Patricia Sylla, Department of Surgery, Massachusetts General Hospital, 15 Parkman Street, WACC 460, Boston, MA 02114, United States.
World J Gastrointest Surg. 2010 Jun 27;2(6):193-8. doi: 10.4240/wjgs.v2.i6.193.
Clinical implementation and widespread application of natural orifice translumenal surgery (NOTES) has been limited by the lack of specialized endoscopic equipment, which has prevented the ability to perform complex procedures including colorectal resections. Relative to other types of translumenal access, transanal NOTES using transanal endoscopic microsurgery (TEM) provides a stable platform for endolumenal and direct translumenal access to the peritoneal cavity, and specifically to the colon and rectum. Completely NOTES transanal rectosigmoid resection using TEM, with or without transgastric endoscopic assistance, was demonstrated to be feasible and safe in a swine survival model. The same technique was successfully replicated in human cadavers using commercially available TEM, with endoscopic and laparoscopic instrumentation. This approach also permitted complete rectal mobilization with total mesorectal excision to be performed completely transanally. As in the swine model, transgastric and/or transanal endoscopic assistance extended the length of proximal colon mobilized and overcame some of the difficulties with TEM dissection including limited endoscopic visualization and maladapted instrumentation. This extensive laboratory experience with NOTES transanal rectosigmoid resection served as the basis for the first human NOTES transanal rectal cancer excision using TEM and laparoscopic assistance. Based on this early clinical experience, NOTES transanal approach using TEM holds significant promise as a safe and substantially less morbid alternative to conventional colorectal resection in the management of benign and malignant colorectal diseases. Careful patient selection and substantial improvement in NOTES instrumentation are critical to optimize this approach prior to widespread clinical application, and may ultimately permit completely NOTES transanal colorectal resection.
经自然腔道内镜手术（NOTES）的临床实施和广泛应用受到缺乏专用内镜设备的限制，这阻碍了包括结直肠切除术在内的复杂手术的开展。与其他类型的经腔道入路相比，经肛门NOTES 联合经肛门内镜微创手术（TEM）为经内腔道和直接经腔道进入腹腔、特别是进入结肠和直肠提供了一个稳定的平台。完全经肛门NOTES 直肠乙状结肠切除术，联合或不联合经胃内镜辅助，在猪生存模型中被证明是可行和安全的。使用商业上可获得的 TEM 和内镜和腹腔镜器械，在人体尸体上成功地复制了相同的技术。这种方法还允许完全经肛门进行完整的直肠游离和全直肠系膜切除。与猪模型一样，经胃和/或经肛门内镜辅助延长了近端结肠游离的长度，并克服了 TEM 解剖的一些困难，包括有限的内镜可视化和不适应的器械。NOTES 经肛门直肠乙状结肠切除术的广泛实验室经验为首次使用 TEM 和腹腔镜辅助进行人类 NOTES 经肛门直肠癌切除术奠定了基础。基于这一早期临床经验，NOTES 经肛门 TEM 方法在治疗良性和恶性结直肠疾病方面具有显著的安全性和更低的发病率，作为传统结直肠切除术的替代方法具有重要的应用前景。在广泛应用于临床之前，对患者进行仔细选择和对 NOTES 器械进行实质性改进对于优化该方法至关重要，最终可能允许完全经肛门NOTES 结直肠切除术。
