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  • br In this study we aimed

    2019-10-12


    In this study, we aimed to evaluate the safety and feasi-bility of NOSES by comparing the short-term outcomes with those of conventional laparoscopic resection (CLR) in a multicenter retrospective study in three centers in China and Russia.
    Methods
    This retrospective multicenter study was conducted in three centers between January 2015 and December 2017. The three chief surgeons (X.W., P.T., and G.W.) had experience with more than 800 laparoscopic surgeries. Generally, the main indication for performing a NOSES rectal resection was the technical ability for this approach. The patients with tumors up to 5 cm in diameter with no signs of mesorectal fascia involvement, anal stenosis, or anal incontinence were offered a choice between NOSES and the standard laparoscopic approach. In women, additional selection criteria for the NOSES approach encountered included absence of endome-triosis and vaginal stenosis. Those patients who agreed to the NOSES procedure were operated on using this technology unless there were any contraindications encountered intra-operatively. The study was approved by the Ethics Committee in each hospital. Informed consent was obtained for partici-pation in the study.
    We included all patients with a histological diagnosis of adenocarcinoma of the rectum within 15 cm of the anal verge. 
    Patients with T4 tumors, distant CORM-3 (M1), or an involved circumferential resection margin on preoperative imaging were excluded. Women with a history of endome-triosis, a major abdominal operation, a narrow vagina, extensive pelvic adhesions, and lesions larger than 5 cm and those who refused the procedure were not considered candi-dates for the transvaginal removal route. Patients with anal stenosis or incontinence were excluded from transanal spec-imen extraction. Patients with a tumor larger than 5 cm in diameter on preoperative imaging were excluded from the NOSES procedure. Emergent cases were excluded from the analysis.
    All procedures were performed using either a NOSES or CLR approach, with the choice left to the discretion of the patient and the chief surgeons based on the intraoperative findings. The surgical technique was the same for both NOSES and CLR rectal resection except for the specimen extraction approach. The patient was placed in the lithotomy-Trendelenburg position and tilted to the right. The number of ports and the pattern of their placement were left to the surgeon’s preference. The medial-to-lateral dissection and total mesorectal excision were performed in all patients. High or low tie of the inferior mesenteric artery was performed according to surgeon’s preference. In the CLR approach, the left colon and rectum were mobilized, and the rectum was transected below the tumor (distal resection margin) either with a linear endoscopic stapler or transanally. The specimen was extracted via a suprapubic minilaparotomy and left colon was transected (proximal resection margin). In the NOSES approach after mobilization of the rectum and left colon, the rectum was transected below the tumor with a linear stapler. The specimen was extracted either through the rectal stump or through a separate vaginal incision. For transanal extrac-tion, an incision was made below the staple line of the rectal stump (Fig. 1) and a sterile plastic sleeve was introduced through the port. Next, a grasper was brought through the anus, and the specimen was pulled outside through the plastic sleeve (Fig. 2). For transvaginal extraction, a 3- to 4-cm transverse posterior colpotomy was performed trans-vaginally with laparoscopic control (Fig. 3). A sterile plastic sleeve was introduced through the vaginal incision, and with a grasper brought through Late-replication materials the specimen was pulled outside. The anvil of a circular stapler was placed at the end of the proximal colon (Fig. 4). The rectum stump was restapled with a linear stapling device (Fig. 5). After washout of the rectal stump, intracorporeal end-to-end or side-to-end colorectal anastomosis was performed with the use of a circular stapling device. The patients had at least one draining tube in the pelvic cavity. The 12-mm surgeon’s operating port was usually