectal intraperitoneal
assess with transanal endoscopic operation (TEO) device in pig
model. Surg Laparosc Endosc Percutan Tech 2009;19:e109–12.
42 Pai RD, Fong DG, Bundga ME, et al. Transcolonic endoscopic
cholecystectomy: a NOTES survival study in a porcine model .
Gastrointest Endosc 2006;64:428–34.
43 Fong DG, Ryou M, Pai RD, et al. Transcolonic ventral wall hernia
mesh fi xation in a porcine model . Endoscopy 2007;39:865–69.
44 Sylla P, Sohn DK, Cizginer S, et al. Survival study of natural
orifi ce translumenal endoscopic surgery for rectosigmoid resection using transanal endoscopic microsurgery with or without
transgastric endoscopic assistance in a swine model . Surg Endosc
2010;24:2022–30.
45 Leroy J , Cahill RA, Perretta S, et al. Natural orifi ce translumenal
endoscopic surgery (NOTES) applied totally to sigmoidectomy:
an original technique with survival in a porcine model . Surg
Endosc 2009;23:24–30.
46 Dubcenco E, Grantcharov T, Eng FC, et al. “No scar ” small bowel
resection in a survival porcine model using transcolonic NOTES
and transabdominal approach . Surg Endosc 2011;25;930–34.
47 Ryou M, Fong DG, Pai RD, et al. Dual-port distal pancreatec-
tomy using a prototype endoscope and endoscopic stapler: a
natural orifi ce transluminal endoscopic surgery (NOTES) survival study in a porcine model . Endoscopy 2007;39:881–7.
48 Gavagan JA, Whiteford MH, Swanstrom LL. Full-thickness
intraperitoneal excision by transanal endoscopic microsurgery
does not increase short -term complications . Am J Surg
2004;187:630–34.
49 Baatrup G, Borschitz T, Cunningham C, et al. Perforation into
the peritoneal cavity during transanal endoscopic microsurgery
for rectal cancer is not associated with major complications or
oncological compromise . Surg Endosc 2009;23:2680–83.
50 Leroy J, Costantino F, Cahill RA, et al. Laparoscopic resection
with transanal specimen extraction for sigmoid diverticulitis . Br
J Surg 2011;98:1327–34.
51 Kim D, Tsang C, Wong W, et al. Complete rectal prolapse: evolu-
tion of management and results . Dis Colon Rectum 1999;42:
460–69.
52 Rullier E, Laurent C, Bretagnol F, et al. Sphincter -saving resec-
tion for all rectal carcinomas. The end of the 2 -cm distal rule .
Ann Surg 2005;241:465–9.
53 Schiessel R, Karner -Hanusch J, Herbst F, et al. Intersphincteric
resection for low rectal tumours . Br J Surg 1994;81:1376–8.
54 Chamlou R, Parc Y, Simon T, et al. Long-term results of inter-
sphincteric resection for low rectal cancer . Ann Surg 2007;246:
916–21.
55 Marks J, Mizrahi B, Dalane S, et al. Laparoscopic transanal
abdominal transanal resection with sphincter preservation for
rectal cancer in the distal 3 cm of the rectum after neoadjuvant
therapy . Surg Endosc 2010;24:2700–707.
56 Gamagami R, Istvan G, Cabarrot P, et al. Fecal continence fol-
lowing partial resection of the anal canal in distal rectal cancer:
long-term results after coloanal anastomoses . Surgery 2000;127:
291–5.
57 Bretagnol F, Rullier E, Laurent C, et al. Comparison of functional
results and quality of life between intersphincteric resection and
conventional coloanal anastomosis for low rectal cancer . Dis
Colon Rectum 2004;47:832–8.
58 Whiteford MH, Denk PM, Swanstrom LL. Feasibility of radical
sigmoid colectomy performed as natural orifi ce translumenal
endoscopic surgery (NOTES) using transanal endoscopic microsurgery . Surg Endosc 2007;21:1870–74.
59 Sylla P, Willingham FF , Sohn DK, et al. NOTES rectosigmoid
resection using transanal endoscopic microsurgery (TEM) with
transgastric endoscopic assistance: a pilot study in swine . J Gas-
trointest Surg 2008;12:1717–23.
60 Trunzo JA, Delaney CP . Natural orifi ce protectomy using a
transanal endoscopic microsurgical technique in a porcine
model. Surg Innov 2010;17:48–52.
160
CHAPTER 14 NOTES Applied for Rectal Surgery
https://t.me/med1917
61 Sohn DK, Yeong SY , Park JW , et al. Comparative study of NOTES
rectosigmoidectomy in a swine model: E -NOTES vs. P -NOTES.
Endoscopy 2011;43(6):526–32.
62 Sylla P, Kim MC, Dursun A, et al. Completely NOTES rectosig-
moid resection using Transanal Endoscopic Surgery (TEM):
experience in human cadavers . Poster presentation at the American Society of Colon and Rectal Surgeons, Minneapolis, MN,
June 2010.
63 Reider E, Spaun GO, Khajanchee YS, et al. A natural orifi ce
transrectal approach for oncologic resection of the rectosigmoid:
an experimental study and comparison with conventional laparoscopy . Surg Endosc 2011;25(10):3357–63.
64 Sylla P, Rattner DW , Delgado S, et al. NOTES transanal rectal
cancer resection using transanal endoscopic microsurgery and
laparoscopic assistance . Surg Endosc 2010;24:1205–10.
65 Tuech JJ, Bridoux V, Kianifard B, et al. Natural orifi ce total
mesorectal excision using transanal port and laparoscopic assistance. Eur J Cancer Surg 2011;37:334–5.
66 Franklin ME, Kazantsev GB, Abrego D, et al. Laparoscopic
surgery for stage III colon cancer: long -term follow -up. Surg
Endosc 2000;14:612–16.
67 Cheung HY , Leung AL, Chung CC, et al. Endo-laparoscopic
colectomy without mini -laparotomy for left -sided colonic
tumors. World J Surg 2009;33:1287–91.
68 Knol J, D’Hondt M, Dozois EJ, et al. Laparoscopic-assisted sig-
moidectomy with transanal specimen extraction: a bridge to
NOTES? Tech Coloproctol 2009;13:65–8.
69 Ooi BS, Quah HM, Fu CW , et al. Laparoscopic high anterior
resection with natural orifi ce specimen extraction (NOSE) for
early rectal cancer . Tech Coloproctol 2009;13:61–4.
70 Leroy J, Cahill RA, Asakuma M, et al. Single-access laparoscopic
sigmoidectomy as defi nitive surgical management of prior diverticulitis in a human patient . Arch Surg 2009;144:173–9.
71 Eshuis EJ, Voermans RP , Stokkers PC, et al. Laparoscopic resec-
tion with transcolonic specimen extraction for ileocaecal Crohn ’s
disease. Br J Surg 2010;97:569–74.
72 Leroy J, Diana M, Wall J, et al. Laparo-endoscopic single -Site
(LESS) with transanal natural orifi ce specimen extraction
(NOSE) sigmoidectomy: a new step before pure colorectal
natural orifi ces transluminal endoscopic surgery (NOTES ®). J
Gastrointest Surg 2011;15(8):1488–92.
73 Nishimura A, Kawahara M, Suda K, et al. Totally laparoscopic
sigmoid colectomy with transanal specimen extraction . Surg
Endosc 2011;25(10):3459–63.
74 Boni L, Tenconi S, Beretta P, et al. Laparoscopic colorectal resec-
tions with transvaginal specimen extraction for severe endometriosis. Surg Oncol 2007;16(suppl 1 ):S157–60.
75 Franklin ME, Jr , Kelley H , Kelley M, et al. Transvaginal extrac-
tion of the specimen after total laparoscopic right hemicolectomy with intracorporeal anastomosis . Surg Laparosc Endosc
Percutan Tech 2008;18:294–8.
76 Palanivelu C, Rangarajan M, Jategaonkar PA , et al. An innova-
tive technique for colorectal specimen retrieval: a new era of
“natural orifi ce specimen extraction ” (NOSE) . Dis Colon Rectum
2008;51:1120–24.
77 García Fl órez LJ, Argüelles J, Quijada B, et al. Transvaginal
specimen extraction in a laparoscopic anterior resection of a
sigmoid colon neoplasia with en bloc right salpingo oophorectomy . Tech Coloproctol 2010;14:161–3.
78 Park JS, Choi GS, Lim KH, et al. Clinical outcome of
laparoscopic right hemicolectomy with transvaginal resection,
anastomosis, and retrieval of specimen . Dis Colon Rectum
2010;53:1473–9.
79 Sanchez JE, Rasheid SH, Krieger BR, et al. Laparoscopic-assisted
transvaginal approach for sigmoidectomy and rectocolpopexy .
JSLS 2009;13:217–20.
161
15
https://t.me/med1917
Bariatric NOTES Procedures
Michel Vix , Michele Diana, James Wall , & Jacques Marescaux
IRCAD (Research Institute Against Digestive Cancer), Strasbourg, France
Introduction
The World Health Organization estimates that over 1.6
billion adults are overweight worldwide and over 500
million are obese. In 2010, more than one in ten adults
worldwide had a BMI over 30, which is more than double
the rate of obesity in 1980. The epidemic of obesity is spreading and represents a major, if not the major, challenge to
human health in the twenty -fi rst century. Obesity is the fi fth
leading risk for global deaths, with at least 2.8 million deaths
attributed to being overweight or obese; 44% of the diabetes
burden, 23% of the ischemic heart disease burden, and
between 7% and 41% of certain cancer burdens are attributable to obesity [1]. In the United States, obesity is predicted
to soon overtake smoking as the leading cause of death and
contribute to an overall decrease in life expectancy [2].
The rapidly increasing effects of obesity on morbidity,
premature mortality, and healthcare costs have forced physicians to face obesity as a disease and consider a wide variety
of options in prevention and treatment. The role of surgery
in the management of obesity has markedly increased in
recent decades, with several weight loss procedures. The
three fundamental impacts of obesity procedures are restriction, malabsorption, and hormone modulation. The most
commonly performed bariatric procedures worldwide are
the Roux -en-Y gastric bypass, the gastric band, the sleeve
gastrectomy, vertical banded gastroplasty, and the duodenal
switch. Figure 15.1 highlights the basic confi guration of the
most common gastric bariatric procedures and Figure 15.2
the most common bypass procedures. The choice of procedure is complex and should be tailored to the patient based
on many factors, including BMI, comorbidities, and surgeon
experience.
American NIH and European guidelines are similar concerning the indications for bariatric surgery. Patients with
BMI over 40 kg/m
candidates [3,4]. The consensus guidelines for bariatric
surgery in Asia have lower BMI indications as epidemiologic
data shows that people of Asian ethnicity have a higher
adiposity for a given BMI and suffer from metabolic derangement at lower BMIs [5]. Patients of Asian ethnicity with BMI
over 35 kg/m
30 kg/m
candidates [6].
2
with central obesity and a metabolic syndrome are
2
or over 35 kg/m2 with comorbidities are
2
, over 32 kg/m2 with comorbidities, and over
Bariatric challenges for NOTES
Obese patients present a variety of challenges for the surgeon
that can be divided into three major categories: (i) pre operative comorbidities and anesthetic risk, (ii) intraoperative technical considerations, and (iii) postoperative
complications. Each of these areas should be considered
carefully in applying NOTES techniques to the treatment of
obesity.
Pre -operative comorbidities and anesthetic risks
NOTES techniques, specifi cally with a fl exible operating
platform, can be performed with very low -pressure pneumoperitoneum once the scope is put in place. Combining
low pneumoperitoneum and no abdominal trauma, it is
conceivable that NOTES bariatric procedures could be performed under sedation rather than general anesthesia. The
potential benefi t of less pneumoperitoneum and less anesthetic includes improvement in many possible risks, including deep venous thrombosis, pulmonary embolism, depressed
respiratory drive, and cardiac failure.
Natural Orifi ce Translumenal Endoscopic Surgery (NOTES): Textbook and Video Atlas, First Edition. Edited by Anthony N. Kalloo, Jacques Marescaux,
Ricardo Zorron.
© 2012 John Wiley & Sons, Ltd. Published 2012 by John Wiley & Sons, Ltd.
162
CHAPTER 15 Bariatric NOTES Procedures
https://t.me/med1917
(a)
Figure 15.1 Common gastric bariatric surgical procedures: (a) sleeve gastrectomy, (b) gastric banding, and (c) vertical banded gastroplasty.
(a)
Figure 15.2 Common bypass bariatric surgical procedures: (a) duodenal switch, and (b) Roux -en-Y gastric bypass.
Intraoperative technical considerations
The size of many bariatric patients can push standard laparoscopic equipment to its limits. Extra -long trocars and instruments are necessary in many cases. Additionally, the liver
in obese patients is often fatty, producing an additional challenge for the bariatric surgeon. Procedures that require
access to the upper stomach often require signifi cant force
to retract an enlarged left lobe of the liver. Current fl exible
(b) (c)
(b)
infection for laparoscopic gastric bypass ranges from 2% to
8% while the rate of hernia ranges from 1% to 5% [7–9].
Additionally, between 3% and 8% of patients who undergo
gastric bypass will need additional abdominal surgery for
either complications or unrelated pathology [10]. NOTES
techniques offer the possibility to eliminate abdominal wall
complications and decrease the diffi culty of re -operations
[11] (Table 15.1).
endoscopes and endoscopic instrumentation can be adapted
to almost unlimited lengths, but the instruments do not
translate the magnitude of force necessary for liver retraction or manipulation of heavy structures, such as a fatty
Laparo -endoscopic single-site surgery as a
bridge to bariatric NOTES
omentum.
Laparo-endoscopic single -site surgery (LESS) attempts to
Postoperative complications
Bariatric patients carry a high risk of postoperative complications. Complications related to abdominal incisions include
incisional hernias and wound infections. The rate of wound
minimize the complications of abdominal access by using a
single but larger than standard port incision through which
multiple instruments pass simultaneously. LESS is a logical
step en route to NOTES bariatric surgery as it increases the
163
Соседние файлы в папке Библиотека им академика М.И. Перельмана