Clinical Application of Single-Surgeon, Three-Port, Laparoscopic Resection for Colorectal Cancer with Natural Orifice Specimen Extraction
Summary
Here, we present a protocol to successfully perform single-surgeon, three-port, laparoscopic resection for colorectal cancer with natural orifice specimen extraction.
Abstract
Reduced-port laparoscopic surgery (RPLS) has been widely used for the radical resection of gastrointestinal tumors. Single-surgeon, three-port, laparoscopic radical resection for sigmoid colon or high rectal cancer with natural orifice specimen extraction surgery (NOSES) has the advantage of a small incision, quick postoperative recovery, and short hospital stay. Yet, there are still only a few reports on NOSES. This paper describes the indications, preoperative preparations, surgical steps, and precautions for single-surgeon, three-port, laparoscopic radical resection of the sigmoid colon and high rectal cancer, and intraoperative specimen collection through the natural orifice.
The protocol focuses on the steps of radical dissection and the main technical points of resection and reconstruction. At the same time, a procedure for fixing an anvil seat by self-traction of extracorporeal silk thread, used for purse-string suture fixation after the proximal anvil was placed in the abdominal cavity, was creatively improved. This operation could effectively avoid problems such as an insufficient proximal intestinal tube, shaking off the anvil seat, and weak purse-string suture during a single operation. The surgical care had less variability and was easy to perform, effectively avoiding postoperative anastomotic leakage and bleeding due to excessive intraoperative anastomotic tissue. This surgery could be widely promoted in primary hospitals.
Introduction
Natural orifice specimen extraction surgery (NOSES) is a modified approach to open surgery and conventional laparoscopic surgery, which relies on laparoscopic or robotic techniques. Its major advantages include a shorter length of hospital stay, reduction in wound complications and postoperative pain, faster recovery of bowel function, and better cosmetic and psychological effects. During NOSES, the surgical specimen is removed from a natural orifice (rectum or vagina) without requiring an auxiliary incision in the abdominal wall1. The "Expert Consensus on NOSES for Colorectal Tumors (2019 Edition)" recommends NOSES with the five-port technique2,3.
Omori et al.4 first applied reduced-port laparoscopic surgery (RPLS) to treat gastric cancer. In 2016, Kim et al. proposed that porosity reduction laparoscopic surgery was technically feasible and safe for the treatment of colorectal cancer and was comparable to conventional multiport laparoscopic surgery (CMLS) in terms of postoperative pain5. Oh et al., 2 years later, discussed the perioperative clinical outcomes of sigmoid colon cancer patients undergoing RPLS and traditional multiport laparoscopic surgery (MPLS); the results suggested that single-surgeon, three-port, laparoscopic radical sigmoidectomy was a feasible and safe surgical option for patients with favorable tumor characteristics6. However, the surgeries for sigmoid colon or high rectal cancer and specimen extraction through NOSES were mainly performed by one chief surgeon without the help of other assistants during intraoperative separation.
Currently, there are still only a few reports on NOSES. In NOSES, the placement and fixation of the anvil seat, which mainly depends on the tumor's location, the method of specimen collection, and the surgeon's ability, may be challenging. At present, a number of anvil fixation methods have been proposed, including the fixed extrusion method, reverse puncture method, snare ligation method, and manual purse-string suture method. Each method has its unique advantages and shortcomings. This study retrospectively analyzed the clinical data of 10 patients who underwent single-surgeon, three-port, laparoscopic surgery for sigmoid colon or high rectal cancer with NOSES to explore the safety and feasibility of this operation. The external anvil seat self-traction and fixation method was creatively improved, which could be used for manual purse-string suture fixation after placement of the anvil seat. Following the principle of tumor-free asepsis, the risk of anastomotic leakage and bleeding could be effectively avoided, and this surgicalprocedure could be widely promoted in primary hospitals.
Protocol
Representative Results
Discussion
With the improvement in surgical skills and the advancement in surgical equipment, especially the development of visualization devices, robotic surgery is often considered a reasonable choice for complex procedures, such as lateral pelvic lymph node dissection7. Reduced-port laparoscopic surgery is an emerging procedure, characterized by reduced incision number and size, making the operation less invasive than traditional laparoscopic surgery8. In 2016, Inaki<sup class='xre…
Disclosures
The authors have nothing to disclose.
Acknowledgements
This research was supported by the Key R&D Projects Medical and Health Key Technology Research and Application Program in Guangzhou, China (Project No. 202206010104).
Materials
| antibacterial polydioxanone | Johnson & Johnson | 8622H,SXPP1A403 | |
| Laparoscopic system | STORZ | 26003BA | |
| Ring stapler | Johnson & Johnson | CDH29A | |
| Straight cut closure | Johnson & Johnson | EC45A | |
| Trocar | Johnson & Johnson | B5LT,B11LT,B12LT |
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