Department of Surgery, Section of Colon and Rectal Surgery, Washington University in St. Louis School of Medicine, 660 S. Euclid Avenue, Campus Box 8109, Saint Louis, MO 63110, USA.
Surg Endosc. 2010 Jul;24(7):1765. doi: 10.1007/s00464-009-0838-z. Epub 2010 Jan 7.
Natural orifice transluminal endoscopic surgery (NOTES), a recent development in the field of minimally invasive surgery, provides theoretical advantages over open and laparoscopic surgery. Challenges with the use of NOTES for colon resections include the need to extract a large specimen and perform an intestinal anastomosis. A transanal single-port laparoscopic proctectomy uses the potential advantages of NOTES yet provides easy specimen extraction and anastomosis.
Fresh frozen then thawed human cadavers were used. Access was obtained via transanal mucosectomy, and a transanal endoscopic microsurgery (TEM) system was used to perform the proctectomy once the procedure was above the pelvic floor. After the peritoneal cavity was entered, a hand port was placed through the sphincter and above the pelvic floor. The left colon was mobilized using two 5-mm working ports and a 10-mm camera port for the flexible-tipped laparoscope that were placed through the hand port. The specimen was removed transanally.
The critical steps for an oncologic resection of the rectum were achieved using a combination of TEM and laparoscopic instrumentation transanally. The rectum and mesorectum were mobilized. The left ureter was identified and preserved, the inferior mesenteric artery (IMA) ligated at its origin, the inferior mesenteric vein ligated near the ligament of Treitz, the proximal colon mobilized for transanal extraction, the specimen resected proximal to the ligated IMA, and a hand-sewn coloanal anastomosis performed. Postresection examination showed preservation of the hypogastric nerves and an intact mesorectum. Challenges included maneuverability around the sacral promontory and length of the instruments. However, this was easily overcome by the use of long reticulating instruments and a flexible-tipped laparoscope.
Transanal single-port low anterior resection using TEM and laparoscopic techniques is feasible and can maintain the principles of an oncologic resection.
经自然腔道内镜外科手术（NOTES）是微创外科领域的一项新进展，与开放性和腹腔镜手术相比具有理论优势。NOTES 用于结肠切除术的挑战包括需要提取大标本和进行肠吻合。经肛门单孔腹腔镜直肠切除术利用了 NOTES 的潜在优势，同时提供了易于标本提取和吻合的方法。
使用新鲜冷冻然后解冻的人体尸体。通过经肛门黏膜切除术获得通道，并在手术高于骨盆底后使用经肛门内镜微创手术（TEM）系统进行直肠切除术。进入腹腔后，通过括约肌上方的盆腔放置手动端口。使用两个 5mm 工作端口和一个 10mm 摄像头端口通过手动端口来移动左结肠，该端口用于柔性尖端腹腔镜。标本经肛门取出。
使用 TEM 和腹腔镜器械的组合经肛门完成了直肠的关键步骤，实现了肿瘤切除。直肠和直肠系膜被移动。识别并保留左输尿管，在其起源处结扎肠系膜下动脉（IMA），在Treitz 韧带附近结扎肠系膜下静脉，将近端结肠向肛门方向移动以进行经肛门提取，在结扎的 IMA 近端切除标本，并进行手工缝合的结肠直肠吻合术。切除后检查显示，腹下神经得到保留，直肠系膜完整。挑战包括围绕骶骨岬的操作和器械的长度。然而，通过使用长的网篮器械和柔性尖端腹腔镜，这很容易克服。
使用 TEM 和腹腔镜技术的经肛门单孔低位前切除术是可行的，并可以保持肿瘤切除术的原则。
