Division of Gastrointestinal Surgery, Massachusetts General Hospital, Boston, MA 02114, USA.
Surg Endosc. 2013 Jan;27(1):74-80. doi: 10.1007/s00464-012-2409-y. Epub 2012 Jun 30.
The authors' group has previously described successful transanal rectosigmoid resection via natural orifice translumenal endoscopic surgery (NOTES) in both porcine and cadaveric models using the transanal endoscopic microsurgery platform. This report describes the largest cadaveric series to date as optimization of this approach for clinical application continues.
Between December 2008 and September 2011, NOTES transanal rectosigmoid resection with total mesorectal excision (TME) was successfully performed in 32 fresh human cadavers using transanal dissection alone (n = 19), with transgastric endoscopic assistance (n = 5), or with laparoscopic assistance (n = 8). The variables recorded were gender, body mass index (BMI), operative time, length of the mobilized specimen, integrity of the mesorectum and the resected specimen, and complications. Univariate statistical analysis was performed.
Of the 32 cadavers, 22 were male with a mean BMI of 24 kg/m(2) (range 16.3-37 kg/m(2)). The mean operative time was 5.1 h (range 3-8 h), and the mean specimen length was 53 cm (range 15-91.5 cm). After the first five cadavers, specimen length significantly improved, and a trend toward decreased operative time was demonstrated. The mesorectum was intact in 100% of the specimens. In nine cadavers, endoscopic dissection was complicated by organ injury. Evaluation by the operative approach demonstrated a significantly longer specimen with laparoscopic assistance (67.7 cm) than with transgastric assistance (45.4 cm) or transanal dissection alone (49.2 cm) (p = 0.013). Comparison of the technique used for inferior mesenteric pedicle division demonstrated both significantly decreased operative time (4.8 vs 6 h; p = 0.024) and increased specimen length (57.7 vs 39.6 cm; p = 0.025) when a stapler was used in lieu of a bipolar cautery device.
Transanal NOTES rectosigmoid resection with TME is feasible and demonstrates improvement in specimen length and operative time with experience. Transitioning to clinical application requires laparoscopic assistance to overcome limitations related to NOTES instrumentation, as well as procedural training with fresh human cadavers.
作者所在团队先前已经在猪和尸体模型中使用经肛门内镜微创手术（NOTES）平台成功地完成了经自然腔道内镜手术（NOTES）的经肛门直肠乙状结肠切除术。本报告描述了迄今为止最大的尸体系列，因为该方法的临床应用正在不断优化。
在 2008 年 12 月至 2011 年 9 月期间，通过单独经肛门解剖（n = 19）、经胃内镜辅助（n = 5）或腹腔镜辅助（n = 8），成功地在 32 具新鲜人体尸体中完成了 NOTES 经肛门直肠乙状结肠切除术并联合全直肠系膜切除术（TME）。记录的变量包括性别、体重指数（BMI）、手术时间、游离标本的长度、直肠系膜和切除标本的完整性以及并发症。进行了单变量统计分析。
在 32 具尸体中，22 具为男性，平均 BMI 为 24 kg/m2（范围为 16.3-37 kg/m2）。平均手术时间为 5.1 小时（范围为 3-8 小时），平均标本长度为 53 cm（范围为 15-91.5 cm）。在前 5 具尸体之后，标本长度显著增加，手术时间呈下降趋势。所有标本的直肠系膜均完整。在 9 具尸体中，内镜解剖因器官损伤而变得复杂。通过手术方法评估发现，腹腔镜辅助下的标本长度明显更长（67.7 cm），明显长于经胃辅助（45.4 cm）或单独经肛门解剖（49.2 cm）（p = 0.013）。用于肠系膜下动脉蒂分离的技术比较表明，当使用吻合器代替双极电凝器时，手术时间明显缩短（4.8 与 6 小时；p = 0.024），标本长度增加（57.7 与 39.6 cm；p = 0.025）。
经肛门NOTES 直肠乙状结肠切除术联合 TME 是可行的，并且随着经验的积累，标本长度和手术时间都有所改善。向临床应用的过渡需要腹腔镜辅助，以克服与 NOTES 仪器相关的限制，以及使用新鲜人体尸体进行手术程序培训。
