No-Scar Transanal Total Mesorectal Excision The Last Step to Pure NOTES for Colorectal Surgery

Hypothesis: Because of the concerns over the operative platform, accidental organ injury, and viscerotomy closure, natural orifice transluminal endoscopic surgery (NOTES) currently remains an experimental technique. Transanal NOTES for colorectal surgery overcomes all of these issues; however, all of the reports to date have used hybrid laparoscopic techniques. We demonstrate herein the first case, to our knowledge, of pure transanal NOTES colorectal surgery. Design: Case report. Setting: University hospital. Patient: The patient was a 56-year-old woman with a midrectal neoplasia. Intervention: Pure transanal NOTES total mesorectal excision with a coloanal anastomosis and without a diverting stoma. Using a transanal endoscopic operation device as a surgical platform, we created a viscerotomy distal to an endoluminal purse-string suture. We performed a total mesorectal excision using a "bottom-up" approach. The sigmoid colon was mobilized by a posterior, retroperitoneal approach and the colon was divided intraperitoneally. A hand-sewn, side-to-end, coloanal anastomosis was performed. Because the viscerotomy was incorporated into the anastomosis, the concerns of both accidental organ damage and viscerotomy closure were abrogated. Results: The procedure was completed entirely by a transanal fashion. We successfully mobilized the rectum, mesorectum, and sigmoid colon. The specimen length was more than 20 cm. The patient required minimal analgesia and her pain was nonabdominal. Conclusions: To our knowledge, the first pure transanal NOTES total mesorectal excision with retroperitoneal sigmoid mobilization and coloanal, side-to-end anastomosis was successfully performed using what we called a Peri-Rectal Oncologic Gateway for Retroperitoneal Endoscopic Single Site Surgery (PROGRESSS). This monumental case could pave the way for a new era in pure transanal NOTES for colorectal surgery. JAMA Surg. 2013; 148(3): 226-230. Published online November 19, 2012. doi: 10.1001/jamasurg.2013.685