Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases (ICMDM), Hospital Clínic, IDIBAPS, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Centro Esther Koplowitz, University of Barcelona, Barcelona, Spain.
Surg Endosc. 2013 Sep;27(9):3165-72. doi: 10.1007/s00464-013-2872-0. Epub 2013 Mar 22.
The transanal minilaparoscopy-assisted natural orifice transluminal endoscopic surgery (NOTES) approach holds significant promise as a safe and less morbid alternative to conventional low anterior rectal resection. Previous reports have shown satisfactory short-term oncologic results. We evaluated the safety and short-term outcomes in rectal cancer subjects who underwent transanal minilaparoscopy-assisted natural orifice surgery total mesorectal excision (TME) rectal resection.
Twenty selected patients with rectal cancer were enrolled onto a prospective study of minilaparoscopy-assisted natural orifice surgery TME rectal resection. The study endpoints were safety of access (intra- or postoperative morbidity) and adequacy of oncological resection criteria; intact TME; distal and circumferential margins; and number of lymph nodes retrieved.
All procedures were successfully completed with the transanal NOTES and minilaparoscopy technique. The mean age was 65 ± 10 years; 55% of patients were male; the mean body mass index was 25.3 ± 3.8 kg/m(2). Thirty-five percent of tumors were in the distal rectum, 50% in midrectum, and 15% in proximal rectum. Coloanal anastomoses were hand sewn in 65% and stapled in 35%. Mean operative time was 235 ± 56 min. There were no procedure-related complications. Pathologic analysis demonstrated negative distal and circumferential margins in all patients. An average of 15.9 ± 4.3 lymph nodes were retrieved. The mesorectal fascia was intact in all the specimens.
This study demonstrates that transanal NOTES with minilaparoscopic assistance in the hands of a specialized team is safe; meets the oncologic requirements for high-quality rectal cancer surgery; and may offer advantages over pure laparoscopic approaches for visualizing and dissecting out the distal mesorectum. Minilaparoscopic assistance allows one to compensate for the limitations of current NOTES instrumentation to ensure the safety and adequacy of oncologic resection in these difficult cases. Careful patient selection, a specialized team, and long-term outcome evaluation are critical before this procedure can be considered for routine clinical use.
经肛门迷你腹腔镜辅助自然腔道内镜手术（NOTES）作为一种安全、微创的替代传统低位前切除术的方法，具有很大的潜力。先前的报告显示其短期肿瘤学结果令人满意。我们评估了接受经肛门迷你腹腔镜辅助自然腔道手术全直肠系膜切除术（TME）直肠切除术的直肠癌患者的安全性和短期结果。
20 名选定的直肠癌患者被纳入迷你腹腔镜辅助自然腔道手术 TME 直肠切除术的前瞻性研究。研究终点为入路的安全性（围手术期发病率）和肿瘤学切除标准的充分性；完整的 TME；远端和环周切缘；以及检出的淋巴结数量。
所有手术均成功完成经肛门 NOTES 和迷你腹腔镜技术。平均年龄为 65 ± 10 岁；55%的患者为男性；平均体重指数为 25.3 ± 3.8kg/m²。35%的肿瘤位于直肠下段，50%位于直肠中段，15%位于直肠上段。结肠直肠吻合术手工缝合占 65%，吻合器吻合占 35%。平均手术时间为 235 ± 56 分钟。无手术相关并发症。病理分析显示所有患者的远端和环周切缘均为阴性。平均检出淋巴结 15.9 ± 4.3 个。所有标本的直肠系膜筋膜均完整。
本研究表明，在专业团队的手中，经肛门 NOTES 联合迷你腹腔镜辅助是安全的；符合高质量直肠癌手术的肿瘤学要求；并且在可视化和解剖远端直肠系膜方面可能优于纯腹腔镜方法。迷你腹腔镜辅助可以弥补当前 NOTES 器械的局限性，确保在这些困难病例中肿瘤学切除的安全性和充分性。在考虑将该手术常规用于临床之前，需要进行仔细的患者选择、专业团队和长期结果评估。
