Experimental experience and the technological evolution of minimally invasive surgical devices have allowed initial reports describing the clinical applicability of natural orifice translumenal endoscopic surgery (NOTES). Colorectal resections are an interesting target for the NOTES platform. Theoretically, the transrectal approach could overcome the proposed limitations of transvaginal access, increasing NOTES clinical applicability. Hybrid procedures such as minilaparoscopy-assisted natural orifice surgery (MA-NOS) are the safe progression to pure NOTES. This report describes the first clinical case of a transrectal MA-NOS total colectomy.
The patient was a 36-year-old man with severe ulcerative colitis (UC) who experienced failure of immunosuppressive therapy. The standard steps of laparoscopic total colectomy were respected, with basic triangulation maintained throughout the case. A transrectal endoscopic device was used for optic assistance, colon dissection, ileum section, and specimen retrieval. Transrectal MA-NOS total colectomy was assisted by three laparoscopic ports: a 12-mm port used as the terminal ileostomy site, a 2-mm needle epigastric port, and a 5-mm umbilical port used as a drain site at the final intervention. No intraoperative complications occurred.
The total operative time was 240 min. Oral intake was initiated on postoperative day 2. Because of UC rectal activity, a course with azathioprine was completed, and the patient was discharged receiving 1 g of rectal mesalazine for maintenance. The final pathology demonstrated pancolonic inflammatory bowel disease in the form of UC with severe activity.
Transrectal MA-NOS total colectomy was feasible and safe in the reported case. Improvement in NOTES instrumentation and selective clinical applications are mandatory before clinical trials.
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Antonio M. Lacy is a consultant for Covidien and Olympus Medical. David Saavedra-Perez, Cedric Adelsdorfer, Raquel Bravo, Montserrat Aceituno, and Jaume Balust have no conflicts of interest or financial ties to disclose.
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Lacy, A.M., Saavedra-Perez, D., Bravo, R. et al. Minilaparoscopy-assisted natural orifice total colectomy: technical report of a minilaparoscopy-assisted transrectal resection. Surg Endosc 26, 2080–2085 (2012). https://doi.org/10.1007/s00464-011-2117-z
- Total colectomy
- Ulcerative colitis