3-Port incisionless laparoscopic surgery for rectal cancer with a transrectal assistance

doi:10.4236/crcm.2013.27103

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Vol.2, No.7, 386-389 (2013) Case Reports in Clinical Medicine

http://dx.doi.org/10.4236/crcm.2013.27103

3-Port incisionless laparoscopic surgery for rectal

cancer with a transrectal assistance

Lin Zhang, Guohu Zhang, Peihong Wang, Yonghua Wang, Yaning Song, Hong Zou,

Lijun Tang*

Center of General Surgery, Chengdu General Hospital of Chengdu Military Area Command, Chengdu, China;

*Corresponding Author: [email protected]

Received 25 July 2013; revised 26 August 2013; accepted 8 September 2013

permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Introduction: To present the initial experience of

3-port incisionless laparoscopic surgery for rec-

tal cancer with a transrectal assistance by using

a toothed oval clamp. Case Presentation: One

p atient re ceiv ed 3-port incis ionless laparoscopic

surgery for rectal cancer with a transrectal as-

sistance by using a toothed oval clamp. Better

direct visi on and exposur e could be ac quired for

performing lap aroscopic surgical procedure, avoid-

ing additional port inserted. Using this proce-

dure, with strictly adhering to the principles of

laparoscopic colectomy and oncological proce-

dure, along with the specimen exteriorized via

recta, transacted and a stapled anastomosis

performed, no incision can be achieved at the

end of an operation. The operative time was 180

minutes. The estimated blood loss in the course

of an operation was 80 ml. The p atient recov ered

quickly after surgery, with no post-operative pain

and no incision. The patient was dischanged

home on the 6th postoperative day. Conclusions:

With a transrectal assistance by using a toothed

oval clamp, 3-port laparoscopic surgery for rec-

tal cancer could be achieved w ithout no incision

at the end of the operation, the same as NOTES.

It is enormously advantageous to the p atient and

suitable for application in developing countries,

especially in a rural area.

Keyw ords: Laparoscopic Su rge ry; Incisionle ss;

Rectal Cancer; Transrect a l; Assistanc e

1. INTRODUCTION

In recent years, laparoscopic surgeries have been

widely accepted as a treatment of colon diseases, includ-

ing colon cancer [1-3]. The short term benefit of the

laparoscopic approach in colorectal surgery is obvious,

namely, faster postoperative recovery, improved postop-

erative pain control, reduced pulmonary dysfunction, and

shorter hospitalization [4-6].

In order to further improve upon the results of multi-

port laparoscopic colectomies (LACs), efforts have been

made to further reduce the trauma caused by incisions,

even in a minimum number of port sites inserted with

trocars used. Now natural orifice transluminal endo-

scopic surgery (NOTES) provides the potential for per-

formance of scarless operations. In 2007, Whiteford et al.

described the first transanal NOTES radical sigmoidec-

tomy in human cadavers [7]. However, the progress con-

tinues to be hampered by always needing for expensive

specialized equipment as well as safety concerns regard-

ing NOTES translumenal access, particularly regarding

access closure [8]. To some extent, it has hindered the

widespread acceptance of this approach.

Since 2008, when single-incision laparoscopic colec-

tomy (SILC) was first introduced, the number of relevant

publications has been increasin g yearly. In comparison to

multiport laparoscopic colectomy, the potential advan-

tages of SILS are thought to be improved cosmesis as

well as incisional and/or parietal pain and avoidance of

port site-related complications [9]. But expensive pro-

prietary equipment and additional incisions are needed

for retrieval of the specimen.

In this paper, we introduce a new surgical procedure of

3-port incisionless laparoscopic surgery for rectal cancer

with a t ransrect al assi stance by us ing a to othed oval cl amp.

2. CASE REPORT

A 38-year-old married female presented to her local

doctor with bloody stools. Than the patient was referred

to our hospital for the reason that a crater lesion of ~30

mm in diameter and 8 cm from the anal verge had been

L. Zhang et al. / Case Reports in Clinical Medicine 2 (201 3) 386-389

387

found in the middle rectum by colonoscopy. The biopsy

outcome confirmed rectal adenocarcinoma. The patient’s

past history and laboratory test results were not con-

tributory.

The potential risks and benefits of the operation were

discussed with the patient, who gave informed consent.

All of the principles of laparoscopic colectomy and on-

cological procedure were strictly adhered to.

The patient was placed in the lithotomy position. three

ports (Johnson & Johnson, USA) were used, with place-

ment in the left upper for 5 mm trocar, right upper for 12

mm trocar which was later used as a drain site, umbili-

cum upper for 12 mm trocar and for 30˚-angled scopes

(Olympus, Japan). At the beginning of procedure, the

operator was located in the two legs of the patient, in

order to visualize abdominal organs in line with the 30˚-

angled scopes without the need for retroflexion. En-bloc

resection and mobilization of the sigmoid colon and its

mesentery proceeded cephalad along the avascular plane.

The inferior mesenteric artery (IMA) was highly dis-

sected and staple divided (Clips, Johnson & Johnson

MEDICAL GmbH, USA) (Figure 1). After the adequate

length of the sigmoid colon was carefully preserved for

anastomosis, the colon was subsequently obtained to

introduce an endoscopic linear stapler (Johnson & John-

son, USA) into the peritoneal cavity and divided fol-

lowed by introducing the anvil of the circular stapler

(Johnson & Johnson, USA) into the proximal colon via

transrectum.

Following this, the operator changed to located in the

left position of the patient, in order to perform procedure

in line with the field of vision of the 30˚-angled scopes.

The left and right ureter were identified, and the

presacral plane was carefully caudally developed with

preservation of the autonomic nerve fibers using the

technique of sharp total mesor ectal excition with a trans-

rectal assistance by using toothed oval clamp (Figure 2).

Once the peritoneal reflection was reached, the colon

was then pulled out through the rectum, transected and a

intracorporeally stapled colorectal anastomosis perform-

ed with the circular stapler (Johnson & Johnson, USA)

used (Figure 3). A drainage tube was posited upper an-

astomotic line via transrectum, avoiding temporary di-

verting loop ileostomy and anastomotic leakage (Figure

4).

The operative time was 180 minutes. The estimated

blood loss in the course of operation was 80 ml. The pa-

tient recovered quickly after surgery, with no postopera-

tive pain and no insicion. On postoperative day 3 the

patient had completely resumed total gastrointestinal

function and had her first flatus. The blood loss of

drainage tube was about 30 - 50 ml per day and was

pulled out on postoperative day 4. The patient was dis-

changed home on postoperative day 6. Pathology re-

Figure 1. The inferior mesenteric artery

(IMA) was highly dissected and staple di-

vided.

Figure 2. Excision of mesorectum along

the prescaral plane with exposure by using

transrectal toothed oval clamp.

Figure 3. View of intracorporeally coloanal

anastomosis performed between the proxi-

mal sigmoid colon and distal anorectal

cuff.

Figure 4. 3-port used after incisionless

laparoscopic rectal operation, one of which

was used as a drain site.

vealed an intact mesorectum with 3 out of 12 retrieved

lymph nodes positiv e for aden oc arcinoma (pT3 N1 ). Mar-

L. Zhang et al. / Case Reports in Clinical Medicine 2 (201 3) 386-389

388

gins were free of tumor.

3. DISCUSSION

Although many large randomized trials with the la-

paroscopic approach in colon cancer had demonstrated

equivalent oncologic efficacy with similar overall sur-

vival, disease-free survival and local and distant recur-

rences [10-12], the relevant data of large randomized

trials with the laparoscopic approach in rectal cohort is

scarce, hampering its widely accepted.

Overall laparoscopic rectal resection for malign ancy is

technically more demanding in that concerns about nerve

preservation, complete total mesorectal excision, and

adequate lymph node yield are still unsettled in this set-

ting. But the remarkable magnified view provided by the

monitor of laparoscopic operation system has become

more advantageous and fascinating and enables safe and

accurate manipulation at sites such as the deep pelvic

floor, lower bladder, posterior surface of the prostate and

anal region, where visualization is difficult to achieve

during open surgery and manipulation is usually carried

out under nearly blind conditions [13].

In order to further improve upon the results of LACs,

efforts have been made to further reduce the trauma

caused by incisions, even in a minimum number of port

site inserted with trocars used. This results in a paradox.

on one hand, both operator and patient persue scarless or

minor insicions; on the other hand, with reduction num-

ber of port site, exposure of operating site should be

more difficult for performing adequately surgical proce-

dure. So we put forward a useful laparoscopic assisting

approach with a transrectal assistance by using toothed

oval clamp.

In our opinion, a new transrectal laparoscopic assisting

approach offers multiple advantages: 1) with respect to

laparoscopic surgery for rectal cancer，the sharp angle of

the sacral promontory and narrow pelvis hindered the

proximal dissection of rectal wall and its attached mes-

entery. To overcome those anatomic constraints, expo-

sure turned out to be more important. Based on our early

experience, with a transrectal assistance by using toothed

oval clamp performed by second assistant, operator

could acquire better direct vision and exposure for per-

forming laparoscopic surgical procedure, avoiding addi-

tional port inserted; 2) Patients, both male and female,

independent of age and body shape, usually dislike scars,

not only for cosmetic reasons but because scars indicate

they have undergone treatment before. This resulted in

NOTES, eliminating the incision through the abdominal

wall and using natural orifices，meeting the aspirations of

the patients and su rgeons [14]. But in the level of LACs,

minor incision always needed. Using our above-men-

tioned procedure, along with the specimen exteriorized

via transrectal, transacted and a stapled anastomosis per-

formed, incisionless can be achieved at the end of opera-

tion, same as NOTES; 3) Our new transrectal laparo-

scopic assisting device is much cheaper than instrument

of other minimally invasive surgeries in that it is a sim-

ple device whose cost is approximately 50 USD. So it is

suitable for application in developing countries, espe-

cially in a rural area.

Nevertheless，we have to refer some caveats emerged

in our initially experience with this technique. Firstly,

strict selection of patients for this approach include tho se

with biopsy proven resectable rectal malignancy located

4 - 12 cm from anal verge who are otherwise eligible to

undergo standard open or laparoscopic low anterior re-

section with temporary diverting stoma. Meanwhile tu-

mors must be preoperatively staged as node negative, T1,

T2 or T3 based on pelvic MRI with no evidence of me-

tastasis on staging CT scans. Secondly, lesions of eligi-

ble patients which causing no more than 50% stenosis of

the lumen, as well as better mechanical bowel prepara-

tion, could ensure a satisfied operation outcome, avoid-

ing temporary diverting loop ileostomy and anastomotic

leakage.

4. CONCLUSION

On the basis of our preliminary experience, we believe

that with a transrectal assistance by using a toothed oval

clamp, 3-port laparoscopic surgery for rectal cancer can

be done without an incision at the end of the operation,

same as NOTES. With this useful technique, made from

commonly used and relatively inexpensive surgical equip-

ment, avoiding long and complex learning curves, op-

erator could acquire much more exposure, assistance

during performing surgical procedure. Above all, it is

suitable for application in developing countries, espe-

cially in a rural area.

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