Cahill R A, Perretta S, Forgione A, Leroy J, Dallemagne B, Marescaux J
Institut de Recherche contre les Cancers de l'Appareil Digestif (IRCAD/EITS), Strasbourg, France.
Dis Colon Rectum. 2009 Apr;52(4):725. doi: 10.1007/DCR.0b013e31819a69af0.
We demonstrate localized sigmoidectomy with sentinel node biopsy performed entirely via natural orifice transluminal endoscopic surgery in a porcine model (see Video, Supplemental Digital Content 1, http://links.lww.com/A1170).
To perform transluminal endoscopic sentinel node biopsy in the sigmoid mesocolon, a conventional double-channel gastroscope created both the gastrotomy and pneumoperitoneum enabling peritoneoscopy. The sigmoid colon was exposed by an intracolonic magnet under extracorporeal control while intraluminal colonoscopy performed lymphatic mapping via submucosal injection of methylene blue dye. After searching the mesocolon for blue-stained lymph channels, the sentinel nodes were resected and retrieved by the intraperitoneal fiberscope. Immediate thereafter localized sigmoidectomy was performed via an additional transcolonic access just above the rectosigmoid junction. With the circular stapler anvil placed early into the proximal colon, mesenteric dissection and proximal transection were performed using conventional laparoscopic instruments worked through a long standard trocar passed transanally through the colotomy. The specimen was delivered per ano (pull-through technique) and the distal margin cross-stapled extracorporeally, including the colotomy within the specimen. Stapled intestinal anastomosis was fashioned by passing a circular stapler transanally (thus returning the rectal stump to its anatomic position) and mating it with the in situ anvil. The gastrotomy was closed as previously described.
The operative duration was 31.4 minutes and technical success was readily achieved. Patency and integrity of the anastomosis was confirmed by sigmoidoscopy.
Oncologically propitious surgery for germinal colonic neoplasia may be encompassed by natural orifice transluminal endoscopic surgery. This provocative proposal challenges the conventional treatment paradigm for early stage colonic neoplasia although much further validation of the concepts involved is required.
我们在猪模型中展示了完全通过自然腔道内镜手术进行的局部乙状结肠切除术及前哨淋巴结活检（见视频，补充数字内容1，http://links.lww.com/A1170）。
为在乙状结肠系膜中进行经腔内镜前哨淋巴结活检，使用传统双通道胃镜建立胃切开术和气腹以实现腹腔镜检查。在体外控制下通过结肠内磁铁暴露乙状结肠，同时腔内结肠镜检查通过黏膜下注射亚甲蓝染料进行淋巴绘图。在系膜中寻找蓝色染色的淋巴通道后，通过腹腔内纤维镜切除并取出前哨淋巴结。此后立即通过直肠乙状结肠交界处上方的额外经结肠入路进行局部乙状结肠切除术。将圆形吻合器钉砧早期置入近端结肠，使用通过经肛门穿过结肠切开术的长标准套管针操作的传统腹腔镜器械进行肠系膜分离和近端横断。标本经肛门取出（拖出技术），远端切缘在体外进行交叉吻合，包括标本内的结肠切开术。通过经肛门插入圆形吻合器（从而将直肠残端恢复到其解剖位置）并与原位钉砧配合进行吻合器肠道吻合。胃切开术按先前描述进行关闭。
手术时间为31.4分钟，技术成功很容易实现。通过乙状结肠镜检查确认吻合口的通畅性和完整性。
自然腔道内镜手术可能涵盖对原发性结肠肿瘤的肿瘤学有利手术。这一具有启发性的提议挑战了早期结肠肿瘤的传统治疗模式，尽管需要对所涉及的概念进行更多的验证。
