Natural Orifice Specimen Extraction Surgery 9819927498, 9789819927494

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Xishan Wang Editor

Natural Orifice Specimen Extraction Surgery

Natural Orifice Specimen Extraction Surgery

Xishan Wang Editor

Natural Orifice Specimen Extraction Surgery With 2839 Figures and 10 Tables

Editor Xishan Wang Colorectal Surgery Department National Cancer Center/Cancer Hospital Chinese Academy of Medical Sciences Beijing, China

ISBN 978-981-99-2749-4 ISBN 978-981-99-2750-0 (eBook) https://doi.org/10.1007/978-981-99-2750-0 © People’s Medical Publishing House, PR of China 2023 Jointly published with People’s Medical Publishing House, PR of China This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publishers, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publishers nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publishers remain neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore Paper in this product is recyclable.

Foreword by Jie He

At present, the overall incidence and mortality of colorectal cancer in China are still showing an obvious increasing trend, which leads to a very serious situation in the prevention and treatment of colorectal cancer in China. How to effectively prevent and control the incidence of colorectal cancer, reduce the mortality of patients, and improve their quality of life will become an important proposition in the field of cancer prevention and treatment in China. As a leading figure in the field of colorectal cancer in China, Prof. Wang Xishan has created a series of microinnovation techniques in the field of surgery. Especially natural orifice specimen extraction surgery (NOSES) technology, which is called the “minimally invasive of minimally invasive” in the industry, leads the new direction of minimally invasive surgery development in China and even internationally. Under the leadership of Prof. Wang Xishan, China and international colleagues have collaborated in improving the theoretical system of NOSES, conducting clinical research, developing technical equipment, standardizing technical training, promoting academic popularization, etc. A lot of work has been carried out one after another. One of the most significant part of his academic achievements is Chinese surgical monographs and their translations into various languages. From the first edition on colorectal cancer, to the second edition on gastrointestinal tumor, to the third edition on abdominal-pelvic tumors, and then to the fourth edition, the indications continue to be expanded to include standardized procedures for neck and thoracic tumors. At the same time, the work has been translated into English, Korean, Russian, Japanese, French, and other languages by many famous international experts for global promotion, among which the second edition in English has been downloaded nearly 30,000 times on the official website of Springer Publishing House, all of which objectively reflects the feasibility of NOSES and its great social promotion value, as well as the prestige and status of Chinese NOSES technology in the international arena, and once again explains the broad application prospects of NOSES. In order to present NOSES technology to international colleagues in a more comprehensive, systematic, and complete way, invited by Springer Publishing, Prof. Xishan Wang, together with dozens of international colleagues who are enthusiastic about NOSES, has written another academic masterpiece of NOSES – the major reference work (MRW) for NOSES, which also brings the theoretical and technical system of NOSES to a new level. In this book, the theoretical system of NOSES is introduced more completely, the professional disciplines involved are more extensive, and the technical details are more comprehensively depicted, which can be regarded as another milestone of NOSES. The book leverages the collective expertise of over a hundred international experts in the field of NOSES (Natural Orifice Surgery). It illustrates standardized surgical techniques, promotes the concept of incisionless surgery, and showcases methods for treating diseases with minimal trauma. It is through ongoing summarization and practice that we can effectively advance NOSES technology and industry development. From a single procedure applied for the treatment of colorectal cancer in the early stage, NOSES has now formed a complete set of theoretical and technical systems; from a littleknown specialty technology, it has now won the highest scientific and technological awards in the medical field; from a minimally invasive surgery that only a small number of surgeons were v

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willing to carry out, it has now been popularized worldwide, benefiting more than 40,000 patients and families, which reflects the strong vitality and unique charm of NOSES. I fully believe that after the third edition of the monograph is released, NOSES will definitely usher in a vibrant development in the international surgical field, allowing the advantages and charms of NOSES to benefit more international colleagues and patients.

Jie He Academician Chinese Academy of Sciences President, National Cancer Center of China President, Cancer Hospital, Chinese Academy of Medical Sciences

Foreword by Jie He

Foreword by Daiming Fan

As the concept of integrated medicine continues to develop, deep integration between different disciplines is receiving more and more attention. Natural orifice specimen extraction surgery (NOSES), a high-potential, fast-growing, and widely accessible minimally invasive technique, which realizes the perfect combination of incision-less surgery and natural orifice surgery, is also a hot spot of common concern for endoscopists and laparoscopic surgeons. In the establishment of the theoretical and technical system and clinical application of NOSES, Prof. Wang Xishan has conducted a series of explorations and pioneered many challenging tasks and has established a complete theoretical system of NOSES. The third edition of the NOSES monographs was also born in the context of the rapid development of integrative medicine. As the first and second editions of the NOSES monograph published by Prof. Xishan Wang were highly recognized by Springer and widely praised by readers, he was invited by the publisher to write the third edition of the NOSES monograph. The third edition is based on the previous editions, and it introduces the latest advances in NOSES more systematically and comprehensively and also integrates the concept of integrative medicine into it. First, the book not only horizontally integrates many of the latest techniques of gastrointestinal NOSES techniques but also integrates many other specialties, such as hepatobiliary surgery, gynecology, urology, etc., to achieve the status of vertical integration between disciplines with NOSES as the center. In addition, NOSES itself is a perfect embodiment of the integration concept. Due to the reduction of abdominal surgical incisions, patients have less pain and recover faster after surgery and have better quality of life and medical experience, which also reflects the integration idea that doctors should not only cure the disease but also cure the patient. More importantly, the rapid development of NOSES is not only the result of medical progress but also a clever integration between different fields such as psychology, sociology, and even art, which together advance the understanding and cure of diseases from a deep and new perspective. NOSES has entered the 4.0 era in China and now has a mature and complete theoretical and technical system. At the same time, the technology has been written into undergraduate textbooks, into CACA guidelines, and also into a technical guideline of NOSES. The publication of the third edition of the monograph marks a new era in natural orifice surgery. After a new transition from division to union, the technique will become more mature, allowing more colleagues to understand, master, and enjoy performing this technique, elevating NOSES to a new level. Furthermore, the publication of this monograph also opens the door of communication between China and the world, presenting the Chinese original minimally invasive

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technology and integration concept to more international colleagues. I believe that under the leadership of this book, NOSES will be able to shine in the long history of surgery.

Professor Daiming Fan Academician, Chinese Academy of Engineering President of Chinese Anti-Cancer Association

Foreword by Daiming Fan

Foreword by Jacques Marescaux

Paradigm shifts happen a few times in the history of medicine bringing unexpected findings that go well beyond the foreseeable expansion of knowledge. New research avenues in the current era of technology-mediated surgery push the boundaries of innovation to extraordinary results unimaginable just a few years ago. The possibility to operate through natural orifices without visible scar, with no or very limited pain, faster hospitalization, and abolishing the risk of incisional hernias represents one of those unique disruptive changes in the “Revolution” of surgery. Nowadays no scar surgery – NOTES Natural Orifice Transluminal Endoscopic Surgery – has found its place in the surgeons’ armamentarium and has shown benefits and limitations for several clinical applications stimulating also the design of completely new procedures. The integration of multiple technologies, including robotics, augmented imaging, AI, and innovative materials, is laying the foundation for the development of specialized tools that will expand and simplify the application of scarless surgery to a wider range of patients, enabling the treatment of a greater variety of medical conditions. Flexible and steerable robots automatically driven by intelligent software with the capacity to see beyond the visible spectrum of light are not anymore available only in science fiction movies but are in use in several high-level international research centers and will soon become commercially available. The level of evidence provided in this book together with the growing amount of clinical data coming from established groups all around the world and clear guidelines from consensus conferences are creating the momentum to foster attention from the wider global surgical community towards the proper indication and advantages of NOTES for the treatment of common and highly specific diseases. The inter- and transdisciplinary scientific nature of NOTES will certainly greatly benefit from the extensive amount of insights and perspectives provided by the numerous experts that contributed to this well-conceived and elaborate book.

Jacques Marescaux Professor of Surgery Founding President of the Research Institute against Digestive Cancer (IRCAD) Founder and member of the Board of Directors of the Hospital-University Institute of Strasbourg (IHU) Founder of the European Institute of Telesurgery (EITS) Officer of the French National Order of Merit (2007)

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Foreword by Woo Yong Lee

First of all, it is my honor and great pleasure to write the foreword of the book Natural Orifice Specimen Extraction Surgery – Thoracic, Abdominal and Pelvic Surgery because the previous book for colorectal cancer was very helpful for colorectal surgeons and gave us great impact for minimal invasive colorectal surgery progression. In this new book, the authors cover not only colorectal surgery but also all the intraabdominal organs, and this is so far the only and the most extensively covered textbook in this field. The most impressive parts of this book for me were ▶ Chaps. 10 and ▶ 11. In ▶ Chap. 10, the authors share their experience of prevention and management of complication which will be very helpful for beginners and for those who hesitate to start the NOSES. In ▶ Chap. 11, each section deals with special topics of unmet needs for NOSES. I am sure this textbook will be a big step towards the expansion of NOSES in the surgical field. I have known Prof. Xishan Wang for over 15 years, andI hold great respect for his exceptional surgical skills and strong work ethic. He is also very academic, and so, with this talent and effort, he became a pioneer and authority on NOSES. His accomplishments are well known not only in China but also in many countries such as Korea, Russia, Vietnam, etc. I would like to extend my congratulations to the team for the publication of this book, and I hope that it fosters stronger connections among international surgery societies.

Woo Yong Lee, M.D. Phd. Professor of Surgery, Sungkyunkwan University President of Samsung Comprehensive Cancer Center Immediate past chairman of Korean Society of Surgery Vice-President of Korean Medical Association President-Elect International Society of University Colorectal Surgeons

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Foreword by Cem Terzi

I would like to thank Prof. Xishan Wang for the opportunity to write a foreword for the book titled Natural Orifice Specimen Extraction Surgery – Thoracic, Abdominal and Pelvic Surgery. In this book, the reader will find a comprehensive theory of natural orifice specimen extraction surgery (NOSES). There have been dizzying developments in technology in the last 40 years, and these technological advances have created many revolutions in surgery. One of the major changes was “minimally invasive” methods, and they have become more and more popular. The number of surgeries that can be performed laparoscopically and robotically has increased rapidly and has become available for almost all diseases. However, no matter how minimally invasive surgical methods develop, the need to remove the surgical specimen through a small incision still remains. As a result of the reduction of the incisions in the abdomen, the complications of the incision, which continue to decrease, and the ever-increasing aesthetic expectations in the transforming world have brought NOSES to the agenda. Although the use of natural orifices for the removal of surgical material is considered a new method, it is being applied increasingly in many different centers. Incision-related complications are eliminated, postoperative pain is reduced, and hospital stay is shortened. However, despite all these well-intentioned developments, the difficulty of the technique, the inexperience of surgeons about the procedure, the insufficiency of medical documents, and the reservations about its compliance with the principles of cancer surgery prevent the spread of NOSES. Prof. Wang has made considerable contributions in promoting minimally invasive surgery in China and other countries in the form of NOSES. He has established the China and International NOSES Alliance, which has provided a strong platform for academic communication regarding NOSES. He has led a number of gastrointestinal NOSES expert consensus panels that have developed standards for NOSES worldwide. He has written books and monographs on NOSES that have been translated into English, Korean, Russian, Japanese, and other languages for global promotion. In addition, he also organized several NOSES training courses and lectures, which trained thousands of surgeons. The development and achievements of these efforts have played an important role in promoting the standardized treatment and safe technique of NOSES around the world. With the establishment of a theoretical system and promotion in clinical practice, NOSES has gradually grown to be a series of well-developed surgical procedures in the past decade. Numerous clinical reports have revealed the broad application prospects of NOSES. When performing NOSES, following the indications and technical details in this book will help surgeons carry out this procedure in a safer and more standardized way. Meanwhile, it should be noted that more high-level clinical evidence is still needed to demonstrate the safety, advantages, and health and economic benefits of NOSES. It is expected that more multicenter

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clinical studies will be conducted all around the world to further support the implementation of NOSES. Through the efforts of Prof. Wang, more clinicians worldwide will be exposed to this platform and embrace its utility in performing surgery in a safe and truly minimally invasive fashion.

Prof. Cem Terzi Past President of European Society of Surgery and Turkish Surgical Association

Foreword by Cem Terzi

Preface

It has been more than 3 years since the new coronavirus ravaged China and the world. Although the virus is small, it has tested the strengths and weaknesses of the culture and policy system of each country and tested the responsibility and commitment of doctors. During this period of fighting the epidemic, all sectors of society, together with doctors, have been united in their determination and courage to achieve one victory after another. As with the epidemic, China and its international counterparts have worked together to improve the NOSES technique, making it a minimally invasive technique that is constantly approaching perfection. Looking at the manuscript of the third edition of the NOSES monograph, which was compiled by Chinese and international colleagues during the epidemic, I feel joy and pride and have a lot of thoughts and emotions for how NOSES has evolved in the past few years.

Review of History The rapid development of NOSES in China in the past decade is a product of medical history and also the inevitable development of social medicine. From a little-known surgical technology to a hot and popular surgical concept, NOSES has gone through a budding stage, a starting stage, a development stage, and a maturity stage. The budding stage was mainly in 2012 and before. In this stage, the development of NOSES had historical limitations: it was mainly for the treatment of colorectal cancer and could only be performed by a small number of surgeons. At this stage, NOSES faced great controversies and questions in academic circles. The theoretical system of NOSES in China and even internationally had not been established, and there were many irregular nomenclatures such as HybridNOTES, Pre-NOTES, and Like-NOTES. The starting stage was mainly from 2013 to 2015. In this stage, NOSES in colorectal cancer treatment became standardized, the preliminary theoretical and technical system of NOSES was established, and 10 NOSES techniques for colorectal cancer were perfected. Gradually, these techniques became recognized and caught the attention of numerous surgeons. At this stage, NOSES also kept accumulating energy, which provided an important premise and foundation for the rapid development in the later stage. In the face of challenges, NOSES constantly improved and got perfected, while at the same time perfecting sterile and tumor-free operation so as to reach a nearly perfect state. The development stage was mainly from 2016 to 2020. In this phase, NOSES experienced unprecedented development: the theoretical and technical system of gastrointestinal tumor matured and the specialties in which NOSES was carried out increased; reports of NOSES have been shown in gastrointestinal surgery, hepatobiliary surgery, gynecology, and urology. Most provinces in China gradually carried out NOSES. Since the establishment of China NOSES Alliance and NOSES Special Committee in 2017, NOSES entered a scientific, standardized, healthy, and orderly stage of development. The maturity stage was mainly from 2021 to the present. In this stage, the theoretical and technical system of NOSES has been completed, clinical promotion has been fully popularized, NOSES technology has been carried out in all provinces of China, and NOSES has been xv

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involved in various disciplines of head and neck tumors, thoracic tumors, and abdominopelvic tumors. At the same time, NOSES has been generally recognized by domestic and international experts. With everyone’s joint efforts, NOSES has ushered in a breakthrough development in the field of surgery and become a popular procedure in the field of minimally invasive surgery, using the international surgical stage as a carrier to propagate the positive message from China to the world.

Looking Ahead It is widely recognized that a surgical procedure comprises five essential elements: the surgical approach, the extent of tumor resection, the extent of lymph node dissection, the method of digestive reconstruction, and the method of specimen extraction. If we want to innovate, we must seek variables from these five elements. Innovation is the main theme of future development. NOSES explores the variables of innovation from the approach of specimen retrieval. First, the surgeon’s skill regarding tumor resection and digestive reconstruction has no technical barriers. NOSES could be performed to bring a sense of accomplishment or innovation to the surgeon without increasing the operational difficulties. Secondly, for patients, the main experience of surgery is to feel the pain and see the surgical incision. NOSES could avoid these two uncomfortable experiences. Furthermore, NOSES is associated with reduced abdominal wall dysfunction, favorable cosmetic outcomes, minimized psychological impact, decreased mental stress, and a more positive state of mind. Therefore, the patient could build up self-confidence, which is favorable for recovery and return to society. Therefore, from the patient’s point of view, NOSES is their choice and the direction for the future. Third, NOSES is a conceptual issue, not a technical issue. This is also in line with the process of medical understanding and is exemplified by the fact that surgeons did not accept or even denigrated laparoscopy 20–30 years ago but now generally accept and strive to adopt it. Hence, the ability to alter perceptions will undoubtedly pave the way for the rational acceptance of future advancements in NOSES. Fourth, from the development of specialties, the current development of NOSES specialties, not only colorectal surgery, and gastric surgery, hepatobiliary and pancreatic surgery, thoracic surgery, thyroid surgery, urology and other specialties are being carried out, there must be commonalities and similarities, the existence of commonality and individuality also prove that NOSES is the future development direction. Fifth, from the analysis of the current situation, there are more and more experts carrying out NOSES, an increasing number of hospitals carrying out NOSES, and it is becoming widely distributed geographically. From the analysis of NOSES data, the recent effect of NOSES is good and there is no increase of complication rate. Sixth, device development is the future direction. Surgical innovation relies on the construction and development of surgical platforms, including energy platforms, instrumentation platforms, and vision platforms. Nowadays, experts have developed, invented, and researched NOSES-related instruments, equipment, and consumables, and it is believed that these developments will further promote the growth of NOSES. NOSES aligns not only with the historical progression of surgery but also with the demands of human medical advancement, making it an inevitable progression in surgical innovation.

Thanksgiving for the Past As the third edition of the NOSES monograph goes to press, we look back on the development of NOSES and feel moved and grateful. I am grateful for the trust and confidence between patients and doctors. I am grateful to all the editors for their persistent pursuit and for taking the patients’ requirements as their own pursuit. The dedication of each editor has made this book a wonderful presentation. We are especially grateful for the strong support from Academician

Preface

Preface

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Hedje, and also thank Prof. Zheng Shu, Prof. Zheng Minhua, Academician Chen Xiaoping, Academician Fan Deming, Academician Guo Yinglu, Academician Lang Jinghe, and Academician Dong Jiahong for their professional guidance and great support to the NOSES series. NOSES, from one technique to a series of techniques and a surgical system; from a professional procedure to becoming popular in the whole industry; from the first edition of the Chinese NOSES book to the fourth edition of the Chinese NOSES book; from the first and second editions of the English NOSES book to the Russian edition translated by Prof. Petr in Russia; from the Korean edition translated by Prof. Chun to the Japanese edition translated by Prof. Nishimura; and finally the French edition translated by Prof. Leroy have formed a complete theoretical system, which is the result of the hard work, wisdom, and fearlessness of domestic and foreign experts. It will open a new era of minimally invasive surgery. NOSES is a masterpiece for surgeons and a gospel for patients; it belongs to China and also to the world. Beijing, China November 2023

Xishan Wang

Quotes

我们现有的知识和经验以及惯性思维, 往往是我们创新的最大敌人, 也是我们否认别人 的理由。 The knowledge, experience, and inertial thinking we currently possess are at times the greatest enemy of innovation, and a justification for the denial of others. 人类机体的完美弥补了医学的不足和我们的自以为是。 The perfection of the human body makes up for the shortage of medicine and our selfrighteousness. 用欣赏的眼光看待别人的成绩, 用挑剔的目光看待自己的不足。 Be appreciative of others’ achievements; be critical with one’s own deficiencies. 用技术赢得天下, 靠德行赢得未来。 Lead the way with skill, win the future with virtue. 个人吃一堑, 行业长一智。 A surgeon’s fall into a pit, a gain in the whole profession’s wit. 实力是唯一的话语权, 实干是唯一的兴邦路 Power speaks, practice matters.

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Contents

Section I General Statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Xishan Wang and Xu Guan

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Overview of NOSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Xishan Wang

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Perioperative Preparation of NOSES . . . . . . . . . . . . . . . . . . . . . . . . . . . Xishan Wang, Yinggang Chen, Lei Yu, and Rui Huang

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Laparoscopic Abdominal Pelvic Anatomical Landmarks and Essentials of Surgical Exploration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Haipeng Chen, Xu Guan, Yong Li, Qingfeng Zheng, and Xishan Wang

Section II NOSES for Colorectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . Xishan Wang and Petr V. Tsarkov 4

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Laparoscopic Lower Rectal Cancer Resection with Transanal Specimen Extraction (CRC-NOSES IA, IB, and IB+, Eversion Method) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Xishan Wang, Enrui Liu, and Haipeng Chen Laparoscopic Ultralow Rectal Cancer Resection with Transanal Specimen Extraction: Park Method (CRC-NOSES IC) . . . . . . . . . . . . . Xishan Wang, Yinghu Jin, and Zheng Jiang Laparoscopic Ultralow Rectal Cancer Resection with Transanal Specimen Extraction: Intersphincteric Resection Method (CRC-NOSES ID) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Xishan Wang, Meng Wang, and Zheng Jiang

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Laparoscopic Ultralow Rectal Cancer Resection with Transanal Specimen Extraction: Bacon Method (CRC-NOSES IE) . . . . . . . . . . . . Bo Jiang and Yi Feng

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Laparoscopic Lower Rectal Cancer Resection with Rectal Eversion and Extra-Abdominal Resection: Tsarkov Method (CRC-NOSES IF) . . . . . . Sergey Efetov, Inna Tulina, and Petr V. Tsarkov

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Laparoscopic Low Rectal Cancer Conformal Resection with Transanal Natural Orifice Specimen Extraction (CRC-NOSES IG) . . . . . . . . . . . . Zhang Wei, Zhu Xiaoming, and Yu Guanyu

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Laparoscopic Middle Rectal Cancer Resection with Transanal Specimen Extraction (CRC-NOSES II) . . . . . . . . . . . . . . . . . . . . . . . . . Xishan Wang, Ziming Yuan, and Zhixun Zhao

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Contents

Laparoscopic Middle Rectal Cancer Resection with Transanal Natural Orifice Specimen Extraction (CRC-NOSES IIB) . . . . . . . . . . . . Xishan Wang and Xu Guan

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Laparoscopic Middle Rectal Cancer Resection with Transvaginal Specimen Extraction (CRC-NOSES III) . . . . . . . . . . . . . . . . . . . . . . . . . Xishan Wang, Qian Zhang, and Haipeng Chen

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Laparoscopic Middle Rectal Cancer Resection with Transvaginal Natural Orifice Specimen Extraction (NOSES IIIB) . . . . . . . . . . . . . . . . Xishan Wang, Haipeng Chen, and Xu Guan

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Laparoscopic Upper Rectal Cancer Resection with Transanal Specimen Extraction (CRC-NOSES IV) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Xishan Wang, Song Wang, and Peng Sun

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Laparoscopic Upper Rectal Cancer Resection with Transvaginal Specimen Extraction (CRC-NOSES V) . . . . . . . . . . . . . . . . . . . . . . . . . Xishan Wang and Zhixun Zhao

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Laparoscopic Left Hemicolectomy with Transanal Specimen Extraction (CRC-NOSES VI A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Xishan Wang and Zheng Jiang

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Laparoscopic Left Hemicolectomy with Transrectal Specimen Extraction (CRC-NOSES VIB) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Haipeng Chen, Zhaoxu Zheng, and Xishan Wang

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Laparoscopic Left Hemicolectomy with Transvaginal Specimen Extraction (CRC-NOSES VII) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Xishan Wang, Zheng Liu, and Zhao Lu

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Laparoscopic Right Hemicolectomy with Transvaginal Specimen Extraction (CRC-NOSES VIIIA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Xishan Wang, Xu Guan, and Hai-Yang Huang

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Laparoscopic Right Hemicolectomy with Transrectal Specimen Extraction (CRC-NOSES VIB) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Xiyue Hu and Haitao Zhou

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Laparoscopic Right Hemicolectomy with Transcolonic Specimen Extraction (CRC-NOSES VIIIC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Jian Peng and Jie Chen

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Laparoscopic Total Colectomy with Transanal Specimen Extraction (CRC-NOSES IX) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Xishan Wang and Zheng Jiang

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Laparoscopic Total Colectomy with Transvaginal Specimen Extraction (CRC-NOSES X) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Xishan Wang, Zheng Jiang, and Runkun Yang

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Section III NOSES for Gastrointestinal Cancer . . . . . . . . . . . . . . . . . . . . . . Su Yan and Gang Yu 24

Laparoscopic Distal Gastrectomy (Billroth I) with Transrectal Specimen Extraction (GC-NOSES I) . . . . . . . . . . . . . . . . . . . . . . . . . . . Su Yan

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Laparoscopic Distal Gastrectomy (Billroth I) with Transvaginal Specimen Extraction (GC-NOSES II) . . . . . . . . . . . . . . . . . . . . . . . . . . . Su Yan

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Laparoscopic Distal Gastrectomy (Billroth II) with Transrectal Specimen Extraction (GC-NOSES III) . . . . . . . . . . . . . . . . . . . . . . . . . . Gang Yu

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Laparoscopic Distal Gastrectomy (Billroth II) with Transvaginal Specimen Extraction (GC-NOSES IV) . . . . . . . . . . . . . . . . . . . . . . . . . . Gang Yu

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Laparoscopic Proximal Gastrectomy with Transanal Specimen Extraction (GC-NOSES V) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gang Yu

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Laparoscopic Proximal Gastrectomy with Transvaginal Specimen Extraction (GC-NOSES VI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gang Yu

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Laparoscopic Total Gastrectomy with Transrectal Specimen Extraction (GC-NOSES VII) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gang Yu

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Laparoscopic Total Gastrectomy with Transvaginal Specimen Extraction (GC-NOSES VIII) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gang Yu

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Robotic Gastric Tumor Resection with Transoral Specimen Extraction (GC-NOSES IX) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Zhi-Wei Jiang

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Section IV NOSES for Hepato-Biliary-Pancreatic and Splenic Surgery . . . Zheng Liu and Xiyue Hu 33

Laparoscopic Liver Tumor Resection with Transvaginal Specimen Extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Feng Gao

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Laparoscopic Hepatectomy with Transvaginal Specimen Extraction . . . Fan Wu and Hongguang Wang

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Laparoscopic Splenectomy with Transvaginal Specimen Extraction . . . . Jian Peng and Jie Chen

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Laparoscopic Pancreaticoduodenectomy with Transanal/Transvaginal Specimen Extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gang Yu and Song Wang

Section V NOSES for Urinary Tumor Surgery . . . . . . . . . . . . . . . . . . . . . . Nianzeng Xing and Sujun Han 37

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507

517

Laparoscopic Uterus, Fallopian Tube, and Ovary Sparing Cystectomy with Transvaginal Specimen Extraction . . . . . . . . . . . . . . . . . . . . . . . . . Nianzeng Xing, Sujun Han, and Liyuan Wu

519

Laparoscopic Partial Nephrectomy with Transvaginal Specimen Extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nianzeng Xing, Sujun Han, and Qinxin Zhao

525

xxiv

39

Contents

Laparoscopic Radical Cystectomy with Transanal Specimen Extraction and Orthotopic Sigmoid Neobladder . . . . . . . . . . . . . . . . . . . Nianzeng Xing, Sujun Han, and Qinxin Zhao

Section VI NOSES for Uterine Tumor Surgery . . . . . . . . . . . . . . . . . . . . . . Bin Li and Danbo Wang 40

41

Laparoscopic Surgical Staging with Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) for Endometrial Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yanzhou Wang Laparoendoscopic Single-Site Radical Hysterectomy and Pelvic Lymph Node Dissection with Transvaginal Natural Orifice Specimen Extraction for Cervical Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yanzhou Wang

533

543

545

551

42

Vaginal-Assisted Laparoscopic Radical Trachelectomy . . . . . . . . . . . . . . Dan Zhao and Bin Li

43

Laparoscopic Comprehensive Surgical Staging for Endometrial Cancer with Transvaginal Specimen Extraction . . . . . . . . . . . . . . . . . . . Dan Zhao and Bin Li

571

Vaginal-Assisted Laparoscopic Surgical Staging for Endometrial Cancer Without Uterine Manipulation . . . . . . . . . . . . . . . . . . . . . . . . . . Danbo Wang

581

Vaginal-Assisted Laparoscopic Radical Cervical Cancer Resection Without Uterine Manipulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Danbo Wang

587

44

45

Section VII Rare and Complicated NOSES . . . . . . . . . . . . . . . . . . . . . . . . . Xishan Wang and Xiyue Hu 46

47

48

49

50

559

595

Laparoscopic Small Intestinal Tumor Resection with Transrectal Specimen Extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Haitao Zhou

597

Laparoscopic Small Intestinal Tumor Resection with Transvaginal Specimen Extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Xishan Wang and Haipeng Chen

607

Laparoscopic Extended Lower Rectal Cancer Resection with En Bloc Lateral Lymph Node Dissection (Wang’s Approach) . . . . . . . . . . . . . . . Xishan Wang, Zhaoxu Zheng, and Haipeng Chen

615

Laparoscopic Radical Transverse Colon Cancer Resection with Transvaginal Specimen Extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bao Mandula and Zhou Haitao

631

Laparoscopic Radical Transverse Colon Cancer Resection with Transrectal Specimen Extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Jingfang Lü, Haipeng Chen, and Xishan Wang

643

Contents

xxv

51

52

Esophagogastric Junction Cancer Surgery with Natural Orifice Specimen Extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Su Yan and Xinfu Ma Endoscopic Radical Resection of Lower and Middle Esophageal Carcinoma with Transvaginal Natural Orifice Specimen Extraction (NOSES) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Jingtao Wang and Guo-Jun Wang

Section VIII Multiple Organ Resection and Combined Organ Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gui-Yu Wang and Xu Guan 53

54

55

56

57

58

Laparoscopic Right Hemicolectomy Combined with Pancreaticoduodenal Resection with Natural Orifice Specimen Extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gang Yu

653

663

677

679

Laparoscopic Right Hemicolectomy and Rectal Cancer Resection with Transrectal Specimen Extraction . . . . . . . . . . . . . . . . . . . . . . . . . . Gui-Yu Wang, Tianyi Ma, and Qian Zhang

691

Laparoscopic Right Hemicolectomy and Sigmoidectomy with Transvaginal Specimen Extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Xishan Wang and Haipeng Chen

705

Laparoscopic Rectal Cancer Resection Combined with Liver Metastasis Resection with Transanal Specimen Extraction . . . . . . Chuangang Fu

719

Laparoscopic Posterior Pelvic Exenteration with Transvaginal Natural Orifice Specimen Extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . Jianqiang Tang

733

Laparoscopic Combined Gastric Cancer and Rectal Cancer Resection with Transanal Specimen Extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . Jianqiang Tang

751

Section IX Natural Orifice Transluminal Endoscopic Surgery . . . . . . . . . . Bing-Rong Liu and Yun-Shi Zhong

763

59

Overview of NOTES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bing-Rong Liu, Dan Liu, Xu Guan, and Xishan Wang

765

60

Endoscopic Transgastric Abdominal Exploration . . . . . . . . . . . . . . . . . . Dan Liu and Bing-Rong Liu

773

61

Flexible Endoscopic Cholecystolithotomy via Natural Orifice Transluminal Endoscopic Surgery (NOTES) . . . . . . . . . . . . . . . . . . . . . Liu Bingrong and Liu Dan

779

Transvaginal Radical Resection of Rectal Cancer Through Rigid Endoscopy (Rectal Tv-NOTES) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Zheng Liu and Xishan Wang

797

62

xxvi

63

64

Contents

Pure Natural Orifice Transluminal Endoscopic Surgery Transintestinal Appendectomy (Ta-NOTES) . . . . . . . . . . . . . . . . . . . . . Yun-Shi Zhong and Pinghong Zhou

801

Pure Natural Orifice Transluminal Endoscopic Surgery Transgastric Appendectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yun-Shi Zhong and Pinghong Zhou

807

65

Transanal Total Mesorectal Excision (taTME) . . . . . . . . . . . . . . . . . . . . Liang Kang

811

66

Pure NOTES for Transoral Endoscopic Thyroidectomy . . . . . . . . . . . . . Li Xinying

825

Section X Complications and Management . . . . . . . . . . . . . . . . . . . . . . . Xiyue Hu and Xu Guan

835

67

Complications and Management of NOSES for Gastrointestinal Tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yinggang Chen, Yan-Tao Tian, and Qian Liu

68

Common Complications and Management of Urinary NOSES . . . . . . . . Nianzeng Xing, Sujun Han, and Liyuan Wu

69

Common Complications in Gynecological Natural Orifice Specimen Extraction Surgery and Their Management . . . . . . . . . . . . . . . . . . . . . . Dan Zhao and Bin Li

837 845

849

Section XI Collection of Expert Experience on NOSES . . . . . . . . . . . . . . . Xishan Wang

855

70

Experience Sharing in NOSES from Different Regions . . . . . . . . . . . . . Joel Leroy, Frederic Bretagnol, Dan Nguyen, Ming Li Leonard Ho, William Tzu-Liang Chen, Joaquim Manuel da Costa Pereira, Carlos Costa Pereira, Cuneyt Kayaalp, Atsushi Nishimura, Mikako Kawahara, Yasuyuki Kawachi, Shigeto Makino, Chie Kitami, and Keiya Nikkuni

857

71

Experience Sharing on Digestive Tract Reconstruction in NOSES . . . . . Junmin Song, Wei Zhang, Xishan Wang, Jinchun Cong, Hong Zhang, Yangchun Zheng, and Donglin Ren

889

72

Experience Sharing on New Ideas and New Techniques in NOSES . . . . Sheng-Chi Chang, Ming Li Leonard Ho, William Tzu-Liang Chen, Jian-Chun Cai, and Hongliang Yao

903

73

Comprehensive Experience Sharing on NOSES . . . . . . . . . . . . . . . . . . . Gui-Yu Wang, Xuejun Sun, Yangchun Zheng, Qing-Si He, and Taiyuan Li

913

74

Aseptic and Tumor-Free Operation and Other Key Techniques Sharing on NOSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Qingchao Tang, Haipeng Chen, Xishan Wang, Junhong Hu, Dan Ma, and Chuangang Fu

931

Contents

xxvii

Section XII International Consensus on Natural Orifice Specimen Extraction Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Xishan Wang and Zheng Liu 75

76

International Guideline on Natural Orifice Specimen Extraction Surgery (NOSES) for Colorectal Cancer (2023 Version) . . . . . . . . . . . . . Zheng Liu, Xu Guan, Mingguang Zhang, Xiyue Hu, Ming Yang, Junge Bai, Jun Li, Shaojun Yu, Kefeng Ding, Qing-Si He, Liang Kang, Dan Ma, Chuangang Fu, Junhong Hu, Ye Wei, Dong-Hui Sun, Gang Yu, Songbing He, Changyou Wang, Yanwei Gao, Gui-Yu Wang, Hongliang Yao, Jian Peng, Yangchun Zheng, Bo Jiang, Taiyuan Li, Zhiguo Xiong, Xuejun Sun, Zhenning Wang, William Meng, William Tzu-Liang Chen, Ming-Yin Shen, John H. Marks, Charles A. Ternent, Darcy D. Shaw, Jim S. Khan, Petr V. Tsarkov, Inna Tulina, Sergey Efetov, Joaquim Manuel da Costa Pereira, Fernanda Nogueira, Ricardo Escalante, Joel Leroy, Avanish Saklani, Audrius Dulskas, Cuneyt Kayaalp, Atsushi Nishimura, Kay Uehara, Woo-Yong Lee, Sang-Hoo Kim, Suk-Hwan Lee, Xishan Wang, Committee of Colorectal Cancer Society Chinese Anti-Cancer Association, and International NOSES Alliance International Consensus on Natural Orifice Specimen Extraction Surgery (NOSES) for Gastric Cancer (2019) . . . . . . . . . . . . . . . . . . . . . Xu Guan, Zheng Liu, Amjad Parvaiz, Antonio Longo, Avanish Saklani, Ali A. Shafik, Jian-Chun Cai, Charles A. Ternent, Lin Chen, Cuneyt Kayaalp, Fatih Sumer, Fernanda Nogueira, Feng Gao, Fang-Hai Han, Qing-Si He, Ho-Kyung Chun, Chang-Ming Huang, Hai-Yang Huang, Rui Huang, Zhi-Wei Jiang, Jim S. Khan, Joaquim Manuel da Costa Pereira, Joseph W. Nunoo-Mensah, Jung Tack Son, Liang Kang, Keisuke Uehara, Ping Lan, Le-Ping Li, Han Liang, Bing-Rong Liu, Juan Liu, Dan Ma, Ming-Yin Shen, Mohammad Rashidul Islam, Narimantas Evaldas Samalavicius, Kai Pan, Petr V. Tsarkov, Xin-Yu Qin, Ricardo Escalante, Sergey Efetov, Seung Kyu Jeong, Suk-Hwan Lee, Dong-Hui Sun, Li Sun, Tatiana Garmanova, Yan-Tao Tian, Gui-Yu Wang, Guo-Jun Wang, Guo-Rong Wang, Xiao-Qiang Wang, William Tzu-Liang Chen, Woo-Yong Lee, Su Yan, Zu-Li Yang, Gang Yu, Pei-Wu Yu, Dan Zhao, Yun-Shi Zhong, Jian-Ping Wang, Xishan Wang, and The International Alliance of NOSES

951

953

963

Contributors

Junge Bai Department of Colorectal Surgery, National Cancer Center, National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China Liu Bingrong The Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China Frederic Bretagnol High Tech Digestive Center, Saint Paul University Hospital, Hanoi, Vietnam Jian-Chun Cai Department of Gastrointestinal Surgery, Zhongshan Hospital of Xiamen University, Xiamen, Fujian, P. R. China Sheng-Chi Chang Division of Colorectal Surgery, China Medical University Hospital, Taichung, Taiwan Haipeng Chen Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Jie Chen Department of Geriatric Surgery, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China Lin Chen Department of General Surgery, Chinese People’s Liberation Army General Hospital, Beijing, P. R. China William Tzu-Liang Chen Department of Colorectal Surgery, China Medical University Hsinchu Hospital, Taichung, Taiwan Department of Surgery, China Medical University Hospital, Taichung, Taiwan, China Yinggang Chen Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Shenzhen Center, Shenzhen, China Ho-Kyung Chun Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea Jinchun Cong Department of General Surgery, Shengjing Hospital China Medical University, Shenyang, China Joaquim Manuel da Costa Pereira Department of Surgery, Hospital de Braga, Braga, Portugal Liu Dan The Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China Kefeng Ding Department of Colorectal Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China

xxix

xxx

Audrius Dulskas Department of Abdominal and General Surgery and Oncology, National Cancer Institute, Vilnius, Lithuania Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania Sergey Efetov Colorectal Surgery Department, Sechenov First Moscow State Medical University, Moscow, Russia Clinic of Faculty Surgery N2, Surgical Department N2, University Clinical Hospital N4, I.M. Sechenov First Moscow State Medical University, Moscow, Russia Ricardo Escalante Universidad Central de Venezuela, Centro Medico Loira, Caracas, Venezuela Yi Feng Anal and Colorectal Surgery, Shanxi Cancer Hospital, Affiliated Cancer Hospital of Shanxi Medical University, Taiyuan, China Chuangang Fu Department of Gastrointestinal Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China Feng Gao Department of Gastrointestinal Surgery, The Affiliated Hospital of Medical School of Ningbo University, Ningbo, Zhejiang, China Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, P. R. China Yanwei Gao Inner Mongolia Autonomous Region People’s Hospital, Huhhot, Inner Mongolia Autonomous Region, China Tatiana Garmanova Clinic of Colorectal and Minimally Invasive Surgery, Sechenov First Moscow State Medical University, Moscow, Russia Xu Guan Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Department of Colorectal Surgery, National Cancer Center, National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China Yu Guanyu The Colorectal Surgery Department, First Affiliated Hospital of Naval Medical University, Shanghai, China Zhou Haitao Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Fang-Hai Han Department of Gastroenterological Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China Sujun Han Department of Urology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China Qing-Si He Department of General Surgery, Shandong University Qilu Hospital, Jinan, Shandong, P. R. China Songbing He Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China Ming Li Leonard Ho Department of General Surgery, Sengkang General Hospital, Singapore, Singapore Junhong Hu Department of General Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China Department of Anorectal Surgery, First Affiliated Hospital, Zhengzhou University, Zhengzhou, Henan, China

Contributors

Contributors

xxxi

Xiyue Hu Department of Colorectal Surgery, National Cancer Center, National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China Chang-Ming Huang Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, P. R. China Hai-Yang Huang Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China Rui Huang Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, P. R. China Mohammad Rashidul Islam Department of Surgery, Shaheed Suhrawardy Medical College, Dhaka, Bangladesh Seung Kyu Jeong Department of Surgery, Yang Hospital, Seoul, South Korea Bo Jiang Anal and Colorectal Surgery, Shanxi Cancer Hospital, Affiliated Cancer Hospital of Shanxi Medical University, Taiyuan, China Zheng Jiang Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Zhi-Wei Jiang Department of General Surgery, Jiangsu Province Hospital of Traditional Chinese Medicine, Nanjing, Jiangsu, P. R. China Yinghu Jin Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Liang Kang Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China Yasuyuki Kawachi Nagaoka Chuo General Hospital, Niigata, Japan Mikako Kawahara Nagaoka Chuo General Hospital, Niigata, Japan Cuneyt Kayaalp Department of Gastrointestinal Surgery, Inonu University, Malatya, Turkey Gastrointestinal Surgery, Yeditepe University Medical School, Istanbul, Turkey Jim S. Khan Anglia Ruskin University Chelmsford, Chelmsford, UK Department of Colorectal Surgery, Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Portsmouth, UK Sang-Hoo Kim IRCAD China, Wuxi, China Chie Kitami Nagaoka Chuo General Hospital, Niigata, Japan Ping Lan Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China Suk-Hwan Lee Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea Woo-Yong Lee Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea Joel Leroy Hanoi High Tech & Digestive Center, St. Paul Hospital, Digestive Colorectal, Hano, Vietnam Bin Li Department of Gynecologic Oncology, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China

xxxii

Jun Li Department of Colorectal Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China Le-Ping Li Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, P. R. China Taiyuan Li Department of General Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, China Yong Li Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Han Liang Department of Gastric Cancer, Tianjin Medical University Cancer Institute & Hospital, Tianjin, P. R. China Bing-Rong Liu Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, P. R. China Dan Liu The Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China Enrui Liu Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Juan Liu Department of Obstetrics and Gynecology, Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, P. R. China Qian Liu Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Zheng Liu Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China Antonio Longo European Center of Coloproctology and Pelvic Diseases-Multimedica Hospital, Milan, Italy Zhao Lu Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Jingfang Lü Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Dan Ma Department of General Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing, P. R. China Tianyi Ma Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China Xinfu Ma Department of Gastrointestinal Surgery, Affiliated Hospital of Qinghai University, Qinghai University, Xining, China Shigeto Makino Nagaoka Chuo General Hospital, Niigata, Japan Bao Mandula Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China John H. Marks Division of Colorectal Surgery, Lankenau Medical Center, Wynnewood, PA, USA Lankenau Medical Center, Medical Office Building West, Wynnewood, PA, USA William Meng Minimally Invasive Surgery Centre and Endoscopy Centre, Matilda International Hospital, Hong Kong, China

Contributors

Contributors

xxxiii

Dan Nguyen High Tech Digestive Center, Saint Paul University Hospital, Hanoi, Vietnam Keiya Nikkuni Nagaoka Chuo General Hospital, Niigata, Japan Atsushi Nishimura Department of Surgery, Institute of Gastroenterology, Nagaoka Chuo General Hospital, Nagaoka, Niigata, Japan Fernanda Nogueira Department of Surgery, Hospital de Braga, Braga, Portugal Joseph W. Nunoo-Mensah King’s College Hospital, London, UK Kai Pan Department of Gastrointestinal Surgery, Shenzhen People’s Hospital & Second Clinical Medical College of Jinan University, Shenzhen, Guangdong, P. R. China Amjad Parvaiz Poole Hospital NHS Trust, Poole, UK Jian Peng Department of Geriatric Surgery, Xiangya Hospital, Central South University, Changsha, China National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China Carlos Costa Pereira Department of Surgery, Hospital de Braga, Braga, Portugal Xin-Yu Qin Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, P. R. China Donglin Ren Department of Colorectal Surgery and Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China Avanish Saklani Department of GI Surgical Oncology, Tata Memorial Hospital, Mumbai, India Narimantas Evaldas Samalavicius Department of Surgery, Klaipeda University Hospital, Klaipeda, Lithuania Ali A. Shafik Department of Colorectal Surgery, Cairo University, Cairo, Egypt Darcy D. Shaw Colorectal Surgery Associates, Kansas City, MO, USA Kansas City University, Kansas City, MO, USA Ming-Yin Shen Colorectal Surgery Division, China Medical University Hsinchu Hospital, Zhubei, Taiwan, China Department of Surgery, China Medical University Hospital, Taichung, Taiwan, China Jung Tack Son Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea Junmin Song The Department of Colorectal and Anal Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China Fatih Sumer Department of Gastrointestinal Surgery, Inonu University, Malatya, Turkey Dong-Hui Sun Department of Gastric and Colorectal Surgery, Jilin University First Hospital, Changchun, Jilin, P. R. China Li Sun Department of Gynecologic Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China Peng Sun Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Shenzhen Center, Shenzhen, China

xxxiv

Xuejun Sun Department of General Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China Jianqiang Tang Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Qingchao Tang Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China Charles A. Ternent Section of Colon and Rectal Surgery, Creighton University School of Medicine, Omaha, NE, USA Yan-Tao Tian Department of Colorectal Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China Petr V. Tsarkov Clinic of Colorectal and Minimally Invasive Surgery, Department of Surgery ICM, I.M. Sechenov First Moscow State Medical University, Moscow, Russia Inna Tulina Clinic of Colorectal and Minimally Invasive Surgery, Department of Surgery ICM, I.M. Sechenov First Moscow State Medical University, Moscow, Russia Kay Uehara Department of Surgery, Division of Surgical Oncology, Nagoya Graduate School of Medicine, Nagoya, Japan Keisuke Uehara Department of Surgery, Division of Surgical Oncology, Nagoya University School of Medicine, Nagoya, Japan Changyou Wang Affiliated Hospital of North China University of Science and Technology, Tangshan, Hebei, China Danbo Wang The Gynecological Unit, Liaoning Cancer Hospital & Institute, Shenyang, Liaoning, China Gui-Yu Wang Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, P. R. China Guo-Jun Wang Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, P. R. China Guo-Rong Wang Department of General Surgery, Shanxi Provincial People’s Hospital, The Third Affiliated Hospital, Medical College, Xi’an Jiao Tong University, Xi’an, Shaanxi, P. R. China Hongguang Wang Department of Hepatobiliary Surgery, National Cancer Center, National Clinical Research Center for Cancer, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China Jian-Ping Wang Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yatsen University, Guangzhou, Guangdong, P. R. China Jingtao Wang Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China Meng Wang Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Song Wang Department of Colorectal Cancer Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China Department of General Surgery, Zibo Municipal Hospital, Zibo, Shandong, China

Contributors

Contributors

xxxv

Xiao-Qiang Wang Department of General Surgery, Shanxi Provincial People’s Hospital, The Third Affiliated Hospital, Medical College, Xi’an Jiao Tong University, Xi’an, Shaanxi, P. R. China Xishan Wang Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China Yanzhou Wang Department of Obstetric and Gynecology, First Affiliated Hospital, Army Medical University, Chongqing, China Zhenning Wang Department of Gastrointestinal Surgery, The First Affiliated Hospital of China Medical University, Shenyang, China Ye Wei Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China Zhang Wei The Colorectal Surgery Department, First Affiliated Hospital of Naval Medical University, Shanghai, China Fan Wu Department of Hepatobiliary Surgery, National Cancer Center, National Clinical Research Center for Cancer, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China Liyuan Wu Department of Urology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China Zhu Xiaoming The Colorectal Surgery Department, First Affiliated Hospital of Naval Medical University, Shanghai, China Nianzeng Xing Department of Urology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China Li Xinying Department of General Surgery, Division of Thyroid Surgery, Xiangya Hospital, Central South University, Hunan, Changsha, China Zhiguo Xiong Department of Gastrointestinal Surgery, Hubei Provincial Cancer Hospital, Wuhan, China Su Yan Department of Gastrointestinal Surgery, Qinghai University Affiliated Hospital, Xining, Qinghai, P. R. China Ming Yang Department of Colorectal Surgery, National Cancer Center, National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China Runkun Yang Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China Zu-Li Yang Department of Gastrointestinal Surgery, The Sixth Affiliated Hospital of Sun Yatsen University, Guangzhou, Guangdong, P. R. China Hongliang Yao Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China Gang Yu Department of General Surgery, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University Qingdao, Qingdao, Shandong, China Lei Yu Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China

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Pei-Wu Yu Department of General Surgery, Center of Minimal Invasive Gastrointestinal Surgery, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, P. R. China Shaojun Yu Department of Colorectal Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China Ziming Yuan Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China Hong Zhang Department of General Surgery, Shengjing Hospital China Medical University, Shenyang, China Mingguang Zhang Department of Colorectal Surgery, National Cancer Center, National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China Qian Zhang Department of Colorectal Cancer Surgery, Cancer Hospital of the University of Chinese Academy of Sciences, Hangzhou, China Wei Zhang The Department of Colorectal and Anal Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China Dan Zhao Department of Gynecologic Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China Qinxin Zhao Department of Urology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China Zhixun Zhao Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Qingfeng Zheng Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Yangchun Zheng Department of Gastrointestinal Surgery, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Cancer Hospital Affiliate to School of Medicine, UESTC, Chengdu, China Zhaoxu Zheng Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Yun-Shi Zhong Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, P. R. China Haitao Zhou Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Pinghong Zhou Endoscopy Center, Zhongshan Hospital, Fudan University, Shanghai, China Committee of Colorectal Cancer Society Chinese Anti-Cancer Association International NOSES Alliance The International Alliance of NOSES

Contributors

Introduction of Chief Editor

colorectal cancer treatment; has taken charge of more than 10 projects, including 3 projects of the National Natural Science Foundation and the national city cancer early diagnosis and early treatment; presided over the national major project on precision medicine titled “The Application of Precision Medicine in Colorectal Cancer Diagnosis and Treatment.”

Wang Xishan Professor, Chief Physician, Doctoral Tutor, National Cancer Center/Cancer Hospital Chinese Academy of Medical Sciences, Director of Colorectal Surgery Department. The Main Academic Titles The Chairman of the Colorectal Cancer Committee of the Chinese Medical Doctor Association; the Chairman of the Colorectal Cancer Committee of the Chinese Anti-Cancer Association; the President of the International Alliance of NOSES; the President of the China Alliance of NOSES; the Chairman of the Youth Committee of Colorectal Cancer Committee of the Chinese Anti-Cancer Association; the Vice Chairman of the Tumor Metastasis Committee of the Chinese Anti-Cancer Association; the Vice Chairman of the MDT Committee of the Chinese Medical Doctor Association; the Standing Committee of the Surgeon Committee of the Chinese Medical Doctor Association; the Chief Editor of the Chinese Journal of Colorectal Diseases (Electronic Edition); the President of the Russian-Chinese Society of Colorectal Surgeons; Honorary Member of Russian School of Colorectal Surgery. Scientific Research and Clinical Achievements Totally published 116 SCI papers; edited and participated in 18 monographs and 31 audiovisual materials related to

Novel Techniques Being proficient in minimally invasive surgery for colorectal cancer as well as combined organ resection for difficult cases. Currently, improved the theoretical system of natural orifice specimen extraction surgery (NOSES) in the treatment of colorectal cancer, including 10 different surgical procedures for colorectal cancer resection, and performed more than 1000 cases of NOSES for colorectal cancer, which is ranked first in China. Established evaluation standards to determine the low and ultra-low anastomosis surgery based on the location of the tumor to the dentate line instead of the anal verge. The introduction of the “risk/benefit ratio theory” aims to establish a more rational, more patient-centered and standardized treatment principle for sphincter-preserving surgery. Carried out a variety of difficult surgeries, such as hemicolectomy combined with pancreaticoduodenectomy. Proposed the distinction of concepts between combined organ resection and multiple organ resection. According to the different invasion manners (cancerous invasion or inflammatory invasion), proposed refinement T4 staging recommendations. On the basis of the expanded radical resection of rectal cancer, the selective expanded radical resection of rectal cancer was proposed to fully retain the physiological function of patients after operation. In addition, other new technologies also include radical rectal cancer surgery through the sacrococcygeal route, radical colectomy with the omentum preserved, and total colectomy with the rectal ampulla preserved. These clinical works play an important role in improving the current treatment status of colorectal cancer.

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Section I General Statement Xishan Wang and Xu Guan

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Overview of NOSES Xishan Wang

Contents Minimally Invasive Surgery and Surgical Incisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Nomenclature and Definition of NOSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Classification and Surgical Procedures of NOSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Classification According to the Routes for Specimen Extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Classification According to the Procedures for Specimen Extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NOSES for Colorectal Neoplasms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NOSES for Gastric Neoplasms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NOSES for Gynecological Neoplasms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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The Concept and Application of Passing By-NOSES and Like-NOSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Indications of NOSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Selecting Routes for Specimen Extraction in NOSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Aseptic and Tumor-Free Technique of NOSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Advantages and Limitations of NOSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 The Past and Present of NOSES with Enhanced Recovery After Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Current Status and Achievements of NOSES in China . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 The International NOSES Alliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 The Future of NOSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Abstract

With the rapid development of surgical techniques and the widespread acceptance of minimal invasiveness, minimally invasive surgery has become the focal point of new medical technology. Natural orifice transluminal endoscopic surgery (NOTES) has overturned the conventional concept and pushed minimally invasive technique to the extreme of “no incision.” Recently, as one of the new techniques in minimally invasive surgery, natural orifice specimen extraction surgery (NOSES) has gradually attracted extensive attention and heated discussion X. Wang (*) Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China © People’s Medical Publishing House, PR of China 2023 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-99-2750-0_1

both domestically and overseas. It is well known that NOSES is a new type of hybrid surgical procedure with the “no incision” idea of NOTES and the surgical techniques of laparoscopic surgery, to achieve better clinical and minimally invasive outcomes with satisfying safety and operability. Currently, the application of NOSES is not only limited to the colorectal field but has also extended gradually to perform gastrointestinal, hepatobiliary, splenopancreatic, and urogynecologic surgeries, reflecting the vitality and potentiality of NOSES. In order to build a comprehensive theory of NOSES, we have extended the application of NOSES to surgeries for other abdominal and pelvic organs and then present a detailed surgical monograph of NOSES.

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Keywords

Natural orifice specimen extraction surgery · Minimally invasive surgery · Aseptic and Tumor-Free technique · Transvaginal · Transanal

Minimally Invasive Surgery and Surgical Incisions Minimally invasive surgery (MIS) is one of the most popular concepts in modern surgery. However, what is the exact definition of minimally invasive? What does it mean to do something minimally invasive? Broadly speaking, “minimally invasive” is an idea that minimizes or limits the damage to the tissues and organs caused by any human factors. This concept applies to all the invasive surgical operations or procedures and is central to the current era of MIS. In this context, the concept of functional surgery in tumor therapy emerged. On the basis of radical cancer treatment, functional surgery of tumor requires that the normal function of organs and tissues should be retained to the maximum extent. It can be seen that the concept of MIS and tumor functional surgery is essentially dialectically unified, and the ultimate purpose of MIS is to retain the normal function. Narrowly, minimally invasive is a kind of surgical approach that minimizes the size of the surgical abdominal incision. In the past, incision and pain were considered as the inevitable outcome of surgery; the larger the incision, the greater the surgical damage. Moreover, surgeons usually pay more attention to intra-abdominal operations, while ignoring a series of negative physical and psychological effects of the incision on patients. In fact, in NOTES, NOSES, or other minimally invasive surgical procedures, the intra-abdominal steps are almost the same as that of traditional open surgery, consisting of tissue dissection, lesion resection, and digestive tract reconstruction. The main difference lies in the abdominal incisions. Compared with open surgery and conventional laparoscopic surgery, the most direct advantage of NOSES procedure is the avoidance of abdominal incision for specimen retrieval. However, the necessity to avoid this small incision is a conceptual problem that must be faced before starting NOSES. Firstly, incision is the main cause of postoperative pain. The larger the incision, the greater the damage to the superficial nerves, consequently, the more severe the postoperative pain is. Wolthuis and colleagues compared the short-term outcomes of the patients received conventional laparoscopic surgery and NOSES, and found that conventional laparoscopic surgery group showed more severe postoperative pain and greater dependence on postoperative pain relievers. Severe pain at or around the incision site is also an important factor affecting postoperative recovery. Secondly, abdominal incision also increases the risk of incision complications, including infection, incisional

Table 1.1 Classification of incisions Classification Mini incision

Length 35 kg/m2).

Fig. 5.3 Rectal MRI: female, T3, 2.0 cm from the dentate line, maximum diameter of 2.8 cm

Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position Anesthesia Method Fig. 5.1 Tumor location suitable for NOSES I

General anesthesia or general epidural anesthesia.

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Fig. 5.4 The patient’s position

Surgeon's Auxiliary Trocar (5 mm)

CameraTrocar (10 mm)

Surgeon's Main Trocar (12 mm)

Assistant's Main Trocar (5 mm) Assistant's Auxiliary Trocar (5 mm)

being isolated, and will form a vertical angle to transect the mesentery. 3. The surgeon’s auxiliary trocar (5 mm trocar) is located at about 10 cm from the right side of the umbilicus, so as to reduce the interference of laparoscopy when operating in the lower rectum. 4. The assistant’s auxiliary trocar (5 mm trocar) is located opposite the McBurney’s point, which is mainly used for lifting and retracting, while, in the meantime, facilitating to place the drainage tube. 5. The assistant’s main trocar (5 mm trocar) is located at the left side of upper umbilical level adjacent to the lateral edge of the rectus abdominis (Fig. 5.5).

Fig. 5.5 Trocar sites (five-ports method)

Patient Positioning

Surgical Team Position

The patient is placed in a functional lithotomy position, with the right thigh slightly flattened, which facilitated to perform the operation for the surgeon (Fig. 5.4).

Abdominal operation: The surgeon stands on the right side of the patient, the assistant stands on the left side of the patient, and the camera holder stands on the same side of the surgeon. Perineal operation: The surgeon stands between the patient’s legs, and the assistants separately stand on the left and right side of the patient (Fig. 5.6).

Trocar Placement 1. Camera trocar (10 mm trocar) is located just above the umbilicus. 2. The surgeon’s main trocar (12 mm trocar) is located below the McBurney’s point, which will make the lower rectal operation easier, especially when the lower rectal wall is

Special Surgical Instruments Ultrasonic scalpel, electric scalpel with needle electrode, and anal retractor.

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Fig. 5.6 (a) Surgeons’ positions (abdominal operation); (b) surgeons’ positions (perineal operation)

Dissection and Separation

Surgical Procedures, Techniques, and Key Points The schematic view of main surgical procedures of specimen extraction and digestive reconstruction in NOSES IC (Fig. 5.7).

Exploration and Surgical Planning Based on the detailed preoperative examination and surgical plan discussion, surgical exploration mainly includes three steps:

General Exploration After the laparoscope being placed into the umbilical port, we recommend an overall exploration within the abdominal cavity in a clockwise manner from the right upper quadrant, to ensure that nothing abnormal is overlooked. The involved organs include liver, gallbladder, stomach, spleen, greater omentum, colon, small intestine, pelvic cavity, and ascites (Fig. 5.8). Tumor Exploration This procedure is suitable for lower rectal cancer, which is located below the peritoneal reflection. The surgeon should certify the location and size of the tumor by a digital rectal examination to determine the feasibility of the operation. Evaluation of Anatomical Structures Evaluation of the length and thickness of sigmoid colon and mesentery is performed to further determine the feasibility of transanal specimen extraction.

The First Point of the Incision Place the patient in the head-down position (Trendelenburg position), block the small intestine to the upper abdomen with a gauze, and expose the entire pelvic cavity and the roots of the inferior mesenteric vessels. The assistant lifts the upper rectal wall upward to the left with the forceps in the left hand and lifts the root of the mesentery with the forceps in the right hand to fully expose the surgical field (Fig. 5.9). The surgeon performs the first point of the incision at a thin region of the mesentery below the sacral promontory with an ultrasonic scalpel. The scalpel tip generates heat and spreads along with the mesorectal presacral space (Fig. 5.10). The white presacral fascia is visible by moving the scalpel tip up and down, which proves that the correct space has been entered (Fig. 5.11). The inferior hypogastric nerve is sometimes visible by extending the space up and down with an ultrasonic scalpel (Fig. 5.12). Isolation and Ligation of the Root of Inferior Mesenteric Artery and Vein The surgeon lifts the mesentery along the course of the superior rectal artery and the inferior mesenteric artery with the forceps in the left hand to provide tension. Perform dissection with the ultrasonic scalpel in the right hand along the Toldt’s fascia to the mesenteric root (Fig. 5.13). Care should be taken to protect the ureters and gonadal vessels during the dissection. Apply an ultrasonic scalpel to dissect the root of the inferior mesenteric artery layer by layer at the intended resection line, and dissect the lymph nodes at the root of the vessels (Fig. 5.14). The isolated length of the vessels should be long enough for ligation

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Fig. 5.7 The main surgical procedures of specimen extraction and digestive reconstruction in NOSES IC

Fig. 5.8 Exploration of the pelvic cavity

Fig. 5.9 The surgical field is fully exposed

(Fig. 5.15). Ligation and transection of the inferior mesenteric artery are performed (Fig. 5.16). The dissection is continued in a medial to lateral fashion and the inferior mesenteric vein can be seen. The vein is ligated and

transected after full exposure (Figs. 5.17 and 5.18). During the dissection, the blade of the ultrasonic scalpel should be placed upward, which could prevent additional injury to surrounding tissues.

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Fig. 5.10 The first cutting point of the incision Fig. 5.13 Dissection to the root of the inferior mesenteric artery

Fig. 5.11 Entering the Toldt’s space Fig. 5.14 Dissection of lymph nodes at the root of mesentery

Fig. 5.12 Exposure of the inferior hypogastric nerves Fig. 5.15 Isolation of the inferior mesenteric artery

Dissection of the Sigmoid Mesocolon When the inferior mesenteric vessels are transected, the avascular area of sigmoid mesocolon can be partially opened. The assistant lifts the mesentery with the forceps in the left hand and flip the stump of the inferior mesenteric vessels with the forceps in the right hand. The surgeon further dissects the sigmoid mesocolon space downward from medial to lateral to the bifurcation of the left common iliac artery (Fig. 5.19). Attention should be paid to protect the ureters and gonadal vessels (Fig. 5.20). During the dissection of the mesentery, the surgeon may apply the

scalpel to hold the gauze to perform blunt dissection along the Toldt’s fascia (Fig. 5.21). After dissection, a gauze is placed underneath the sigmoid mesocolon (Fig. 5.22). Continue to dissect the right rectal wall and the posterior rectal wall downward along with the space (Fig. 5.23).

Dissection of the Right Rectal Wall and the Posterior Rectal Wall Based on sufficient separation of the posterior mesorectum, the dissection of the right side of the rectum is much easier.

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Fig. 5.16 Ligation and transection of the inferior mesenteric artery Fig. 5.19 Dissection of the sigmoid mesocolon downward from medial to lateral

Fig. 5.17 Exposure of the inferior mesenteric vein Fig. 5.20 Exposure and protection of ureters and gonadal vessels

Fig. 5.18 Ligation and transection of the inferior mesenteric vein

Look for the Toldt’s fascia (the border between yellow and white tissue) on the right and dissect the right rectal wall along the Toldt’s fascia (Fig. 5.24). Dissection of the right rectal wall should be in conjunction with the dissection of the posterior rectal wall (Figs. 5.25 and 5.26). Then the surgeon should dissect the right side of the rectum down to the peritoneal reflection, and continually incise the peritoneal

Fig. 5.21 Blunt dissection with gauze

reflection from the right side to the left side (Fig. 5.27). According to the operative characteristics of this procedure, the distal rectum should be dissected to the levator ani hiatus until the level of the dentate line.

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Fig. 5.25 Dissection of the posterior rectal wall Fig. 5.22 Placing gauze underneath the mesentery

Fig. 5.26 Dissection of the posterior rectal wall Fig. 5.23 Dissection downward along the Toldt’s fascia

Fig. 5.27 The peritoneal reflection is incised from right side to left side Fig. 5.24 Dissection of the right rectal wall

Dissection of the Sigmoid Colon, the Left and the Anterior Rectal Wall The lateral attachments of the sigmoid colon are dissected free, the sigmoid colon is completely mobilized, and the gauze can be observed underneath the mesocolon (Fig. 5.28). The dissection of mesentery is then preceded upward and downward sufficiently (Figs. 5.29 and 5.30). Dissect the left side of the rectum downward to the peritoneal

reflection and join with the right side (Fig. 5.31). During the dissection of the anterior rectal wall, care should be taken to expose and protect bilateral seminal vesicles (male patients) or the posterior vaginal wall (female patients) (Figs. 5.32 and 5.33). At the same time, the rectal wall should be further isolated until the level of the dentate line (Fig. 5.34). For female patients, the assistant could perform a digital vaginal examination to instruct the dissection of the anterior rectal wall, so as to prevent damages to the posterior vaginal wall.

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Fig. 5.28 The peritoneum on the left of mesocolon is opened Fig. 5.31 The left side of the peritoneal reflection is opened

Fig. 5.29 The left side of the mesocolon is dissected upward

Fig. 5.32 The anterior rectal wall is dissected downward

Fig. 5.30 The left side of the mesocolon is dissected downward

Dividing the Sigmoid Mesocolon Turn the sigmoid colon to the left, a gauze is placed underneath the sigmoid mesocolon (Fig. 5.35). In order to sufficiently expand the surface of the sigmoid mesocolon, the assistant may lift the sigmoid mesocolon with two atraumatic forceps and pull it laterally. The scope of surgical resection and proposed proximal intestinal resection line is measured visually. The extent of division should be long enough to allow the specimen to be easily extracted through the anus.

Fig. 5.33 The dissection of the anterior rectal wall

After the extent of division is determined, the mesentery is continuously dissected till to the intended resection line of the bowel (Fig. 5.36), with ligation of 2–3 sigmoid colon vessels (Fig. 5.37). The exposed length of the bowel wall of the sigmoid colon is proposed to be appropriately 2–3 cm (Fig. 5.38).

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Fig. 5.34 Isolation of the bowel wall below the tumor

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Fig. 5.37 Ligation of vessels within the sigmoid mesocolon

Fig. 5.35 A gauze is placed underneath the sigmoid mesocolon

Fig. 5.38 Isolation of bowel wall of sigmoid colon

Fig. 5.36 Dividing the sigmoid mesocolon

Fig. 5.39 Transection of the sigmoid colon

Specimen Resection and Digestive Tract Reconstruction

with an anal retractor or bladder retractor to clearly expose the rectum, then the rectal lumen is thoroughly disinfected with an iodoform gauze (Fig. 5.40). The rectum is opened 0.5 cm above the dentate line, and the full thickness of the rectum is excised with an electric scalpel (damage to the internal sphincter should be avoided) (Fig. 5.41). During the resection of the rectal wall, the position of the distal resection margin can be determined under direct vision to ensure safety of the distal resection margin (Fig. 5.42). At the same time, the assistant should provide timely suction, which is critical for both aseptic and tumor-free operations. Finally, the proximal bowel and mesentery are extracted through the anus (Fig. 5.43).

Specimen Resection After complete dissection of the rectum, the sigmoid colon is transected with a linear Endo-GIA stapler at the intended resection line above the tumor (Fig. 5.39). When the laparoscopic rectal dissection finished, a gauze can be placed around the isolated rectum near to the anal canal, which can be used for identification and protection during the transrectal procedures. After the abdominal operation is completed, the perineal operation starts. The anus should be fully expanded

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Fig. 5.40 Disinfection of the rectal lumen with iodoform gauze

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Fig. 5.43 Transanal extraction of rectal specimen

Fig. 5.44 Full-thickness suture of reserved sutures to anal stump Fig. 5.41 Incision of the rectal wall above the dentate line

Fig. 5.42 The distal resection margin could be clearly exposed under direct vision

Fig. 5.45 Four stitches at the four cardinal points of orientation of the distal anal canal

Digestive Tract Reconstruction Digestive tract reconstruction is performed after irrigation with a dilute iodophor solution. The manual single-layer sigmoid-anal anastomosis is performed. The reserved sutures (Fig. 5.44) are, respectively, sutured at the four cardinal points of the orientation of the anal canal, and the reserved sutures are expanded in four directions (Fig. 5.45). Insert the oval forceps through the anus to pull the sigmoid colon out of

the anus. After confirming that no mesenteric volvulus has been observed, open the sigmoid colon stump outside the anus and perform the anastomosis. Perform full-thickness suture of the sigmoid colon with the four reserved sutures at the anal canal. Knot and fix the sutures after slowly returning the sigmoid colon back to the anal canal. Lift two adjacent fixation sutures, respectively, and perform full-thickness suture of 2–3 stitches between the two sutures for

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Fig. 5.46 Stitch-by-stitch reinforcement and suture of anastomosis

Fig. 5.48 Display of abdominal wall after operation

Fig. 5.47 Inspection of anastomotic integrity

reinforcement (Fig. 5.46). After completing the suturing of the four quadrants, check for the density of suture, the patency of anastomosis, then complete the manual singlelayer sigmoid-anal end-to-end anastomosis (Fig. 5.47).

Postoperative Abdominal Wall and Specimen Pictures See Figs. 5.48 and 5.49.

Key Points, Difficulties, and Hotspots Related to Surgery Indications and Precautions At present, sphincter-preserving surgery for lower rectal cancer has always been a hot and difficult issue in the surgical field. There is still lack of consistent conclusions as to what kind of patients are suitable for sphincter preservation, what techniques to use, and how to deal with complications

Fig. 5.49 Display of specimen

(Temple et al. 2009; Rullier et al. 2013). Parks proposed transabdominal resection of rectal cancer with transanal coloanal anastomosis. The main steps of this procedure are laparoscopic dissection of the mesorectum to the upper edge of the anal canal, transection of the rectal specimen with an ultrasonic scalpel at the upper edge of the anal canal, transanal resection of the rectal mucosa above the dentate line at the perineum, transanal extraction of colon out of the body, and manual intermittent suture of the colon stump to the dentate line. Since the proposal of this procedure, more and more practice confirmed that the Parks procedure can preserve the anal function to the maximum extent without affecting the radical resection of tumor. Parks procedure is mainly suitable for lower rectal cancer with the distal edge of tumor 5–6 cm from the anus. It is especially suitable for male patients with the narrow pelvis or obese patients. For

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these patients, a double stapling technique is not applicable, and only manual transanal suture can be performed. Of course, tumor location is not the only criterion to determine whether the procedure is applicable. The tumor should be well differentiated (moderately and well-differentiated adenocarcinoma) and the local infiltration depth should be shallow (T1 or T2). In addition, patients need to have a strong willingness to preserve anus and have a good preoperative anal function. Before the surgery, doctors should fully inform patients that postoperative bowel control dysfunction and altered bowel habit may occur. The author also recommends routine intraoperative pathological examination of the distal resection margin. This not only ensures the radical resection of the tumor, but also acts as a protection for the doctors themselves. The main complications of Parks procedure include anastomotic leakage and fecal incontinence (Rutgers et al. 2021). Among the several high-risk factors for anastomotic leakage, the issue of anastomotic tension should be specifically emphasized for the Parks procedure. Since the rectum and mesentery have been completely resected, the anastomotic colon is half-suspended in the pelvic cavity. The anastomotic tension will be increased when it is subjected to the effects of gravity and the peristaltic tension of bowel, which is prone to cause anastomotic leakage. Therefore, the author suggests that it must be ensured that anastomosis is tension free before coloanal anastomosis, and the dissection of splenic flexure can be performed if necessary. In addition, fecal incontinence is also a shortterm problem for patients’ status after the Parks procedure (Yamada et al. 2019). It has been reported that the incidence of postoperative fecal incontinence is related to the length of the remnant rectum. Patients with remnant rectum less than 0.5 cm in length have poor bowel control, whereas those with remnant rectum more than 1 cm in length have better bowel control. Besides, violent anal dilation in operation may damage the anal sphincter, resulting in poor postoperative bowel control. Patients with fecal incontinence can be given a modified diet, such as low-residue diet or enteral nutrition, and external administration of zinc oxide paste. The condition can be recovered in half a year or so. This procedure has a great advantage in sphincterpreserving surgery for lower rectal cancer. Compared with the traditional open surgery, laparoscopic operation can dissect the rectum to the lowest possible level, which greatly reduces the difficulty of the Parks procedure. In addition, laparoscopy can facilitate the protection of pelvic autonomic nerves with clear exposure of the operative field and delicate dissection. On the premise of ensuring the radical resection of the tumor, the anal sphincter control, urinary function and sexual function of patients can be protected to the maximum extent.

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Four-Point Suture Fixation Technique for Anastomosis When sigmoid-anal anastomosis is performed manually, the narrow operating space of the anal canal and the different caliber of the colon and anal canal are prone to cause inaccurate positioning of suture and uneven length between stitches. The four-point suture fixation technique for anastomosis can effectively solve this technical difficulty. First, the sutures are fixed at the four cardinal points of the orientation of the anal stump for positioning. Then, the sigmoid colon is extracted out of the anus. After the adjustment of direction, the full-thickness suturing is performed at the four cardinal points of the orientation of the sigmoid colon stump under direct vision. After the suturing, the sigmoid colon is slowly returned back to the anal canal. This operation can ensure that the caliber of the colon stump corresponds to that of the anal stump, and the stitch length of suture is consistent. After the four-point suture fixation anastomosis, additional stitches are evenly performed between each two adjacent sutures to complete the manual single-layer sigmoid-anal end-to-end anastomosis. After completing the suturing of the four quadrants, check for the density of suture, the patency of anastomosis, and bleeding.

The Role of Peritoneal Reflection Line The peritoneal reflection line is an important anatomical landmark. For the surgical resection of lower rectal cancer, it is a routine to detach the peritoneal reflection. In this process, the selection of the incision site is particularly important. Attention should be paid to avoid entering the wrong layer, which may cause injury to the vas deferens, seminal vesicles, and bleeding. Attention should also be paid to avoid injury to neurovascular fiber bundles. The location of the peritoneal reflection line is significantly different between males and females, and the interindividual difference is significant in the same gender. In addition, the location of the peritoneal reflection line affects the T stage of rectal cancer. The anterior rectal wall below the peritoneal reflection line is not covered by visceral peritoneum. Therefore, there is no T4a stage for the tumor located below the peritoneal reflection, which is different from that located above the peritoneal reflection. Surgical exposure is difficult for patients whose peritoneal reflection line is low. In addition, if the position of incision is too low, it is prone to damage the seminal vesicles or vas deferens due to poor exposure. If the dorsal side of the seminal vesicle is bleeding, it is prone to damage the neurovascular fiber bundles, and adversely affect the postoperative sexual function and urinary function.

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References Temple LK, et al. Factors associated with sphincter-preserving surgery for rectal cancer at national comprehensive cancer network centers. Ann Surg. 2009;250(2):260–7. Rullier E, et al. Low rectal cancer: classification and standardization of surgery. Dis Colon Rectum. 2013;56(5):560–7.

X. Wang et al. Rutgers ML, et al. Influence of minimally invasive resection technique on sphincter preservation and short-term outcome in low rectal cancer in the Netherlands. Dis Colon Rectum. 2021;64(12): 1488–500. Yamada K, et al. Long-term results of intersphincteric resection for low rectal cancer in Japan. Surg Today. 2019;49(4):275–85.

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Laparoscopic Ultralow Rectal Cancer Resection with Transanal Specimen Extraction: Intersphincteric Resection Method (CRC-NOSES ID) Xishan Wang, Meng Wang, and Zheng Jiang

Contents Indications and Contraindications of NOSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 Indications (Figs. 6.1, 6.2, and 6.3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . . Anesthesia Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Patient Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trocar Placement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Special Surgical Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Surgical Procedures, Techniques, and Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Exploration and Surgical Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dissection and Separation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Intersphincteric Specimen Resection and Digestive Tract Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postoperative Abdominal Wall and Specimen Pictures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Key Points, Difficulties, and Hotspots Related to Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Precautions for NOSES ID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Problems in Conventional Laparoscopic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

Abstract

NOSES ID is mainly applicable to patients with lower and ultralow rectal cancer with good mobility. Laparoscopic operation should strictly follow the principles of total mesorectal excision (TME). The characteristics of NOSES ID are intersphincteric transection of bowel from the posterior wall to the lateral wall, eventually to the anterior wall in the anal canal after adequate laparoscopic dissection and closure of intended resection line of sigmoid colon, extraction of the specimen transanal to confirm the integrity of the resection margin, and anastomosis of the proximal sigmoid colon to X. Wang (*) Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China M. Wang · Z. Jiang Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China © People’s Medical Publishing House, PR of China 2023 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-99-2750-0_6

the anal canal, which required a sufficient length of sigmoid mesocolon. The procedure requires excellent cooperation between the surgeon and assistant for the ultralow operation in the narrow space of the pelvic cavity. In addition, the aseptic and tumor-free principles must be strictly practiced. The operation should be gentle to protect the sphincter from being damaged and intermittent sutures of the sigmoid colon stump to the anal canal are performed to complete the anastomosis. NOSES ID can not only ensure the radical resection of small tumors located in the lower and ultralow rectum, but also preserve the anal function to the maximum extent, and avoid the auxiliary incision in the abdominal wall. Therefore, this procedure fully satisfies the requirements of functional surgery and minimally invasive surgery. Keywords

Ultralow rectal cancer · Laparoscopic · Transanal specimen extraction · Intersphincteric resection · NOSES ID 79

Middle Rectum

5 cm

Upper Rectum

Lower Rectum

5 cm

NOSES ID is mainly applicable to patients with small tumors located in the lower and ultralow rectum. As with conventional laparoscopic radical resection of rectal cancer, the laparoscopic operation should strictly follow the principles of total mesorectal excision (TME). Anatomy and dissection should be performed in the correct plane, and the dissection of the pelvic floor should be more adequate to facilitate transperineal operation in the intersphincteric space, which is key to the accurate completion of the procedure. The operating characteristics of NOSES ID are intersphincteric transection (Schiessel et al. 1994) of bowel in the anal canal after adequate laparoscopic dissection, extraction of the specimen through a natural orifice, and anastomosis of the proximal sigmoid colon to the anal canal. The operating characteristics of NOSES I are: (1) intraperitoneal transection and closure of intended resection line of sigmoid colon; (2) adequate dissection of mesorectum at the pelvic floor to the intersphincteric sulcus; (3) accurate searching of the approach to intersphincteric space at the perineum. This procedure requires excellent cooperation between the surgeon and assistant for the ultralow operation in the narrow space of the pelvic cavity. In addition, the aseptic and tumor-free principles must be strictly practiced. NOSES ID can not only ensure the radical resection of small tumors located in the lower and ultralow rectum, but also preserve the anal function to the maximum extent, and avoid the auxiliary incision in the abdominal wall. Therefore, this procedure fully satisfies the requirements of functional surgery and minimally invasive surgery.

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5 cm

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Fig. 6.1 Tumor location suitable for NOSES I

Indications and Contraindications of NOSES Indications (Figs. 6.1, 6.2, and 6.3) 1. Lower and ultralow rectal cancer. 2. Infiltrative or ulcerated tumor with good mobility. 3. The protuberant-type tumor and the thickness of tumor should be less than 2 cm. 4. The depth of local invasion should be T1 or T2. 5. The pathological type should be moderately welldifferentiated adenocarcinoma (Schiessel et al. 2005).

Contraindications 1. The distal edge of tumor is within 3 cm above the dentate line. 2. The thickness of tumor is more than 3 cm. 3. The depth of the rectal cancer invasion reaches T3.

Fig. 6.2 Colonoscopy: tumors of protuberant type, 2–4 cm from the dentate line, maximum diameter of 2 cm

4. Poorly differentiated or mucinous adenocarcinoma, with distal resection margin status, cannot be determined by intraoperative fast-frozen pathology. 5. Severely obese patients.

Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position Anesthesia Method General anesthesia or general epidural anesthesia.

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Patient Positioning

Trocar Placement

The patient is placed in a functional lithotomy position, with the right thigh lowered and flattened, which facilitates to perform the operation for the surgeon (Fig. 6.4).

1. Camera trocar (10 mm trocar) is located just above the umbilicus. 2. The surgeon’s main trocar (12 mm trocar) is located below the McBurney’s point, which will make the lower rectal operation easier, especially when the lower rectal wall is being isolated, and will form a vertical angle to transect the mesentery. 3. The surgeon’s auxiliary trocar (5 mm trocar) is located at about 10 cm from the right side of the umbilicus, so as to reduce the interference of laparoscopy when operating in the lower rectum. 4. The assistant’s auxiliary trocar (5 mm trocar) is located opposite the McBurney’s point, which is mainly used for lifting and retracting, while, in the meantime, facilitating to place the drainage tube. 5. The assistant’s main trocar (5 mm trocar) is located at the left side of upper umbilical level adjacent to the lateral edge of the rectus abdominis (Fig. 6.5).

Surgical Team Position

Fig. 6.3 Rectal MRI: female, T2, 4 cm from the dentate line, maximum diameter of 3 cm

Fig. 6.4 The patient’s position

Abdominal operation: The surgeon stands on the right side of the patient, the assistant stands on the left side of the patient, and the camera holder stands on the same side of the surgeon.

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Perineal operation: The surgeon stands between the patient’s legs, and the assistants separately stand on the left and right side of the patient (Fig. 6.6).

Exploration and Surgical Planning

Special Surgical Instruments

General Exploration After the laparoscope being placed into the umbilical port, we recommend an overall exploration within the abdominal cavity in a clockwise manner from the right upper quadrant, to ensure that nothing abnormal is overlooked. The involved organs include liver, gallbladder, stomach, spleen, greater omentum, colon, small intestine, and pelvic and ascites (Figs. 6.8 and 6.9).

Ultrasonic scalpel, electric scalpel with needle electrode, and anal retractor.

Surgical Procedures, Techniques, and Key Points The schematic view of the main surgical procedures of specimen extraction and digestive reconstruction in NOSES ID (Fig. 6.7).

Surgeon’s Auxiliary Trocar (5 mm)

CameraTrocar (10 mm)

Surgeon’s Main Trocar (12 mm)

Fig. 6.5 Trocar sites (five-ports method)

Assistant’s Main Trocar (5 mm) Assistant’s Auxiliary Trocar (5 mm)

Based on a detailed preoperative examination and surgical plan discussion, the exploration mainly includes three steps.

Tumor Exploration Generally, low rectal tumors are often undetectable under laparoscope, and most tumors are located below the peritoneal reflection. The surgeon can perform the digital rectal examination with the laparoscopic forceps to determine the location and size of the tumor, confirming whether the patient is suitable for the procedure (Fig. 6.10). Evaluation of Anatomical Structures Evaluate the length of the sigmoid colon and mesenteric vessels, evaluate the thickness of mesorectum, and determine whether the length of mesentery allows the proximal colon to be extracted out of the anus (Fig. 6.11). This procedure requires a sufficient length of sigmoid mesocolon.

Dissection and Separation The First Point of the Incision Place the patient in the head-down position (Trendelenburg position), block the small intestine to the upper abdomen with

Fig. 6.6 (a) Surgeons’ positions (abdominal operation); (b) surgeons’ positions (perineal operation)

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Fig. 6.7 The main surgical procedures of specimen extraction and digestive reconstruction in NOSES ID

Fig. 6.8 Exploration of the liver

Fig. 6.9 Exploration of the pelvic cavity

a gauze, and expose the entire pelvic cavity and the roots of the inferior mesenteric vessels. The assistant needs to lift the anterior rectal wall toward the abdominal wall with forceps in the left hand, so that the complete course of the rectum will be shown in the pelvic cavity. At the same time, the assistant lifts the inferior mesenteric vessels with forceps in the right hand,

so that the region from their root to the rectum and the peritoneal reflection will be under full visualization (Fig. 6.12). The incision should be selected at 3–5 cm below the sacral promontory. There is often a thin area (Fig. 6.13), especially for obese patients, from where to

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Fig. 6.10 Exploration of the tumor

Fig. 6.13 The first cutting point of the incision

Fig. 6.11 Exploration of the sigmoid mesocolon

Fig. 6.14 Entering the Toldt’s space

Fig. 6.12 Adequate exposure of the root of the mesentery

Fig. 6.15 Dissection downward along the Toldt’s fascia

start dissection with an ultrasonic scalpel. Along the course of presacral space, the white connective tissue of Toldt’s fascia is visible by moving the scalpel tip up and down, which indicates the correct space for dissection (Fig. 6.14).

mesentery, the surgeon may apply the scalpel to hold the gauze to perform blunt dissection along the Toldt’s fascia, with enough attention to distinguish and protect the inferior hypogastric nerves (Fig. 6.16). Then, the adipose connective tissue is separated and dissected at the root with an ultrasonic scalpel (Fig. 6.17). The isolated length of the vessels should be long enough for ligation. Ligation and transection of the inferior mesenteric artery and vein are performed separately (Figs. 6.18 and 6.19). Care should be taken to protect the ureters and gonadal vessels during the dissection (Fig. 6.20). Place a small gauze underneath the mesentery (Fig. 6.21).

Isolation and Ligation of Inferior Mesenteric Artery and Vein Perform separation up and down along the Toldt’s space (Fig. 6.15), and start the dissection toward the root of the inferior mesenteric vessels when the mesentery could be lifted to a certain extent. During the dissection of the

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Fig. 6.16 Exposure and protection of the inferior hypogastric nerve

Fig. 6.20 Exposure and protection of ureters

Fig. 6.17 Dissection of the root of the inferior mesenteric artery

Fig. 6.21 Placing a gauze underneath the mesentery

Fig. 6.18 Ligation of the inferior mesenteric artery

Fig. 6.22 Dissection of the sigmoid mesocolon to the left lateral side

Fig. 6.19 Ligation of the inferior mesenteric vein

Dissection of the Mesorectum The surgeon further separates the sigmoid mesocolon downward from medial to lateral along the Toldt’s fascia to the bifurcation of the common iliac artery (Fig. 6.22). During separation along the presacral space (Fig. 6.23), the inferior hypogastric nerves could be visible, and the separation should be performed on the nerve surface at a uniform cutting

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Fig. 6.23 Dissection along the presacral space Fig. 6.25 Dissection downward to the level of the coccyx

Fig. 6.24 Exposure of the inferior hypogastric nerves

Fig. 6.26 Display of levator ani muscles of both sides

speed. The presacral separation must be performed along the correct space. Too deep separation may injury presacral vein causing bleeding, while too superficial separation will lead to incomplete mesorectal excision. Dissect downward to the left and right along the presacral space, where 3–5 nerves in the pelvic plexus are visible (Fig. 6.24), and down to the level of the coccyx (Fig. 6.25). The levator ani muscles can be seen on both sides (Fig. 6.26).

Dissection of the Right Rectum Wall After adequate presacral dissection, dissection of the right side of the rectum will be relatively easy to perform, like separating a thin membrane. The assistant lifts the fundus of the bladder with the forceps in the left hand or lifts the uterus with a uterine manipulator, and lifts the mesorectum with the right hand, followed by a clear vision of mesenteric boundary (Fig. 6.27). Then the surgeon should dissect the right side of the rectum down to the peritoneal reflection, and continually incise the peritoneal reflection from the right side to the left side (Fig. 6.28).

Fig. 6.27 Dissection of the right rectal wall

Dissection of the Sigmoid Colon, the Left and the Anterior Rectal Wall Do not detach the lateral adhesion of the sigmoid colon in advance, because it can fix the sigmoid colon. The lateral attachments of the sigmoid colon are dissected free, and the sigmoid colon is completely mobilized (Fig. 6.29), paying attention to protecting the gonadal vessels and

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Fig. 6.28 The peritoneal reflection is incised from right side to left side

Fig. 6.31 The left side of the mesocolon is dissected downward

Fig. 6.29 Dissection of the lateral adhesion of the sigmoid colon

Fig. 6.32 Dissection of the anterior rectal wall

Fig. 6.30 The peritoneum on the left of mesocolon is opened

Fig. 6.33 Isolation of the right rectum wall

ureters. Turn the sigmoid colon to the right, the gauze can be observed underneath the mesocolon, which can prevent damages to tissues and organs such as the ureters. The dissection of mesentery is then preceded upward and downward sufficiently (Fig. 6.30) When dissecting upward, most cases do not require to mobilize splenic flexure, then dissect the left side of the rectum downward to the peritoneal reflection and join with the right side (Fig. 6.31).

Isolation of the Mesorectum Separate downward along the anterior rectal wall to expose and protect the posterior vaginal wall (Fig. 6.32). At this point, the assistant needs to perform a digital rectal examination again to confirm the tumor location, and to ensure that the rectum can be dissected to the intersphincteric sulcus below the distal edge of the tumor. At the same time, the right and left walls of the rectum (Fig. 6.33) should be further isolated to the pelvic floor to reach the intersphincteric sulcus.

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Fig. 6.34 A gauze is placed underneath the sigmoid mesocolon

Fig. 6.36 Isolation of the wall of sigmoid mesocolon

Fig. 6.35 Ligation of vessels of sigmoid mesocolon

Fig. 6.37 Transection of the proximal sigmoid colon

Dividing the Sigmoid Mesocolon Turn the sigmoid colon to the left, a gauze is placed underneath the sigmoid mesocolon (Fig. 6.34). In order to sufficiently expand the surface of the sigmoid mesocolon, the assistant may lift the sigmoid mesocolon with two atraumatic forceps and pull it laterally. The scope of surgical resection and proposed proximal intestinal resection line is measured visually. The course of the superior rectal artery and vein will be seen after lifting the mesocolon. After the extent of division is determined, the mesentery is continuously dissected till to the intended resection line of the bowel, with ligation of 2–3 sigmoid colon vessels (Fig. 6.35). Then the intended resection line is divided, and vascular clips are not recommended to be used near the bowel wall to avoid affecting the anastomosis. The exposed length of bowel wall of the sigmoid colon is proposed to be appropriately 2–3 cm (Fig. 6.36). Transect the bowel at the intended resection line of the proximal sigmoid colon with Endo-GIA stapler (Fig. 6.37).

Intersphincteric Specimen Resection and Digestive Tract Reconstruction Transanal Specimen Resection After adequate dilation of the anus, the distal resection margin is determined at about 1–2 cm distal to the tumor, then the

Fig. 6.38 Opening the rectal wall

rectal wall is incised circumferentially (Rullier et al. 2005) (Fig. 6.38). Afterward, dissection is performed upward to the pelvic cavity within the intersphincteric space from the posterior wall to the lateral wall, eventually to the anterior wall (Figs. 6.39 and 6.40). The rectum and mesentery are then transanally extracted to confirm the integrity of the resection margin (Fig. 6.41). The oval forceps is inserted into the anus to pull the proximal sigmoid colon out of the body, during which attention should be paid to the prevention of mesenteric volvulus. The operation should be gentle to protect the sphincter from being damaged by excessive retraction tension.

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Fig. 6.39 Opening the lateral rectal wall

Fig. 6.41 Transanal specimen extraction

Fig. 6.40 Opening the anterior rectal wall

Fig. 6.42 Opening of the sigmoid colon stump

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Digestive Tract Reconstruction The extracted proximal sigmoid colon stump is opened (Fig. 6.42), and intermittent sutures of the sigmoid colon stump to the anal canal are performed to complete the anastomosis (Fig. 6.43). Check the anastomosis to confirm that there is no bleeding and perform local disinfection (Fig. 6.44). Place two drainage tubes in the pelvic cavity and close the trocar incisions.

Postoperative Abdominal Wall and Specimen Pictures See Figs. 6.45 and 6.46.

Key Points, Difficulties, and Hotspots Related to Surgery Precautions for NOSES ID 1. The site of the surgeon’s main trocar should be low to facilitate the formation of the operation triangle during the isolation of ultralow rectum, thereby prevent the

Fig. 6.43 Suture of the sigmoid colon stump to the anal canal

instruments from interfering with one another (“chopsticks effect”). 2. The first point of the incision should be selected at the thin area of the mesorectum below the sacral promontory, from where it is easier to enter the operation plane (presacral space). 3. Placing a small gauze underneath the root of the inferior mesenteric artery can facilitate the dissection and isolation of the root of the inferior mesenteric artery. This approach facilitates the control of accidental bleeding and can avoid accidental damage to other tissues.

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Fig. 6.44 Inspection of anastomosis

Fig. 6.45 Display of abdominal wall after operation

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6. For the protection of the inferior hypogastric plexus, the assistant and the surgeon stretch appropriately to form the operation plane, and perform separation along the course of the pelvic wall on the nerve surface at a uniform speed until 3–5 nerve branches in the pelvic plexus are visible. 7. The dissection of Denonvilliers’ fascia should have proper tension and natural division by light touch of the ultrasonic scalpel. If not necessary, the seminal vesicles should not be overisolated. 8. The isolation of the bowel below the tumor and the determination of the tumor location are critical for the success of the operation. The surgeon can perform the digital rectal examination with the right hand to rendezvous with the forceps in the left hand for determination. 9. The division of sigmoid mesocolon should be performed to a longer distance from the resection line of the bowel to facilitate the extraction of sigmoid colon for anastomosis. 10. The aseptic and tumor-free techniques should be applied when natural orifices are opened intracorporeally and extracorporeally. 11. Under direct vision, the distance from the distal edge of the tumor to the resection line should be determined according to the tumor size, gross type, and degree of differentiation. 12. The posterior wall of the mesorectum should be dissected across the hiatal ligament to adequately isolate the rectal until the edge of the levator ani hiatus. 13. Dissection in both side of the mesorectum should reach the levator ani hiatus and sharp dissection should be performed downward along the longitudinal muscle of rectum to near the dentate line. 14. Determine the resection margin when the intersphincteric space is opened from the perineum. Successively dissect the mucosa, submucosal layer to the internal sphincter with circumferential incision, dissect along the posterior lateral wall to the abdominal cavity, and the anterior wall should be treated lastly.

Problems in Conventional Laparoscopic Surgery

Fig. 6.46 Display of specimen

4. The lateral band of the sigmoid colon should be detached lastly so that it can fix the sigmoid colon. 5. The dissection of the mesorectum should be performed in the order of the posterior side, bilateral side, and anterior side.

1. Limitations of exploration. Conventional laparoscopic exploration of occult sites in the abdominal and pelvic cavity has limited visual field for observation. For nodules of unknown nature, the lack of tactile sensation makes it hard to differentiate the texture, resulting in inaccurate evaluation. Therefore, the exploration of occult sites should be particularly careful, and the adjustment of the position may facilitate to cooperate with the exploration. For nodules of undetermined nature, intraoperative biopsy

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Fig. 6.48 Gauze is put in the protective sleeve and removed along with specimen Fig. 6.47 Separated resection of lymph nodes

2.

3.

4.

5.

for the pathological examination should be performed if necessary. Gasification of tumor cells. Gas is confined to the peritoneal cavity under the environment of CO2 pneumoperitoneum; gasification of tumor cells caused by the heat of ultrasonic scalpel leads to the potential risk of intraperitoneal tumor dissemination. We recommend that (1) the “no touch” principle should be followed during operation to avoid touching tumor tissue with an ultrasonic scalpel or other instruments; (2) we prefer to connect the suction device with the stopcock valve of the assistant’s trocar. By adjusting the stopcock valve, the intrabdominal gas can be drawn out with a low flow rate, which can not only prevent the smoke from affecting the visual field, but also ensure the gas circulation. Protection for the rectal stump. After the excision of the bowel, if there is no effective protection for the rectal stump, it is recommended to cover the surface of the stump with iodoform gauze to avoid bacterial contamination and prevent it from being touched by other organs. Separated resection of lymph nodes. Conventional laparoscopic surgery often involves separated resection of lymph nodes (Fig. 6.47), such as lymph nodes at the root of the inferior mesenteric artery, lateral lymph nodes, etc., unable or rarely able to complete en bloc resection of the specimen. It is recommended that en bloc excision of the specimen should be performed as far as possible and excised lymph nodes should be extracted with a retrieval bag. Size of incisions. In the conventional laparoscopic surgery, the resected specimen is removed transabdominally. For some open surgeries with small incision, e.g., cholecystectomy, appendectomy, etc., the size of the incision is similar to that of laparoscopic surgery, and the minimally

invasive advantage of laparoscopic surgery is not exhibited. 6. Common mistakes in gauze removal. When the gauze is saturated with blood and tissue fluid, if the surgeon removes the gauze through the trocar directly, the fluid in the gauze may flow back to the abdominal cavity through the trocar, which may increase the risk of intraperitoneal neoplasm seeding. The correct method is that the dry gauze can be inserted into the abdominal cavity through the trocar, whereas the gauze should be removed with a retrieval bag. This method is more in compliance with the principle of tumor free (Fig. 6.48). 7. Common mistakes in the use of incision protector. In order to exhibit the minimally invasive advantage, most surgeons are unwilling to make a large incision in the abdominal wall for specimen extraction. However, most incisions in the abdominal wall are about 5 ~ 10 cm in length, which are in the range of middle incision. When using the incision protector, surgeons often ignore that the small incision and the extrusion and friction on the specimen can cause the cancer cells to fall off to the abdominal cavity, and thereby cause the neoplasm seeding. The correct approach is to place the transected specimen in a protective sleeve for isolation before removing it. Therefore, in order to perform a flawless tumor-free surgery, we must take every detail into consideration.

References Rullier E, et al. Sphincter-saving resection for all rectal carcinomas: the end of the 2-cm distal rule. Ann Surg. 2005;241(3):465–9. Schiessel R, et al. Intersphincteric resection for low rectal tumours. Br J Surg. 1994;81(9):1376–8. Schiessel R, et al. Technique and long-term results of intersphincteric resection for low rectal cancer. Dis Colon Rectum. 2005;48(10): 1858–67.

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Laparoscopic Ultralow Rectal Cancer Resection with Transanal Specimen Extraction: Bacon Method (CRC-NOSES IE) Bo Jiang and Yi Feng

Contents Indications and Contraindications of NOSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Indications (Figs. 7.1, 7.2, and 7.3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . Anesthesia Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Patient Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trocar Placement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Special Surgical Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Surgical Procedures, Techniques, and Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Exploration and Surgical Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Dissection and Separation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Postoperative Abdominal Wall and Specimen Display . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Key Points, Difficulties, and Hotspots Related to Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Indications of NOSES IE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Laparoscopic Exposure to the Lowest Realignment Plane of the Pelvic Cavity and the Use of Surgical Instruments and Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Transanal and Pelvic-Free Plane Meeting Operation and Aseptic and Tumor-Free Operation . . . . . . . . . . . . . Prediction and Management of Postoperative Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Operation Opportunity of the Secondary Anoplasty and the Function of Defecation and Anal Continence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Abstract

NOSES IE is the combination of laparoscopy surgery and improved Bacon method, mainly applicable to patients with lower rectal cancer who have a large circumference of invasion. The main differences between conventional laparoscopic surgery and NOSES IE are digestive tract reconstruction and specimen extraction. The operation characteristics of NOSES IE are as follows: (1) The rectum is dissected into the internal and external space of the sphincter according to the TME principles; (2) the anus is annularly sutured from 1–2 cm below the tumor and above the intersphincteric sulcus; (3) the rectal wall is circularly incised and then dissected upward into the abdominal

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plane; (4) the rectum is extracted from the anus and the normal rectum is retained at 3–5 cm, then cutting off the rectum at 5–7 cm above the upper edge of tumor; and (5) the anoplasty is conducted after 2–3 weeks. This technique requires excellent skills and tacit cooperation between the surgeon and assistant. In addition, the aseptic principle and nontouch technique must be strictly practiced. The NOSES IE can not only ensure the R0 resection but also achieve anal function preservation in lower rectal cancer, which is an ideal operation in line with the requirements of functional surgery.

B. Jiang (*) · Y. Feng Anal and Colorectal Surgery, Shanxi Cancer Hospital, Affiliated Cancer Hospital of Shanxi Medical University, Taiyuan, China © People’s Medical Publishing House, PR of China 2023 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-99-2750-0_7

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5. Local inflammation is serious in patients with rectovaginal fistula.

Keywords

Noses 1E · Improved Bacon · Low rectal cancer · Sphincter preserving

Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position Indications and Contraindications of NOSES Anesthesia Method Indications (Figs. 7.1, 7.2, and 7.3) General anesthesia with or without epidural anesthesia. 1. Lower rectal cancer or benign tumor that cannot be excised under endoscopy. 2. Tumor involving over 1/2 or all of the rectal circumference is suitable for Bacon surgery. The flat-type tumor is the best. 3. The tumor should not invade the internal and external sphincters. 4. Patients with lower rectal cancer who are in need of additional radical resection after transanal local excision, but anastomosis cannot be performed with regular laparoscopic instruments.

Contraindications

Middle Rectum

5 cm

Lower Rectum

5 cm

Upper Rectum

Fig. 7.1 Tumor location suitable for NOSES I

Fig. 7.2 Colonoscopy: tumor of protuberant type, 2–4 cm from the dentate line, maximum diameter of 3 cm

5 cm

1. The tumor is too large to be extracted out of the anus. 2. The length of the sigmoid colon and mesentery is too short for them to be prolapsed from anus. 3. The mesorectum is too thick to be extracted out of the anus. 4. Severely obese patients (BMI > 30 kg/m2).

Fig. 7.3 Rectal MRI: male, T2, with tumor 0.5 cm from the dentate line, the maximum diameter of 3.0 cm

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Patient Positioning The patient is placed in a modified lithotomy position, with the head lowered and tilted to the right, and the right thigh slightly flattened, which facilitates to perform the operation for the surgeon (Fig. 7.4).

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the patient’s legs, and the assistants separately stand on the left and right side of the patient (Fig. 7.6b).

Special Surgical Instruments Ultrasonic scalpel, electric scalpel with needle electrode, and anal tractor.

Trocar Placement 1. Camera trocar (10 mm trocar) is located within 2 cm of the umbilicus or on the umbilicus. 2. The surgeon’s main trocar (12 mm trocar) is located at a point 1/3 between the umbilicus and right anterior superior iliac spine (McBurney’s point). 3. The surgeon’s auxiliary trocar (5 mm trocar) is located at 5 cm above the right paramedian of the umbilicus. 4. The assistant’s auxiliary trocar (5 mm trocar) is located opposite the McBurney’s point. 5. The assistant’s main trocar (5 mm trocar) is located on the intersection of the umbilicus level and the outer edge of left rectus abdominis (Fig. 7.5).

Surgical Team Position Abdominal operation: The surgeon stands on the right side of the patient, the assistant stands on the left side of the patient, and the camera holder stands on the same side of the surgeon (Fig. 7.6a). Perineal operation: The surgeon stands between

Fig. 7.4 The patient’s position

Surgical Procedures, Techniques, and Key Points The schematic view of the main surgical procedures of specimen extraction and digestive reconstruction in NOSES IE (Fig. 7.7).

Exploration and Surgical Planning Based on a detailed preoperative examination and surgical plan discussion, the exploration mainly includes three steps:

General Exploration After the laparoscope being placed into the umbilical port, we recommend an overall exploration within the abdominal cavity in a clockwise manner from the right upper quadrant, to ensure that nothing abnormal is overlooked. The involved organs include liver, gallbladder, stomach, spleen, greater omentum, colon, small intestine, and pelvic and ascites (Fig. 7.8).

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Tumor Exploration The lower rectal tumor is often located below the peritoneal reflection, and the surgeon can palpate the tumor by digital rectal examination. If the tumor is small, the use of tracers before surgery can help locating the tumor under laparoscopy (Fig. 7.9). Evaluation of Anatomical Structures The surgeon should identify the location of the iliac vessels and inferior mesenteric vessels (Fig. 7.10), and then evaluate the length of the sigmoid colon and mesenteric vessels, which helps the surgeon further determine the extent of surgical resection (Fig. 7.11).

Camera Trocar

Surgeon's AuxiliaryTrocar (5 mm)

(10 mm)

Surgeon's Main Trocar (12 mm)

Assistant's Main Trocar (5 mm) Assistant's Auxiliary Trocar (5 mm)

Dissection and Separation The First Point of the Incision Place the patient in the head-down position (Trendelenburg position), block the small intestine to the upper abdomen with a gauze, and expose the entire pelvic cavity and the roots of the inferior mesenteric vessels. The assistant needs to lift the anterior rectal wall toward the abdominal wall with forceps in the left hand, so that the complete course of the rectum will be shown in the pelvic cavity. At the same time, the assistant lifts the inferior mesenteric vessels with forceps in the right hand, so that the region from their root to the rectum and the peritoneal reflection will be under full visualization. The first cutting point of the incision should be performed at the thin mesenteric region which is 3–5 cm below the sacral promontory (Fig. 7.12). Isolation and Ligation of the Root of Inferior Mesenteric Vessels Perform separation up and down along the Toldt’s space (Fig. 7.13), and start the dissection toward the root of the inferior mesenteric vessels when the mesentery could be lifted to a certain extent. The course and peristalsis of the left ureter can be observed during the dissection, which should be carefully protected. Dissect and isolate the inferior mesenteric vessels at the root of the intended resection line with an ultrasonic scalpel (Figs. 7.14, 7.15, 7.16, and 7.17).

Fig. 7.5 Trocar sites (five-ports method)

Fig. 7.6 (a) Surgeons’ positions (abdominal operation); (b) surgeons’ positions (perineal operation)

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Fig. 7.7 The main surgical procedures of specimen extraction and digestive reconstruction in NOSES IE

Fig. 7.9 Exploration of the tumor

Fig. 7.8 Exploration of the small intestine

Dissection of the Mesorectum When the inferior mesenteric vessels are transected, the avascular area of the sigmoid mesocolon can be partially opened (Fig. 7.18). During the operation, the left ureter and the left

gonadal vessels beneath the mesentery need to be identified and protected (Fig. 7.19). The surgeon should continue dissecting downward and laterally to the bifurcation of the left common iliac artery, where the course of the inferior hypogastric nerves could be exposed. Separation is performed on the nerve surface at a uniform speed (Figs. 7.20 and 7.21). The presacral space needs to be further

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Fig. 7.10 Location of inferior mesenteric vessels and iliac vessels Fig. 7.13 Entry of the space above Toldt’s fascia

Fig. 7.11 Assessment of mesenteric length

Fig. 7.14 Dissecting the root of the inferior mesenteric artery

Fig. 7.12 The first cutting point of the incision

Fig. 7.15 Isolation of the root of the inferior mesenteric artery

expanded in combination with the dissection in the left and right sides of the rectum.

to the peritoneal reflection, and continually incise the peritoneal reflection from the right side to the left side (Fig. 7.23).

Dissection of the Right Side of the Rectum The dissection of the right side of the rectum should be combined with the presacral separation (Fig. 7.22). Much attention should be paid to the extent of dissection. Then the surgeon should dissect the right side of the rectum down

Dissection of the Sigmoid Colon and the Left Side of the Rectum Detach the adhesion of the sigmoid colon (Fig. 7.24) and dissect in a lateral to medial fashion along the Toldt’s fascia and open the mesocolon (Fig. 7.25). When the sigmoid

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Fig. 7.16 Ligation of the inferior mesenteric artery

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Fig. 7.19 Exposure and protection of ureter and gonadal vessels

Fig. 7.20 Protection of left inferior hypogastric plexus Fig. 7.17 Ligation of the inferior mesenteric vein

Fig. 7.21 Display of bilateral inferior hypogastric nerves Fig. 7.18 Opening the avascular area of sigmoid mesocolon

mesocolon is opened, the gauze placed in advance beneath the mesocolon can play the role of identification and protection to prevent accidental damage. In most cases, there is no need to mobilize the splenic flexure of the colon when dissecting upward (Fig. 7.26). Dissect the left side of the rectum downward to the peritoneal reflection and join with the right side (Fig. 7.27).

Dissection of the Posterior Wall of the Rectum The surgeon should dissect downward along the presacral space to the sacrorectal ligament (Fig. 7.28). When this ligament is cut off, there will be a sense of breakthrough, then another loose connective tissue space will appear (Fig. 7.29). The dissection of the posterior wall of the rectum should be continued until the sacral coccyx ligament is cut off (Fig. 7.30).

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Fig. 7.25 The peritoneum on the left of mesocolon is opened Fig. 7.22 Dissection of the right rectal wall

Fig. 7.23 The peritoneal reflection is incised from right side to left side

Fig. 7.26 Separation of mesocolon upward

Fig. 7.24 Dissection of the lateral adhesion of the sigmoid colon

Dissection of the Pelvic Floor of Rectum Due to the tumor location of rectal cancer, the surgeon should dissect the rectum to the nadir of the pelvic cavity. There are three different paths of dissection along the Denonvilliers’ fascia from the peritoneal reflection: (1) Open the Denonvilliers’ fascia and dissect the tissue downward below this fascia. (2) Dissect the tissue downward between two lobes of the Denonvilliers’ fascia. (3) Dissect the tissue along the anterior lobe of Denonvilliers’ fascia to the seminal vesicles, then open this fascia and continue the dissection downward below this fascia. When the seminal vesicles (male) (Fig. 7.31) or the posterior wall of the vagina (female) (Fig. 7.32) is clearly exposed, dissect the space in the right side (Fig. 7.33) and then in the left side (Fig. 7.34). Dissect the bilateral spaces of the rectum until the attachment point of the levator ani muscle is cut off (Figs. 7.35 and 7.36).

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Fig. 7.27 Separation of mesocolon downward

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Fig. 7.30 Cutting off the sacrococcygeal ligament

Fig. 7.28 Cutting off the sacrorectal ligament Fig. 7.31 Dissection of the anterior rectal wall (male)

line is measured visually. After the extent of division is determined, the mesentery is continuously dissected till to the intended resection line of the bowel, with ligation of 2–3 sigmoid colon vessels (Fig. 7.37). The length of the mobilized sigmoid mesocolon should be long enough to facilitate the specimen extraction from the anus.

Fig. 7.29 Dissection of presacral space

Dividing the Sigmoid Mesocolon In order to sufficiently expand the surface of the sigmoid mesocolon, the assistant may lift the sigmoid mesocolon with two atraumatic forceps and pull it laterally. The scope of surgical resection and proposed proximal intestinal resection

Perineal Operation The anus should be fully expanded to expose the dentate line (Fig. 7.38). Disinfect the anal canal with iodoform cotton ball (Fig. 7.39) and suture the anus by purse string at about 1 cm below the tumor (Fig. 7.40). Purse string suture of anal canal can not only effectively reduce the risk of tumor planting and intestinal contents contamination, but also ensure the distance of the distal resection margin. The surgeon should open the intestinal wall near the dentate line, preserving the internal sphincter, and dissect upward in order to meet the dissected bowel in the peritoneal cavity (Fig. 7.41). To remove the specimen, the dissected bowel is extracted from the anus

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Fig. 7.32 Dissection of the anterior rectal wall (female)

Fig. 7.35 Dissection of the right rectal wall to the point of the levator ani muscle

Fig. 7.33 Cutting off the right neurovascular bundle

Fig. 7.36 Dissection of the left rectal wall to the point of the levator ani muscle

Fig. 7.34 Cutting off the left neurovascular bundle Fig. 7.37 Dividing the sigmoid mesocolon

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Laparoscopic Ultralow Rectal Cancer Resection with Transanal Specimen Extraction: Bacon Method (CRC-NOSES IE)

and then transected at 7–10 cm above the tumor (Fig. 7.42). During this procedure, the surgeon should follow the asepsis and tumor-free principles, and operate gently to avoid any damage to the bowel and the mesentery. About 5–8 stitches are needed to fix the redundant bowel to the anus.

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In this process, the surgeon should avoid suturing mesenteric vessels so as not to affect the blood supply. Finally, rinse the pelvic cavity and place a drainage tube in the pelvic cavity (Figs. 7.43 and 7.44). The specimen is removed and the sigmoid colon is fixed on the anus with sutures (Fig. 7.45).

Secondary Anoplasty The secondary anoplasty can be performed after 2–3 weeks. The perineum is fully exposed (Fig. 7.46), and the excess bowel is transected at the level of good blood supply at the anal margin, leaving a 0.5 cm bowel stump (Fig. 7.47). It should be noted that when the bowel mucosa is sutured with the anal skin, the blood vessels on the mesentery side should be fully ligated and embedded. In addition, intestinal mucosa should not have excessive eversion so as to avoid mucosa necrosis or mucosa prolapse (Fig. 7.48).

Fig. 7.38 The anus is clearly explored

Postoperative Abdominal Wall and Specimen Display See Figs. 7.49 and 7.50.

Key Points, Difficulties, and Hotspots Related to Surgery Indications of NOSES IE

Fig. 7.39 Disinfection with iodoform cotton ball

Fig. 7.40 Pursing string suture

1. Benign rectal diseases: The large lower rectal adenoma, such as laterally spreading tumors, occupies a large circumference of the lumen, has a long super inferior diameter (S-I diameter), and the distal margin of the tumor is close to the dentate line. It is not easy to perform transanal local excision.

Fig. 7.41 Cutting off the rectal wall

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Fig. 7.42 (a) Extract the rectum transanally; (b) extract the rectum transanally

Fig. 7.43 Rinse pelvic cavity

Fig. 7.45 Remove the specimen and fix the bowel with sutures

Fig. 7.44 Place drainage tube

Fig. 7.46 Full exposure of perineum

2. Lower rectal cancer: Patients with the lower edge of the tumor being 2~5 cm away from the dentate line and the pelvic MR stage being T2 ~ 3 N0 are eligible for this surgery. Patients with difficulties in undergoing a double

stapling anastomosis, such as male narrow pelvic, are eligible for this surgery. 3. Neoadjuvant therapy is recommended for patients with lower rectal cancer in the stage of T3N+ by MR.

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Laparoscopic Ultralow Rectal Cancer Resection with Transanal Specimen Extraction: Bacon Method (CRC-NOSES IE)

4. Elderly patients or patients with multiple medical comorbidities may have anastomotic leakage factors, such as diabetes, chronic obstructive pulmonary disease, and hypoproteinemia. 5. To reduce the serious consequence of anastomotic leakage, ultralow anastomosis and preventive laparostomy are suitable for patients with lower rectal cancer.

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NOSES IE is also applicable to female patients with lower rectal cancer, which can avoid the complication of rectovaginal fistula. From the perspective of health economics, the cost of anoplasty is much lower than that of closure ostomy. 6. In order to ensure the safety of the distal resection margin, the ultrasonic scalpel can be used to reach the end point of mesenteric dissection, and the tumor distal resection margin can be determined under direct vision from the anus.

Laparoscopic Exposure to the Lowest Realignment Plane of the Pelvic Cavity and the Use of Surgical Instruments and Materials

Fig. 7.47 Extracorporeal excision of the rectum

Fig. 7.48 Anus after the anoplasty is completed

Fig. 7.49 Display of postoperative specimen

1. The difficulty of the NOSES IE is to dissect the pelvic cavity in depth under laparoscope. In this procedure, the neurovascular bundle, Denonvilliers’ fascia, pelvic plexus, male seminal vesicles, female vagina wall, and sphincter sulcus need to be clearly exposed while the mesenteric membrane is intact until it reaches the mesenteric end point. 2. Specific operation A folded thin gauze rope (the “shoelace”) is firmly fastened to the rectum slightly below the sacral promontory. When the surgeon dissects the posterior rectal space, the assistant should clamp the esophageal band with duck-jaw forceps held in the left hand and pull it toward the abdominal wall. Meanwhile, the forceps in the right hand is splayed in the mustache shape to push the mesorectum in the same direction until the rectococcygeal ligament is severed. When the right pelvic nerve and the lateral rectal ligament are exposed, the assistant should clamp the esophageal band with duck-

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surgeon should avoid intestinal fluid contamination and the implantation of exfoliated tumor cells on the wound. 3. When the tumor is large, the surgeon can split the bowel and remove the tumor under direct vision. For example, when the tumor is semicircular, the surgeon may remove the mucosa with an electric scalpel, and the assistant may simultaneously use suction instruments to gather intestinal fluid. Prior to the procedure, an iodoform gauze can be inserted at the proximal end of the bowel, which may be more conducive to tumor-free and aseptic operation.

Prediction and Management of Postoperative Complications

Fig. 7.50 Display of postoperative abdominal wall

jaw forceps and pull it from medial to lateral at the 9 o’clock position. The surgeon should push the right pelvic nerve lateral by the left forceps and perform the reverse traction to clearly expose the lateral rectal ligament. Then a sharp dissection can be successfully performed along the smooth surface of the mesorectum. This method can effectively avoid the cumbersome motion of repeatedly grabbing and lowering the mesorectum, avoiding destructing the integrity of the mesorectum. Maintaining a pull direction, the surgeon can successfully complete the dissection until the end point of the right mesorectum. The left side is exposed in the same way as the right side. Finally, the surgeon can dissect the rectum to the pelvic floor and reach the superior margin of the surgical anal canal, waiting to meet the anal side operation.

Transanal and Pelvic-Free Plane Meeting Operation and Aseptic and Tumor-Free Operation 1. Firstly, the dentate line can be exposed by radial everting suture of the anal canal with a 0–0 mersilk suture. Generally, four stitches are enough. 2. When the tumor is small, purse suture can be performed on the anus at 1 cm of the distal edge of the tumor. During the operation of circumferential mucosa resection with an electric scalpel and pelvic operation, the

1. Retraction and necrosis of the colon segment extracted out of the anus are two of the most troublesome complications. In order to prevent such complications, the length of the bowel, the appropriate tightness of mesentery, and the blood supply should be ensured during the operation. An additional 5 cm bowel should be reserved in the pelvic cavity. Splenic flexure of the colon can be mobilized if necessary. 2. The importance of preoperative anus examination. Bacon’s operation is not suitable for patients with anal stenosis, sphincter hypertonia, sphincter weakness, or anal incontinence. 3. Rectovaginal leakage is a rare complication in female patients. There may be two reasons for this complication. Firstly, the posterior wall of the vagina is damaged when the anterior wall of the rectum is dissected. Secondly, during anoplasty, the colon retracts after excision of the redundant colon, exposing the defected or perforated posterior wall of the vagina.

The Operation Opportunity of the Secondary Anoplasty and the Function of Defecation and Anal Continence The secondary anoplasty can be performed 2–4 weeks after Bacon’s operation. Anoplasty is performed in this time frame in a large number of literatures. After the secondary anoplasty, the patient may experience anal incontinence. During the flatus, a small amount of loose stool is discharged at the same time. The patient may experience perianal eczema and have a feeling of incomplete evacuation, which may last for 1 year. Under the guidance of outpatient doctors, all patients need to receive pelvic floor training and bowel retraining.

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Laparoscopic Lower Rectal Cancer Resection with Rectal Eversion and Extra-Abdominal Resection: Tsarkov Method (CRC-NOSES IF) Sergey Efetov, Inna Tulina, and Petr V. Tsarkov

Contents Indications and Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Indications (Figs. 8.1, 8.2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . Anesthesia Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Patient Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trocar Placement (Fig. 8.4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Special Surgical Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

108 108 108 108 108 109

Surgical Procedure, Techniques, and Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Exposure and Operation Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dissection and Separation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rectal Resection and Digestive Tract Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

109 109 110 113

Robotic NOSES Operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Trocar Positioning for Operations with the Da Vinci Si System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117

Abstract

In the surgical treatment for low rectal cancer, there are a few options to extract the specimen transanally, which are united into NOSES I group. In each variation intra-abdominal proximal colon division is followed by specimen extraction by pulling or everting the rectum through anus. The rectum is divided distally to the tumor; the rectal stump is closed with a linear stapler and prepared for the anastomosis. This chapter

S. Efetov Colorectal Surgery Department, Sechenov First Moscow State Medical University, Moscow, Russia Clinic of Faculty Surgery N2, Surgical Department N2, University Clinical Hospital N4, I.M. Sechenov First Moscow State Medical University, Moscow, Russia

will describe an additional method to perform a low rectal resection (NOSES IF) which differs from the abovementioned techniques in totally extra-abdominal bowel division proximally and distally to the tumor. The main steps of NOSES IF include lymph node dissection, vessels division, TME, mobilization of the sigmoid colon, and splenic flexure, if necessary. Also, it involves rectum eversion through the anus and colon division distally to the tumor and then proximally, installing the circular stapler anvil in the proximal colon limb, returning it back to the abdomen, closing up the rectal stump and colorectal anastomosis creation. NOSES IF technique is suitable for patients with a small tumor located in middle or lower rectum. The main advantage of this method is the possibility of direct visual control of the distal resection margin. Unlike other NOSES I methods, in this technique the bowel segment with the tumor is resected, while it is totally outside the abdominal

I. Tulina · P. V. Tsarkov (*) Clinic of Colorectal and Minimally Invasive Surgery, Department of Surgery ICM, I.M. Sechenov First Moscow State Medical University, Moscow, Russia © People’s Medical Publishing House, PR of China 2023 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-99-2750-0_8

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cavity. With no intra-abdominal bowel division, the risk of abdominal cavity contamination is minimized.

Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position

Keywords

Anesthesia Method

Laparoscopic surgery · Natural orifice specimen extraction · NOSES IF · Transrectal · Lower rectal cancer · Tsarkov method · Rectal eversion · Extraabdominal resection

General anesthesia with or without epidural component

Patient Positioning The patient is placed in a modified lithotomy position (Fig. 8.3)

Indications and Contraindications Trocar Placement (Fig. 8.4) Indications (Figs. 8.1, 8.2) 1. 2. 3. 4.

Tumor is located in the middle or lower rectum Localized tumor, prolapsing into the lumen Tumor diameter less than 3 cm The distance from the lower tumor margin to the dentate 3–5 cm

Contraindications 1. Locally advanced tumor 2. Tumor diameter more than 3 cm 3. Mucinous adenocarcinoma or signet ring cell carcinoma or uncertain pathology of lower tumor margin 4. Morbid obese patients (BMI > 35 kg/m2)

1. Camera trocar (10 mm): in the umbilicus. 2. The surgeon’s main trocar (12 mm): On the external 1/3 between right anterior superior iliac spine and the umbilicus, which facilitates deep operation in pelvic cavity and is easier to place the straight linear cutter. 3. The surgeon’s auxiliary trocar (5 mm): On the right side about 2 cm lower and 10 cm laterally to the umbilicus. The positioning of the trocar can be changed based on patient’s constitution; however, it should be at a sufficient distance from two neighboring trocars. 4. The assistant’s main trocar (5 mm): On the intersection of the umbilicus level and the lateral edge of left rectus abdominis. 5. The assistant’s auxiliary trocar (5 mm): On the external 1/3 between umbilicus and left anterior superior iliac spine.

Surgical Team Position

Fig. 8.1 (a) The outline of mobilization of the rectum, the fixation of special instrument. (b) Pulling out the rectum through the anus with eversion

Middle Rectum

5 cm

Lower Rectum

5 cm

Upper Rectum

5 cm

The operating surgeon stands on the right side of the patient, the assistant surgeon stands on the left side of the

Fig. 8.2 Tumor location suitable for NOSES IF

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Fig. 8.3 Patient’s position

Surgeon’s Auxiliary Trocar (5 mm)

CameraTrocar (10 mm)

Surgeon’s Main Trocar (12 mm)

Assistant’s Main Trocar (5 mm) Assistant’s Auxiliary Trocar (5 mm)

Fig. 8.4 Trocar placement (five-port method)

patient, and the camera holder stands on the same side of surgeon, to his left (Fig. 8.5).

Fig. 8.5 Surgical team position

Exposure and Operation Planning Special Surgical Instruments Dissecting device (ultrasonic scalpel), an instrument for everting, circular stapler (29 mm), straight linear cutter stapler (optional), and laparoscopic graspers.

Surgical Procedure, Techniques, and Key Points The schematic view of main surgical procedures of specimen extraction and digestive reconstruction in NOSES IF (Fig. 8.6).

Based on detailed preoperative examination and surgical plan discussion, the intraoperative exploration mainly includes three steps.

Abdominal Cavity Examination After the laparoscope is placed into the umbilical port, we recommend an overall examination in a clockwise manner starting from the right upper quadrant, to exclude ascites or any unexpected findings in the liver, gallbladder, stomach, spleen, greater omentum, colon, and small bowel.

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Fig. 8.6 The main surgical procedures of specimen extraction and digestive reconstruction in NOSES IF

determination of the tumor location, size, and the depth of tumor invasion (Fig. 8.7).

Adjusted Anatomical Structures Evaluation Evaluation of the sigmoid colon, rectum, and vascular anatomy of mesenteric vessels is taken out to further determine the extent of surgical resection.

Dissection and Separation

Fig. 8.7 Intraoperative examination of tumor size and localization

Tumor Examination The lower rectal cancer is located below the peritoneal reflection; the surgeon can directly palpate the tumor transanally and help himself with a laparoscopic instrument. It enables

Initial Dissection After establishing the carboxyperitoneum through the umbilical port, additional three or four ports are placed in selected sites. The patient should be tilted into a head-down position (Trendelenburg position), and the operating table should be tilted to the right. It is necessary to move the small bowel apart from the operative field. A small gauze pad can also be used to retract and protect the small bowel and to ensure access to the inferior mesenteric artery (Fig. 8.8).

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Fig. 8.8 The projection of the inferior mesenteric artery origin

Fig. 8.9 Common iliac arteries serve as a reference point for identifying the place of initial dissection

Fig. 8.10 Initial dissection

Initial dissection involves incising the peritoneum at the level of the sacral promontory. This spot is an optimal choice, because peritoneum here is weak and thin, making it possible to see the structures of the colonic mesentery and retroperitoneal pelvic organs (Figs. 8.9 and 8.10). After entering the interfascial layer, the dissection continues cranially along the right splanchnic nerve (Fig. 8.11).

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Fig. 8.11 Dissection of peritoneum along the aorta in cranial direction. Right splanchnic nerve is a lateral border of paraaortic lymph node dissection

Fig. 8.12 Dissection of peritoneum continues cranially up to the level of the lower horizontal part of duodenum

Inferior Mesenteric Vessels Division Using a medial approach, the first step is to expose the root of the inferior mesenteric artery. The assistant retracts mesosigmoid to the left and ventrally. Meanwhile, the surgeon continues the dissection along the aorta to the level of the duodenum (Fig. 8.12). When the root of the inferior mesenteric artery is exposed, the direction of the dissection shifts and continues along the lower horizontal part of the duodenum, toward the descending colon. Tissue dissection is performed to the level of the ascending branch of the left colic artery. It allows, on one side, to remove all the connective tissue with lymph nodes and to complete paraaortic lymph node dissection and, on the other, to visualize the artery during each step of the dissection, consequently avoiding its unintentional damage. Meanwhile, all connective tissue with lymph nodes around the root of the inferior mesenteric artery is shifted toward the specimen (Fig. 8.13). The root of the mesentery should be gently drawn under tension ventrally using the grasping forceps; the dissection should then continue medially in the interfascial plane along the Toldt’s fascia. The medial to lateral approach allows a clear view of the left ureter and the gonadal vessels under Gerota’s fascia. Skeletonization of the inferior mesenteric

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mesorectum along its posterior surface. The rectum is moved anteriorly; its mobilization continues in a caudal direction. Hypogastric nerves and the distal pelvic nerve plexus should be visualized and spared. The dissection in presacral space is taken out between the fascia propria of the rectum and the presacral fascia. The dissection should continue into the pelvis down to the level of the coccyx, at the same time visualizing both sides of the levator ani muscles.

Fig. 8.13 The connective tissues with lymph nodes at the origin of inferior mesenteric artery are moved toward the specimen

Fig. 8.14 The skeletonization of the proximal part of the inferior mesenteric artery, removal of apical lymph nodes, and preservation of left colic artery

artery allows to preserve the left colic artery and to complete the extended lymph node dissection (Fig. 8.14). The inferior mesenteric vein, which is located laterally to the artery, is skeletonized and divided.

Dissection of the Mesorectum In rectal cancer, intermediate regional lymph nodes are located along the superior rectal artery. This artery is moved to the right, and the direction of mesosigmoid division is accurately planned in order to preserve adequate blood flow in the proximal colon limb that will be involved in colorectal anastomosis. Mesosigmoid is mobilized in the lateral and distal directions to the level of iliaс vessels. However, during this step, it is not recommended to completely dissect the peritoneum of the left lateral canal. The colon can be left attached to the peritoneum. For comfortable and safe completion of this step, the assistant retracts to the left the root of the mesentery using graspers. It is important during this step to visualize the ureter and gonadal vessels. The gauze is placed under mesosigmoid. Proceeding the dissection distally, total mesorectal excision is started. It is recommended to start separating

Rectum Right Side Dissection During mobilization of the posterior side of the rectum, it is preferable to expand the presacral space in a semicircle (from the middle to the right and from the middle to the left). Based on sufficient mobilization of the rectum during initial steps, further dissection becomes much easier. The dissection of the right side of the rectum is further facilitated if the working trocar is not placed too close to the anterior superior iliac spine. The bladder in a male patient or the uterus in a female patient is lifted ventrally using grasping forceps from the left lower quadrant cannula. The rectum is also moved to the left side of the pelvis under slight tension with the use of grasping forceps inserted from the left upper quadrant. Then the surgeon should dissect the right side of the rectum down to the peritoneal reflection and continually incise the peritoneal reflection from the right side to the left side. Detachment and Dissection of the Sigmoid Colon and Left Side of Rectum The gauze that was earlier placed under sigmoid mesentery can now be identified from the lateral side of the colon. The adhesion of the sigmoid colon to the left lateral canal is easily detached over the gauze, and the sigmoid colon is completely mobilized. During the dissection, the ureter and/or gonadal vessels should be identified and preserved. We apply selective policy toward splenic flexure mobilization, so in most cases it is not necessary. The assistant draws the sigmoid colon to the left. The dissection continues along with the peritoneal reflection on the left side of the rectum. Distal Rectal Dissection Once the peritoneum is incised at the peritoneal reflection, the posterior vaginal wall (female patient) or seminal vesicles (male patients) can then be exposed. The rectum is drawn to the lower side of the pelvis, placing the anterior rectal space under tension, making the embryological interfacial layers easier to be identified and dissected. It is necessary to continue the mobilization of the rectum on the anterior surface in the caudal direction. By applying tension to the right side of the rectum at the proposed resection line, the mesorectum is divided from the right side wall of the rectum without damaging the rectal wall. Similarly, the mesorectum is dissected on the left side, exposing the rectal wall there and connecting the right and left resection lines posteriorly.

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Proximal Division of the Sigmoid Colon and Mesentery The sigmoid colon is drawn to the left side to unfold the sigmoid mesocolon. The proposed line of resection is measured no less than 10 cm from the proximal edge of the tumor, by stretching a previously measured thread between the tumor and the line of resection. The line of resection should run parallel to the inferior mesenteric vessels, moving toward the intestinal wall, so as not to contact with surrounding lymph nodes (usually 2–4 cm). If Harmonic scalpel is used, then the additional homeostasis tools are not usually required; however, when it comes to choosing an instrument, it is up to the surgeon’s preference which instrument to use. The incision continues until the marked distal line of resection. After reaching that point a surgeon dissects mesosigmoid toward the bowel wall. This maneuver always requires skeletonization and ligation of sigmoid vessels (marginal arteries). The vascular clip is not recommended to be used in the vicinity of the bowel wall. The exposed length of the bowel wall of the sigmoid colon is proposed to be appropriately 2–3 cm. In some situations, it is not recommended to incise the mesentery right to the bowel wall, better to do it extra-abdominally after the eversion on the colon through the anus.

structure, with the rectum being as the outer cylinder and the sigmoid colon being the inner cylinder (Fig. 8.1). During this eversion, it is important to laparoscopically control the length of the intra-abdominal part of the colon to prevent its overtension. The rectum is everted until the tumor comes out and is under the direct view (Fig. 8.16) (Efetov et al. 2019).

Rectal Resection The rectal wall is treated with an antiseptic solution. It is important to measure the distal line of resection, which should be located at least 2 cm above the everted tumor toward the anal canal. Under direct vision, the circular line of resection is marked by electrosurgery instrument (Fig. 8.17). The rectal wall is carefully divided at the marked line (Fig. 8.18). It is important not to damage the wall of sigmoid colon located below. Following the resection of the outer cylinder under the direct view, the distal edge of the rectal stump is grasped with Alice graspers. Importantly, if TME was performed, the line of resection should be as close

Rectal Resection and Digestive Tract Reconstruction Rectal Eversion Through the Anus For extra-abdominal resection of the specimen, it is important to make sure that the length of the colon is enough for transanal extraction. A special metal rod is inserted through the anal canal until its head is located above the tumor. A wire is used to secure the colon around the rod below its head (Fig. 8.15). The rod is carefully pilled out, dragging the everted colon outside the anal canal resulting in a double cylindric

Fig. 8.15 The instrument for rectal eversion is placed above the tumor and is fixed by the ligature

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Fig. 8.16 Eversion of the rectum with the tumor through the anus

Fig. 8.17 The distal resection line is marked under direct vision

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to the bowel edge as possible, so as not to leave the fragments of mesorectal cellular tissue on the rectal stump. Then the proximal line of resection should be planned. The rectum is then unrolled, and the specimen acquires its usual look. The colon is divided with a linear stapler. End-to-end or side-toend anastomosis can be done. For the end-to-end anastomosis, the colon is transected between a purse string and a straight clamp, the anvil is inserted, and the lumen is closed with a purse-string suture around the anvil shaft. When forming a side-to-end anastomosis, the anvil is inserted into the lumen through the small distal incision, and the anvil shaft is pulled from the side (Fig. 8.19). The lumen is closed with a linear stapler or uninterrupted suture proximally to previously made incision. The colonic stump with the anvil is disinfected and returned into the abdomen. The purse-string suture is performed at the rectal

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stump to enable the fixation of the circular stapler. A thin polymer tube is inserted transanally to the rectum, with one end being outside the anal canal and the other end protruding outside the purse string to the abdominal cavity. The pursestring suture is closed around it (Fig. 8.20).

Digestive Tract Reconstruction The anastomosis is performed using the circular stapler. To ensure that the center rod of the circular stapler correctly passes through the rectal stump, it is first fixed to the previously inserted polymer tube. The tube is used as a guide to position the rod of circular stapler right to the center of the purse-string suture. The tube is pulled and then extracted through one of the trocars (Figs. 8.21 and 8.22). The anvil shaft and center rod are joined and closed using laparoscopic instruments, and the stapled colorectal anastomosis is formed (Fig. 8.23). It is important to prevent fatty tissues or other structures from getting caught in the anastomotic site.

Fig. 8.18 Creation of the distal resection line of the outer cylinder

Fig. 8.20 Closing the rectal stump

Fig. 8.19 The anvil is introduced into the lumen to perform a side-toend anastomosis

Fig. 8.21 Using the tube as a guide, the center rod of the circular stapler is inserted into the abdomen

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Fig. 8.22 The center rod of the circular stapler and the anvil shaft are joined and closed

Fig. 8.25 The view of the abdominal wall

Robotic NOSES Operation Fig. 8.23 Colorectal anastomosis is performed using a circular stapler

Fig. 8.24 The bubble test is performed to ensure the completeness of the anastomosis

After the extraction of the circular stapler, the integrity of the proximal and the distal rings is verified. The bubble test is performed to ensure the completeness of the anastomosis (Fig. 8.24). A drainage tube is installed into the pelvic cavity through the right lower trocar (Fig. 8.25).

Using a robotic platform for these types of operations looks promising and fully justified from the standpoint of the development of the method of extraction of the specimen through natural orifices (Yao et al. 2020). In our practice, we widely use these two advanced technologies. Both the advantages and disadvantages of robotic technologies in colorectal surgery are well known (Park and Baik 2016). Robotics allows to use the instruments with higher number of freedom degrees, to eliminate tremor, and to have 3D image and a stable surgeon-controlled exposure; it makes possible tissue traction and countertraction in a narrow space and offers the surgeon a comfortable working position for the whole duration of the operation. The limitations of robotic surgeries are the increased surgical time, the possibility of technologies malfunctioning, and high cost. The specific disadvantage of robotics when using NOSES technique is difficulty to access natural orifices when the working console is located between the patient’s legs. In our practice, we are using modified trocar positioning during robotic operations for rectal cancer (Fig. 8.26), and we are positioning the working console at the angle to the left of the patient (Fig. 8.27). Thus, we are avoiding redocking even in cases when it is necessary to mobilize the splenic flexure at the beginning of the operation. Also,

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Trocar B (8 mm)

Trocar A (10 mm) Trocar D (12 mm)

Trocar E (8 mm)

Trocar C (8 mm)

Fig. 8.28 Insertion of the anvil into the proximal stump during the robotic operation

Fig. 8.26 Trocars positioning for robotic rectal resection

Fig. 8.29 Manipulations involving the vaginal wall during the robotic operations

Fig. 8.27 The patient console positioning

this positioning is convenient for mobilization of the rectum. An additional and significant bonus of a modified trocar and working console positioning is making all the steps of NOSES surgery easier, particularly inserting and fixating the anvil in the proximal colon stump (Fig. 8.28). Also, articulating instruments make it possible to perform any manipulations in the vagina (Fig. 8.29) and the rectal stump (Fig. 8.30), no matter how low or deep they are located. At last, the positioning of the console to the side of the patient enables the surgeon to work between the patient’s legs, therefore makes it possible to perform specific steps, necessary for NOSES technique.

Fig. 8.30 Manipulations involving the rectal stump during the robotic operations

Trocar Positioning for Operations with the Da Vinci Si System 1. Trocar A for laparoscope (10 mm): 1 cm to the right and 1 cm cranially to the umbilicus 2. Trocar B for a third robotic hand (8 mm): 4 cm lower and 2 cm to the right of the xiphoid process

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3. Trocar C for a first robotic hand (8 mm): on the external 1/3 between right anterior superior iliac spine and the umbilicus 4. Trocar D for an assistant (12 mm): in the right mesogastric region at the level of the umbilicus, 2 cm laterally to the outer edge of musculus rectus abdominis: on the external 1/3 between umbilicus and left anterior superior iliac spine 5. Trocar E for a second robotic hand (8 mm): in the left mesogastric region 2 cm below the level of the umbilicus and 1 cm laterally to the outer edge or rectus abdominis (Fig. 8.31) Thus, applying the robotic system during NOSES operations facilitates a performance of difficult steps of procedure that are specific to the NOSES, which opens up the prospects of combining these methods.

References

Fig. 8.31 The view of abdominal wall after the robotic NOSES procedure

Efetov SK, et al. Natural orifice specimen extraction (NOSE) surgery with rectal eversion and total extra-abdominal resection. Tech Coloproctol. 2019;23(9):899–902. Park EJ, Baik SH. Robotic surgery for colon and rectal cancer. Curr Oncol Rep. 2016;18(1):5. https://doi.org/10.1007/s11912-0150491-8. Yao H, Li T, et al. Safety and feasibility of robotic natural orifice specimen extraction surgery in colorectal neoplasms during the initial learning curve. Front Oncol. 2020;10:1355.

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Laparoscopic Low Rectal Cancer Conformal Resection with Transanal Natural Orifice Specimen Extraction (CRC-NOSES IG) Zhang Wei, Zhu Xiaoming, and Yu Guanyu

Contents Indications and Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Indications (Figs. 9.1 and 9.2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . Anesthesia Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Patient Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trocar Placement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Special Surgical Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

121 121 121 121 121 121

Surgical Procedure, Techniques, and Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Exploration and Patient Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Specimen Resection and Digestive Tract Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Key Points, Difficulties, and Hotspots Related to Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Elastic Fibers and Pacinian Corpuscles in the Intersphincteric Space . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Safe Lateral Resection Margin in Ultralow Rectal Cancer Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Oncological and Functional Prognosis of Pull-Through Conformal Resection for Ultralow Rectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131

Abstract

Laparoscopic conformal sphincter-preserving operation for low rectal cancer with transanal natural orifice specimen extraction could solve the problem of performing transpelvic or transanorectal intracorporeal rectal transection in narrow surgical field, and reduce rates of local recurrence and complications, as well as significantly improve anal function. Dissection of the rectum is continued to the levator ani and stopped at the levator hiatus without entering the intersphincteric space, which is filled with nerve fibers, elastic fibers, and pacinian corpuscles. So, excessive dissection in the intersphincteric space could injure these nerve fibers, pacinian corpuscles, and

elastic fibers which may damage the postoperative anal function. An analysis of 102 patients who underwent the conformal sphincter-preserving operation showed that the median distance of the tumor from the anal verge was 3 (3–4) cm, and the median distal resection margin was 0.5 (0.3–0.8) cm. The local recurrence and distant metastasis rates were 2% and 10.8%, respectively. The threeyear overall survival was 100%, and disease-free survival was 83.9%. The mean Wexner and low anterior resection syndrome (LARS) scores at 12 months after ileostomy were 5.9  4.3 and 29.2  6.9, respectively. As an anuspreserving surgery, the advantage of this technique is that it can obtain a good balance between oncological safety and functional outcomes.

Z. Wei (*) · Z. Xiaoming · Y. Guanyu The Colorectal Surgery Department, First Affiliated Hospital of Naval Medical University, Shanghai, China © People’s Medical Publishing House, PR of China 2023 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-99-2750-0_9

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Keywords

Conformal sphincter-preserving Operation · Anal function · Intersphincteric space · Transanal natural orifice specimen extraction

With the continuous advancement of surgical techniques, anus preservation has become possible in a growing number of patients with low rectal cancer. However, owing to the narrow surgical field, performing transpelvic or transanorectal intracorporeal rectal transection may lead to insufficient or excessive resection of the distal rectum and surrounding tissues. This, in turn, may result in higher rates of local recurrence and complications, as well as significantly diminished anal continence following anus-preserving surgery in patients with low rectal cancer. We achieved favorable results through the use of laparoscopic pull-through conformal resection to treat very low rectal cancer (Zhang 2022; Lou et al. 2018). Dissection of the rectum is continued to the levator plate and stopped at the levator hiatus without entering the patient’s intersphincteric space. The rectum is then everted through the anal opening and transected with direct visualization. The distal resection margin is designed according to tumor morphology, while ensuring a distal resection margin of 1 cm. If a positive resection margin is suspected, the specimen should be evaluated using intraoperative frozen section examination. This ensures that the tumor is radically treated and that the rectal mucosa, rectal wall, and anal sphincter are preserved to a large extent. Thus, protection of the anal continence function is maximized, thereby improving the patient’s postoperative quality of life (Ding et al. 2022). The combination of natural orifice specimen extraction surgery (NOSES) with the extracorporeal resection of the distal rectal specimen under direct vision, followed by the laparoscopic end-to-end anastomosis of the proximal colon and anal canal, ensures minimal invasiveness and functional preservation during radical resection of low rectal cancer.

Fig. 9.1 Colonoscopic view of the tumor located 1 cm from the dentate line. It is ulcerated and has a maximum diameter of 3 cm

Fig. 9.2 T2-weighted rectal MRI: The tumor is located 1 cm from the dentate line, with a maximum diameter of 3 cm

Indications and Contraindications Indications (Figs. 9.1 and 9.2) 1. Patients with a preoperative pathological report of electronic colonoscopic biopsy indicating a highly or moderately differentiated adenocarcinoma or stromal tumor 2. Patients with MRI or B-mode ultrasound images revealing no infiltration of the external anal sphincter or puborectalis and levator ani muscles or whose examination after preoperative neoadjuvant radiotherapy and chemotherapy meets these requirements

3. A mobile tumor mass with a diameter of 35 kg/m2)

Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position Anesthesia Method General anesthesia or combined general and epidural anesthesia.

Patient Positioning The patient is placed in the lithotomy position (Fig. 9.3).

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Trocar Placement 1. The camera port (12 mm trocar) is placed at the umbilicus. 2. The surgeon’s main working port (12 mm trocar) is placed at one-third of the distance from the right anterior superior iliac spine to the umbilicus (i.e., at the McBurney’s point). 3. The surgeon’s auxiliary working port (5 mm trocar) is placed 10 cm to the right of the umbilicus and parallel to it. 4. The assistant’s main working port (5 mm trocar) is placed at the lateral edge of the left superior rectus abdominis. 5. The assistant’s auxiliary working port (5 mm trocar) is placed at one-third of the distance from the left anterior superior iliac spine to the umbilicus (i.e., opposite the McBurney’s point). Forceps introduced via this port have relatively few uses and are mainly used to elevate tissues. The lateral position of the port facilitates drain placement (Fig. 9.4).

Surgical Team Position The operating surgeon stands to the right of the patient. The assistant stands to the left of the patient. The camera-holder stands on the same side as the surgeon (Fig. 9.5).

Special Surgical Instruments Ultrasonic scalpel, 60 mm linear Endo-GIA stapler, 25 mm circular stapler, and rectal stump suture.

Fig. 9.3 Patient positioning

Fig. 9.4 Trocar placement (fiveport method)

Camera port (12 mm) Surgeon’s auxiliary working port (5 mm)

Surgeon’s main working port (12 mm)

Assistant’s main working port (5 mm)

Assistant’s auxiliary working port (5 mm)

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Camera-holder

Surgeon

Assistant

Scrub nurse

Monitor

Fig. 9.5 Operator positioning

Fig. 9.6 The small intestine is transferred to the right upper abdomen to visualize the root of the mesenteric vessels

Surgical Procedure, Techniques, and Key Points Exploration and Patient Positioning 1. Order of abdominal exploration: Exploration is performed in clockwise manner and involves the ileocecal area, appendix, ascending colon, hepatic flexure, liver, gallbladder, transverse colon, greater omentum, descending colon, sigmoid colon, apex of bladder, rectovesical pouch or rectouterine pouch, uterus and bilateral appendages, jejunum, and ileum. Adhesions, hyperemia, edema, pus, and masses must be carefully explored. 2. Adjustment of patient positioning: Once access to the abdominal cavity is established, the patient is generally placed in a modified lithotomy Trendelenburg position with the right side elevated. This position provides room for transfer of the small intestine to the right upper abdomen, which facilitates visualization of the surgical field (Fig. 9.6).

Surgical Approach 1. Midline approach The right pararectal sulcus is incised through a midline approach (Fig. 9.7). The assistant uses Babcock forceps to grasp and elevate the rectum to the level of the sacral promontory while using an atraumatic grasper on the other hand to elevate the peritoneum and blood vessels cephalad within the projection of the inferior mesenteric artery (IMA). The surgeon uses an auxiliary bowel grasper to grasp the peritoneum surrounding the right pararectal sulcus to maintain adequate tension in the

Opening of the sigmoid mesocolon bridge

Fig. 9.7 The sigmoid mesocolon bridge is incised, and vaporization in the ultrasonic scalpel is used to identify the left Toldt’s space

mesorectum to be dissected. Dissection is performed superior to the root of the small-bowel mesentery and continued toward the left to visualize the left Toldt’s space, which is a loose horizontal space. 2. Dissection of the left Toldt’s space Dissection is performed along Toldt’s space, which is dilated superiorly, inferiorly, and toward the left side and subsequently continued leftward to the left paracolic sulcus and superiorly to the root of the IMA. Special care is required when dissecting this space; excessively deep dissection will easily damage the deeper structures, including the inferior mesenteric nerve plexus, left ureter, and left gonadal vessels (Fig. 9.8). 3. Mobilization and transection of the roots of the inferior mesenteric vessels When skeletonizing the IMA, the inferior mesenteric nerve plexus seen in the figure above must be protected. Transection is performed 0.5 cm from the root of the

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Inferior mesenteric vein

Left ureter

Left colic artery

Inferior mesenteric nerve plexus

Fig. 9.8 Dilation of the left Toldt’s space, with special care given to protecting the left ureter, inferior mesenteric nerve plexus, and left gonadal vessels

Inferior mesenteric artery

Fig. 9.9 Dissection and isolation of the inferior mesenteric artery with nerve preservation

Left colic artery

Inferior mesenteric artery

Fig. 9.10 Preservation of the left colic artery

IMA (Fig. 9.9). For patients undergoing conformal resection, the left colic artery is routinely preserved (Fig. 9.10), and the IMA is transected at the distal end

Inferior mesenteric artery

Fig. 9.11 Transection of the inferior mesenteric vein

of the left colic artery, except in cases where the origin of the left colic artery is relatively distant from the root of the IMA or if the arterial diameter is small. The No. 253 lymph nodes are also dissected while preserving the left colic artery. Subsequently, the inferior mesenteric vein (IMV) is transected distal to where the left colic vein drains into the IMV (Fig. 9.11). 4. Division of the sigmoid mesocolon With the surgeon using forceps to grasp the transected IMA root on the left hand, the assistant uses two forceps to unfold the sigmoid mesocolon and mobilize it in an inferior direction. The left colic artery is mobilized first, with its distal end ligated using hem-o-lock clips before being transected using the ultrasonic scalpel. Mobilization is then continued inferiorly to release 1–3 sigmoid vessels, the distal ends of which are also ligated using hem-o-lock clips before transection with the ultrasonic scalpel. The sigmoid mesocolon is divided to preserve the marginal vessels, thus allowing the colon to be pulled into the pelvic floor to achieve a tension-free anastomosis. When transecting the IMA, damage to the marginal vessels must be avoided, particularly in obese patients and patients with a short mesentery. 5. Incision of left paracolic sulcus peritoneal reflection The left paracolic sulcus peritoneal reflection (left line of Toldt) is a white-yellow junction that begins at the adhesion band between the lateral edge of the first curve of the sigmoid colon and the left abdominal wall and continues until the phrenicocolic ligament. This is a key anatomical landmark for lateral mobilization of the sigmoid colon and descending colon. The adhesion band is the caudal end of the left paracolic sulcus peritoneal reflection and is the peritoneal incision point for lateral dissection of the colon. The left line of Toldt is dissected from this point; dissection is continued superiorly to incise the left paracolic sulcus peritoneal reflection (Fig. 9.12).

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Incision of the sigmoid mesocolon

Dilation of the retrorectal space

Fig. 9.12 Incision of the congenital adhesion of the sigmoid colon

Fig. 9.14 Tunneling dissection of the retrorectal space

Pelvic plexus

Retrorectal space

Fig. 9.13 Entry into the retrorectal space

6. Dissection of the retrorectal space Visualization of the retrorectal space: The assistant first uses Babcock forceps to grasp the transected inferior mesenteric vessels and mesentery, which are retracted cephalad. The assistant uses a bowel grasper on the other hand to block the mesorectum caudally and ventrally. This enables visualization of the loose retrorectal space posterior to the sacral promontory, and sharp dissection is performed inferiorly along this space (Fig. 9.13). 7. Dilation of the retrorectal space Tunneling dissection of the retrorectal space: The retrorectal space is identified posterior to the sacral promontory, and sharp dissection is performed up to the bilateral sides of the mesorectal surface in an “apple-paring” fashion centered at the midline of the retrorectal space (Figs. 9.14 and 9.15). 8. Incision of the rectosacral fascia The rectosacral fascia (also known as Waldeyer’s fascia) is a fusion zone between the rectal fascia propria and

Right hypogastric nerve

Fig. 9.15 Care must be taken to preserve the bilateral hypogastric nerves and pelvic plexus when dissecting the retrorectal space

presacral fascia that extends from the level of the fourth sacral vertebrae (S4) to the pelvic diaphragm (superior to the anorectal ring). When dissection reaches the corresponding retrorectal space below the peritoneal reflection, this loose space disappears, and the rectosacral fascia, which is a layer of dense, fibrous connective tissues, can be observed (Fig. 9.16). Transection of the rectosacral fascia in this region leads to another loose space, i.e., the “inferior presacral space,” where the vine-like presacral venous plexus can be observed. If resistance is met, the fascia along the sacral fascial surface is incised to enter the mesorectum, where a large area of residual presacral adipose tissue can be observed. Ideally, the rectosacral fascia (fused fascia) should be detached to reveal a smooth presacral space with no visible venous plexus. The inner transition zone between the sacral plane and vertical plane of the levator ani muscle is at nearly a 90 angle. This is a common site for incomplete total mesorectal excision (TME). The

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Right seminal vesicle

Right pelvic wall nervous tissues Waldeyer’s fascia Mesorectum

Fig. 9.16 Waldeyer’s fascia

Fig. 9.18 Right rectal dissection

Left seminal vesicle Peritoneal reflection

Pelvic floor

Fig. 9.17 Dissection up to the level of the levator ani muscle surface

vertical plane of the levator ani muscle is observed when the presacral venous plexus disappears. Dissection should closely follow the surface of the levator ani muscle (Fig. 9.17) to avoid entering the mesorectum. 9. Dissection of the lateral rectal space In cases where the “holy plane” is not clearly visible lateral to the rectum, if blind cutting and dissection is performed, medial deviation will easily result in mesorectal entry, whereas lateral deviation will damage the pelvic nerves. In such cases, the area of rectum approximately 5 cm above the peritoneal reflection should be grasped using Babcock forceps and retracted cephalad. The surgeon and assistant can then use one pair of forceps each to push and pull the area between the lateral rectal wall and pelvic wall in opposite directions to form traction and countertraction, which enables clear visualization of the “holy plane.” When the bilateral caudal seminal vesicles and hypogastric nerves are exposed, cutting is performed in a superior direction along a virtual incision plane while simultaneously aligning the bilateral hypogastric nerves with the caudal seminal vesicles. Dissection is continued up to the caudal seminal

Mesorectum

Fig. 9.19 Left rectal dissection

vesicles and immediately curved medially to avoid nerve damage lateral to the caudal seminal vesicles (Figs. 9.18 and 9.19). 10. Anterior rectal dissection The anterior tension of the tissues superior and inferior to the incision line of the peritoneal reflection must be maintained. To achieve this, the surgeon retracts the rectum cephalad, while the assistant pushes the peritoneum above the incision line anteriorly using a bowel grasper. An arc-shaped incision is made at 0.5–1 cm on the peritoneal reflection to reveal a loose space. Sharp dissection is performed inferiorly along the loose anterior rectal space until the smooth greyish white Denonvilliers’ fascia is visible. Denonvilliers’ fascia is incised using the ultrasonic scalpel at the inferior margin of the seminal vesicle to access the anterior rectal space (Fig. 9.20). Dissection of the anterior rectal space is slightly complicated in female patients. The assistant forcefully pushes open the posterior vaginal wall using the atraumatic forceps in the left hand, while the surgeon grasps the incised peritoneal reflection using the forceps in the left hand and pulls the rectum inferiorly, which

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Denonvilliers’ fascia

Anterior rectal space

Mesorectum Rectum

Fig. 9.20 Transection of Denonvilliers’ fascia after visualizing the seminal vesicles

Fig. 9.22 Entering the anterior rectal space posterior to Denonvilliers’ fascia

Vagina Rectum

DVF

Rectum

Levator ani muscle

Hiatal ligament

Fig. 9.21 Entering the anterior rectal space posterior to the vagina

facilitates visualization of the anterior rectal space (Fig. 9.21). Alternatively, the peritoneum can be incised at the peritoneal reflection to gain access to the anterior rectal space between the Denonvilliers’ fascia and rectal fascia propria (Fig. 9.22). Some studies have demonstrated the presence of several communicating nerve branches originating from the pelvic plexus anterior to the Denonvilliers’ fascia, which can affect postoperative urinary and sexual function. Thus, directing entry posterior to the Denonvilliers’ fascia can ensure complete nerve preservation, which would help preserve the genitourinary system function to the greatest extent possible. 11. Dissection end point of the distal rectum As mobilization is continued posteriorly, the level of the levator ani muscle can quickly be reached. The levator ani hiatus surrounding the distal rectum is the end point of TME dissection. Posteriorly, the rectal fascia propria continues from the posterior presacral fascia toward the pelvic floor, forming a thickened fusion fascia on the

Fig. 9.23 Posterior end point of rectal dissection

surface of the levator ani muscle. Posterior to this surface, the fusion fascia thickens to form the hiatal ligament, which fixes the distal rectum in place. The levator ani hiatus forms a white fascia-like tissue on both sides of the distal rectum (Fig. 9.23) and is the posterior end point of rectal dissection. Anteriorly, the rectal fascia propria fuses with the anterior Denonvilliers’ fascia where it meets the perineum and forms a white fascial structure, which is the anterior end point of rectal dissection (Fig. 9.24). At this point in surgical dissection, mobilization of the entire mesorectum is achieved. 12. Preservation and significance of the intersphincteric space Notably, one major difference between our conformal resection technique for low rectal cancer and the intersphincteric specimen resection (ISR) technique is that in our method, dissection ends at the opening of the levator ani hiatus and does not include the

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DVF

Rectum

Fig. 9.26 Nerve endings in the intersphincteric sulcus. IAS: internal anal sphincter; EAS: external anal sphincter. The blue arrows indicate nerve endings positive for S100 staining

Fig. 9.24 Anterior end point of rectal dissection

Rectum Levator ani

sphincter function, which may also be the reason for poor anal function following ISR. Therefore, we believe that in cases of ultralow rectal cancer, dissection until the level of the intersphincteric sulcus, or even until the dentate line should not be performed for reasons other than oncological safety. Damage to the sphincter structure or to adjacent nerve endings should be minimized in order to protect anal function.

Hiatal ligament

Specimen Resection and Digestive Tract Reconstruction

Fig. 9.25 Transection of the hiatal ligament

intersphincteric sulcus. This is because for the majority of ultralow rectal cancer cases, the requirements for TME are met when dissection reaches the level of the levator ani hiatus, which allows for bowel isolation and transection under direct visualization. With respect to ultralow rectal cancer with excessively low-lying or relatively small tumors, a safe distal resection margin cannot be determined using laparoscopy. Thus, transanal pullthrough resection is required in such cases, and the hiatal ligament needs to be transected after the end point is reached; however, the levator ani hiatus does not need to be dissected to enter the intersphincteric sulcus. When the hiatal ligament is transected, the last anchor that fixes the rectum in the pelvic cavity is removed (Fig. 9.25). Thus, performing transanal pull-through of the rectum at this point provides adequate space and distance to perform resection under direct vision. We also performed nerve staining of intersphincteric sulcus specimens resected using the Miles’ resection technique; a relatively large number of nerve endings were observed within the intersphincteric sulcus (Fig. 9.26). Damage to these nerve endings can affect internal and external anal

1. Specimen resection The bowel is transected using a linear Endo-GIA stapler at the intended site of anastomosis. Transanal pull-through of the distal rectum is performed as follows: the rectum and anal canal are irrigated with iodoform, and the anus is dilated to accommodate 3–4 fingers to ensure that the anal sphincter is completely relaxed. Oval forceps are used to clamp the top of the rectal stump, and the bowel together with the mesentery are gradually inserted deeper into the rectal cavity and pulled out of the anus. For patients who are obese or who have a thick mesentery, the excess proximal mesorectum can first be divided. The rectum that was previously pushed out through the abdomen is clamped transanally and retracted extracorporeally via the anus in order to fully evert the rectum. The distal rectum is then thoroughly irrigated with warm water. The tumor is prevented from coming into contact with surrounding tissues, and the surgical team should also minimize contact with the tumor. Conformal resection and anastomosis of the distal rectum (Figs. 9.27, 9.28, and 9.29): The resection line is designed according to the tumor location after the tumor is visualized. The lower the resection line on the ipsitumoral side, the higher the resection line on the contralateral normal bowel wall should be, thus ensuring that

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more of the bowel and mucous membrane is preserved. If the distal edge of the tumor is >2 cm from the dentate line, the resection line marked on the distal rectum is 2 cm from the distal-most edge of the tumor, and the contralateral

Proposed curved resection line

Fig. 9.27 Marking of the proposed curved resection line after pullthrough

resection margin is elevated in a curved fashion toward the proximal rectum while ensuring a lateral resection margin of 2 cm. If the distal edge of the tumor is 1–2 cm from the dentate line, the ipsitumoral resection line is marked on the distal edge of the dentate line, ensuring a distal resection margin of at least 1 cm; the contralateral incision is elevated in a curved fashion to preserve a semicircular dentate line. If the distal edge of the tumor is 36 kg/m2).

The positions of the surgeon, assistant, and camera holder should be on the right side, left side, and the same side of the surgeon, separately (Fig. 14.6).

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Fig. 14.3 Rectal MRI: T3, 12 cm from the dentate line, maximum diameter of 2.9 cm

Fig. 14.4 The patient’s position

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greater omentum, and pelvic cavity are routinely examined for the presence of tumor seeding or ascites (Figs. 14.8 and 14.9). Camera Trocar

Surgeon’s Auxiliary Trocar (5 mm)

(10 mm)

Surgeon’s Main Trocar (12 mm)

Assistant’s Main Trocar

(5 mm) Assistant’s Auxiliary Trocar (5 mm)

Fig. 14.5 Trocar placement (five-port method)

Tumor Exploration The location and size of the tumor and the feasibility of specimen extraction should be evaluated (Fig. 14.10). Evaluation of Anatomical Structures Also, the surgeon needs to evaluate the length of sigmoid colon, the length of mesenteric marginal vessels, and the thickness of mesentery to determine the feasibility of transanal extraction. Tumor location determines whether to preserve inferior mesenteric vessels and superior rectal artery.

Dissection and Separation

Fig. 14.6 Surgical team position

Special Surgical Instruments Ultrasonic scalpel, 60 mm linear Endo GIA stapler, 30 mm circular stapler, and sterile protective sleeve.

Surgical Procedure, Techniques, and Key Points The schematic view of main surgical procedures of specimen extraction and digestive reconstruction in NOSES IV (Fig. 14.7).

Exploration and Surgical Planning General Exploration After the laparoscope is placed into the umbilical port, the liver, gallbladder, stomach, spleen, colon, small intestine,

The First Point of the Incision The patient is placed in the head down position (Trendelenburg position). The assistant lifts the anterior rectal wall upward and toward the abdominal wall with forceps in the left hand, so that the complete course of rectum will be showed in the pelvic cavity. At the same time, the assistant lifts the inferior mesenteric vessels with forceps in the right hand, so that the region from their root to the rectum and the peritoneal reflection will be under clear visualization. There is often a thin area, especially for obese patients, at 3–5 cm below the sacral promontory, from where start the operation with an ultrasonic scalpel (Fig. 14.11). After the incision of mesentery, the scalpel tip will generate heat. Along the course of presacral space, the white cellular tissue of Toldt’s fascia can be identified by moving the scalpel tip up and down (Figs. 14.12 and 14.13). Isolation and Ligation of Inferior Mesenteric Artery and Vein Dissection is performed upward to the left along the Toldt’s fascia and continued toward the root of the inferior mesenteric artery along the boundary between the sigmoid mesocolon and mesoileum (Fig. 14.14). Attention should be paid to protect the inferior mesenteric plexus (Fig. 14.15). The course and peristalsis of the left ureter can be observed during the dissection (Fig. 14.16). A gauze is placed underneath the root of the inferior mesenteric artery and vein for protection and indication. The gauze underneath the avascular area of sigmoid mesocolon can be observed by changing the direction of the camera (Fig. 14.17). It is safe to dissect lymphatic and adipose tissues around the intended resection line at the root of the inferior mesenteric artery and then ligate the inferior mesenteric artery at the root (Fig. 14.18). Continue dissecting to the left lateral side. The mesentery is flipped for the identification of the course

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Fig. 14.7 The main surgical procedures of specimen extraction and digestive reconstruction in NOSES IV

Fig. 14.8 Exploration of the left lobe of the liver

Fig. 14.9 Exploration of the small intestine

of the inferior mesenteric vein. Pay attention that the inferior mesenteric vein should not be isolated more than necessary (Fig. 14.19) (Han et al. 2013). Once the inferior mesenteric vein is exposed, it is ligated and transected (Fig. 14.20), and the avascular area of sigmoid mesocolon can be partially opened.

Dissection of the Upper Mesorectum The mesorectum is lifted and dissected to 5 cm below the distal edge of tumor. The peritoneum is incised downward along the lateral side of the upper rectum to the marker line. The surgeon adequately dissects the posterior wall while paying attention to the extent of dissection, as well as the

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Fig. 14.10 Exploration of the tumor

Fig. 14.11 Application of gauze to block the small intestine and expose the surgical field

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Fig. 14.13 Entering the space anterior to Toldt’s fascia

Fig. 14.14 Dissection to the root of the inferior mesenteric artery

Fig. 14.15 Exposure and protection of nerves

protection of the inferior hypogastric nerves (Fig. 14.21) and presacral vessels (Fig. 14.22).

lateral to medial pattern, a gauze can be seen, which can be used as a landmark (Fig. 14.24) and help to protect the ureter underneath. Most cases do not require to mobilize splenic flexure. The left side of the rectum is also dissected downward to the same level as the right side (Fig. 14.25).

Dissection of the Lateral Sigmoid Colon and Rectosigmoid Colon A gauze is placed underneath the dissected mesentery, and the tumor is pulled to the right. The lateral sigmoid adhesion is detached (Fig. 14.23), and dissection is continued along the Toldt’s fascia. Attention should be paid to protect the ureters and gonadal vessels. When dissection is performed in a

Isolation and Transection of the Bowel Below the Tumor After full circle of mesorectum is carefully dissected to the same level, the rectum can be transected along with the mesorectum. In general, the distal end of superior rectal artery and vein (or the retained end) can be ligated with the vascular clip. The extent of isolation below the tumor is

Fig. 14.12 The first point of the incision

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Fig. 14.19 Isolation of the inferior mesenteric vein Fig. 14.16 Dissection to the left lateral side to expose the course of the left ureter

Fig. 14.20 Ligation and transection of the inferior mesenteric vein Fig. 14.17 Gauze is visible beneath the mesocolon

Fig. 14.21 Dissection downward along the posterior rectal space Fig. 14.18 Ligation and transection of the inferior mesenteric artery

3–5 cm (Figs. 14.26, 14.27, and 14.28). Lastly, the isolated bowel is transected with a linear Endo GIA stapler (Fig. 14.29).

Dividing the Sigmoid Mesocolon Next, a gauze is inserted underneath the sigmoid mesocolon. Several sigmoid vessels are ligated while the sigmoid mesocolon is divided toward the intended resection line of sigmoid colon wall (Figs. 14.30 and 14.31). Total 2 cm of bowel wall

should be isolated around the proximal intended resection line (Fig. 14.32).

Specimen Resection and Digestive Tract Reconstruction Specimen Resection The protective sleeve is inserted into the abdominal cavity through the main trocar (Fig. 14.33). Next, a window is opened at the top of the rectal stump by the ultrasonic scalpel,

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Fig. 14.22 Presacral vessels

Fig. 14.25 Dissection of the left rectal wall

Fig. 14.23 Detachment of physiological adhesion of the sigmoid colon

Fig. 14.26 Isolation of the anterior rectal wall

Fig. 14.27 Isolation of the right rectum wall Fig. 14.24 Sigmoid mesocolon is dissected in a lateral to medial fashion

insert the oval forceps through the anus to pull the protective sleeve out of the anus (Fig. 14.34), then apply oval forceps to hold the anvil, and slide it into the abdominal cavity through the protective sleeve (Fig. 14.35) (Ooi et al. 2009). The proximal bowel stump can be put into the protective sleeve, and a small longitudinal incision is made on the bowel wall above the tumor (Fig. 14.36). Iodoform gauze is inserted into the sigmoid colon lumen through the longitudinal incision to disinfect the bowel lumen (Fig. 14.37). The anvil is introduced into the sigmoid colon lumen through the longitudinal incision (Fig. 14.38). The isolated bowel is transected with a

Fig. 14.28 Isolation of the left rectum wall

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Fig. 14.32 Isolation of wall of the sigmoid colon Fig. 14.29 Transection of the distal rectum

Fig. 14.30 Dissection of the sigmoid mesocolon

Fig. 14.33 Insertion of protective sleeve through the main trocar

Fig. 14.31 Ligation and transection of vessels of the sigmoid mesocolon

Fig. 14.34 Transanal extraction of protective sleeve

linear Endo GIA stapler above the longitudinal incision (Fig. 14.39), and the sigmoid colon stump is disinfected with iodoform gauze (Fig. 14.40). At this point, the specimen is completely resected (Fig. 14.41). The used gauze in the protective sleeve is accompanied by the resected specimen (Fig. 14.42). Afterward, the surgeon tightens the drawstring on the protective sleeve to prevent the leakage and slowly pulls the protective sleeve out through the rectum and anus (Fig. 14.43).

Digestive Tract Reconstruction The rectal stump is restapled with a linear Endo-GIA stapler (Fig. 14.44). Since the location of the tumor is high, in most cases, the transection can be completed with one cartridge. The resected rectal stump is placed in a retrieval bag or a self-made finger cot (resected from a rubber glove), and removed through the 12 mm trocar (Fig. 14.45). The surgeon grabs the anvil from the outside of the bowel and takes the anvil shaft out of the sigmoid colon stump through one

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Fig. 14.35 Inserting the anvil with the protective sleeve Fig. 14.38 Inserting the anvil into the proximal sigmoid colon

Fig. 14.36 Placing the distal bowel in the protective sleeve and making a small longitudinal incision on the bowel wall above the tumor

Fig. 14.39 Transection of the sigmoid colon

Fig. 14.37 Disinfection in the sigmoid colon lumen

Fig. 14.40 Disinfection of the sigmoid colon stump

corner of it (Figs. 14.46 and 14.47). The assistant inserts a circular stapler transanally and extends the trocar to pierce the rectal stump through its corner (Fig. 14.48). The anvil shaft is connected, and the direction of mesocolon should be adjusted before completing the sigmoid colorectal end-to-

end anastomosis (Fig. 14.49). After the stapler is removed, the integrity of the anastomosis is doubled checked. Laparoscopic suturing is performed to minimize the “danger triangle of the anastomosis” (Figs. 14.50 and 14.51). Air leak test is performed to confirm the integrity of the

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Fig. 14.44 Closing of the rectal stump Fig. 14.41 Resected specimen is placed into the protective sleeve

Fig. 14.42 Placing the small gauze and specimen in the protective sleeve

Fig. 14.45 Removal of the resected rectal stump with the retrieval bag

Fig. 14.43 Transanal extraction of rectal specimen

Fig. 14.46 Grab the anvil from the outside of the bowel

anastomosis (Figs. 14.52 and 14.53). After irrigating the abdominal cavity, two drainage tubes are placed in the left and right lower abdomen, respectively (Figs. 14.54 and

14.55). The pneumoperitoneum is released, and trocar sites are closed. Local anesthetic drugs, e.g., procaine, can be used to reduce postoperative pain.

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Fig. 14.51 Suture to reinforce the “danger triangle of the anastomosis”

Fig. 14.48 Extend trocar to pierce the rectal stump Fig. 14.52 Air leak test

Fig. 14.49 Sigmoid colorectal end-to-end anastomosis

Fig. 14.53 Air leak test to confirm the integrity of the anastomosis

Fig. 14.50 “Danger triangle of the anastomosis”

Fig. 14.54 Drainage tube is placed on the left side of the pelvic cavity

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Postoperative Abdominal Wall and Specimen Display

Key Points, Difficulties, and Hot Spots Related to Surgery

See Figs. 14.56 and 14.57.

Surgical Plane and Operating Procedure of TME

Fig. 14.55 Drainage tube is placed on the right side of the pelvic cavity

The ideal surgical plane of TME surgery is the posterior rectal space, which extends around the rectum. The posterior rectal space is located posterior to the rectum (Fig. 14.58). The lateral rectal ligaments are located on the two lateral sides. The anterior is the space between the two layers of the Denonvilliers’ fascia. During the dissection of the mesorectum, the first step is to enter the posterior rectal space, adequately dissect the posterior rectal wall, then dissect from the posterior wall to the bilateral sides, and finally dissect the anterior rectal wall. Performing TME in this posterior-to-anterior order facilitates to keep the dissection in the correct space anterior to the Toldt’s fascia, avoids secondary damage to the greatest extent, and reduces the operative difficulties. Most importantly, operating in this space better meets the oncological requirements and achieves radical resection. In addition, even in this space, the dissection of the rectum should be performed closely along the rectal visceral fascia, which can better protect the pelvic autonomic nerve and presacral vein in the presacral fascia.

Anatomy of Lateral Ligaments of the Rectum Anatomically, the bilateral rectal space contains a large amount of loose connective tissues. Connective tissue bundles containing blood vessels and visceral nerve enter into the rectal wall vertically to form the lateral ligament of the rectum (Fig. 14.59). Surgeons often emphasize the presence of these ligaments, but the morphology, extent, and structure of them are not clear yet. Lateral ligaments of the rectum have no obvious and robust beam shape, and the anatomical position is not fixed. Some studies have shown that while these Fig. 14.56 Abdominal wall after surgery

Fig. 14.57 Specimen display

Fig. 14.58 Presacral plane (after TME resection)

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The significance of this structure for the radical resection of rectal cancer is far less than that of the mesorectum. Longterm experience has shown that although many surgeons believe that middle rectal vessels are presented in the lateral ligaments of the rectum, there is no need to perform extra ligation while performing dissection in this area.

References

Fig. 14.59 Lateral ligaments of the rectum

fiber bundle structures on both sides of rectum can be identified in 71% of patients, middle rectal artery and vein can only be found in the “lateral ligaments” of 57% of patients.

Han FH, Hua LX, Zhao Z, Wu JH, Zhan WH. Transanal natural orifice specimen extraction for laparoscopic anterior resection in rectal cancer. World J Gastroenterol. 2013;19(43):7751–7. Hisada M, Katsumata K, Ishizaki T, Enomoto M, Matsudo T, Kasuya K, Tsuchida A. Complete laparoscopic resection of the rectum using natural orifice specimen extraction. World J Gastroenterol. 2014;20(44):16707–13. Ooi BS, Quah HM, Fu CW, Eu KW. Laparoscopic high anterior resection with natural orifice specimen extraction (NOSE) for early rectal cancer. Tech Coloproctol. 2009;13(1):61–4.

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Contents Indications and Contraindications of NOSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204 Indications (Figs. 15.1, 15.2, 15.3, and 15.4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204 Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205 Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . Anesthesia Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Patient Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trocar Placement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Special Surgical Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

205 205 205 205 205 205

Surgical Procedure, Techniques, and Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Exploration and Surgical Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dissection and Separation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Specimen Resection and Digestive Tract Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postoperative Abdominal Wall and Specimen Display . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Key Points, Difficulties, and Hot Spots Related to Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214 Skills in the Use of Stapler in Anus Preserving Surgery for Rectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214 Application of Air Leak Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217

Abstract

NOSES V is mainly applicable to female patients with large tumor in the upper rectum and distal sigmoid colon. The main operating procedures of NOSES V include complete dissection and transection of specimen in abdominal cavity, transvaginal specimen extraction, and totally laparoscopic end-to-end anastomosis between the sigmoid colon and rectum. Natural orifice specimen extraction has been shown to reduce postoperative pain and wound complications and provide better cosmetic outcome. In female patients, transvaginal specimen X. Wang (*) Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China

extraction could facilitate specimen extraction and avoid drastic squeezing, tumor rupture, and dissemination during specimen removing. Compared with NOSES IV, the main features of NOSES V are as follows: (1) because of the strong vaginal extensibility, the indications of NOSES V are wider, but this procedure is limited to female patients; (2) the anvil is inserted by making a small incision on the bowel wall above the tumor, which minimizes abdominal contamination and meets the principle of aseptic operation. After the drainage tubes are in place, the pneumoperitoneum is released, and the trocar sites are closed. As long as the key operations are mastered and the principles of aseptic and tumor-free operation are met, NOSES V can not only ensure the radical resection of tumor but also preserve organ functions.

Z. Zhao Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China © People’s Medical Publishing House, PR of China 2023 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-99-2750-0_15

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Keywords

Natural orifice specimen extraction surgery (NOSES) · Upper rectal cancer · Transvaginal specimen extraction · Function preservation in oncology surgery principle · Minimally invasive surgery

Indications and Contraindications of NOSES Indications (Figs. 15.1, 15.2, 15.3, and 15.4)

5cm

Lower Rectum

5cm

Middle Rectum

5cm

Lower Rectum

5cm

Middle Rectum

Upper Rectum

5cm

Upper Rectum

5cm

1. Tumor is located in the upper rectum, rectosigmoid colon, and distal sigmoid colon. 2. The circumferential diameter of tumor is 3–5 cm. 3. The tumor should not invade beyond the serosa.

Fig. 15.3 Rectal MRI: T2, 11 cm from the dentate line, maximum diameter of 3.5 cm

Fig. 15.1 Tumor location suitable for NOSES V

Fig. 15.2 Colonoscopy: tumor of protuberant type, 13 cm from the dentate line, and maximum diameter of 4 cm

Fig. 15.4 CT virtual endoscopy: The tumor is located at the upper rectum, involving one-third of the rectal circumference

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Contraindications 1. The tumor is located elsewhere. 2. Circumferential diameter of tumor is more than 5 cm, which makes it hard to be extracted through the vagina.

Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position

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5. The assistant’s auxiliary trocar (5 mm trocar) is located opposite the McBurney’s point, which facilitates to place the drainage tube (Fig. 15.6).

Surgical Team Position The positions of the surgeon, assistant, and camera holder should be on the right side, left side, and the same side of the surgeon, separately (Fig. 15.7).

Anesthesia Method Special Surgical Instruments General anesthesia or general epidural anesthesia.

Patient Positioning The patient is placed in functional lithotomy position, with the right thigh slightly flattened, which facilitates to perform the operation for the surgeon (Fig. 15.5).

Trocar Placement 1. Camera trocar (10 mm trocar) is located 3–5 cm above the umbilicus. 2. The surgeon’s main trocar (12 mm trocar) is located above the McBurney’s point. 3. The surgeon’s auxiliary trocar (5 mm trocar) is located beside the right rectus abdominis at 5–10 cm from the right side of the umbilicus. 4. The assistant’s main trocar (5 mm trocar) is located at the umbilical level beside the left rectus abdominis.

Fig. 15.5 The patient’s position

Ultrasonic scalpel, 60 mm linear Endo GIA stapler, 29 mm circular stapler, vaginal suture line, uterine manipulator, and sterile protective sleeve.

Surgical Procedure, Techniques, and Key Points The schematic view of main surgical procedures of specimen extraction and digestive reconstruction in NOSES V (Fig. 15.8).

Exploration and Surgical Planning Based on adequate preoperative examination and surgical plan discussion, the exploration mainly includes three steps.

General Exploration After the laparoscope is placed into the umbilical port, the liver, gallbladder, stomach, spleen, colon, small intestine,

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Dissection and Separation

Surgeon’s Auxiliary Trocar (5 mm)

Camera Trocar (10 mm)

Surgeon’s Main Trocar (12 mm)

Assistant’s Main Trocar (5 mm) Assistant’s Auxiliary Trocar (5 mm)

Fig. 15.6 Trocar placement (five-port method)

Fig. 15.7 Surgical team position

greater omentum, and pelvic cavity are routinely examined for the presence of tumor seeding or ascites (Figs. 15.9 and 15.10).

Tumor Exploration The location and size of the tumor is explored to assess the feasibility of transvaginal specimen extraction (Figs. 15.11 and 15.12). Evaluation of Anatomical Structures The feasibility of transvaginal specimen extraction is evaluated by the length of sigmoid colon and mesorectum and the thickness of mesorectum.

The First Point of the Incision Since the location of the tumor is high, the assistant lifts the anterior rectal wall below the tumor with the forceps in the left hand and lifts the mesentery with the forceps in the right hand (Fig. 15.13). The surgeon may open the mesentery at or below the sacral promontory as appropriate (Fig. 15.14). Dissection and Ligation of Inferior Mesenteric Artery and Vein Dissection is performed upward to the left along the Toldt’s fascia and continued toward the root of the inferior mesenteric artery along the boundary between the sigmoid mesocolon and mesoileum (Fig. 15.15). The course and peristalsis of the left ureter can be observed during the dissection (Fig. 15.16). A gauze is placed underneath the root of the inferior mesenteric artery and vein for protection and indication (Fig. 15.17). The gauze underneath the avascular area of sigmoid mesocolon can be observed by changing the direction of the camera (Fig. 15.18). Under the protection of the gauze, the surgeon can dissect lymphatic and adipose tissues around the root of the inferior mesenteric artery and ligate the inferior mesenteric artery at the root (Fig. 15.19). Continue dissecting to the left lateral side. The mesentery is flipped for the identification of the course of the inferior mesenteric vein. Pay attention that the inferior mesenteric vein should not be isolated more than necessary. Once the inferior mesenteric vein is exposed, it is ligated and transected (Figs. 15.20 and 15.21), and the avascular area of sigmoid mesocolon can be partially opened (Fig. 15.22). Dissection of the Mesorectum When the inferior mesenteric artery and vein are transected, the assistant can lift the posterior mesorectum, and the surgeon applies the ultrasonic scalpel to dissect along the Toldt’s fascia downward to the posterior (Figs. 15.23 and 15.24). The dissection of mesorectum proceeds distally to 5 cm below the distal edge of tumor, and the extent of dissection should not be too large. Dissection of the Right Side of the Rectum For the dissection of the right rectal wall, the distal resection line of the bowel can be predetermined, and the dissection is performed from the lateral side to the intended resection line (Fig. 15.25). Dissection of the Sigmoid Colon and the Left Side of the Rectum A gauze is placed underneath the sigmoid colon and mesorectum (Fig. 15.26), and the sigmoid colon is pulled to the right. The lateral sigmoid adhesion is detached (Fig. 15.27),

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Fig. 15.8 The main surgical procedures of specimen extraction and digestive reconstruction in NOSES V

Fig. 15.9 Exploration of the left lobe of liver and stomach

Fig. 15.10 Exploration of the greater omentum

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Fig. 15.11 Exploration of the tumor location

Fig. 15.15 Entering the space anterior to Toldt’s fascia

Fig. 15.12 Posterior vaginal fornix

Fig. 15.16 Ureter exposing

Fig. 15.13 Exposure of the root of mesentery Fig. 15.17 Placing gauze underneath the mesentery

Fig. 15.14 The first point of the incision

Fig. 15.18 Exposure of the avascular area of sigmoid mesocolon

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Fig. 15.22 Opening of the avascular area of sigmoid mesocolon Fig. 15.19 Ligation and transection of the inferior mesenteric artery

Fig. 15.20 Exposure of the inferior mesenteric vein

Fig. 15.23 Dissection downward along the Toldt’s fascia

Fig. 15.24 Dissection downward along the right side of the rectum Fig. 15.21 Ligation and transection of the inferior mesenteric vein

and dissection is continued upward along the Toldt’s fascia in a lateral to medial pattern (Fig. 15.28). Most cases do not require to mobilize splenic flexure. The left side of the rectum is also dissected downward to the same level as the right side (Fig. 15.29).

Isolation of the Bowel Below the Tumor The mesorectum is transected at about 5 cm below the tumor. If the superior rectal vessels are thick (Fig. 15.30), the stump can be ligated with the vascular clip. The length of the isolated bowel below the tumor should be appropriately 2 cm (Fig. 15.31).

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Fig. 15.29 Dissecting the left rectal wall downward Fig. 15.25 Dissection of the right rectal wall

Fig. 15.30 Ligation of the superior rectal artery Fig. 15.26 Placing small gauze underneath the mesentery

Fig. 15.31 Isolation of the bowel below the tumor Fig. 15.27 Detachment of physiological adhesion of the sigmoid colon

Dividing the Sigmoid Mesocolon Next, a gauze is inserted underneath the sigmoid mesocolon. The surgeon should check the extent of division and determine the intended resection line again. Division is performed along the course of the inferior mesenteric vessels (Figs. 15.32 and 15.33), and approximately 2 cm of the sigmoid colon is isolated (Fig. 15.34).

Specimen Resection and Digestive Tract Reconstruction

Fig. 15.28 Opening the peritoneum to the left of the sigmoid colon

Specimen Resection The surgeon inserts the protective sleeve into the pelvic cavity through the main trocar (Fig. 15.35). After the vaginal

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Fig. 15.32 Dividing the sigmoid mesocolon Fig. 15.35 Insertion of protective sleeve through the main trocar

Fig. 15.33 Ligation and transection of vessels of the sigmoid mesocolon

Fig. 15.36 Indication of bladder retractor

Fig. 15.34 Isolation of wall of the sigmoid colon

Fig. 15.37 Opening the posterior vaginal fornix

irrigation, the assistant introduces the bladder retractor through the vagina to indicate the posterior vaginal fornix (Fig. 15.36), and the surgeon applies the ultrasonic scalpel to open the vagina transversely for approximately 3 cm and extends the incision to 5–6 cm by longitudinal stretch (Fig. 15.37). The assistant inserts the oval forceps through the vagina to pull the distal end of the protective sleeve out of the body (Fig. 15.38). Subsequently, the anvil is introduced into the abdominal cavity through the protective sleeve (Fig. 15.39). A small longitudinal incision is made in the bowel wall between the tumor and the proximal intended

resection line (Fig. 15.40). Through the incision, the surgeon inserts iodoform gauze into the colon lumen for disinfection and lubrication, and the assistant applies the suction to push the iodoform gauze into the distal bowel lumen of the incision (Figs. 15.41 and 15.42). The anvil is introduced into the proximal sigmoid colon lumen (Fig. 15.43) and the proximal bowel is transected with the linear Endo-GIA stapler (Fig. 15.44). Following this, the isolated bowel below the tumor is transected with a linear Endo-GIA stapler (Fig. 15.45). At this point, the rectal tumor and the bowel segment are completely resected. The surgeon and an

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Fig. 15.38 Transvaginal extraction and spreading of the protective sleeve

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Fig. 15.41 Timely suction of intestinal contents

Fig. 15.42 Disinfection in the sigmoid colon lumen

Fig. 15.39 Inserting the anvil through the protective sleeve

Fig. 15.43 Inserting the anvil into the proximal sigmoid colon

Fig. 15.40 A small incision on the bowel wall above the tumor

assistant place the specimen and the used gauze into the protective sleeve, and another assistant applies the oval forceps to clamp the bowel wall stump below the tumor in the protective sleeve. The protective sleeve is tightened and slowly pulled out along with the specimen and gauze at a uniform speed (Fig. 15.46).

Digestive Tract Reconstruction The anvil shaft is protruded from one corner of the proximal colon stump (Fig. 15.47). The assistant inserts a circular stapler transanally and extends the trocar to pierce the rectal stump from one side of the staple line (Fig. 15.48). The anvil is connected to the trocar of stapler (Fig. 15.49) to complete the sigmoid colorectal end-to-end anastomosis (Fig. 15.50). After the stapler is removed, the integrity of the anastomosis is doubled checked. Laparoscopic suturing is performed to minimize the “danger triangle of the anastomosis”

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Fig. 15.44 Transection of the bowel of the sigmoid colon

Fig. 15.45 Transection of the rectal bowel below the tumor

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Fig. 15.47 Taking out the anvil shaft

Fig. 15.48 Extend trocar to pierce the rectal stump

Fig. 15.46 Transvaginal extraction of rectal specimen and gauze

Fig. 15.49 Connecting the anvil and trocar

(Fig. 15.51). Lastly, air leak test is performed to confirm the integrity of the anastomosis (Fig. 15.52). After irrigating the abdominal cavity, transabdominal or transvaginal drainage tubes are placed.

incision with two Allis forceps, and interrupted suture is performed with absorbable sutures to close the incision (Fig. 15.53) (Zhang et al. 2022).

Closure of Trocar and Suture of Vaginal Incision After the drainage tubes are in place, the pneumoperitoneum is released, and the trocar sites are closed. The vaginal incision is exposed by lifting the anterior and posterior wall of the

Postoperative Abdominal Wall and Specimen Display See Figs. 15.54 and 15.55.

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Fig. 15.50 Sigmoid colorectal end-to-end anastomosis Fig. 15.53 Transvaginal placement of drainage tube

Fig. 15.51 Suture to reinforce the “danger triangle of the anastomosis”

Fig. 15.54 Postoperative abdominal wall display

Fig. 15.52 Air leak test

Key Points, Difficulties, and Hot Spots Related to Surgery Skills in the Use of Stapler in Anus Preserving Surgery for Rectal Cancer The instruments and devices of NOSES mainly rely on the platform of laparoscopic technique. With the popularization of laparoscopic technique, the rational use of various laparoscopic instruments, especially the stapler, puts forward higher

Fig. 15.55 Specimen display

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requirements for surgeons. Surgeons should be extremely familiar with the size, operating principles, structure, and performance of different staplers, so as to make better use of the staplers and ensure the safety and efficiency of the surgery (Li et al. 2013). The stapler primarily applied in the NOSES is the linear Endo GIA stapler. The length of cartridge mainly includes 30, 45, 60 mm, etc. The selection of different length of stapler cartridge should be decided based on the width of tissue. In the middle and lower rectal resection, the selection of stapler should abide by the following principles: 1. Articulating staplers should be applied for the anastomosis in the lower rectal cancer resection due to the deep location of the anastomotic plane. 2. Try to complete the transection of bowel with one stapler. 3. The transection line should form a vertical angle with the bowel to avoid affecting the blood supply of bowel and subsequent operation. 4. If the closure cannot be completed with one stapler and more than one staplers are needed, try to ensure that the transection lines are at the same level and avoid angulation of transection lines (Fig. 15.56).

25, 28, 29, 31, 33 mm, and several other sizes. The selection of stapler should be made according to the diameter of the bowel (Richardson et al. 2013). The use of circular stapler should comply with the following principles: 1. Adjust the spacing appropriately. Compressing the two walls is the key to ensure the quality of anastomosis. As the thickness of bowel wall varies in different individuals,

Fig. 15.57 Remnant bowel after the first closure

According to the author’s experience, in most cases, the transection of the rectum in the middle and lower rectal operation can be completed with one 60 mm stapler. For some obese patients, the transection of the rectum cannot be completed using a 60 mm stapler at one time (with 5–10 mm of the remnant bowel). We take this part of remnant bowel tissue as the piercing point of stapler trocar (Figs. 15.57, 15.58, 15.59, and 15.60). This approach can reduce a “danger triangle of the anastomosis,” decrease the risk of anastomotic leakage, and lower the surgical cost by avoiding the use of one more stapler. The circular staplers applied in NOSES and conventional rectal surgery are consistent, mainly including Fig. 15.58 Extend trocar to pierce the rectal stump

Fig. 15.56 “Z”-shaped transection line formed by three linear Endo GIA staplers

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Fig. 15.59 Transection of the remnant rectum

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6.

the appropriate stapler spacing is 1.5–2.0 mm (60–70% in the indicating block) and attention should be paid to the thickness of the surrounding bowel wall. After firing the stapler, reduce the trauma to the tissue by minimizing the compression time. It has been reported that some postoperative anastomotic stenosis is associated with excessive compression of the bowel wall by instruments. However, some scholars believe that a few extra seconds of compression after firing the stapler can help prevent anastomotic bleeding. These different views remain to be further validated by clinical practice. Reduce the anastomotic tension. Anastomotic tension can cause staples to cut or tear the bowel wall tissue, which may further interfere with the healing and cause concomitant anastomotic leakage. Careful handling of residual tissues. Careful dissection of residual tissues or fatty appendices hanging around the anastomosis within the scope of 2.0 cm can prevent bleeding and leakage. However, too much dissection may cause anastomotic necrosis. The blood supply of upper and lower bowel wall should be guaranteed. The edge distance of the purse-string suture should be within the range of 0.5 cm to minimize excessive residual tissue or tissue inhomogeneities that can result in incomplete stapling or transection. When extracting the stapler out of the rectum, slow rotation can prevent the tearing of anastomosis mucosa. After the removal of stapler, the integrity of the circular bowel wall tissues on both ends should be checked immediately. If necessary, air leak test should be performed to check the integrity of the anastomosis.

X. Wang and Z. Zhao

the incidence of anastomotic leakage. Air leak test after anastomosis is one of the main methods to check the integrity of anastomosis. Air leak test positive is mainly manifested by the presence of obvious bubbles at the anastomotic site. The leakage of dilute iodine solution into the pelvic cavity can be observed after transanal injection of dilute iodine solution (Fig. 15.61). Eight-figure sutures can be performed on the two “dog ears” or the leakage site with 4–0 absorbable suture, followed by circumferential reinforcement of the anastomosis (Figs. 15.62 and 15.63). During this process, the assistant

Fig. 15.61 Transanal injection of dilute iodine solution to observe anastomotic leakage

Application of Air Leak Test Anastomotic leakage is the main complication of anus preserving surgery for lower and ultralow rectal cancer. Accurate anastomosis during operation is the main method to reduce Fig. 15.62 Suture the “danger triangle of the anastomosis” for reinforcement

Fig. 15.60 One corner of the rectal stump is pierced by the stapler trocar

Fig. 15.63 Suture around the anastomosis for reinforcement

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injects dilute iodine solution through the anus and moves the anus upward to facilitate the exposure of the surgical field and the surgeon’s operation. After the reinforcement, air leak test is performed again to confirm the integrity of the anastomosis.

References Li SY, et al. Anus-preserving rectectomy via telescopic colorectal mucosal anastomosis for low rectal cancer: experience from a Chinese cohort. World J Gastroenterol. 2013;19(24):3841–6.

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Richardson DP, et al. Population-based use of sphincter-preserving surgery in patients with rectal cancer: is there room for improvement? Dis Colon Rectum. 2013;56(6):704–10. Zhang M, et al. Surgical outcomes and sexual function after laparoscopic colon cancer surgery with transvaginal versus conventional specimen extraction: a retrospective propensity score matched cohort study. Int J Surg. 2022;104:106787.

Laparoscopic Left Hemicolectomy with Transanal Specimen Extraction (CRC-NOSES VI A)

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Xishan Wang and Zheng Jiang

Contents Indications and Contraindications of NOSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220 Indications (Figs. 16.1, 16.2, and 16.3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220 Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220 Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . Anesthesia Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Patient Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trocar Placement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Special Surgical Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

220 220 220 220 220 221

Surgical Procedure, Techniques, and Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Exploration and Surgical Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dissection and Separation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Specimen Resection and Digestive Tract Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postoperative Abdominal Wall and Specimen Display . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Key Points, Difficulties, and Hotspots Related to Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231 Selection of Surgical Approach for Laparoscopic Left Colon Cancer Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . 231 Common Approaches for Preoperative Tumor Localization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234

Abstract

The relative low incidence of left colon cancer (only accounting for 5–6% of colon cancer), with some cases of sclerotic type accompanied by obstructive symptoms, leads to a lower amount of experience in NOSES VI. Compared with conventional laparoscopic left hemicolectomy, the main operating features of NOSES VI A include complete dissection and transection of left colon in abdominal cavity, specimen extraction from the rectum and anus, and totally laparoscopic end-to-end X. Wang (*) Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China Z. Jiang Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China © People’s Medical Publishing House, PR of China 2023 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-99-2750-0_16

anastomosis between transverse colon and rectum. The approach for specimen extraction from the rectum and anus can avoid auxiliary incision in the abdominal wall and only leaves a few tiny trocar scars on the abdominal wall after the surgery. Therefore, NOSES manifests perfect minimally invasive effect and accelerates postoperative rehabilitation. The operating difficulties of NOSES VI A mainly involve the laparoscopic technical difficulties and the challenges of NOSES. Specifically, the laparoscopic technical difficulties include the complete mesocolon resection of left colon, dissection of lymph nodes at the root of mesentery, and the mobilization of splenic flexure. The NOSES technical difficulties include the specimen extraction from the rectum and anus, total laparoscopic digestive tract reconstruction, and application of aseptic and tumor-free operation. These are the challenges the surgeons need to face and overcome. 219

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Keywords

Laparoscopic surgery · Natural orifice specimen extraction · NOSES · Transanal · Left hemicolectomy

X. Wang and Z. Jiang

Patient Positioning The patient is placed in functional lithotomy position, with the right thigh slightly flattened, which facilitates to perform the operation for the surgeon (Fig. 16.4).

Indications and Contraindications of NOSES Indications (Figs. 16.1, 16.2, and 16.3) 1. Tumor is located at the descending colon and proximal sigmoid colon. 2. The circumferential diameter of tumor is preferably less than 3 cm. 3. The tumor should not invade beyond the serosa.

Contraindications 1. Tumor is located at the splenic flexure and transverse colon near the splenic flexure. 2. Circumferential diameter of tumor is more than 3 cm. 3. Tumor invades beyond the serosa. 4. Severely obese patients (BMI > 35 kg/m2).

Trocar Placement 1. Camera trocar (10 mm trocar) is located 2–3 cm below the umbilicus. 2. The surgeon’s main trocar (12 mm trocar) is located at the McBurney’s point. 3. The surgeon’s auxiliary trocar (5 mm trocar) is located at the intersection of 10 cm above the umbilicus and the lateral edge of the right rectus abdominis. 4. The assistant’s main trocar (5 mm trocar) is located at the intersection of 10 cm above the umbilicus and the left midclavicular line. 5. The assistant’s auxiliary trocar (5 mm trocar) is located opposite the McBurney’s point, which facilitates to place the drainage tube (Fig. 16.5).

Surgical Team Position

Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position Anesthesia Method General anesthesia or general epidural anesthesia.

Fig. 16.1 Extent of surgical resection

The surgeon stands on the right side of patient, and the assistant stands on the left side of patient. During mobilization of splenic flexure, the assistant moves to stand between two legs of the patient. During digestive tract reconstruction and specimen extraction, the assistant

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returns to the left side of patient. The camera holder stands on the same side of surgeon (Fig. 16.6).

Special Surgical Instruments Ultrasonic scalpel, 60 mm linear Endo GIA stapler, 29 mm circular stapler, and sterile protective sleeve.

Surgical Procedure, Techniques, and Key Points The schematic view of main surgical procedures of specimen extraction and digestive reconstruction in NOSES VIA (Fig. 16.7).

Fig. 16.2 Colonoscopy: tumor of protuberant type, 29 cm from the dentate line, and maximum diameter of 2.5 cm Fig. 16.3 CT virtual endoscopy: The tumor is located at the descending colon

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Fig. 16.4 The patient’s position

Surgeon’s Auxiliary Trocar (5 mm)

Camera Trocar (10 mm)

Surgeon’s Main Trocar (12 mm)

Assistant’s Main Trocar (5 mm) Assistant’s Auxiliary Trocar (5 mm)

Fig. 16.5 Trocar placement (five-port method)

Exploration and Surgical Planning Based on adequate preoperative examination and surgical plan discussion, the exploration mainly includes three steps.

General Exploration After the laparoscope is placed into the umbilical port, the liver, gallbladder, stomach, spleen, colon, small intestine, greater omentum, and pelvic cavity are routinely examined for the presence of tumor seeding or ascites (Figs. 16.8 and 16.9). Tumor Exploration The tumor is located at the descending colon or the junction between descending colon and sigmoid colon. The tumor size should be evaluated. The surgeon should also evaluate the feasibility of transrectal specimen extraction (Fig. 16.10).

Evaluation of Anatomical Structures First, the anatomic structure of colon and mesocolon is evaluated, i.e., whether the length of the dissected bowel and the course of the marginal vessels facilitate the anastomosis; second, the surgeon should determine whether the thickness of mesentery and the circumferential diameter of tumor facilitate the transrectal specimen extraction.

Dissection and Separation Management of the Root of the Inferior Mesenteric Vessels The surgeon applies the ultrasonic scalpel to open the retroperitoneum at the root of the inferior mesenteric artery (Figs. 16.11 and 16.12) and incises the retroperitoneum toward the Treitz ligament along the lateral side of abdominal aorta. The dissection is continued with caution to enter the space anterior to Toldt’s fascia (Fig. 16.13), then the space above, below, and to the left of the root of the inferior mesenteric artery is extended. Subsequently, the root of the inferior mesenteric artery is isolated, double ligated, and transected (Figs. 16.14 and 16.15). The vascular stump is lifted for the dissection under it with a medial to lateral fashion. The surgeon then dissects upward to the lateral side of the Treitz ligament and transects the inferior mesenteric vein at the inferior boarder of pancreas (Figs. 16.16 and 16.17). Dissection of Left Mesocolon with Medial Approach The inferior mesenteric vessels stumps are lifted as the surgeon applies the ultrasonic scalpel to perform sharp and blunt dissection of the Toldt’s fascia downward and upward in a medial to

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Fig. 16.6 (a) Surgical team position (before the mobilization of splenic flexure); (b) surgical team position (mobilization of splenic flexure); and (c) surgical team position (specimen extraction and digestive tract reconstruction)

lateral fashion (Fig. 16.18). The course and peristalsis of the left ureter can be identified. For the medial side, the surface of the left adipose capsule of kidney is adequately dissected, while for the upper side the inferior boarder of pancreas is dissected toward the tail of pancreas (Figs. 16.19 and 16.20).

Management of the Sigmoid Mesocolon and Mesorectum The extent of resection below the tumor should be assessed again, and the intended resection line of the distal edge of tumor is better at the upper segment of rectum. After the mesentery is lifted along the course of the inferior mesenteric artery, dissection is performed downward to the level of the sacral

promontory. Attention should be paid to protect the nerves anterior to the abdominal aorta (Fig. 16.21). Subsequently, the surgeon divides the mesorectum to the bowel wall, and the distal superior rectal vessels are better ligated with vascular clips (Figs. 16.22 and 16.23). Approximately 3–4 cm of bowel wall is isolated at the junction between the rectum and sigmoid colon (Fig. 16.24).

Management of the Left Transverse Colon and Splenic Flexure In this procedure, the greater omentum should be preserved. The surgeon applies the ultrasonic scalpel to dissect the middle transverse colon to the left and transects the

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Fig. 16.7 The main surgical procedures of specimen extraction and digestive reconstruction in NOSES VIA

Fig. 16.8 Exploration of liver and stomach Fig. 16.9 Exploration of the pelvic cavity

attachment of the greater omentum (Fig. 16.25) until the lower pole of spleen and the peritoneum lateral to the splenic flexure are exposed. At this point, the omental bursa is entered (Fig. 16.26). After that, the greater omentum is flipped upward, the adhesions between the stomach and the

transverse mesocolon are detached, and dissection is continued to the left to the lower pole of spleen (Fig. 16.27). Following this, the course of the pancreas is clearly visible, which is an important anatomic landmark. As the transverse

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Fig. 16.13 Entering the space anterior to Toldt’s fascia Fig. 16.10 Exploration of the tumor location

Fig. 16.11 Exposure of the Treitz ligament and inferior mesenteric vein Fig. 16.14 Isolation of the inferior mesenteric artery

Fig. 16.12 The first point of the incision

colon is lifted, the surgeon transects the transverse mesocolon from the inferior mesenteric vein stump, which lies lateral to the Treitz ligament, to give direct access to the omental bursa. Then the dissection proceeds to the left to lower pole of spleen along the inferior boarder of the pancreas (Figs. 16.28 and 16.29).

Dissection of the Left Paracolic Sulcus The sigmoid colon is pulled to the right, while the left side of the rectum is dissected upward along the Toldt’s fascia

Fig. 16.15 Ligation and transection of the inferior mesenteric artery

(Fig. 16.30). The left paracolic sulcus is incised upward to the lower pole of spleen as indicated by the gauze (Fig. 16.31). At this time, the dissection of the left colon is completed.

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Fig. 16.16 Dissection of the inferior mesenteric vein

Fig. 16.19 Dissection of mesentery upward along the Toldt’s fascia

Fig. 16.17 Ligation of the inferior mesenteric vein

Fig. 16.20 Placing small gauze underneath the mesentery

Fig. 16.18 Dissection of mesentery along the Toldt’s fascia from medial to lateral

Fig. 16.21 Dissection downward along the right side of the bowel to open the mesentery

Dividing and Isolating the Mesocolon Above the Tumor The splenic flexure is pulled downward for the evaluation of the intended resection line. Following this, the surgeon

divides the transverse mesocolon and then ligates and transects the marginal vessels (Fig. 16.32). Dissection is continued to the bowel wall, and 2 cm of the bowel is isolated (Fig. 16.33).

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Fig. 16.22 Dividing the upper mesorectum

Fig. 16.25 Separating of the transverse colon from the greater omentum

Fig. 16.23 Ligation of the superior rectal artery

Fig. 16.26 Dissection to the left to detach the adhesion of the greater omentum to the transverse colon

Fig. 16.24 Isolation of wall of the sigmoid colon Fig. 16.27 Dissection to the lower pole of spleen

Specimen Resection and Digestive Tract Reconstruction Specimen Resection A small transverse window is opened on the isolated bowel of the sigmoid colon below the tumor as the assistant provides

timely suction of intestinal contents (Figs. 16.34 and 16.35). The protective sleeve is inserted through the 12 mm trocar, then the second assistant applies the oval forceps through the incision to pull the end of the protective sleeve out through the anus. The anvil is held by oval forceps and introduced

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Fig. 16.28 Dissection upward to the inferior boarder of the pancreas

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Fig. 16.31 Dissection to the lower pole of spleen along the left paracolic sulcus

Fig. 16.29 Gauze visible at the inferior boarder of pancreas Fig. 16.32 Ligation of the marginal vessels

Fig. 16.30 Opening the left paracolic sulcus

into the abdominal cavity through the protective sleeve (Fig. 16.36). A small longitudinal incision is made in the bowel wall proximal to the tumor (Fig. 16.36). After the opened bowel lumen is disinfected, the anvil is introduced into the proximal colon (Figs. 16.37, 16.38, 16.39, and 16.40). The colon is transected with a linear stapler (Fig. 16.41). At this point, the anvil is left in the proximal bowel, and the bowel stump should be disinfected again with

Fig. 16.33 Isolation of the transverse colon

iodoform gauze (Fig. 16.42). The rectum is transected by extending the transverse incision below the tumor, then the left colon is completely resected. All the gauzes in the abdominal cavity are placed into the protective sleeve and removed through it. The assistant applies the oval forceps to clamp the distal end of the bowel extracorporeally and slowly

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Fig. 16.34 Opening the sigmoid colon below the tumor

Fig. 16.37 Opening the transverse colon wall above the tumor

Fig. 16.35 Timely suction of intestinal contents

Fig. 16.38 Timely suction of bowel contents

Fig. 16.36 Inserting the anvil into the abdominal cavity through the anus and rectum

pulls the specimen out of the rectum and anus (Fig. 16.43). While most of the specimen is extracted, the inner opening of protective sleeve is tightened to facilitate the extraction (Fig. 16.44).

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Fig. 16.39 Disinfection of the bowel lumen with iodoform gauze

Digestive Tract Reconstruction The opened rectal stump is closed with a linear Endo GIA stapler (Fig. 16.45), and the resected stump is placed into retrieval bag and extracted through the 12 mm trocar. The abdominal cavity is irrigated with 1000 mL of dilute iodine

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Fig. 16.40 Inserting the anvil into the proximal transverse colon

Fig. 16.43 Transanal extraction of the left colon specimen

Fig. 16.41 Transection of the transverse colon

Fig. 16.44 Tighten the drawstring on the protective sleeve

Fig. 16.42 Disinfection of bowel stump with iodoform gauze Fig. 16.45 Closing the rectal stump

solution to reduce the risk of intraperitoneal infection. The anvil shaft is taken out from one corner of the resection line on the proximal colon (Fig. 16.46). The assistant inserts a circular stapler transanally and extends the trocar to pierce the left lateral corner of rectal stump (Fig. 16.47). The anvil is connected to the trocar of stapler, and the direction of mesocolon is adjusted (Fig. 16.48), then the stapler is fired to

complete the anastomosis (Fig. 16.49). The surgeon should check the integrity of the anastomotic ring and suture the “danger triangle of the anastomosis” with 8-figure suture for reinforcement (Fig. 16.50). Air leak test is performed to confirm the integrity of the anastomosis (Fig. 16.51). After irrigating the abdominal cavity, two drainage tubes are placed

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Fig. 16.46 Taking out the anvil shaft

Fig. 16.48 Connection of the anvil to the trocar

Fig. 16.47 One corner of the rectal stump is pierced by the trocar of stapler

Fig. 16.49 Transverse colorectal end-to-end anastomosis

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close to the anastomosis (Figs. 16.52 and 16.53). Finally, pneumoperitoneum is released, and the trocar sites are closed.

Postoperative Abdominal Wall and Specimen Display See Figs. 16.54 and 16.55.

Key Points, Difficulties, and Hotspots Related to Surgery Selection of Surgical Approach for Laparoscopic Left Colon Cancer Resection The medial approach is not only applicable to right colon resection but also for the left colon cancer resection. This surgical approach allows for better visualization and identification of the correct operation plane and space and facilitates the surgeon to distinguish the anatomical planes of ureters.

Fig. 16.50 “Danger triangle of the anastomosis”

After entering the Toldt’s fascia, the ureters and gonadal vessels can be clearly exposed, which can effectively prevent the ureters and gonadal vessels from being damaged (Poon et al. 2009). More importantly, the medial approach is more in line with the requirements of tumor-free operation. Ligation of vascular roots first can effectively prevent tumor cell

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Fig. 16.51 Air leak test

Fig. 16.54 Postoperative abdominal wall display

Fig. 16.52 One drainage tube is placed on the right side of the pelvic cavity

Fig. 16.55 Specimen display

Fig. 16.53 One drainage tube is placed on the left side of the pelvic cavity

blood metastasis caused by surgical compression. This approach ensures the safety of ligation of the inferior mesenteric artery at the root and achieves the goal of radical resection of tumor. In the process of dissection from the medial side to the lateral side, the traction of the assistant is necessary to provide tension to the mesentery, which facilitates the

smooth dissection of the mesentery and maintains the integrity of the mesocolon. The difficulty lies in the dissection of the root of the inferior mesenteric vein and the inferior boarder of the pancreatic body and tail (Fig. 16.56) while preserving the inferior mesenteric vein (Fig. 16.57).

Common Approaches for Preoperative Tumor Localization With the development and popularization of laparoscopic technique, the preoperative localization of colon cancer has gradually attracted wide attention. Accurate tumor

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Fig. 16.56 Dissection of the inferior boarder of pancreatic body and tail

Fig. 16.57 Preservation of the inferior mesenteric vein

localization can guide surgeons to select the reasonable surgical approach and to evaluate the extent of surgical resection. Currently, the common methods of colonic tumor localization mainly include colonoscopy, CT virtual endoscopy, gastroscopic injection of carbon nanotubes, etc. Colonoscopy can detect the tumor under direct vision and acquire biopsy specimen, which is currently the most important method for the diagnosis of colon cancer (Hadjipetrou et al. 2017). The sensitivity of colonoscopy to colon cancer identification is up to 85–95%, but its accuracy of colon cancer localization is still controversial. The bowel lumen

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has no obvious anatomical signs other than the ileocecal valve. Therefore, it is difficult to determine the accurate location of tumor, and the judgment is easily affected by the experience of endoscopist. In addition, since the sigmoid colon and transverse colon are peritoneal organs, their mesentery is long and their bowel can be redundant, which may cause error in determining the location of tumor. Localization by the depth of endoscope insertion may have big errors. As a potential alternative to traditional colonoscopy, CT virtual endoscopy is well tolerated, has high diagnostic sensitivity, and allows for a comprehensive observation in localization of colorectal cancer (Jain et al. 2022). CT virtual endoscopy has gradually replaced double-contrast barium radiography (Fig. 16.58). Relevant studies have shown that the accuracy of tumor localization is up to 100%, which is consistent with intraoperative findings. It can observe any angle of the lesion, which clearly shows the specific location of tumor, the presence of bowel stenosis, and the extent of local invasion and metastasis of the lesion, which provide definite basis for surgical plan making and prediction of prognosis. The examination in rectal cancer is of great value as well, especially for patients who are prepared to undergo NOSES II and III. Because the bowel needs to be extracted out of the body in these two procedures, we need to consider whether the length of the sigmoid colon is enough for the bowel to be pulled out. The CT virtual endoscopy can clearly show the course and length of the sigmoid colon, which facilitates adequate assessment of the difficulty of specimen extraction before surgery. Gastroscopic injection of carbon nanotubes is also a common method for tumor localization. The long-term clinical practice has proved that this is a safe, accurate, and economical method for tumor localization, and its accuracy is over 90%. With the extensive application of laparoscopy in colorectal surgery, this method has been widely used in clinical practice. The method mainly involves submucosal injection of carbon nanotubes, through endoscopy, and carbon nanotubes, and then spreads to the muscularis and serosa to form black plaques in the serosa, so as to determine the lesion location and the extent of resection (Fig. 16.59). In addition, the carbon nanotube is also a good indicator for lymph node detection (Fig. 16.60).

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Fig. 16.58 CT Virtual endoscopy shows the tumor location

Fig. 16.59 Tumor localization using carbon nanotube injection

References Hadjipetrou A, et al. Colorectal cancer, screening and primary care: a mini literature review. World J Gastroenterol. 2017;23(33):6049–58.

Fig. 16.60 Lymph nodes labeled with carbon nanotubes Jain S, et al. Optimal strategies for colorectal cancer screening. Curr Treat Options in Oncol. 2022;23(4):474–93. Poon JT, et al. Impact of the standardized medial-to-lateral approach on outcome of laparoscopic colorectal resection. World J Surg. 2009;33(10):2177–82.

Laparoscopic Left Hemicolectomy with Transrectal Specimen Extraction (CRC-NOSES VIB)

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Haipeng Chen, Zhaoxu Zheng, and Xishan Wang

Contents Indications and Contraindications of NOSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236 Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236 Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . Anesthesia Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Patient Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trocar Placement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Special Surgical Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Surgical Procedure, Techniques, and Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Exploration and Surgical Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dissection and Separation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Specimen Resection and Digestive Tract Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postoperative Recovery and Specimen Display . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Key Points, Difficulties, and Hot Spots Related to Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249 Dissection and Anatomy of the Splenic Flexure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249 The Concept of Complete Mesocolic Resection of the Left Colon Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250 Key Points, Difficulties, and Hot Spots Related to Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250 Total Laparoscopic Digestive Tract Reconstruction After Laparoscopic Left Hemicolectomy . . . . . . . . . . . . . 250 Considerations for Transrectal Specimen Extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252

Abstract

For patients with tumors located at the splenic flexure or left transverse colon, specimen extraction through the sigmoid colon is often difficult because the tumor is located far from the anus. For such patients, specimen extraction can be performed after opening the rectum. The main operating features of this procedure include complete dissection and resection of the left colon in the abdominal cavity, specimen H. Chen · Z. Zheng Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China X. Wang (*) Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China © People’s Medical Publishing House, PR of China 2023 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-99-2750-0_17

extraction from a longitudinal incision in the upper rectum, totally laparoscopic side-to-side anastomosis between the transverse colon and sigmoid colon, and closing the incision of the upper rectum. The approach for specimen extraction from the rectum can avoid auxiliary incision in the abdominal wall and only leaves a few tiny trocar scars on the abdominal wall after the surgery. The operating difficulties of this procedure mainly involve laparoscopic technical difficulties and the challenges of NOSES. Specifically, the laparoscopic technical difficulties include the complete mesocolon resection of the left colon, dissection of lymph nodes at the root of the mesentery, and the mobilization of the splenic flexure. The NOSES technical difficulties include the specimen extraction after opening the rectum, totally laparoscopic digestive tract reconstruction, and

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application of aseptic and tumor-free operation. These are the challenges the surgeons need to face and overcome.

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2. The circumferential diameter of the tumor is preferably less than 3 cm. 3. The tumor should not invade beyond the serosa.

Keywords

Laparoscopic surgery · Natural Orifice Specimen Extraction · NOSES · Transrectal · Left hemicolectomy

Indications and Contraindications of NOSES Indications 1. Tumor is located at the splenic flexure and transverse colon near the splenic flexure (Figs. 17.1, 17.2, and 17.3).

Contraindications 1. The circumferential diameter of tumor is more than 3 cm. 2. Tumor invades beyond the serosa. 3. Severely obese patients (BMI > 35 kg/m2).

Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position Anesthesia Method General anesthesia or general epidural anesthesia.

Patient Positioning The patient is placed in functional lithotomy position, with the right thigh slightly flattened, which facilitates to perform the operation for the surgeon (Fig. 17.4).

Trocar Placement

Fig. 17.1 Extent of surgical resection

1. Camera trocar (10 mm trocar) is located 2–3 cm below the umbilicus. 2. The surgeon’s main trocar (12 mm trocar) is located at the McBurney’s point. 3. The surgeon’s auxiliary trocar (5 mm trocar) is located at the intersection of 10 cm above the umbilicus and the lateral edge of the right rectus abdominis. 4. The assistant’s main trocar (5 mm trocar) is located at the intersection of 10 cm above the umbilicus and the anterior axillary line. 5. The assistant’s auxiliary trocar (5 mm trocar) is located opposite the McBurney’s point, which facilitates to place the drainage tube (Fig. 17.5).

Surgical Team Position

Fig. 17.2 Colonoscopy

During the left hemicolectomy, the surgeon stands on the right side of the patient, the assistant stands on the left side of the patient, and the camera holder stands between two legs of the patient. During digestive tract reconstruction and specimen extraction, the camera holder stands on the same side of the surgeon (Figs. 17.6 and 17.7).

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Fig. 17.3 CT virtual endoscopy: The tumor is located at the splenic flexure

Special Surgical Instruments

Exploration and Surgical Planning

Ultrasonic scalpel, 60 mm linear Endo-GIA stapler, barbed suture, and sterile protective sleeve.

Based on the adequate preoperative examination and surgical plan discussion, the exploration mainly includes three steps:

General Exploration

Surgical Procedure, Techniques, and Key Points After the laparoscope is placed into the umbilical port, the The schematic view of the main surgical procedures of specimen extraction and digestive reconstruction in NOSES VIB (Fig. 17.8).

liver, gallbladder, stomach, spleen, colon, small intestine, greater omentum, and pelvic cavity are routinely examined for the presence of tumor seeding or ascites (Figs. 17.9 and 17.10).

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Fig. 17.4 The patient’s position

Surgeon’s Auxiliary Trocar (5 mm)

Camera Trocar (10 mm)

Surgeon’s Main Trocar (12 mm)

Assistant’s Main Trocar (5 mm)

Assistant’s Auxiliary Trocar (5 mm)

Fig. 17.5 Trocar placement (five-ports method)

Fig. 17.7 Surgical team position (specimen extraction and digestive tract reconstruction)

Tumor Exploration The tumor is located at the splenic flexure or transverse colon near the splenic flexure. The tumor size should be determined. The surgeon should also evaluate the feasibility of transrectal specimen extraction (Fig. 17.11).

Fig. 17.6 Surgical team position (left hemicolectomy)

Evaluation of Anatomical Structures First, evaluate the anatomic structure of colon and mesocolon, i.e., whether the length of the dissected bowel and

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Fig. 17.8 The main surgical procedures of specimen extraction and digestive reconstruction in NOSES VIB

the course of the marginal vessels facilitate the anastomosis; second, evaluate whether the thickness of mesentery and the circumferential diameter of the tumor facilitate the transrectal specimen extraction.

Dissection and Separation Management of the Root of the Inferior Mesenteric Vessels The Treitz ligament and inferior mesenteric vein are exposed (Fig. 17.12). The surgeon applies the ultrasonic scalpel to open the retroperitoneum at the root of the inferior mesenteric artery (Fig. 17.13) and incise the retroperitoneum toward the Treitz ligament along the lateral side of the abdominal aorta. The dissection is continued with caution to enter the space anterior to Toldt’s fascia (Fig. 17.14). Then space above, below, and to the left of the root of the inferior mesenteric artery is extended. Subsequently, the root of the inferior mesenteric artery is exposed to isolate the left colic artery.

The station 253 lymph nodes are dissected while preserving the sigmoid artery and superior rectal artery (Fig. 17.15), then the left colic artery is double ligated and transected (Fig. 17.16). Attention should be paid to protect the nerves. After that, dissection is continued upward to the lateral side of the Treitz ligament. The inferior mesenteric vein is isolated to the inferior border of the pancreas, and the surrounding lymphatic tissue is removed (Fig. 17.17). Following this, the left colic vein is isolated, ligated, and transected (Fig. 17.18). The surgical field after dissection of lymph nodes with preservation of the superior mesenteric vein is shown as follows (Fig. 17.19).

Dissection of Left Mesocolon with Medial Approach The surgeon lifts the left mesocolon and applies the ultrasonic scalpel to perform sharp and blunt dissection along the Toldt’s fascia downward and upward in a medial to lateral fashion (Fig. 17.20). The course and peristalsis of the left ureter can be observed. For the medial side, the surface of the

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Fig. 17.9 Exploration of the liver and stomach Fig. 17.12 Exposure mesenteric vein

of

the

Treitz

ligament

and

inferior

Fig. 17.10 Exploration of the pelvic cavity

Fig. 17.13 The first point of the incision

Fig. 17.11 Exploration of the tumor location

left adipose capsule of the kidney is adequately dissected (Fig. 17.21). Dissection is continued along the surface of the pancreas while paying attention to protect the pancreas to avoid postoperative pancreatic leak. Subsequently, dissection proceeds along with the space upward to the left to the tail of the pancreas (Figs. 17.22 and 17.23). A small gauze is placed lateral to the mesentery after adequate dissection (Fig. 17.24).

Fig. 17.14 Entering the space anterior to Toldt’s fascia

Management of the Left Transverse Colon and Splenic Flexure In this procedure, whether to preserve the greater omentum should be determined by whether the tumor invades beyond the serosa. The surgeon applies the ultrasonic scalpel to dissect the middle of the transverse colon to the left to

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Fig. 17.15 Isolation of the left colic artery, preservation of the sigmoid artery and superior rectal artery, and dissection of station 253 lymph nodes

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Fig. 17.18 Isolation of the left colic vein, and ligation and transection of the left colic vein

Fig. 17.19 Surgical field after dissection of lymph nodes with preservation of the superior mesenteric vein Fig. 17.16 Double ligation and transection of the left colic artery

Fig. 17.17 Isolation of the inferior mesenteric vein to the inferior border of the pancreas, and dissection of the surrounding lymphatic tissue

transect the attachment of the greater omentum (Fig. 17.25) until the lower pole of the spleen and the peritoneum lateral to the splenic flexure are exposed. At this point, the omental

Fig. 17.20 Dissection of mesentery along the Toldt’s fascia from medial to lateral

bursa is entered (Fig. 17.26). After that, the greater omentum is flipped upward, the adhesions between the stomach and the transverse mesocolon are detached, and dissection is continued to the left to the lower pole of the spleen (Fig. 17.27). The

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Fig. 17.21 Dissection of mesentery upward along the Toldt’s fascia

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Fig. 17.24 Placing small gauze lateral to the mesentery

Fig. 17.25 Detachment of transverse colon from the greater omentum Fig. 17.22 Dissection along the surface of the pancreas

Fig. 17.26 Entering the omental bursa Fig. 17.23 Dissection along the space upward to the left to the tail of the pancreas

operation must be performed gently to avoid secondary damage to the spleen. At this point, the course of the pancreas is clearly visible, which is an important anatomic landmark. As the transverse colon is lifted, the surgeon transects the transverse mesocolon from the inferior mesenteric vein stump,

which lies lateral to the Treitz ligament, to give direct access to the omental bursa (Fig. 17.28). Then the dissection proceeds to the left to the lower pole of the spleen along the inferior border of the pancreas (Fig. 17.29).

Dissection of the Left Paracolic Sulcus The sigmoid colon is pulled to the right while the left side of the rectum is dissected upward along the Toldt’s fascia

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Fig. 17.27 Dissection toward the spleen

Fig. 17.28 Transection of the transverse mesocolon from the inferior mesenteric vein stump which lies lateral to the Treitz ligament

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Fig. 17.30 Open the left paracolic sulcus

Fig. 17.31 Dissection to the lower pole of spleen along the left paracolic sulcus

(Fig. 17.31). At this time, the dissection of the left colon is completed.

Management of the Sigmoid Mesocolon The extent of resection below the tumor is assessed, and the intended distal resection line of the tumor is better at the middle sigmoid colon. The surgeon lifts the sigmoid mesocolon, divides along the intended resection line to the marginal arteries, and then ligates and transects the marginal vessels (Fig. 17.32). Dissection is continued to the bowel wall, and 2 cm of the bowel is isolated (Fig. 17.33).

Fig. 17.29 Dissection to the left to the lower pole of spleen along the inferior boarder of the pancreas

(Fig. 17.30). The left paracolic sulcus is incised upward to the lower pole of the spleen as indicated by the gauze

Dividing the Mesocolon Above the Tumor and Isolating the Bowel The splenic flexure is pulled downward for the evaluation of the intended resection line. The transverse mesocolon is divided, and the marginal vessels are ligated and transected (Fig. 17.34). Dissection is continued to the bowel wall, and 2 cm of the bowel is isolated (Fig. 17.35).

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Fig. 17.32 Ligation and transection of marginal vessels of the sigmoid colon

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Fig. 17.34 Ligation of marginal vessels of the transverse colon

Fig. 17.35 Isolation of transverse colon Fig. 17.33 Isolation of wall of the sigmoid colon

Specimen Resection and Digestive Tract Reconstruction Specimen Resection The surgeon transects the bowel at the intended resection line of the transverse colon with a linear Endo-GIA stapler (Fig. 17.36). The proximal bowel stump is flipped to the right lower abdomen, and the left paracolic sulcus and spleen are exposed. The blood supply line is clearly visible in the isolated area of the sigmoid colon, and the sigmoid colon is transected below the blood supply line with a linear EndoGIA stapler (Fig. 17.37). At this point, the left hemicolectomy is completed, and the specimen is placed in the left upper abdomen.

Fig. 17.36 Transection of the transverse colon

Digestive Tract Reconstruction (Isoperistaltic SideTo-Side Anastomosis) The transverse colon is straightened, and the sigmoid colon is pulled up to the upper abdomen to overlap with the transverse colon (Fig. 17.38). Perform suture of the transverse colon stump with the bowel 8 cm from the sigmoid colon stump

(Fig. 17.39). Double check the blood supply of the two sides of the bowel and estimate the tension of the anastomosis. The transverse colon wall and sigmoid colon stump are opened with two incisions (1 cm for each) close to staple lines on the antimesenteric border (Figs. 17.40 and 17.41), and both bowel lumens are disinfected with iodoform gauze. The

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Fig. 17.37 Transection of the sigmoid colon Fig. 17.40 Making an incision of 1 cm long on the sigmoid colon stump

Fig. 17.38 Overlapping of the sigmoid colon with transverse colon Fig. 17.41 Making an incision of 1 cm long on the corresponding antimesenteric side of the transverse colon

Fig. 17.39 Suture of the transverse colon stump with the bowel 8 cm from the sigmoid colon stump

Fig. 17.42 Insertion of linear Endo-GIA stapler into the sigmoid colon

linear Endo-GIA stapler is introduced through the surgeon’s main trocar, where afterward the cartridge jaw and the anvil jaw are inserted into the two bowel lumens separately. With

the necessary adjustment, the stapler is fired to complete the side-to-side anastomosis between the transverse colon and sigmoid colon (Figs. 17.42, 17.43, and 17.44).

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Fig. 17.43 Insertion of linear Endo-GIA stapler into the two sides of the bowel

Fig. 17.46 Closing the common opening of the two sides of the bowel

Fig. 17.44 Completion of side-to-side anastomosis between the sigmoid colon and transverse colon

Fig. 17.47 Digestive tract reconstruction with an isoperistaltic side-toside anastomosis

and the middle of the enterotomies, respectively (Fig. 17.45). The surgeon and assistant grasp the tail of traction sutures of the two sides to keep the bowel wall straight and close the enterotomies with linear Endo-GIA stapler. Digestive tract reconstruction with isoperistaltic side-to-side anastomosis is completed (Figs. 17.46 and 17.47). Eight-figure suture is performed for the reinforcement of anastomosis (Fig. 17.48).

Fig. 17.45 Suture each end of the common opening of bowel stump with one stitch

The bowel lumen is disinfected with iodoform gauze, and the integrity of the anastomosis is confirmed. After excluding anastomotic leakage, traction sutures are fixed in both ends

Specimen Extraction The assistant injects dilute iodine solution through the anus for irrigation and places an iodoform gauze through the anus. The surgeon then opens the rectal wall at the site of the iodoform gauze by making an incision of approximately 5 cm longitudinally on the upper rectum (Fig. 17.49). The protective sleeve is inserted through the 12 mm trocar (Fig. 17.50), then the second assistant applies the oval forceps through the incision in the upper rectum to pull the end of the protective sleeve out through the anus (Figs. 17.51 and 17.52). All the used gauzes in the abdominal cavity are

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Fig. 17.48 8-Figure suture for the reinforcement of anastomosis Fig. 17.51 Placement of oval forceps into the abdominal cavity through the incision on the rectum

Fig. 17.49 Longitudinal incision on the upper rectum figure suture is performed for the reinforcement of anastomosis (Fig. 17.48) Fig. 17.52 Pulling the end of the protective sleeve out through the rectum and anus

Fig. 17.50 Insertion of the protective sleeve through the trocar Fig. 17.53 Insertion of oval forceps with the protective sleeve

placed into the protective sleeve and removed through it. One end of the specimen is smoothly placed into the protective sleeve with the cooperation between the surgeon and the assistant. The assistant applies the oval forceps to clamp the end of the specimen (Figs. 17.53 and 17.54) and slowly pulls the specimen out of the rectum and anus. The inner opening

of the sleeve is tightened, and the sleeve is pulled out along with the specimen (Fig. 17.55). The assistant wipes the bowel lumen with iodoform gauze as the surgeon confirms that there is no active bleeding. Continuous suture is performed longitudinally to close the

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Fig. 17.54 Clamping one end of the bowel with oval forceps Fig. 17.57 Continuous seromuscular layer embedding of incision on the rectum

Fig. 17.55 Specimen extraction

Fig. 17.58 Rectal incision in colonoscopy

Fig. 17.56 Full-thickness continuous suture of incision on the rectum

incision on the rectum under laparoscopy (Fig. 17.56), followed by seromuscular layer embedding (Fig. 17.57). The rectal incision was checked again by colonoscopy (Fig. 17.58). The abdominal cavity is irrigated with distilled water (Fig. 17.59), and the drainage tube is indwelled in the abdominal cavity (Fig. 17.60). Pneumoperitoneum is released, and the trocar sites are closed.

Fig. 17.59 Irrigation of abdominal cavity

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Fig. 17.60 Placing a drainage tube in the abdominal cavity

Fig. 17.62 Picture of the abdominal wall after operation

Fig. 17.61 Specimen display

Postoperative Recovery and Specimen Display See Figs. 17.61, 17.62, and 17.63.

Key Points, Difficulties, and Hot Spots Related to Surgery

Fig. 17.63 Rectal incision in colonoscopy, 3 months after surgery (Hu Xiyue, Haipeng Chen, Zhaoxu Zheng, and Xishan Wang)

Dissection and Anatomy of the Splenic Flexure The low morbidity of left colon cancer resulting in less cases of left hemicolectomy (Kim et al. 2010; Fiscon et al. 2015), which is also quite difficult to be performed. In the NOSES, except for the digestive tract reconstruction and specimen extraction, other procedures of the laparoscopic left hemicolectomy are the same as those of the conventional laparoscopic surgery. Therefore, splenic flexure mobilization can be particularly challenging in this procedure as well. Factors contributing to the difficulties in the mobilization of splenic flexure include deep anatomic location, fragile tissue, risk of bleeding which is difficult to control, and complex

relations with adjacent organs. The anterosuperior hilum of the spleen connects to the fundus of the stomach by the gastric surface, and the posteroinferior is adjacent to the left adrenal, left kidney, the tail of the pancreas, and splenic flexure by the colonic surface, pancreatic surface, and renal surface, respectively. At present, the mobilization of the splenic flexure involves the following approaches: (1) open the gastrocolic ligament and gradually dissect to the left to mobilize the splenic flexure; (2) dissect along the left paracolic sulcus upward to the splenic flexure; (3) alternately perform the dissection in the above two ways from the peripheral to the center of the

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splenic flexure; and (4) dissect the connective tissue between the greater omentum and transverse colon from the middle of the transverse colon to the left to the splenic flexure with the greater omentum preserved. Surgeons can select these four approaches according to their different operating habits. Most splenic injuries are caused by inappropriate traction during surgical manipulation (Mangano et al. 2018). Therefore, the spleen should be adequately exposed during operation to avoid excessive traction and bleeding.

The Concept of Complete Mesocolic Resection of the Left Colon Cancer Like the right colon, after embryonic midgut rotation, the posterior lobe of the left mesocolon fuses with the peritoneal membrane to form the Toldt’s fascia, and a visceral fascia wraps up the entire mesocolon like an envelope. The left mesocolon covers the sigmoid colon, descending colon to the posterior of the pancreas. Blood vessels and lymph nodes in the mesocolon are enveloped by the visceral fascia, which converge on the root of blood vessels. During the dissection of the left colon, mesenteric damage may lead to tumor cell dissemination and tumor tissue residue. In addition, if the dissection plane is too superficial, the principle of en bloc resection cannot be met and the mesenteric blood vessels may be damaged, which is prone to cause bleeding and other complications. If the dissection plane is too deep that violates the anterior lobe of the left renal fascia, the left ureter and gonadal vessels are prone to be damaged. Therefore, in the radical resection of left colon cancer, the key operating points of complete mesocolic resection should be mastered as well, which is extremely important for the radical resection of the tumor.

Key Points, Difficulties, and Hot Spots Related to Surgery Total Laparoscopic Digestive Tract Reconstruction After Laparoscopic Left Hemicolectomy We completed total laparoscopic left hemicolectomy while ensuring that the bowel resection margins on both sides of the tumor were adequate. Mobilization of the transverse colon is performed only to a limited extent; thus, excessively high bowel tension must be avoided after digestive tract reconstruction, and careful selection of laparoscopic methods for transverse colon-rectum anastomosis is of particular importance. For patients with high-lying tumors in whom transanal stapler insertion precludes the creation of a circular anastomosis under laparoscopy, a functional side-to-side

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anastomosis can be created between the transverse colon and the rectum under total laparoscopy. This method of anastomosis involves placing two bowel segments with the same direction of peristalsis beside each other, transecting and closing them, and subsequently closing the common opening. This method helps conserve the bowel and is suitable for cases where transanal anastomosis is challenging because relatively short segments of the bowel are intended for anastomosis, which can affect the subsequent bowel tension. The bowel segments intended for anastomosis can be placed parallel to each other, and the postanastomosis tension is evaluated before the segments are secured together using absorbable sutures to reduce this tension. The bowel wall is incised on the antimesenteric side, and the assistant promptly removes any contaminants within the incision using an aspirator to minimize the risk of contaminating the abdominal cavity. After completing laparoscopic side-to-side anastomosis, it is necessary to open the lumen to check for active bleeding and anastomotic stenosis. When closing the common opening, traction can be gained by placing a stitch at each end to ensure that the stumps of the common opening are on the same horizontal level, which will guarantee the effectiveness of the anastomosis. After functional side-toside anastomosis is achieved, the anastomotic “dog ear” is reinforced using an additional suture.

Considerations for Transrectal Specimen Extraction For many years, colorectal surgeons in China and abroad have abided by a long-standing “consensus” regarding longitudinal incisions and transverse sutures on the digestive tract. It is believed that this suture method can ensure patency of the digestive tract and minimize the risk of stenosis. However, at the time of writing, no clinical or basic studies have supported the accuracy of this claim. After an incision is made on the bowel wall, regardless of whether longitudinal incisions and longitudinal sutures or longitudinal incisions and transverse sutures are used, suture healing in all cases must still follow the general pattern of wound healing. In other words, it must undergo three stages: acute inflammation, proliferation, and remodeling. Among the organs in the human digestive tract, the small intestine has the smallest lumen diameter; thus, if a suture method does not affect the patency of the small intestine, it can safely be used in the colon and rectum, which have larger lumen diameters. To compare the advantages and disadvantages of longitudinal incisions and longitudinal sutures with those of longitudinal incisions and transverse sutures, we previously conducted surgical interventions in canine small intestines and investigated the effects of incision and suture methods on intestinal volume, luminal circumference, scar scores, and so

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Fig. 17.64 (a) Longitudinal incision and longitudinal sutures of the colon wall during laparotomy; (b) direct visualization of the previous longitudinal suture wound during the second operation for the second primary tumor; (c) micrograph of a canine small intestinal wall

on. We also observed the postoperative scars at the incision point on patients’ intestinal walls and compared the effects of different suture methods on the healing of the small intestinal wall in Chinese rural dogs. Our findings revealed that scars at the site of wound healing were smaller when longitudinal incisions and longitudinal sutures (Fig. 17.64a, b) were used compared to longitudinal incisions and transverse sutures. In addition, microscopic observations indicated that longitudinal incisions and longitudinal sutures were more advantageous for the three stages of wound healing compared to longitudinal incisions and transverse sutures. More specifically, intestinal walls with longitudinal incisions and longitudinal sutures showed milder acute inflammation, more neatly arranged submucosal collagen fibers, and a smaller scar volume (Fig. 17.64c, d). Thus, longitudinal incisions and longitudinal sutures are more conducive to anastomotic healing. Furthermore, we observed that although longitudinal incisions and transverse sutures increased the luminal

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following longitudinal suturing (40 magnification); (d) micrograph of a canine small intestinal wall following transverse suturing (40 magnification)

Fig. 17.65 Longitudinal suture wound from the previous operation after surgery for the second primary tumor

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Fig. 17.66 Laparoscopic view of the longitudinal incision, specimen extraction, and longitudinal suture of the sigmoid colon wall. Colonoscopic image of the suture 1 month postsurgery

circumference, this suture method did not increase intestinal volume. Thus, given that longitudinal incisions and transverse sutures do not increase intestinal volume nor do longitudinal incisions and longitudinal sutures cause luminal stenosis, it is more rational when suturing the colon and rectal walls (which have larger lumens than that of the small intestine) to choose longitudinal incisions and longitudinal sutures (which can promote healing and are more suited to the physiological structure of tissues). Factors affecting the healing of the bowel wall include patient and surgical factors. The patient’s systemic metabolism and nutritional status can affect the healing process, while the local blood supply, inflammatory response, and edema level of the bowel wall may determine the final outcome of healing. In terms of surgical operations, successful sutures are required to ensure adequate blood supply, tensionfree alignment, and maximum preservation of normal bowel peristalsis and secretory function. We believe that longitudinal incisions and longitudinal sutures on the bowel wall are more effective for blood supply provision to the sutures, reducing the tension of the sutures and preserving the innervation of the bowel wall. Thus, this method facilitates wound healing and functional recovery. We incised a postoperative specimen from a patient with colon cancer relapse in order to observe an old scar from a previous surgery, wherein a

longitudinal incision was made and longitudinal sutures were performed. Comparison of the bowel at the point of incision and suture with the surrounding bowel revealed no differences in luminal diameter and no significant stenosis (Fig. 17.65). The postoperative specimen and colonoscopic findings of the patient with longitudinal incision and longitudinal sutures also showed that the incision healed well with no scarring, and the bowel lumen was patent with no significant changes in diameter (Fig. 17.66). Therefore, the longitudinal incision and longitudinal suture method for the anterior rectal wall is safe and reliable, can maximize the recovery of the digestive tract, and is more conducive to healing. Technical mastery of the longitudinal incision and longitudinal suture method will ensure that issues such as luminal stenosis do not occur.

References Fiscon V, et al. Splenic flexure colon cancers: minimally invasive treatment. Updat Surg. 2015;67:55–9. Kim CW, et al. Clinicopathologic characteristics, surgical treatment and outcomes for splenic flexure colon cancer. Cancer Res Treat. 2010;42:69–76. Mangano A, et al. Iatrogenic spleen injury during minimally invasive left colonic flexure mobilization: the quest for evidence-based results. Minerva Chir. 2018;73(5):512–9.

Laparoscopic Left Hemicolectomy with Transvaginal Specimen Extraction (CRC-NOSES VII)

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Xishan Wang, Zheng Liu, and Zhao Lu

Contents Indications and Contraindications of NOSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254 Indications (Figs. 18.1, 18.2, and 18.3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254 Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254 Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . Anesthesia Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Patient Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trocar Placement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Special Surgical Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Surgical Procedure, Techniques, and Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Exploration and Surgical Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dissection and Separation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Specimen Resection and Digestive Tract Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postoperative Abdominal Wall and Specimen Display . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Key Points, Difficulties, and Hot Spots Related to Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263 Selection and Suture of the Incision of Posterior Vaginal Fornix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267

Abstract

NOSES VII is mainly applicable to female patients with larger tumors located at the left-sided colon. The main operating features of this procedure include totally laparoscopic dissection and transection of the left colon, specimen extraction from the vagina, and totally laparoscopic end-to-end anastomosis between the transverse colon and rectum. Compared with NOSES VI, this procedure has a broader indication because the specimen extraction from the vagina is easier to be performed; however, the vaginal incision should be sutured X. Wang (*) · Z. Liu Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China

properly. The operating difficulties of NOSES VII mainly involve laparoscopic technical difficulties and the challenges of NOSES. Specifically, the laparoscopic technical difficulties include the complete mesocolon excision of left-sided colon, dissection of lymph nodes at the root of mesenteric vessels, and the mobilization of the splenic flexure. The NOSES technical difficulties include the transvaginal specimen extraction, totally laparoscopic digestive tract reconstruction, the suturing of vaginal incision, the strict maintenance of aseptic and tumor-free operation, etc. Keywords

NOSES VII · Laparoscopic left hemicolectomy · Transvaginal specimen extraction · Complete mesocolon excision · Totally laparoscopic digestive tract

Z. Lu Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China © People’s Medical Publishing House, PR of China 2023 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-99-2750-0_18

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reconstruction · Suture of vaginal incision · Maintenance of aseptic and tumor-free operation

Indications and Contraindications of NOSES

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Patient Positioning The patient is placed in functional lithotomy position, with the right thigh slightly flattened, which facilitates to perform the operation for the surgeon (Fig. 18.4).

Indications (Figs. 18.1, 18.2, and 18.3) Trocar Placement 1. The tumor is located at the descending colon, the junction between the descending colon and sigmoid colon, or proximal sigmoid colon. 2. The circumferential diameter of the tumor is preferably less than 5 cm. 3. The tumor should not invade beyond the serosa.

1. Camera trocar (10 mm trocar) is located 2–3 cm below the umbilicus.

Contraindications 1. The tumor is located at the splenic flexure or the left transverse colon. 2. The circumferential diameter of tumor is more than 5 cm. 3. Tumor invades beyond the serosa. 4. Severely obese patients (BMI > 35 kg/m2).

Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position Anesthesia Method General anesthesia or general epidural anesthesia.

Fig. 18.1 Extent of surgical resection

Fig. 18.2 Colonoscopy: tumor of ulcerated type, 33 cm from the dentate line, and maximum diameter of 5 cm

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Fig. 18.3 (a–c) CT virtual endoscopy: The tumor is located at the junction between the descending colon and sigmoid colon, involving one-half of the rectal circumference

2. The surgeon’s main trocar (12 mm trocar) is located at the McBurney’s point. 3. The surgeon’s auxiliary trocar (5 mm trocar) is located at the intersection of 10 cm above the level of the umbilicus and the lateral edge of the right rectus abdominis. 4. The assistant’s main trocar (5 mm trocar) is located at the intersection of 10 cm above the level of the umbilicus and the left midclavicular line. 5. The assistant’s auxiliary trocar (5 mm trocar) is located opposite the McBurney’s point (Fig. 18.5).

Surgical Team Position The surgeon stands on the right side of the patient, and the assistant stands on the left side of the patient. During the mobilization of the splenic flexure, the assistant moves to stand between two legs of the patient. During digestive tract reconstruction and specimen extraction, the assistant returns to the left side of the patient. The camera holder stands on the same side of the surgeon (Figs. 18.6, 18.7, and 18.8).

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Fig. 18.4 The patient’s position

Special Surgical Instruments

Surgeon’s AuxiliaryTrocar (5 mm)

CameraTrocar (10 mm)

Assistant’s Main Trocar (5 mm)

Ultrasonic scalpel, 60 mm linear Endo-GIA stapler, 29 mm circular stapler, vaginal suture line, uterine manipulator, and sterile protective sleeve.

Surgical Procedure, Techniques, and Key Points Surgeon’s Main Trocar (12 mm)

Assistant’s Auxiliary Trocar (5 mm)

The schematic view of the main surgical procedures of specimen extraction and digestive reconstruction in NOSES VII (Fig. 18.9).

Fig. 18.5 Trocar placement (five-port method)

Exploration and Surgical Planning Based on the adequate preoperative examination and surgical plan discussion, the exploration mainly includes three steps:

General Exploration After the laparoscope is placed into the umbilical port, the liver, gallbladder, stomach, spleen, colon, small intestine, greater omentum, and pelvic cavity are routinely examined for the presence of tumor seeding or ascites (Figs. 18.10 and 18.11). Tumor Exploration The tumor is located at the descending colon or the junction between the descending colon and sigmoid colon. The size of the tumor and the feasibility of transvaginal specimen extraction should be evaluated by the surgeon (Fig. 18.12).

Fig. 18.6 Surgical team position (before the mobilization of splenic flexure)

Evaluation of Anatomical Structures 1. Evaluate the anatomical structure of the colon, i.e., the length of the pulled down transverse colon after the

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Fig. 18.7 Surgical team position (mobilization of splenic flexure)

dissection of the splenic flexure. Evaluate the feasibility of laparoscopic anastomosis based on the status of mesenteric marginal vessels. 2. Perform digital vaginal examination to determine whether the status of the posterior vaginal fornix is suitable for incision and specimen extraction.

Dissection and Separation Management of the Root of the Inferior Mesenteric Vessels To completely expose the operative field, the patient should be tilted into the Trendelenburg position. The surgeon lifts the root of the inferior mesenteric artery and dissects along the lateral side of the abdominal aorta upward to open the posterior peritoneum (Fig. 18.13). Ultrasonic scalpel is applied to dissect along the Toldt’s fascia (Figs. 18.14 and 18.15), and expand the space above, below, and to the left of the inferior mesenteric artery (Fig. 18.16). Double ligation and transection of the inferior mesenteric artery are performed (Fig. 18.17). The assistant lifts the stump of the inferior mesenteric artery, and the surgeon continues to dissect from medial to lateral. The lateral side of the abdominal aorta is dissected upward to the Treitz ligament, then the inferior mesenteric vein is transected and ligated at the inferior border of the pancreas (Figs. 18.18 and 18.19). Dissection of Left Mesocolon with Medial Approach The inferior mesenteric vessel stumps are lifted, and dissection is performed along the Toldt’s fascia downward and upward in a medial to lateral fashion (Figs. 18.20 and 18.21). The course and peristalsis of the left ureter as well

Fig. 18.8 Surgical team position (specimen extraction and digestive tract reconstruction)

as the course of the left gonadal vessels can be identified, as well as the left adipose capsule of the kidney. Dissection is continued along the inferior border of the pancreas from medial to lateral, and the dissection plane should be smooth, flat, and clean.

Management of the Sigmoid Mesocolon and Mesorectum Assess the extent of resection below the tumor. The intended distal resection line is better located at the junction between the rectum and sigmoid colon or the upper segment of the rectum. Dissection is performed downward to the sacral promontory along the course of the inferior mesenteric artery, then the sigmoid mesocolon or mesorectum is transected (Fig. 18.22). The distal superior rectal vessels are better ligated with vascular clips (Fig. 18.23). The mesentery is divided into the wall of the sigmoid colon. After 2 cm of the bowel wall is isolated, the sigmoid colon is transected with a linear Endo-GIA stapler (Figs. 18.24 and 18.25), and iodoform gauze is used to disinfect the stump of the sigmoid colon (Fig. 18.26). Management of the Left Transverse Colon and Splenic Flexure The surgical team repositions for the next phase of the operation, i.e., splenic flexure and distal transverse colon mobilization. Start from the middle of the transverse colon; the greater omentum is separated along the colic band to the left (Fig. 18.27). Dissection is performed from the attachment of the greater omentum to the splenic flexure (Fig. 18.28).

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Fig. 18.9 The main surgical procedures of specimen extraction and digestive reconstruction in NOSES VII

Fig. 18.10 Exploration of the spleen

Fig. 18.11 Exploration of the greater omentum

When the dissection continues to the lower pole of the spleen, the peritoneum lateral to the splenic flexure is visible. After the omental bursa is entered, the greater omentum can be turned cephalad to expose the course of the pancreas. A gauze is placed from the inferior boarder of the pancreas to

the lower pole of the spleen (Fig. 18.29). The transverse colon is lifted to expose the transverse mesocolon. From the inferior mesenteric vein stump, which lies lateral to the Treitz ligament, the transverse mesocolon is divided into the bowel wall (Figs. 18.30, 18.31, and 18.32). With the indication and

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Fig. 18.12 Exploration of the tumor location (marked with methylthioninium chloride preoperatively)

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Fig. 18.15 Entering the space anterior to Toldt’s fascia

Fig. 18.16 Isolation of the inferior mesenteric artery Fig. 18.13 Exposure of the inferior mesenteric vein

Fig. 18.17 Ligation and transection of the inferior mesenteric artery Fig. 18.14 The first point of the incision

protection of gauze, dissection is continued along the inferior border of the pancreas and toward the left paracolic sulcus.

Opening the Left Lateral Paracolic Sulcus The sigmoid colon or upper rectal stump is pulled to the right to facilitate the detachment of the lateral adhesion. With the indication of the gauze, dissection is continued cephalad to open the paracolic sulcus (Fig. 18.33), and finally toward the lower pole of the spleen and the tail of the pancreas

(Figs. 18.34 and 18.35). At this point, the dissection of the left colon is completed.

Dividing and Isolating the Mesocolon Above the Tumor The left colon is pulled down to the pelvic cavity for the evaluation of the intended resection line. The mesentery is further divided into the bowel wall, and the marginal vessels within are ligated and transected. The transverse colon wall should be isolated for approximately 2 cm (Fig. 18.36).

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Fig. 18.18 Exposure of the inferior border of pancreas and the inferior mesenteric vein

Fig. 18.21 Placing small gauze underneath the mesentery

Fig. 18.19 Ligation of the inferior mesenteric vein

Fig. 18.22 Dividing the sigmoid mesocolon

Fig. 18.20 Dissection of mesentery along the Toldt’s fascia from medial to lateral

Fig. 18.23 Ligation of the superior rectal artery

Specimen Resection and Digestive Tract Reconstruction Specimen Resection The surgeon inserts the protective sleeve into the pelvic cavity through the main trocar (Fig. 18.37). After the vaginal irrigation, the assistant introduces the bladder retractor through the vagina to indicate the posterior vaginal fornix (Fig. 18.38). The surgeon uses the ultrasonic scalpel to make

a 3–cm transverse incision on the posterior vaginal fornix and extends the incision to 5–6 cm by longitudinal stretch (Fig. 18.39). The assistant inserts the oval forceps through the vagina to pull the distal end of the protective sleeve out of the body. Subsequently, the anvil is introduced into the abdominal cavity through the protective sleeve (Fig. 18.40). A small longitudinal incision is made in the bowel wall between the tumor and the proximal intended resection line. Through the incision, the surgeon inserts iodoform gauze into the colon lumen for disinfection and lubrication (Figs. 18.41

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Fig. 18.24 Isolation of wall of the sigmoid colon

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Fig. 18.27 Separation of the transverse colon from the greater omentum

Fig. 18.28 Dissection to the left to the lower pole of the spleen Fig. 18.25 Transection of the bowel of the sigmoid colon

Fig. 18.26 Disinfection of stump with iodoform gauze

and 18.42), and the assistant applies the suction to push the iodoform gauze into the distal bowel lumen of the incision. Then, the anvil is placed in the proximal bowel lumen through the incision (Fig. 18.43), and the proximal bowel is transected with the linear Endo-GIA stapler (Fig. 18.44). At this point, the left colon is completely resected, and the anvil is left in the proximal bowel stump. Assistant applies the oval forceps to clamp one end of the specimen to slowly pull out the specimen through the vagina (Fig. 18.45).

Fig. 18.29 Indication and protection of the gauze

Digestive Tract Reconstruction The anvil shaft is protruded from one corner of the proximal colon stump (Fig. 18.46). The assistant inserts a circular stapler through the anus and rectum and extends the trocar to pierce the rectal stump from one side of the staple line (Fig. 18.47) to complete the end-to-end anastomosis between colon and rectum (Fig. 18.48). The integrity of the anastomotic ring is checked before the 8-Figure suture is performed on the “danger triangle of the anastomosis” (Fig. 18.49). Air leak test is performed to confirm the integrity of the

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Fig. 18.30 Dissection upward to the inferior border of the pancreas

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Fig. 18.33 Open the left paracolic sulcus

Fig. 18.34 Dissection along the left paracolic sulcus Fig. 18.31 Dividing the transverse mesocolon

Fig. 18.35 Dissection to the lower pole of the spleen Fig. 18.32 Ligation of marginal vessels

anastomosis (Fig. 18.50). After irrigating the abdominal cavity, two drainage tubes are placed through the trocars on the abdominal wall (Fig. 18.51).

Closure of Trocar and Suture of Vaginal Incision After the drainage tubes are in place, intraperitoneal gas is expelled and the trocar sites are closed. The vaginal incision can be sutured under laparoscopy or by extracorporeal suture. The steps of the extracorporeal suture are the

following: Fully expose the vaginal incision, lift the anterior and posterior wall of the incision with two Allis forceps, and perform interrupted suture with absorbable sutures (Fig. 18.52).

Postoperative Abdominal Wall and Specimen Display See Figs. 18.53 and 18.54.

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Fig. 18.36 Isolation of bowel of the transverse colon

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Fig. 18.39 Opening the posterior vaginal fornix transversely

Fig. 18.37 Insertion of the protective sleeve through the main trocar Fig. 18.40 Pulling the protective sleeve through the vagina and introducing the anvil into the pelvic cavity through the protective sleeve

Fig. 18.38 Transvaginal placement of bladder retractor for the indication of the posterior vaginal fornix Fig. 18.41 Timely suction of bowel contents

Key Points, Difficulties, and Hot Spots Related to Surgery Selection and Suture of the Incision of Posterior Vaginal Fornix In addition to the rectum, the vagina is another route of specimen extraction in NOSES. This approach is mainly applicable to female patients with a larger tumor which is

hard to be extracted through the rectum. The vaginal incision is often made in the posterior vaginal fornix (Guan et al. 2019, 2022). However, the majority of colorectal surgeons lack the familiarity of this structure and corresponding surgical operations. We hereby will make a comprehensive illustration of the feasibility of this approach, including the anatomical features of the posterior vaginal fornix, its characteristics, and the clinical practice of the authors.

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Fig. 18.42 Disinfection of the bowel lumen with iodoform gauze

Fig. 18.45 Transvaginal extraction of gauze and the left colon specimen

Fig. 18.43 Inserting the anvil into the proximal transverse colon

Fig. 18.46 The anvil shaft is protruded from the proximal bowel stump

Fig. 18.47 Extend trocar to pierce the rectal stump Fig. 18.44 Transection of the bowel of the transverse colon

Anatomical Features: The upper end of the vagina is wider. The annular cavity between the cervix and vaginal wall is referred to as the vaginal fornix. According to its location, the vaginal fornix is divided into anterior, posterior, left, and right parts. The posterior vaginal fornix is particularly deep and serves as a sperm reservoir. It is the lowest point of the vagina when the patient is placed in the lithotomy position. The posterior fornix is the most extensible part of the vagina, which prevents excessive movement of the cervix

(Fig. 18.55). Physiological Characteristics: The response to sexual stimulation is different in different parts of the vagina. The outer one-third of the vagina is originated from the ectoderm, which is rich in nerve fibers and more sensitive to tactile stimulation. The inner two-third of the vagina is originated from the mesoderm, where there is no nerveending distribution. Therefore, the outer one-third has more sexual sensation than the inner two-third. Since the posterior vaginal fornix is deep without nerve innervation, it does not respond to sexual stimulation. Therefore, damage to the posterior vaginal fornix will not affect sex activity. And,

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Fig. 18.48 Connecting the stapler Fig. 18.52 Extracorporeal interrupted suture of the vaginal incision

Fig. 18.49 “danger triangle of the anastomosis”

Fig. 18.53 Postoperative abdominal wall display

Fig. 18.50 Air leak test

Fig. 18.51 Placing drainage tubes in the pelvic cavity

Fig. 18.54 Specimen display

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Fig. 18.57 The length of the vaginal incision

Fig. 18.55 Posterior vaginal fornix

Fig. 18.58 Dilation of the incision up and down

Fig. 18.56 Introduction of bladder retractor with its tip withstanding the posterior vaginal fornix

our previous studies confirm this view (Zhang et al. 2022). Rectouterine pouch is the lowest point in the abdominal cavity in the female. Peritoneal fluid is most likely to accumulate in this site, it is most likely to be involved by pelvic lesions, and the lateral wall of the posterior vaginal fornix is adjacent to the rectouterine pouch. Therefore, the posterior vaginal fornix is commonly regarded as the preferred location of the abdominal puncture. Selection of Incision: According to our experience, we insert a bladder retractor into the vagina, and withstand the posterior vaginal fornix with its tip (Fig. 18.56). With the

positioning of the bladder retractor, the surgeon transversely opens the posterior vaginal fornix under laparoscopy and makes an approximately 3 cm incision (Fig. 18.57). As the vagina has a strong ductility, the incision can be expanded to 5 cm to meet the requirements of specimen extraction (Fig. 18.58). Suture Skills for Vaginal Incision: Vaginal incision can be sutured either extracorporeally or laparoscopically. According to our experience, it is easier to suture extracorporeally, especially for surgeons who are less experienced in the laparoscopic suture technique. Therefore, extracorporeal suture is the preferred approach. (1) Extracorporeal suture (Fig. 18.59): As the position of the posterior vaginal fornix is deep, adequate exposure of the incision in the posterior vaginal fornix is necessary. In our clinical practice, we apply vaginal speculum or bladder retractor and other instruments to fully expose the posterior vaginal fornix. Two Allis forceps are applied to clamp the upper and lower edge of the vaginal incision, slightly extract the incision to the outside of the body, and then make interrupted or continuous suture for several stitches. (2) Laparoscopic suture (Fig. 18.60): This approach is more difficult and puts forward higher requirements for the surgeon’s operating skills.

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Fig. 18.60 Laparoscopic suturing of vaginal incision

Fig. 18.59 Vaginal incision after extracorporeal interrupted suture

The dedicated vaginal barbed suture is needed for the laparoscopic vaginal suture (no longer than 18 cm to avoid interference with the operation). During the stitching, the upper and lower edges of the vaginal incision should be pulled to the abdominal cavity. The force of traction should be appropriate to prevent vaginal bleeding. The surgeon sutures the incision from one end to the opposite side with the continuous pattern and then performs digital vaginal examination to check whether the incision is perfectly sutured. After the suture, the vagina should be filled with an iodoform gauze, which can be removed 48 h after the operation.

References Guan X, et al. International consensus on natural orifice specimen extraction surgery (NOSES) for colorectal cancer. Gastroenterol Rep. 2019;7(1):24–31. Guan X, et al. Short-term and oncological outcomes of natural orifice specimen extraction surgery (NOSES) for colorectal cancer in China: a national database study of 5055 patients. Sci Bull. 2022;67(13):1331–4. Zhang M, et al. Surgical outcomes and sexual function after laparoscopic colon cancer surgery with transvaginal versus conventional specimen extraction: A retrospective propensity score matched cohort study. Int J Surg. 2022;104:106787.

Laparoscopic Right Hemicolectomy with Transvaginal Specimen Extraction (CRC-NOSES VIIIA)

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Xishan Wang, Xu Guan, and Hai-Yang Huang

Contents Indications and Contraindications of NOSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270 Indications (Figs. 19.1, 19.2, and 19.3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270 Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270 Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . Anesthesia Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Patient Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trocar Placement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Special Surgical Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Surgical Procedure, Techniques, and Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Exploration and Surgical Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dissection and Separation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Specimen Resection and Digestive Tract Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postoperative Abdominal Wall and Specimen Display . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Key Points, Difficulties, and Hot Spots Related to Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281 Anatomy and Exposure of Surgical Trunk of the Superior Mesenteric Vein . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281 The Anatomical Variation of the Right Colic Artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283

Abstract

The right colon has many adjacent organs, complicated vasculature, and large anatomical variations. Therefore, NOSES VIII is one of the most difficult techniques in NOSES. Right colon cancer resection with transvaginal specimen extraction is limited to women. Extraction of the right colon specimen through the transverse colon, descending colon, sigmoid colon, rectum, and anus is theoretically feasible, but the actual operation is extremely X. Wang (*) · H.-Y. Huang Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China X. Guan Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Department of Colorectal Surgery, National Cancer Center, National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China © People’s Medical Publishing House, PR of China 2023 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-99-2750-0_19

difficult and impractical. The main operating features of NOSES VIII include complete dissection and transection of the right colon in the abdominal cavity, specimen extraction from the vagina, and totally laparoscopic functional end-toend anastomosis between the terminal ileum and transverse colon. The main difficulties of this surgical procedure include the technical difficulties in laparoscopic right hemicolectomy and transvaginal specimen extraction. Specifically, the laparoscopic technical difficulties include the correct identification of anatomical landmarks, reasonable surgical approach and complete mesocolon resection, ligation of vessels, dissection of lymph nodes at the root of the mesentery, and the exposure and protection of important tissues and organs. The NOSES technical difficulties include totally laparoscopic digestive tract reconstruction, which is more difficult than other procedures, and requires the surgeon and assistant to be more skillful. In the process of transvaginal specimen extraction, the application of aseptic and tumor-free techniques is crucial. 269

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Keywords

NOSES VIIIA · Laparoscopic right hemicolectomy · Transvaginal specimen extraction · Complete mesocolon excision · Totally laparoscopic digestive tract reconstruction · Suture of vaginal incision · Maintenance of aseptic and tumor-free operation

Indications and Contraindications of NOSES Indications (Figs. 19.1, 19.2, and 19.3) 1. Female patients with right colon tumor. 2. The circumferential diameter of the tumor is better less than 5 cm. 3. The tumor should not invade beyond the serosa.

Contraindications 1. 2. 3. 4.

The circumferential diameter of tumor is more than 5 cm. Tumor invades adjacent tissues and organs. Severely obese patients (BMI > 35 kg/m2). Male patients with right colon cancer.

Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position Anesthesia Method General anesthesia or general epidural anesthesia.

Fig. 19.1 Extent of surgical resection

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Patient Positioning Supine position or functional lithotomy (Fig. 19.4).

Trocar Placement 1. Camera trocar (10 mm trocar) is located at any point from the umbilicus to 5 cm below the umbilicus. 2. The surgeon’s main trocar (12 mm trocar) is located in the middle of the left upper quadrant at the lateral edge of the rectus abdominis. 3. The surgeon’s auxiliary trocar (5 mm trocar) is located in the left lower quadrant, not in the same horizontal level as the camera trocar site. 4. The assistant’s main trocar (12 mm trocar) is located in the right lower quadrant opposite the McBurney’s point, which facilitates the insertion of linear Endo-GIA stapler during digestive tract reconstruction. 5. The assistant’s auxiliary trocar (5 mm trocar) is located in the right upper quadrant at the intersection between the right midclavicular line and the transverse colon projection (Fig. 19.5).

Surgical Team Position Dissection and resection of the right colon: The surgeon stands on the left side of the patient, the assistant stands on the right side of the patient, and the camera holder stands on

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Tumor Exploration The tumor is located at the right colon without invading beyond the serosa. The circumferential diameter of the tumor is better to be less than 5 cm (Fig. 19.11).

Fig. 19.2 Colonoscopy: Tumor of protuberant type, located at the ascending colon (90 cm from the anal verge), and maximum diameter of 4 cm

the same side of the surgeon or between two legs of the patient. Digestive tract reconstruction and specimen extraction: The surgeon stands on the right side of the patient, the assistant stands on the left side of the patient, and the camera holder stands on the same side of the surgeon (Figs. 19.6 and 19.7).

Special Surgical Instruments Ultrasonic scalpel, 60 mm linear Endo-GIA stapler, vaginal suture line, sterile protective sleeve, and uterine manipulator.

Surgical Procedure, Techniques, and Key Points The schematic view of the main surgical procedures of specimen extraction and digestive reconstruction in NOSES VIIIA (Fig. 19.8).

Exploration and Surgical Planning Based on a detailed preoperative examination and surgical plan discussion, the exploration mainly includes three steps.

General Exploration After the laparoscope is placed into the umbilical port, the liver, gallbladder, stomach, spleen, colon, small intestine, greater omentum, and pelvic cavity are routinely examined for the presence of tumor seeding or ascites (Figs. 19.9 and 19.10).

Evaluation of Anatomical Structures The right hemicolectomy is complicated since the right colon has many adjacent organs. It is necessary to identify the ileocolic vessels, the right colic vessels, and the middle colic vessels. In particular, the middle colic artery and vein have many vascular branches. It is recommended to ligate and transect the root of the middle colic vessels if the operation is difficult. In addition, it is necessary to evaluate the feasibility of laparoscopic functional end-to-end anastomosis between the ileum and transverse colon after the dissection of the transverse colon. Total laparoscopic end-to-end or end-toside anastomosis between the ileum and transverse colon with circular stapler is not feasible due to the limitation of the current equipment and technical conditions. For the patients whose transverse mesocolon is too short in length, NOSES VIII should not be performed.

Dissection and Separation Anatomy and Transection of the Root of Ileocolic Artery and Vein The surgeon applies the forceps in the left hand to adequately expose the mesenteric surface along the superior mesenteric vein. A depressed and thin area at the angle between the ileocolic vessels and superior mesenteric vein can be seen (Figs. 19.12 and 19.13). The ultrasonic scalpel is applied to open the mesentery (Fig. 19.14), and the vessels are dissected and isolated gently. Along the Toldt’s fascia, dissection is performed upward from medial to lateral in a cavernous manner. While dissecting upward, the identification of the duodenum proves that the correct space has been entered (Figs. 19.15 and 19.16). The sheath of the superior mesenteric vein is opened as far as possible at the root of the ileocolic artery and vein, then dissection is continued upward to give direct access to the rear on the right side. Following this, the root of the ileocolic artery and vein is isolated, surrounding lymphatic and adipose tissues are removed, and vessels are double ligated (Figs. 19.17 and 19.18). Management of the Root of Right Colic Artery and Vein The surgeon dissects the surface of the duodenum along the Toldt’s fascia (Fig. 19.19), then the right colic vein, the right gastroepiploic vein, and Henle’s trunk, which converge into the superior mesenteric vein, are identified (Fig. 19.20). The right colic vein is ligated and transected (Fig. 19.21), where

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Fig. 19.3 CT virtual endoscopy: The tumor is located at the ascending colon

afterward the dissection is continued upward along the superior mesenteric vein to expose the right colic artery (Fig. 19.22). Double ligation and transection are performed at the root of it.

Management of the Root of the Middle Colic Artery and Vein After the isolation of the right colic vessels, dissection is performed upward until the posterior wall of the gastric antrum is seen through the surface of the pancreatic neck. A small gauze should be placed here. Subsequently, dissection is continued upward along the superior mesenteric vein. The middle colic artery and vein are double ligated and transected at the inferior

border of the pancreas (Figs. 19.23 and 19.24). At this point, all vessels supplying the right colon have been transected.

Dissection of the Mesocolon Dissection is performed from medial to lateral along the Toldt’s fascia to the right paracolic sulcus. The dissection plane should be smooth, flat, and clean (Figs. 19.25 and 19.26). Management of the Mesoileum When the peritoneum below the cecum is penetrated, the surgeon opens the fascia attached to its root as much as

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Fig. 19.4 The patient’s position

Assistant’s Auxiliary Trocar (5 mm)

Camera Trocar (10 mm)

Assistant’s Main Trocar (5 mm)

Surgeon’s Main Trocar (12 mm)

Surgeon’s Auxiliary Trocar (5 mm)

Fig. 19.5 Trocar placement (five-ports method)

Fig. 19.6 Surgical team position (right hemicolectomy)

possible to extend the degree of dissection of the ileum, so as to facilitate the laparoscopic anastomosis of the bowel (Fig. 19.27). The assistant lifts the terminal ileum and the surgeon applies the ultrasonic scalpel to divide the mesoileum. Attention should be paid to the course and direction of the mesenteric blood supply. The division is performed toward the wall of the terminal ileum, and approximately 2 cm of the bowel is isolated (Fig. 19.28).

Management of the Greater Omentum and Station Six Lymph Nodes Subsequently, the surgeon determines the intended resection line of the transverse colon and dissects the greater omentum (Fig. 19.29). Detach the greater omentum from the transverse colon wall and then push it into the right abdominal cavity.

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The assistant lifts the gastric wall with the forceps in the left hand, and the course of the right gastroepiploic artery and vein can be seen. Dissection of the gastrocolic ligament starts at the

Fig. 19.7 Surgical team position (specimen extraction)

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transverse colon, with subsequent entry into the omental cavity (Fig. 19.30). The dissection can be continued to the right along the right gastroepiploic artery and vein (Figs. 19.31 and 19.32). With the dissection to the head of the pancreas, the right

Fig. 19.9 Exploration of the stomach and visceral surface of the left lobe of liver

Fig. 19.8 The main surgical procedures of specimen extraction and digestive reconstruction in NOSES VIIIA

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Fig. 19.10 Exploration of the pelvic cavity

Fig. 19.13 Depressed area at the angle between the ileocolic artery and vein and superior mesenteric vein

Fig. 19.11 Exploration of the tumor location

Fig. 19.14 The first point of the incision

Fig. 19.12 The angle between the superior mesenteric vein and ileocolic vessels

Fig. 19.15 Entering the space anterior to Toldt’s fascia

gastroepiploic vein and Henle’s trunk can be seen, and this dissection plane is connected with the previous dissection plane.

Specimen Resection and Digestive Tract Reconstruction

Management of the Transverse Mesocolon After the mesentery is transected in the antrum area, the mesentery is further divided transversely to the avascular area of the transverse mesocolon (Fig. 19.33). Subsequently, the surgeon ligates and transects the marginal vessels and then dissects to the intended resection line of the transverse colon. The bowel wall is isolated for 1 cm (Fig. 19.34).

Specimen Resection The mobilized transverse colon is isolated using a linear Endo-GIA stapler at the intended resection line (Fig. 19.35). The proximal bowel stump is pulled to the right lower abdomen, so as to expose the attachments between the bowel and the right paracolic sulcus and the liver. The ultrasonic scalpel is applied to dissect along the right paracolic sulcus to

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Fig. 19.19 Dissection of the surface of the duodenum Fig. 19.16 Dissection along the Toldt’s fascia from medial to lateral

Fig. 19.20 Exposure of Henle’s trunk Fig. 19.17 Isolation of the root of the ileocolic vessels

Fig. 19.21 Ligation of the right colic vein Fig. 19.18 Ligation and transection of ileocolic vessels

the right iliac fossa, as indicated and protected by the gauze until the dissection plane is connected with the dissection plane below (Fig. 19.36). In the isolated area of ileum, the blood supply line is clearly visible (Fig. 19.37). Following this, the surgeon transects the ileum medial to the blood supply line with a linear Endo-GIA staple (Fig. 19.38). At this point, the right hemicolectomy is completed and the specimen is placed in the pelvic cavity.

Digestive Tract Reconstruction The transverse colon is straightened, and the terminal ileum is pulled up to the upper abdomen to be placed parallel with the transverse colon (Fig. 19.39). The surgeon makes an incision of 5 mm in one corner of the resection line of the ileum with ultrasonic scalpel (Fig. 19.40). The assistant inserts the 60 mm linear Endo-GIA stapler through the 12 mm trocar in the right lower quadrant and places the anvil jaw into the ileum lumen (Fig. 19.41). Similarly, another incision of

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Fig. 19.25 Dissection along the Toldt’s fascia from medial to lateral Fig. 19.22 Isolation of the right colic artery

Fig. 19.26 Placing small gauze underneath the mesentery Fig. 19.23 Isolation of the middle colic artery and vein

Fig. 19.27 Opening the peritoneum posterior to the cecum Fig. 19.24 Ligation and transection of the middle colic artery and vein

10 mm is made in one corner of the transverse colon stump (Fig. 19.42). Then, the assistant and the surgeon lift the colon and place the cartridge jaw into the colon lumen (Fig. 19.43). The stapler is fired to complete the functional end-to-end anastomosis between the ileum and transverse colon (Fig. 19.44). The presence of anastomotic bleeding in the bowel lumen is checked (Fig. 19.45). After confirming that there is no

active bleeding, the bowel stump is lifted, the linear EndoGIA stapler is inserted through the 12 mm trocar to close the stump transversely, then the functional end-to-end anastomosis is completed (Fig. 19.46). The resected stump tissue is placed into the protective sleeve and extracted through the 12 mm trocar. Then, the seromuscular layer suturing of the anastomosis between ileum and transverse colon is performed to reduce the tension of anastomosis (Fig. 19.47). The digestive tract reconstruction after right hemicolectomy is completed.

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Fig. 19.28 Isolation of wall of the ileum

Fig. 19.31 Dissection to the right along the right gastroepiploic artery and vein

Fig. 19.29 Dissection of the greater omentum

Fig. 19.32 Dissection gastroepiploic vein

Fig. 19.30 Dissection and transection of the gastrocolic ligament

Fig. 19.33 Dividing the transverse mesocolon

Specimen Extraction The sterile plastic protective sleeve is inserted through the 12 mm trocar in the left upper quadrant (Fig. 19.48). The opening of the protective sleeve is expended, the gauze and specimen in the abdominal cavity are placed into the protective sleeve (Fig. 19.49), then the opening of the protective sleeve is closed with the ligating clip (Fig. 19.50). Before transvaginal specimen extraction, the position of the surgeon is changed to the right side of the patient, the position of the laparoscopic display is changed to the left

side, and the patient’s position is changed to the Trendelenburg position. The assistant lifts the uterus extracorporeally with a uterine manipulator to fully expose the posterior vaginal fornix (Fig. 19.51). The surgeon applies the ultrasonic scalpel to open the vagina transversely for approximately 3 cm (Fig. 19.52) and extends the incision to 5–6 cm by longitudinal stretch. With the cooperation of the surgeon, the assistant applies the oval forceps to clamp one end of the specimen extracorporeally and then slowly

of

lymph

nodes

along

the

right

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Fig. 19.34 Isolation of the bowel wall of the transverse colon

Fig. 19.37 Blood supply line of the terminal ileum

Fig. 19.35 Transection of the transverse colon

Fig. 19.38 Transection of ileum

Fig. 19.36 Dissection downward along the right paracolic sulcus

pulls the specimen and the protective sleeve out of the body (Figs. 19.53 and 19.54).

Suture of Vaginal Incision and Closure of Trocar Sites The assistant fully exposes the vaginal incision by lifting the anterior and posterior wall of the incision with two Allis forceps. Interrupted suture is performed with absorbable sutures to close the incision (Figs. 19.55

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Fig. 19.39 The transverse colon is parallelly placed to the ileum

and 19.56). Two drainage tubes are placed in the right upper quadrant through the two trocars on the right side (Fig. 19.57).

Postoperative Abdominal Wall and Specimen Display See Figs. 19.58 and 19.59.

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Fig. 19.40 Making an incision on the terminal ileum

Fig. 19.44 Functional end-to-end anastomosis between ileum and transverse colon

Fig. 19.41 Placing the side of the anvil into the ileum

Fig. 19.45 Inspection of anastomotic bleeding

Fig. 19.42 Making an incision on the transverse colon

Fig. 19.46 Closing the stump transversely

Fig. 19.43 Placing the side of cartridge into the transverse colon

Fig. 19.47 Suture for the reinforcement of anastomosis

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Fig. 19.48 Insertion of the protective sleeve through the trocar

Fig. 19.51 Exposure of the posterior vaginal fornix

Fig. 19.49 Placing the gauze and specimen into the protective sleeve

Fig. 19.52 Opening the posterior vaginal fornix

Fig. 19.50 Opening of the protective sleeve clipped with the vascular clip

Key Points, Difficulties, and Hot Spots Related to Surgery Anatomy and Exposure of Surgical Trunk of the Superior Mesenteric Vein There are two main criteria to measure the radical effect of right hemicolectomy: One is the anatomy and exposure of the surgical trunk of the superior mesenteric vein, and the other is

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Fig. 19.53 Transvaginal placement of oval forceps to clamp the protective sleeve

the completeness of resection of the anterior pancreaticoduodenal fascia. Laparoscopic surgery is more conducive to the implementation of these two procedures. The surgical trunk of the superior mesenteric vein refers to the segment of vein between the gastrocolic trunk and the point at which the ileocolic vein drains into the superior mesenteric vein. The average length of this segment is approximately 3.88 cm (Yang et al. 2005). It is adjacent to the ileocolic vein, right colic vein, and the gastrocolic trunk on the right side. It is also adjacent to the superior mesenteric artery on the left side,

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Fig. 19.54 Transvaginal extraction of specimen

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Fig. 19.57 Placing drainage tubes in the abdominal cavity

Fig. 19.55 Adequate exposure and closure of the vaginal incision

Fig. 19.58 Specimen display

Fig. 19.56 Inspection of the suturing of the vaginal incision

which branches into the ileocolic artery, right colic artery, and middle colic artery to the right colon from anterior to the surgical trunk (from the posterior to the right colon in rare cases). In order to ensure the completeness of the right hemicolectomy, it is necessary to adequately expose the surgical trunk of the superior mesenteric vein, and the

Fig. 19.59 Postoperative abdominal wall display

branches of the vessels should be ligated and transected at the root (Fig. 19.60).

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Fig. 19.60 Surgical trunk of superior mesenteric vein

The Anatomical Variation of the Right Colic Artery The right colic artery originates from the middle of the superior mesenteric artery, slightly below the middle colic artery (sometimes combined with the middle colic artery) (Garcia-Ruiz et al. 1996). This artery goes to the right side along the parietal peritoneum of the posterior abdominal wall and divides into an ascending branch and a descending branch. The ascending branch joins with the right branch of the middle colic artery, and the descending branch joins with the ascending branch of the ileocolic artery, to provide the blood supply of the ascending colon and hepatic flexure. The right colic artery has a variable origin. About 63% of patients

have right colic artery (Ignjatovic et al. 2007). Because of the large variation in the right colic artery, surgeons should be more careful during the management of vessels and take various possible variations into consideration.

References Garcia-Ruiz A, et al. Right colonic arterial anatomy. Implications for laparoscopic surgery. Dis Colon Rectum. 1996;39:906–11. Ignjatovic D, et al. Vascular relationships in right colectomy for cancer: clinical implications. Chin J Anat Tech Coloproctol. 2007;11: 247–50. Yang Z, et al. Anatomical observation and clinical significance of Henle trunk and surgical trunk. Chin J Anat. 2005;28(1):87–9.

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Contents Indications and Contraindications of NOSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286 Indications (Figs. 20.1, 20.2, and 20.3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286 Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286 Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . Anesthesia Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Patient Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trocar Placement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Special Surgical Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

286 286 286 286 287 287

Surgical Procedure, Techniques, and Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Exploration and Surgical Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dissection and Separation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Specimen Resection and Digestive Tract Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postoperative Recovery and Specimen Display . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

288 288 289 292 296

Key Points, Difficulties, and Hot Spots Related to Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296 The Advantages and Feasibility of Overlapped Delta-Shaped Anastomosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297

Abstract

Previously, the possibility to use NOSES to treat right colon cancer is described only for women. However, for male patients transrectal specimen extraction after laparoscopic right hemicolectomy is possible. The right colon has many adjacent organs, complicated vasculature, and major anatomical variations. In addition, the specimens need to be extracted through the incision on the upper rectum, and the closure of this incision needs to be completed under the laparoscopy. Therefore, this procedure is

X. Hu Department of Colorectal Surgery, National Cancer Center, National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China H. Zhou (*) Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China e-mail: [email protected] © People’s Medical Publishing House, PR of China 2023 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-99-2750-0_20

a difficult, risky technique with high damage-benefit ratio in NOSES. The main operating features of this procedure include complete dissection and transection of the right colon in the abdominal cavity, totally laparoscopic digestive tract reconstruction of the terminal ileum and transverse colon, and right colon specimen extraction through the incision on the rectum. The laparoscopic technical difficulties include the correct identification of anatomical landmarks, reasonable surgical approach, complete mesocolon resection, ligation of vessels and dissection of lymph nodes at the root of vessels, and the exposure and protection of important tissues and organs. The NOSES technical difficulties include totally laparoscopic digestive tract reconstruction, i.e., laparoscopic overlapped deltashaped anastomosis with stapler, which is more difficult than the other procedures. The third difficulty lies in the opening and closure of the upper rectum. Therefore, in the process of transrectal specimen extraction, the

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application of aseptic and tumor-free techniques and the accurate understanding of indications of this procedure is crucial. Compared with NOSES-VIIIA, this procedure requires more accurate understanding of indications, clear surgical thinking, and proficient skills.

X. Hu and H. Zhou

Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position Anesthesia Method General anesthesia or general epidural anesthesia.

Keywords

Laparoscopic right hemicolectomy · Digestive tract reconstruction · Complete mesocolon resection · Overlapped delta-shaped anastomosis · Transrectal specimen extraction · NOSES

Patient Positioning The patient is placed in functional lithotomy position, with the left thigh slightly flattened, which facilitates to perform the operation for the surgeon (Fig. 20.4).

Indications and Contraindications of NOSES Indications (Figs. 20.1, 20.2, and 20.3) 1. Male patients with right colon cancer or benign tumor. 2. The circumferential diameter of tumor less than 3 cm is more suitable. 3. The tumor should not invade beyond the serosa.

Contraindications 1. The circumferential diameter of tumor is more than 3 cm. 2. Tumor invades adjacent tissues and organs. 3. Patients who have undergone rectal or anal surgery and patients with middle and lower rectal and anal stenosis caused by rectal or anal diseases. 4. Severely obese patients (BMI > 35 kg/m2).

Fig. 20.1 Extent of surgical resection

Trocar Placement 1. Camera trocar (10 mm trocar) is located at any point from the umbilicus to 5 cm below the umbilicus. 2. The surgeon’s main trocar (12 mm trocar) is located in the middle of the left upper quadrant at the lateral edge of the rectus abdominis. 3. The surgeon’s auxiliary trocar (5 mm trocar) is located in the left lower quadrant, not in the same horizontal level as the camera trocar site. 4. The assistant’s main trocar (12 mm trocar) is located at the McBurney’s point. 5. The assistant’s auxiliary trocar (5 mm trocar) is located in the right upper quadrant at the intersection between the right midclavicular line and the transverse colon projection (Fig. 20.5).

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Surgeon’s Auxiliary Trocar (5 mm)

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Camera Trocar (10 mm)

Surgeon’s Main Trocar (12 mm)

Assistant’s Main Trocar (5 mm) Assistant’s Auxiliary Trocar (5 mm)

Fig. 20.5 Trocar sites (five-ports method)

Fig. 20.2 Colonoscopy: tumor of superficial protuberant type, with partial mucosal depressions and erosions

Monitor

Assistant

Surgeon

Monitor Scrub Nurse Camera Holder

Fig. 20.6 Surgical team position (right hemicolectomy)

Surgical Team Position Fig. 20.3 Abdominal CT: The tumor is located at the ascending colon

Dissection and resection of the right colon and digestive tract reconstruction: The surgeon stands on the left side of the patient, the assistant stands on the right side of the patient, and the camera holder stands on the same side of the surgeon or between the patient’s legs. Specimen extraction: The surgeon stands on the right side of the patient, the assistant stands on the left side of the patient, and the camera holder stands on the same side of the surgeon (Figs. 20.6 and 20.7).

Special Surgical Instruments

Fig. 20.4 The patient’s position

Ultrasonic scalpel, 60 mm linear Endo-GIA stapler, and sterile protective sleeve.

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Surgical Procedure, Techniques, and Key Points Camera Holder

The schematic view of main surgical procedures of specimen extraction and digestive reconstruction in NOSES VIIIB (Fig. 20.8).

Surgeon

Exploration and Surgical Planning Assistant

Based on the thorough preoperative examination and surgical planning, the exploration mainly includes three steps: Monitor

Scrub Nurse

Fig. 20.7 Surgical team position (specimen extraction)

General Exploration After the laparoscope is placed into the umbilical port, the liver, gallbladder, stomach, spleen, colon, small intestine, greater omentum, and pelvic cavity are routinely examined for the presence of tumor seeding or ascites (Figs. 20.9 and 20.10).

Fig. 20.8 The main surgical procedures of specimen extraction and digestive reconstruction in NOSES VIIIB

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Fig. 20.9 Exploration of the stomach and visceral surface of the left lobe of the liver

Fig. 20.10 Exploration of the pelvic cavity

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Fig. 20.12 The first point of the incision

Fig. 20.13 Entering the space anterior to Gerota’s fascia

vein have many branches. It is recommended to ligate and transect the root of the middle colic artery and vein if the operation is difficult. In addition, it is necessary to evaluate the feasibility of laparoscopic overlapped delta-shaped anastomosis between the ileum and transverse colon after the dissection of the transverse colon.

Dissection and Separation

Fig. 20.11 Exploration of the tumor location

Tumor Exploration The tumor is located at the right colon without invasion beyond the serosa, and the circumferential diameter of the tumor is less than 3 cm (Fig. 20.11). Evaluation of Anatomical Structures The right colon has many adjacent organs and complicated vasculature. It is necessary to evaluate the ileocolic vessels, the right colic vessels, and the middle colic artery vessels (Strey et al. 2018). In particular, the middle colic artery and

Anatomy and Transection of the Root of Ileocolic Artery and Vein The cecum is retracted by grasping forceps in the left hand, exposing the area along the superior mesenteric vein. The thin fossa between the “bow-stringing” of ileocolic artery and vein and superior mesenteric vein will be seen. An ultrasonic scalpel is used to incise the peritoneum of the ileal mesentery (Fig. 20.12), and slowly dissect and isolate the vessels. A mesenteric window is then opened to achieve the surface of Gerota’s fascia and the duodenum. The surgeon should clearly identify the duodenum to avoid injury. The duodenum should be visualized through this opening to allow for true retroperitoneal plane (Figs. 20.13 and 20.14). The dissection of the superior mesenteric pedicle should start in the root of ileocolic vessels; dissect upward and give

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Fig. 20.14 Dissection along the Toldt’s fascia from medial to lateral

Fig. 20.17 Isolation of the root of the right colic artery

Fig. 20.15 Isolation of the root of the ileocolic vessels

Fig. 20.18 Ligation and transection of the right colic artery

Fig. 20.16 Ligation and transection of ileocolic vessels

Fig. 20.19 Isolation of the root of the accessory right colic vein

direct access to the rear on the right side. The roots of ileocolic vessels are cleared of surrounding fat. The ileocolic artery and vein are clipped (Figs. 20.15 and 20.16).

vein, the right gastroepiploic vein, and anterior superior pancreaticoduodenal vein which formed Henle’s trunk, then drained into the superior mesenteric vein. The right colic vein is isolated and clipped (Figs. 20.19 and 20.20).

Management of the Root of Right Colic Artery The right colic artery is then separated with the dissection upward along the superior mesenteric vein (Fig. 20.17), then the right colic artery is isolated and clipped (Fig. 20.18). The dissection continued on the surface of the duodenum and head of the pancreas along the Toldt’s fascia, reaching the right colic

Management of the Right Branch of the Middle Colic Artery and Vein The dissection is continued upward after the dissection of the right colic artery and accessory right colic vein. The head of the pancreas is then swept posteriorly and separated from the middle colic vessels. The right branch of the middle colic

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Fig. 20.20 Ligation and transection of the accessory right colic vein

Fig. 20.23 Dissection along the Toldt’s fascia from medial to lateral

Fig. 20.21 Isolation of the right branch of the middle colic artery and vein

Fig. 20.24 Opening the peritoneum posterior to the cecum

mesoileum, ascending mesocolon, and the right transverse mesocolon is completed by medial-to-lateral dissection (Fig. 20.23).

Fig. 20.22 Ligation and transection of the right branch of the middle colic artery and vein

artery and vein are divided and clipped (Figs. 20.21 and 20.22). At this point, all the vessels supplying the right colon have been transected.

Dissection of the Mesocolon Dissection is performed from medial to lateral along the Toldt’s fascia to the right paracolic sulcus. Attention should be paid to protect the right gonadal vessels, head of the pancreas, and duodenum. Mobilization of the terminal

Management of the Mesoileum When the peritoneum below the cecum is penetrated, the surgeon opens the fascia attached to its root as much as possible to further mobilize the ileum, so as to facilitate the laparoscopic anastomosis of the bowel (Fig. 20.24). The assistant lifts the terminal ileum, and the surgeon applies the ultrasonic scalpel to divide the mesoileum. Attention should be paid to the course and direction of the mesenteric blood supply. The division is performed toward the wall of the terminal ileum, and approximately 2 cm of bowel is isolated (Fig. 20.25). Management of the Greater Omentum and Station Six Lymph Nodes Subsequently, the surgeon determines the intended resection line of the transverse colon and dissects the greater omentum (Fig. 20.26). The ultrasonic scalpel is used to free the right greater omentum from the transverse colon wall, then it is pulled to the right abdominal cavity. The assistant lifts the gastric wall with the forceps in the left

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Fig. 20.25 Isolation of wall of the ileum

Fig. 20.26 Dissection of the greater omentum

X. Hu and H. Zhou

Fig. 20.28 Dividing the transverse mesocolon

Fig. 20.29 Isolation of the bowel wall of the transverse colon

Management of the Transverse Mesocolon After the mesentery is transected in the antrum area, the mesentery is further divided transversely to the avascular area of the transverse mesocolon (Fig. 20.28). Subsequently, the surgeon ligates and transects the marginal vessels and then dissects to the intended resection line of the transverse colon. The bowel wall is isolated for 1 cm (Fig. 20.29).

Specimen Resection and Digestive Tract Reconstruction Fig. 20.27 Dissection and transection of the gastrocolic ligament and entry into the omental cavity

hand, and the course of the right gastroepiploic artery and vein can be seen. Dissection is performed from the transverse colon to the gastroepiploic vessels, the gastrocolic ligament is transected, and the omental sac is entered (Fig. 20.27). The dissection can be continued toward the right along the right gastroepiploic artery and vein. With the dissection to the head of the pancreas, the right gastroepiploic vein and Henle’s trunk can be seen, and this dissection plane is connected with the previous dissection plane.

Specimen Resection The mobilized transverse colon is isolated using a linear Endo-GIA stapler at the intended resection line (Fig. 20.30). The proximal bowel stump is pulled to the right lower abdomen, so as to expose the attachments between the bowel and the right paracolic sulcus and the liver. The ultrasonic scalpel is applied to dissect along the right paracolic sulcus to the right iliac fossa until connected with space below. In the isolated area of ileum, the blood supply line is clearly visible (Fig. 20.31). Following this, the surgeon transects the ileum medial to the blood supply line with a linear Endo-GIA stapler (Fig. 20.32). At this point, the right hemicolectomy is completed.

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Fig. 20.30 Transection of the transverse colon

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Fig. 20.33 Overlapping of the terminal ileum with transverse colon

Fig. 20.31 Blood supply line of the terminal ileum Fig. 20.34 Suture of the transverse colon stump with the bowel wall 8 cm from the terminal ileum stump

Fig. 20.32 Transection of the ileum

Digestive Tract Reconstruction The transverse colon is straightened, and the terminal ileum is pulled up to the upper abdomen to be placed overlapped with the transverse colon (Fig. 20.33). Suture for fixation is performed between the transverse colon stump and the bowel wall at 8 cm from the terminal ileum stump (Fig. 20.34). The surgeon then checks the blood supply of both sides of the bowel and estimates the tension of the anastomosis. The transverse colon and terminal ileal stumps are opened with two incisions (1 cm for each) close to staple

Fig. 20.35 Making an incision of 1 cm long on the terminal ileum stump

lines on the antimesenteric border (Figs. 20.35 and 20.36), then both bowel lumens are disinfected with iodoform gauze. The linear Endo-GIA stapler is introduced through the surgeon’s main trocar, where afterward the cartridge jaw and the anvil jaw are inserted into the two bowel lumens separately. With the necessary adjustment, the stapler is fired to complete the side-to-side anastomosis between the ileum and transverse colon (Figs. 20.37, 20.38, and 20.39).

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Fig. 20.36 Making an incision of 1 cm long on the corresponding antimesenteric side of the transverse colon

Fig. 20.39 Side-to-side anastomosis between ileum and transverse colon

Fig. 20.37 Insertion of linear Endo-GIA stapler into the terminal ileum

Fig. 20.40 Fixing traction sutures at both ends and in the middle of the enterotomies

Fig. 20.38 Insertion of linear Endo-GIA stapler into both sides of the bowel

Fig. 20.41 Closing the enterotomies of the bowel stump

The bowel lumen is disinfected with iodoform gauze, and the integrity of the anastomosis is confirmed. After excluding anastomotic leakage, traction sutures are fixed at both ends and in the middle of the enterotomies, respectively (Fig. 20.40). The surgeon and assistant grasp the tail of traction sutures to keep the bowel wall straight and close the enterotomies with a linear Endo-GIA stapler. The overlapped delta-shaped anastomosis between ileum and transverse colon is completed (Figs. 20.41 and 20.42).

Specimen Extraction Before making the incision in the rectal wall, the surgeon should change to the right side of the patient and change the position of the laparoscopic display. The patient’s position is changed from the anti-Trendelenburg position to the Trendelenburg position. The assistant injects dilute iodine solution through the anus for irrigation of the rectum. A longitudinal incision (3 cm) is made in the anterior rectal wall by the ultrasonic scalpel (Fig. 20.43). The protective sleeve is inserted through the 12 mm trocar (Fig. 20.44), then

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Fig. 20.42 Overlapped delta-shaped anastomosis

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Fig. 20.45 Placement of oval forceps through the incision in the upper rectum through the anus

Fig. 20.43 Transverse incision on the upper rectum Fig. 20.46 Pulling the end of the protective sleeve out through the anus

Fig. 20.44 Insertion of the protective sleeve through the trocar

the second assistant applies the oval forceps through the incision in the upper rectum to pull the end of the protective sleeve out through the anus (Figs. 20.45 and 20.46). One end of the specimen is smoothly placed into the protective sleeve with the cooperation between the surgeon and the assistant. The second assistant places the oval forceps into the protective sleeve to clamp one end of the bowel (Figs. 20.47 and 20.48) and slowly pulls the specimen along with the protective sleeve out of the rectum and anus (Fig. 20.49). The assistant wipes the bowel lumen with iodoform gauze as the surgeon confirms that there is no active bleeding. Traction sutures are fixed at both ends of the rectal incision,

Fig. 20.47 Placement of oval forceps into the abdominal cavity through the protective sleeve

respectively (Fig. 20.50). The surgeon and assistant grasp the tail of the suture on two sides to keep the incision away from the opposite bowel wall and close the incision with a linear Endo-GIA stapler (Figs. 20.51 and 20.52). Laparoscopic seromuscular layer embedding of the anastomosis is performed (Fig. 20.53). The abdominal cavity is irrigated with distilled water, and one drainage tube is indwelled in the abdominal cavity through the 12 mm trocar on the right side. Pneumoperitoneum is released, and the trocar sites are closed.

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Fig. 20.48 Clamping one end of the bowel with oval forceps

Fig. 20.50 Traction sutures are fixed at both ends of the rectal incision

Fig. 20.49 Specimen extraction

Fig. 20.51 Closing the rectal incision with the linear Endo-GIA stapler

Postoperative Recovery and Specimen Display See Figs. 20.54 and 20.55.

Key Points, Difficulties, and Hot Spots Related to Surgery The Advantages and Feasibility of Overlapped Delta-Shaped Anastomosis The end-to-side anastomosis between ileum and transverse colon is the anastomotic technique applied in conventional right hemicolectomy. However, in the laparoscopic right colon cancer resection with transrectal specimen extraction, the digestive tract reconstruction is performed by an overlapped delta-shaped anastomosis between the ileum and transverse colon (Zhou et al. 2017). This approach only applies four linear Endo-GIA staplers, and it is a safe and feasible anastomotic approach for laparoscopic digestive tract reconstruction after right hemicolectomy. Compared with the end-to-side anastomosis, overlapped delta-shaped anastomosis mainly has the following advantages: (1) reduction of the anastomotic stenosis: with this approach, the diameter of anastomosis is large, which not only avoids the incidence of

Fig. 20.52 Closing the rectal incision

anastomotic stenosis but also solves the problem of mismatch between the diameters of the ileum and colon; (2) operation is simple to be performed, which can further shorten the duration of operation, lower the difficulty of surgery, and reduce the risk of intraoperative contamination; and (3) the ileocecal pouch formed by end-to-side anastomosis can be avoided. End-to-side anastomosis forms a blind pouch in the colon, which is often a main cause for postoperative complications (Liu et al. 2014). At the same time, the avascular area of one side of the bowel that occurs in the end-to-side anastomosis can be avoided, and the possibility of poor blood supply of

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Fig. 20.53 Seromuscular layer embedding of anastomosis

Fig. 20.55 Display of postoperative abdominal wall recovery

Therefore, the possibility of excessive anastomotic tension and related complications is reduced; (2) in the overlapped anastomosis, the peristaltic direction of the two ends of the anastomosis is consistent, which avoids intestinal contents stasis and antiperistalsis, and therefore prevents the interference with intestinal function and the healing of anastomosis.

References

Fig. 20.54 Specimen display

the anastomosis can be reduced. Compared with functional end-to-end anastomosis, the overlapped delta-shaped anastomosis mainly has the following advantages: (1) With the overlapped delta-shaped anastomosis between the terminal ileum and transverse colon, the resected bowel and mesentery is shorter than that of the functional end-to-end anastomosis.

Liu Z, Wang G, Yang M, Chen Y, Miao D, Muhammad S, Wang X. Ileocolonic anastomosis after right hemicolectomy for colon cancer: functional end-to-end or end-to-side? World J Surg Oncol. 2014;12:306. Strey CW, Wullstein C, Adamina M, Agha A, Aselmann H, Becker T, Grützmann R, Kneist W, Maak M, Mann B, et al. Laparoscopic right hemicolectomy with CME: standardization using the “critical view” concept. Surg Endosc. 2018;32:5021–30. Zhou HT, Wang P, Liang JW, Su H, Zhou ZX. Short-term outcomes of overlapped delta-shaped anastomosis, an innovative intracorporeal anastomosis technique, in totally laparoscopic colectomy for colon cancer. World J Gastroenterol. 2017;23:6726–32.

Laparoscopic Right Hemicolectomy with Transcolonic Specimen Extraction (CRC-NOSES VIIIC)

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Jian Peng and Jie Chen

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300 Indications and Contraindications of NOSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300 Indications (Figs. 21.1, 21.2, and 21.3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300 Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300 Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . Anesthesia Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Patient Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trocar Placement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Special Surgical Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

300 300 300 301 301 301

Surgical Procedure, Techniques, and Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Exploration and Surgical Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dissection and Separation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Specimen Extraction and Digestive Tract Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postoperative Abdominal Wall and Specimen Display . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Key Points, Difficulties, and Hot Spots Related to Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313

Abstract

Both laparoscopic-assisted and total laparoscopic resection have been well described for the surgical management of colorectal diseases. However, both approaches require about 5–10 cm auxiliary abdominal incisions for specimen extraction and anastomosis of the bowel. With the advent of Natural Orifice Specimen Extraction Surgery (NOSES), it has been possible to perform the surgery without the J. Peng (*) Department of Geriatric Surgery, Xiangya Hospital, Central South University, Changsha, China National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China e-mail: [email protected] J. Chen Department of Geriatric Surgery, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China e-mail: [email protected] © People’s Medical Publishing House, PR of China 2023 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-99-2750-0_21

need of auxiliary abdominal incision. NOSES has been widely used by laparoscopic radical resection for colorectal cancer. The specimens of laparoscopic radical right hemicolectomy are mainly extracted transvaginally (NOSES VIII A) or transrectally (NOSES VIII B). Extracting the right-side colon specimen from the colon is feasible theoretically, but the actual operation is extremely difficult. Nevertheless, we have successfully completed laparoscopic right hemicolectomy with transcolonic specimen extraction (NOSES VIII C), which provides a new operation for right colonic cancer patients. Here, we introduce the new procedure of NOSES VIII C in this chapter, including the indications, contraindications, surgical procedures, and some surgical techniques of NOSES VIII C. The keys to the success of NOSES VIII C include the following: (a) adequate preoperative bowel preparation; (b) removing the specimen through left transverse colon, splenic flexure, descending colon, sigmoid colon, rectum,

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and anus; and (c) aseptic and tumor-free surgical procedures intraoperatively. NOSES VIII C is a safe and feasible procedure for well-selected patients with satisfactory surgical outcomes and less visible surgical scars.

J. Peng and J. Chen

descending colon, sigmoid colon, rectum, and anus (Ouyang et al. 2020a). We classify this procedure as NOSES VIIIC.

Indications and Contraindications of NOSES Keywords

Natural Orifice Specimen Extraction Surgery (NOSES) · Laparoscopic radical right hemicolectomy · Colonoscopy · Right-sided colon cancer · Complete laparoscopic colon ileal anastomosis

Introduction Natural Orifice Specimen Extraction Surgery (NOSES) is a new surgical approach that combines traditional laparoscopic surgery with specimen extraction through the natural orifice (Pascual et al. 2016; Leung et al. 2014). Currently, specimens of laparoscopic radical right hemicolectomy are mainly extracted transvaginal for female patients (NOSES VIII A) (Wang et al. 2021; Kayaalp et al. 2015) or transrectally for male patients (NOSES VIII B). There are reports of operation failures that specimens are extracted transcolon after laparoscopic radical right hemicolectomy due to oversized specimens (Kayaalp et al. 2015; Eshuis et al. 2010), indicating that there is some difficulty in this type of surgery. After rigorous case selection, we successfully completed laparoscopic radical resection of right hemicolectomy with specimen extraction via left transverse colon, splenic flexure,

Fig. 21.1 Extent of resection

Indications (Figs. 21.1, 21.2, and 21.3) 1. Patients with right-sided colon cancer. 2. The circumferential diameter of the tumor should be less than 5 cm. 3. The tumor should not invade beyond the serosa.

Contraindications 1. The circumferential diameter of tumor is more than 5 cm. 2. Tumor invades adjacent organs and structures. 3. Severely obese patients (BMI > 30 kg/m2).

Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position Anesthesia Method General anesthesia or general epidural anesthesia.

Patient Positioning Supine position or functional lithotomy (Fig. 21.4).

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Trocar Placement 1. Camera trocar (10 mm trocar) is located at any point from the umbilicus to 5 cm below the umbilicus. 2. The surgeon’s main trocar (12 mm trocar) is located in the middle of the left upper quadrant at the lateral edge of the rectus abdominis, which facilitates the insertion of linear Endo-GIA stapler. 3. The surgeon’s auxiliary trocar (5 mm trocar) is located in the left lower quadrant, not in the same horizontal level as the camera trocar site.

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4. The assistant’s main trocar (12 mm trocar) is located in the right lower quadrant opposite the McBurney’s point. 5. The assistant’s auxiliary trocar (5 mm trocar) is located in the right upper quadrant (Fig. 21.5).

Surgical Team Position The dissection of the right colon: The surgeon stands on the left side of the patient, and the assistant stands on the right side of the patient. The camera holder stands between two legs of the patient.

Special Surgical Instruments Dissecting device (ultrasonic scalpel), 60 mm linear EndoGIA stapler, sterile plastic protective sleeve, colonoscopy, and endoscopic forceps. Specimen extraction and digestive tract reconstruction: The surgeon stands on the right side of the patient; the assistant stands on the left side of the patient. The camera holder is on the same side as the surgeon. The endoscopist and assistant stand between two legs of the patient (Figs. 21.6 and 21.7).

Surgical Procedure, Techniques, and Key Points

Fig. 21.2 Colonoscopy: The tumor is located at the ascending colon (arrow), 1.5  2.0 cm

The schematic view of main surgical procedures of specimen extraction and digestive reconstruction in NOSES VIIIC (Fig. 21.8).

Fig. 21.3 CT: Computed tomography scans with the ascending colon. The wall of the ascending colon is thickened inhomogeneously, and the thicker part is 22 mm (arrow). Image view: (a) horizontal; (b) coronal

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Camera Holder

Assistant

Surgeon

Scrub Nurse

Fig. 21.4 The patient’s position Monitor Endoscopist

Fig. 21.7 Surgical team position (specimen extraction and digestive tract reconstruction) Assistant’s Auxiliary Trocar (5 mm)

Surgeon’s Main Trocar (12 mm)

Camera Trocar (10 mm)

Assistant’s Main Trocar (5 mm)

Surgeon’s Auxiliary Trocar (5 mm)

Fig. 21.5 Trocar placement (five-ports method)

General Exploration After the laparoscope is placed into the umbilical port, the liver, gallbladder, stomach, spleen, colon, small intestine, greater omentum, and pelvic cavity are routinely examined for the presence of tumor seeding or ascites (Figs. 21.9 and 21.10). Exploration of Tumor The tumor is located at the ascending colon. The surgeon should examine the tumor location, tumor size, and depth of tumor invasion (Fig. 21.11). Exploration of Anatomical Structure Evaluation of the anatomy of the right colon along with mesentery and vessels should be performed to further determine the extent of surgical resection.

Monitor

Surgeon

Assistant

Monitor

Dissection and Separation

Scrub Nurse Camera Holder

Fig. 21.6 Surgical team position (right hemicolectomy)

Exploration and Surgical Planning Based on a detailed preoperative examination and surgical plan discussion, the intraoperative exploration mainly includes three steps:

Dissection of Ileocolic Vessels After the establishment of pneumoperitoneum through an umbilical trocar, four additional trocars are placed in selected sites. The operating table is tilted into the slight Trendelenburg position with the left side down to move the small intestine toward the left upper quadrant. The right mesocolon is well visualized, and the optimal surgical field can be achieved. The root of the ileocolic pedicle is usually located at the inferior border of the duodenum (Fig. 21.12). First, the mesocolon near the ileocecal junction is lifted to confirm the ileocolic pedicle. The initial incision starts from the root of the ileocolic pedicle (Fig. 21.13). The fat and lymph nodes surrounding the ileocolic vessels are cleared, then the ileocolic artery and vein are identified, ligated, and divided (Fig. 21.14). With adequate traction of the mesocolon

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Fig. 21.8 The main surgical procedures of specimen extraction and digestive reconstruction in NOSES VIIIC

Fig. 21.9 Right liver, gallbladder, and greater omentum

Fig. 21.10 Left lateral liver, stomach, and spleen

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Fig. 21.11 Exploration of the tumor

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Fig. 21.13 The initial incision starts from the root of the ileocolic pedicle

Fig. 21.12 The root of ileocolic pedicle and the duodenum Fig. 21.14 The ileocolic artery and vein are ligated

toward the right upper quadrant, the ileocolic vessels are easily mobilized, and the peritoneal window is expanded from medial to lateral.

Dissection of Right Colic and Middle Colic Vessels The dissection is continued cephalad along the ventral side of the superior mesenteric vein. After dissecting the fat and lymph nodes surrounding the root of the middle colic vessels, the right branch of the middle colic artery and vein are ligated and divided separately (Fig. 21.15). Henle’s trunk is fused of the right gastroepiploic vein with the right colic vein. The right colic vein is ligated and divided (Figs. 21.16 and 21.17). The right colic artery has variable origin, and it is originated from the superior mesenteric artery in 41% of patients. There is not the right colic artery in 18% of patients.

Dissection of Right Mesocolon and Transverse Mesocolon The right mesocolon is mobilized from medial to lateral allowing dissection into the proper retroperitoneal plane according to the principle of CME. The extent of surgical resection and the intended proximal resection line of the transverse colon is measured visually. The transverse colon is lifted up ventrally by the assistant using a bowel grasper. Under the clear exposure of transverse mesocolon, the surgeon makes an incision in the avascular area of the transverse mesocolon as well as vessels toward the bowel wall of the middle transverse colon. The exposed length of the bowel wall should be appropriately 2–3 cm (Fig. 21.18).

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Fig. 21.15 The right branch of the middle colic artery is identified and ligated

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Fig. 21.17 The ileocolic vessels, the right branch of middle colic vessels, and the right colic vein are ligated and divided; Henle’s trunk is exposed

Fig. 21.16 The right colic vein is identified and ligated

Dissection of Greater Omentum and Hepatocolic Ligament The greater omentum is incised toward the transverse colon with an ultrasonic scalpel. The assistant lifts the anterior wall of the stomach ventrally. In this way, the gastrocolic ligament is placed under tension and thus could be divided more easily. Initial dissection of the gastrocolic ligament starts in the middle of the transverse colon with subsequent entry into the lesser sac (Fig. 21.19). The dissection can be continued from the middle to right along the outer margin of the right gastroepiploic vein. This plane connects the previous dissection plane from the caudal side when the head of the pancreas appears. The hepatocolic ligament and the lateral ligament of the right colon are dissected (Fig. 21.20).

Fig. 21.18 The surrounding fat of the right transverse colon is cleared

Dissection of Ileocecal Mesentery The terminal ileum is lifted up by the assistant using grasper forceps. The distance between the proximal tumor edge and the intended resection line is about 15 cm. The mesentery is incised upward to the bowel wall, then the vessels are ligated along with the dissection. The exposed length of the bowel wall should be appropriately 1–2 cm on the terminal ileum (Fig. 21.21). Afterward, the peritoneum around the ileocecum should be adequately incised along the root of the ileal mesentery toward the right colon to mobilize the ileum, which facilitates the anastomosis under laparoscopy (Fig. 21.22).

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Fig. 21.19 The greater omentum is incised from the middle point of the transverse colon

Fig. 21.21 Dissection of ileocecal mesentery to the bowel wall of terminal ileum at about 12 cm from ileocecum

Fig. 21.20 The hepatocolic ligament is dissected

Fig. 21.22 Dissection of the lateral peritoneum around ileocecum

Division of the Terminal Ileum and Right Transverse Colon The intended resection line on the terminal ileum could be easily identified by the color of the bowel wall (Fig. 21.23), where the division is performed by applying the 60 mm linear Endo-GIA stapler through the left upper quadrant trocar (Fig. 21.24). The stumps of the terminal ileum are disinfected with povidone gauze (Fig. 21.25). Then, the povidone gauze is put into a sterilized plastic bag (Fig. 21.26). The same operational procedure is repeated with the transverse colon after colonoscopic reverification of the tumor lesion in the ascending colon (Figs. 21.27 and 21.28). The transverse colon stump is also disinfected with povidone gauze. The right colon specimen including the tumor-bearing segment is mobilized.

Specimen Extraction and Digestive Tract Reconstruction Specimen Extraction The right colon specimen is packed into a sterile protective sleeve (Fig. 21.29). Under the guidance of laparoscopy, colonoscopy reaches the closed transverse colon through the anus (Fig. 21.30). After bowel irrigation with normal saline in colonoscopy, the stump of the left transverse colon is cut open with ultrasonic scalpel and disinfected with povidone gauze. The tip of the colonoscopy and the endoscopic foreign body retrieval is exposed, then disinfected with povidone gauze. Excess fluid is removed with the suction (Fig. 21.31). The protective sleeve containing the specimen is clamped by endoscopic foreign body retrieval (Fig. 21.32),

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Fig. 21.23 The blood supply line of the terminal ileum

Fig. 21.24 The division of the terminal ileum is performed with linear Endo-GIA stapler

inserted into the colonic lumen, pulled out through the colon, and finally removed through the anus (Figs. 21.33, 21.34, 21.35, 21.36, and 21.37).

Digestive Tract Reconstruction The opened stump of the transverse colon is closed with a 60 mm linear Endo-GIA stapler (Fig. 21.38). The resected stump tissue is put into a small specimen retrieval bag. The transverse colon is straightened, and the terminal ileum is pulled to the upper abdomen to be placed parallel to the transverse colon. The antimesenteric side of the terminal ileum stump is cut open with an ultrasonic scalpel, and the bowel lumen is disinfected with povidone gauze (Fig. 21.39). Similarly, a small incision is made on the antimesenteric bowel wall of the transverse colon about 6 cm from the

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Fig. 21.25 The division ends of the terminal ileum are disinfected with povidone gauze

Fig. 21.26 After disinfection, the povidone gauze is placed into a sterilized plastic bag

stump (Fig. 21.40). Povidone gauze is also put into the opened bowel lumen for disinfection (Fig. 21.41). The assistant inserts a 60 mm linear Endo-GIA stapler through the 12 mm trocar of the left upper quadrant. The terminal ileum and the transverse colon are functionally side-to-side anastomosed with a 60 mm stapler (Fig. 21.42). After careful check of the anastomotic integrity in the bowel lumen and disinfection with povidone gauze (Fig. 21.43), the common opening of the anastomosis is closed with an absorbable suture (Fig. 21.44). The anastomotic seromuscular layer is sutured to reinforce and reduce anastomotic tension. Ileocolic mesentery is sutured to avoid internal abdominal hernia (Fig. 21.45). Two drainage tubes are placed in the abdominal cavity.

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Fig. 21.27 The division of the middle transverse colon is performed with 60 mm linear Endo-GIA stapler

Fig. 21.29 The right colon specimen is put into a sterile plastic protective sleeve, and the opening is fastened

Fig. 21.28 The stumps of the transverse colon are disinfected with povidone gauze

Fig. 21.30 Colonoscopy is inserted into transverse colon lumen from anus

Postoperative Abdominal Wall and Specimen Display See Figs. 21.46 and 21.47.

Key Points, Difficulties, and Hot Spots Related to Surgery In the process of transcolonic specimen extraction, there are two narrow intestinal segments that are the most difficult for the specimen to pass through: the splenic flexure of the colon and the sigmoid. Hence, this surgical procedure is only

applicable to well-selected patients. An appropriate patient should have a normal body mass index (BMI), and the size of the tumor as well as the size of the mesocolon should not be large. During operation, the aseptic and tumor-free principles should be followed, which are key to the success of NOSES VIII C (Ouyang et al. 2020b). Here are a few tips: (a) Transcolonic NOSES is highly dependent on the patient’s clinical condition. The specimen should be less than 5 cm in circumferential diameter to be extracted through the colon, and the patient’s body mass index (BMI) should be less than 25 kg/m2.

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Fig. 21.31 Cut open the bowel stump to expose the colonoscopy and disinfect it with povidone gauze

Fig. 21.32 After being disinfected with the povidone gauze, the protective sleeve is clamped with the endoscopic foreign body retrieval

(b) The bowel remains open in the abdominal cavity during the specimen extraction and digestive tract reconstruction under laparoscopy, so the digestive tract should be fully prepared before operation. (c) Povidone gauze is used all along to disinfect the bowel stump and opened bowel lumen for the functional sideto-side anastomosis. (d) The sterile protective sleeve should be long enough (60 cm), thin, tightened, and lubricated for the specimen to be straightened, closed, and easily dragged out. (e) The sterile protective sleeve should be pulled out slowly by endoscopic foreign body retrieval with tacit surgical cooperation between the laparoscopic physician and

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Fig. 21.33 The protective sleeve with the specimen is moved into the left transverse colon

Fig. 21.34 The protective sleeve with the specimen is moved into the splenic flexure of the colon

endoscopic physician. It can reduce the possibility of bowel contents and tumor cells falling into the abdominal cavity or enteric cavity. (f) In the process of transcolonic extraction of specimens, we should be very careful to avoid damaging the bowel wall and the protective sleeve. Intraoperative aseptic and tumor-free techniques are strictly required. Laparoscopic radical right hemicolectomy with transcolonic specimen extraction is a safe and feasible procedure in well-selected patients (Ouyang et al. 2020a;

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Fig. 21.35 The protective sleeve with the specimen is moved into the descending colon

Fig. 21.36 The protective sleeve with the specimen is moved into the sigmoid colon

Wolthuis et al. 2014). There are several prerequisites for satisfactory surgical outcomes and less visible surgical scars: enough experience in laparoscopic operation, tacit cooperation among surgeons and endoscopists, adequate

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Fig. 21.37 The protective sleeve with the specimen is moved out of the anus

Fig. 21.38 The opened transverse colon stump is closed with 60 mm linear Endo-GIA stapler

preoperative bowel preparation, and strict adherence to aseptic and tumor-free principles. Currently, this surgical procedure can only be performed in well-equipped and large-scale research hospitals.

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Fig. 21.39 The bowel lumen of the terminal ileum is disinfected with povidone gauze

Fig. 21.41 Povidone gauze is inserted into the bowel lumen for disinfection

Fig. 21.40 A small incision is made on the antimesenteric bowel wall of the transverse colon

Fig. 21.42 The functional side-to-side anastomosis between the terminal ileum and the transverse colon is made with 60 mm linear Endo-GIA stapler

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Fig. 21.43 Povidone gauze is inserted into the common opening of the anastomosis for disinfection

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Fig. 21.45 Ileocolic mesentery is sutured to avoid an internal abdominal hernia

Fig. 21.44 The common opening of the anastomosis is closed with absorbable suture

Fig. 21.46 The display of abdominal wall

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References

Fig. 21.47 The display of specimen

Eshuis EJ, Voermans RP, Stokkers PC, van Berge Henegouwen MI, Fockens P, Bemelman WA. Laparoscopic resection with transcolonic specimen extraction for ileocaecal Crohn’s disease. Br J Surg. 2010;97(4):569–74. Kayaalp C, Kutluturk K, Yagci MA, Ates M. Laparoscopic right-sided colonic resection with transluminal colonoscopic specimen extraction. World J Gastrointest Endosc. 2015;7(12):1078–82. Leung AL, Cheung HY, Li MK. Advances in laparoscopic colorectal surgery: a review on NOTES and transanal extraction of specimen. Asian J Endosc Surg. 2014;7(1):11–6. Ouyang Q, Chen J, Wang W, Li X, Tan T, Xu S, Wang X, Peng J. Transcolonic natural orifice specimen extraction for laparoscopic radical right hemicolectomy on ascending colon cancer: one case report and literature review. Transl Cancer Res. 2020a;9(5):3734–41. Ouyang Q, Peng J, Xu S, Chen J, Wang W. Comparison of NOSES and conventional laparoscopic surgery in colorectal cancer: bacteriological and oncological concerns. Front Oncol. 2020b;10:946. Pascual M, Salvans S, Pera M. Laparoscopic colorectal surgery: current status and implementation of the latest technological innovations. World J Gastroenterol. 2016;22(2):704–17. Wang X, Guan X, Huang H. Laparoscopic right hemicolectomy with transvaginal specimen extraction (CRC-NOSES VIIIA). In: Wang X, editor. Natural orifice specimen extraction surgery. Singapore: Springer; 2021. https://doi.org/10.1007/978-981-15-7925-7_16. Wolthuis AM, de Buck van Overstraeten A, D’Hoore A. Laparoscopic natural orifice specimen extraction-colectomy: a systematic review. World J Gastroenterol. 2014;20(36):12981–92.

Laparoscopic Total Colectomy with Transanal Specimen Extraction (CRC-NOSES IX)

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Xishan Wang and Zheng Jiang

Contents Indications and Contraindications of NOSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316 Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316 Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . Anesthesia Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Patient Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trocar Placement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Special Surgical Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

316 316 316 316 317 317

Surgical Procedure, Techniques, and Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Exploration and Surgical Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dissection and Separation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Specimen Resection, Extraction, and Digestive Tract Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postoperative Abdominal Wall and Specimen Display . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

317 317 319 325 328

Key Points, Difficulties, and Hotspots Related to Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Anatomical Characteristics and Management of the Middle Colic Artery and Vein . . . . . . . . . . . . . . . . . . . The Importance of Preserving the Greater Omentum in Total Colectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other Anastomosis Methods for Total Colectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

329 329 329 329

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331

Abstract

NOSES IX is completed on the basis of laparoscopic total colectomy combined with unique digestive tract reconstruction and transanal specimen extraction. The main operating features of this procedure include complete laparoscopic total colectomy, specimen extraction from the anus, and totally laparoscopic side-to-end anastomosis between terminal ileum and rectum. From the technical point of view, total colectomy is one of the most difficult X. Wang (*) Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China

and complex surgical procedures in colorectal cancer resection. This procedure has a wide range of surgical resection, involving all technical difficulties regarding right hemicolectomy, left hemicolectomy, and rectal resection. These difficulties put forward high requirements to the surgeons, especially young surgeons’ operating skills. Theoretically, most surgeons believe that total colectomy with transanal specimen extraction is very difficult or even impossible. As a result, total colectomy with transanal specimen extraction is very rare in the surgical field. We propose the adoption of radical resection of colon cancer with greater omentum preserved in this procedure, so as to

Z. Jiang Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China © People’s Medical Publishing House, PR of China 2023 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-99-2750-0_22

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reduce the difficulty of transanal specimen extraction. This technique is entirely feasible as long as surgeons have clear anatomic understanding and solid operating skills. Keywords

Colorectal surgery · Transanal specimen extraction · NOSES · Laparoscopic total colectomy

Indications and Contraindications of NOSES

X. Wang and Z. Jiang

Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position Anesthesia Method General anesthesia or general epidural anesthesia.

Patient Positioning The patient is placed in functional lithotomy position with the abduction of both thighs, which facilitates to perform the operation for the surgeon (Fig. 22.3).

Indications 1. Familial adenomatous polyposis (Figs. 22.1 and 22.2). 2. Lynch syndrome-associated colorectal cancer. 3. Multiple primary colorectal cancer and the circumferential diameter of the largest tumor is better less than 3 cm. 4. Ulcerative colitis which is not sensitive to medical treatment. 5. Patients with constipation or other benign diseases that need total colectomy.

Trocar Placement 1. Camera trocar (10 mm trocar) is located at the umbilicus, which takes the right and left colic and rectal field of vision into consideration. 2. The surgeon’s main trocar 1 (12 mm trocar) is located at the left upper quadrant, which facilitates the right hemicolectomy.

Contraindications 1. Multiple primary colorectal cancer and the circumferential diameter of the tumor is more than 3 cm. 2. Severely obese patients (BMI > 35/m2) or patients with mesenteric thickening. 3. Tumor invades beyond the serosa.

Fig. 22.1 Extent of surgical resection

Fig. 22.2 CT virtual endoscopy: Tumor 1 is located at the junction between the descending colon and sigmoid colon, and tumor 2 is located at the ascending colon near the hepatic flexure

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Monitor

Assistant Surgeon

Fig. 22.3 The patient’s position Monitor Scrub Nurse Camera Holder

Fig. 22.5 Surgical team position (right hemicolectomy) Auxiliary Trocar 2 (5mm)

Camera Trocar (10mm)

Surgeon’s Main Trocar 2 (12mm)

Surgeon’s Main Trocar 1 (12mm) Auxiliary Trocar 1 (5mm)

Monitor

Camera Holder

Surgeon

Fig. 22.4 Trocar placement (five-ports method)

3. The surgeon’s main trocar 2 (12 mm trocar) is located at the McBurney’s point, which facilitates the left hemicolectomy and rectal resection. 4. The auxiliary trocar 1 (5 mm trocar) is located opposite the McBurney’s point. 5. The auxiliary trocar 2 (5 mm trocar) is located at the intersection between the transverse colon projection and the right midclavicular line (Fig. 22.4).

Surgical Team Position The right hemicolectomy: The surgeon stands on the left side of the patient, and the assistant stands on the right side of the patient. The left hemicolectomy and rectal resection: The surgeon stands on the right side of the patient, the assistant stands on the left side of the patient, and the camera holder stands on the same side of the surgeon or between two legs of the patient (Figs. 22.5 and 22.6).

Assistant

Monitor

Scrub Nurse

Fig. 22.6 Surgical team position (left hemicolectomy, rectal resection)

Surgical Procedure, Techniques, and Key Points The schematic view of main surgical procedures of specimen extraction and digestive reconstruction in NOSES IX (Fig. 22.7).

Exploration and Surgical Planning Based on a comprehensive preoperative examination and surgical plan discussion, the exploration mainly includes three steps:

Special Surgical Instruments Ultrasonic scalpel, 60 mm linear Endo-GIA stapler, 25 mm circular stapler, and sterile protective sleeve.

General Exploration After the laparoscope is placed into the umbilical port, the liver, gallbladder, stomach, spleen, colon, small intestine,

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Fig. 22.7 The main surgical procedures of specimen extraction and digestive reconstruction in NOSES IX

Fig. 22.8 Exploration of the transverse colon and its mesocolon

greater omentum, and pelvic cavity are routinely examined for the presence of tumor seeding or ascites (Fig. 22.8).

Fig. 22.9 Exploration of the tumor location (marked with methylthioninium chloride preoperatively)

Exploration of the Tumor For multiple primary tumors or polyposis with cancerization, the circumferential diameter of the largest tumor should be less than 3 cm (Fig. 22.9).

Evaluation of Anatomical Structures Total colectomy is very difficult since the colon has many adjacent organs and complicated vasculature. Abnormalities in blood vessels, abnormalities in the rectal ampulla, and

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mesenteric thickness should be excluded, and the feasibility of this procedure should be evaluated again.

Dissection and Separation Management of the Root of the Ileocolic Artery and Vein The surgeon stands on the left side of the patient, while the patient is placed in the anti-Trendelenburg position and slightly tilted to the left. The ileocolic vessels are lifted to expose the angle between the ileocolic vessels and the course of superior mesenteric vein (Fig. 22.10). After opening the mesentery at the root of the ileocolic vessels, dissection is performed along the Toldt’s fascia upwards from medial to lateral, then the horizontal part of the duodenum can be identified (Figs. 22.11 and 22.12). Following this, the lymph nodes are dissected at the root of the ileocolic vessels along the surface of the superior mesenteric vein. After adequate isolation (Fig. 22.13), the ileocolic vessels are ligated and transected at the root (Figs. 22.14 and 22.15).

Fig. 22.12 Dissection along the Toldt’s fascia from medial to lateral

Fig. 22.13 Isolation of the ileocolic artery and vein

Fig. 22.10 The angle between the superior mesenteric vein and ileocolic vessels Fig. 22.14 Ligation of the ileocolic artery

Fig. 22.11 Entering the space anterior to Toldt’s fascia

Fig. 22.15 Transection of the ileocolic vein

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Management of the Root of Right Colic Artery and Vein By lifting the stump of ileocolic vessels, dissection is performed the surface of the duodenum along the Toldt’s fascia gradually (Figs. 22.16 and 22.17). After that, dissection is continued along the right colic vein to the head of the pancreas and the superior mesenteric vein. Ligation and transection can be performed at the root of the right colic vein (Fig. 22.18). Subsequently, the surgeon dissects upwards along the surgical trunk of the superior mesenteric vein to expose the right colic artery, then ligates and transects it at the root (Fig. 22.19). Management of the Root of the Middle Colic Artery and Vein After the dissection of the right colic artery and vein, the inferior border of the pancreatic neck and the posterior wall of the gastric antrum can be identified. Then, the surgeon dissects upwards toward the area above the root of the right colic artery to expose the middle colic artery and vein (Fig. 22.20). Dissection in this area should be performed extremely carefully before double ligate and transect the middle colic vessels (Fig. 22.21). Then, the dissection is

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continued along the pancreatic neck to the left, to dissect the transverse mesocolon toward the Treitz ligament.

Management of the Terminal Ileum The mesentery of the terminal ileum is divided into the wall of the ileum. The cecum is free from the posterior peritoneal attachment, and direct access to the Toldt’s fascia is obtained

Fig. 22.18 Ligation of the right colic vein

Fig. 22.19 Ligation of the right colic artery Fig. 22.16 Right colic vein within the mesentery

Fig. 22.17 Exposure of Henle’s trunk

Fig. 22.20 Ligation of the middle colic artery

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Fig. 22.24 Opening the greater omentum Fig. 22.21 Isolation of the middle colic vein

Fig. 22.25 Dissect to the left for the dissection of the greater omentum to the lower pole of the spleen Fig. 22.22 Dissection of the mesoileum

Fig. 22.23 Isolation of wall of the ileum

(Fig. 22.22). Approximately 2–3 cm of the wall of the ileum is isolated (Fig. 22.23). The blood supply line should be checked carefully to ensure the blood supply of the anastomosis.

Management of the Greater Omentum In the middle of the transverse colon, the surgeon detaches the greater omentum from the wall of the transverse colon to enter the omental cavity (Fig. 22.24). The assistant then

flips the greater omentum, and the gauze on the surface of the pancreatic body is visible. On the right side of the stomach and colon, the gastrocolic ligament and transverse mesocolon are mostly fused, but there is a space between them. Dissection is performed along the right gastroepiploic artery and vein to the right to give direct access to the mesentery at the inferior border of the pancreas, as indicated by the gauze placed before. Dissection is further continued to the surface of the duodenum to give direct access to the previous dissection space, then the right greater omentum is separated completely. Subsequently, the attachment of the greater omentum is detached along the taeniae coli to the splenic flexure until the lower pole of the spleen is exposed. A gauze is placed on the surface of the pancreatic tail for protection and indication (Fig. 22.25).

Dissection of the Right Paracolic Sulcus and Its Mesentery The dissection of hepatic flexure is performed downwards along the surface of the duodenum and Toldt’s fascia in a medial to lateral fashion (Figs. 22.26 and 22.27) until reaching the cecum. At this point, the right colon is completely mobilized.

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Fig. 22.26 Dissection of hepatic flexure of the colon

Fig. 22.29 Dissection downwards along the Toldt’s fascia

Fig. 22.27 Opening the right paracolic sulcus from the hepatic flexure of colon downwards

Fig. 22.30 Dissection upwards along the Toldt’s fascia

Fig. 22.28 Dissection along the Toldt’s fascia to the left Fig. 22.31 Isolation of the inferior mesenteric artery

Management of the Root of the Inferior Mesenteric Artery The surgeon stands on the right side of the patient, and the patient is placed in the right-tilted anti-Trendelenburg position. Then the surgeon opens the mesorectum below the sacral promontory to enter the presacral space and dissects upwards to the left (Figs. 22.28 and 22.29) to identify the inferior hypogastric nerves. The dissection is continued upwards to the root of the inferior mesenteric artery

(Fig. 22.30). Approximately 1 cm of the vessel is isolated before double ligation and transection is performed at its origin (Figs. 22.31 and 22.32).

Management of the Inferior Mesenteric Vein The root of the inferior mesenteric artery is lifted, and the posterior peritoneum is incised along the lateral side of the abdominal aorta toward the Treitz ligament. As the space anterior to Toldt’s fascia is further expanded, the course of

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Fig. 22.35 Placing small gauze underneath the mesentery Fig. 22.32 Double ligation of the inferior mesenteric artery

Fig. 22.36 Exposure of the left ureter

Fig. 22.33 Isolation of the inferior mesenteric vein

Fig. 22.37 Exposure of adipose capsule of the kidney

Fig. 22.34 Ligation of the inferior mesenteric vein

the inferior mesenteric vein can be identified (Fig. 22.33). On the left side of the Treitz ligament, the inferior mesenteric vein is ligated and transected at the inferior border of the pancreas (Fig. 22.34). After the dissection of the mesentery, the surgeon places a gauze underneath the dissected mesentery for protection and indication (Fig. 22.35). At this point, all vessels supplying the left colon have been transected.

Management of Left Mesocolon and Left Paracolic Sulcus The mesentery is lifted for the dissection along the Toldt’s fascia from medial to lateral, then the peristalsis and course of the left ureter can be identified (Fig. 22.36), as well as the left gonadal vessels and left adipose capsule of the kidney (Fig. 22.37). The correct dissection plane should be smooth, flat, and clean. Under the indication and protection of gauze, the dissection is performed along the inferior border of the pancreas to the lower pole of the spleen, then the splenic flexure is mobilized (Fig. 22.38). Afterward, the dissection

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Fig. 22.40 Dissection of the posterior rectal wall Fig. 22.38 Dissection of the mesentery to the lower pole of the spleen

Fig. 22.41 Dissection of the right rectal wall Fig. 22.39 Dissection of mesentery along the left paracolic sulcus to the splenic flexure

proceeds downwards along the left paracolic sulcus to the sigmoid colon (Fig. 22.39).

Dissection of the Mesorectum The surgeon should determine the extent of rectal resection according to the nature of the lesion. If the rectal lesion is malignant, the extent of resection may be 3–5 cm below the lesion. If the rectal lesion is benign, the rectal ampulla may be preserved, and polyps in the rectum may be resected under colonoscopy. The posterior and right wall of the mesorectum is dissected along the presacral space according to the principle of TME (Figs. 22.40 and 22.41). Detailed operation is the same as before. Subsequently, the adhesion between the sigmoid colon and the left abdominal wall is detached (Fig. 22.42), and the peritoneum on the left of the rectum is separated to the intended resection line. Isolation of Rectum from the Intended Resection Line On the right side of the intended resection line, the rectum is isolated layer by layer. Following this, the surgeon

Fig. 22.42 Detach the adhesion between the sigmoid colon and the lateral abdominal wall

transects the mesorectum at the same level on the left side of the rectum, and the assistant lifts the rectum to further isolate the posterior rectal wall and get both sides connected (Fig. 22.43). The peritoneal reflection is incised to perform dissection around the anterior rectal wall (Fig. 22.44).

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Fig. 22.43 Isolation of the right rectum wall

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Fig. 22.46 Making an incision on the rectal wall above the intended resection line of the rectum

Fig. 22.44 Cutting open the peritoneal reflection Fig. 22.47 Disinfection of bowel stump with iodoform gauze

Fig. 22.45 Transection of ileum

Specimen Resection, Extraction, and Digestive Tract Reconstruction Specimen Resection The ileum is transected with a linear Endo-GIA stapler at the isolated area of the ileum (Fig. 22.45) and a window is made on the rectal wall above the intended resection line of the rectum (Figs. 22.46 and 22.47). The distal rectum is transected after sufficient safe distal resection margin is doublechecked. At this point, the dissection and resection of the total colon are completed.

Fig. 22.48 Placement of protective sleeve

Specimen Extraction A large amount of research literatures and clinical practice have fully confirmed that the anus is the most ideal orifice to extract colorectal specimen which is more in line with the basic requirements of minimally invasive surgery (Wolthuis et al. 2011; Han et al. 2013). The sterile plastic protective sleeve is inserted into the abdominal cavity through the main trocar, then the distal end of the protective sleeve is pulled out of the anus through the distal rectal stump (Fig. 22.48).

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The assistant and surgeon place the proximal rectal stump into the protective sleeve (Fig. 22.49), then the assistant applies the oval forceps to clamp the rectal stump and slowly pulls the total colon specimen out of the body through the protective sleeve inside the rectum (Figs. 22.50 and 22.51). Previous findings showed that transluminal specimen extraction provided the same degree of protection as in a transabdominal specimen extraction by comparison of peritoneal tumor cytology

Fig. 22.49 Placing the specimen into the protective sleeve

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test (Ngu and Wong 2016). This indicated that NOSES in colorectal surgery can completely meet the requirements of tumor-free technology.

Digestive Tract Reconstruction The pelvic cavity is then irrigated by sufficient dilute iodine solution and inspected for bleeding before digestive tract reconstruction (Fig. 22.52). The assistant inserts the anvil into the abdominal cavity through the protective sleeve inside the rectal stump (Fig. 22.53). The distance between the terminal ileum and the rectal stump is checked to select the anastomosis site in the ileum. The surgeon then makes an incision of approximately 2 cm on the ileum stump along the staple line (Fig. 22.54) and places the anvil into the intended anastomosis site in the ileal cavity (Fig. 22.55). The ileum stump is closed with a linear Endo-GIA stapler (Fig. 22.56), then a small incision is made in the intended anastomosis site of the ileum to take out the anvil shaft (Fig. 22.57). The rectal stump is closed with a linear Endo-GIA stapler (Fig. 22.58), and the resected stump tissue is extracted with a specimen retrieval bag through the 12 mm trocar (Fig. 22.59). The assistant inserts the circular stapler through the anus and extends the trocar to pierce one corner of the rectal stump (Fig. 22.60). The anvil is connected to the stapler (Fig. 22.61),

Fig. 22.50 Transanal extraction of the specimen (intraperitoneal view) Fig. 22.52 Irrigation with dilute iodine solution

Fig. 22.51 Transanal extraction of the specimen (extracorporeal view)

Fig. 22.53 Inserting the anvil through the anus

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Fig. 22.54 Cutting open the ileum stump

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Fig. 22.58 Transection of the rectal stump

Fig. 22.55 Inserting the anvil into the ileum Fig. 22.59 Taking out the rectal stump from the main trocar

Fig. 22.56 Transection of the ileum

Fig. 22.60 Extend the trocar of the stapler to pierce the rectal stump

Fig. 22.57 Taking out the anvil shaft

Fig. 22.61 Connecting the anvil with trocar of the stapler

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Fig. 22.62 Side-to-end anastomosis between the ileum and rectum

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Fig. 22.65 Drainage tube is placed on the right side of the abdominal cavity

Fig. 22.63 Air leak test

Fig. 22.64 Drainage tube is placed on the left side of the abdominal cavity

and the stapler is fired to complete the side-to-end anastomosis between the ileum and the rectum (Fig. 22.62). Check the integrity of the anastomotic ring carefully. An air leak test is also performed to confirm the integrity of the anastomosis (Fig. 22.63). After excluding active bleeding, two drainage tubes are placed in the two sides of the pelvic cavity through the trocars on the left and right

Fig. 22.66 Postoperative abdominal wall display

lower quadrant (Figs. 22.64 and 22.65). Finally, the pneumoperitoneum is released and the trocar sites are closed to complete the surgery.

Postoperative Abdominal Wall and Specimen Display See Figs. 22.66 and 22.67.

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Fig. 22.68 Exposure of the middle colic vein and its left and right branches

The Importance of Preserving the Greater Omentum in Total Colectomy Fig. 22.67 Specimen display

Key Points, Difficulties, and Hotspots Related to Surgery The Anatomical Characteristics and Management of the Middle Colic Artery and Vein According to the principle of radical resection, the middle colic artery and vein should be ligated at the root. The posterior peritoneum is incised along the course of the superior mesenteric vein, and the superior mesenteric vessels are exposed. The superior mesenteric vein is superficial and wide in diameters, and it is therefore easy to be identified and exposed. The superior mesenteric artery is located on the left side of the superior mesenteric vein and gives off the middle colic artery from the inferior border of the pancreas. When the transverse mesocolon is lifted, the middle colic vein and its branches can be seen toward the transverse colon (Fig. 22.68). In the inferior border of the pancreas, the middle colic artery and vein should be ligated at the root with a vascular clip, and the lymph nodes at the root of blood vessels can be dissected. The middle colic vessels should be isolated clean without damage. During the dissection of these vessels, the surgeon should pay attention to the method of applying the ultrasonic scalpel. The blade of the ultrasonic scalpel should be placed away from the blood vessel wall.

Although the extent of the lesion is wide for patients who undergo total colectomy, the lesion stage is often early and the probability of tumor metastasis to the greater omentum is extremely low. Therefore, the preservation of the greater omentum is a key technique in this procedure. Firstly, greater omentum has important physiological functions. The loose connective tissues of the omentum contain a large number of macrophages. When bacteria or other microbes invade into the abdominal cavity, it will be surrounded and swallowed by the macrophages before long. Abdominal inflammation can also be confined by the greater omentum, so that the inflammation does not spread rapidly. In addition, the greater omentum has a secretory function. In normal circumstances, the greater omentum can secrete a small amount of peritoneal fluid to lubricate the surface of the organ to reduce their movement friction. By preserving the greater omentum, its immune function is preserved and the occurrence of intestinal adhesion is reduced as well. Secondly, the technical difficulty of this procedure is the specimen extraction through the natural orifice. If the greater omentum can be preserved, the difficulty of specimen extraction from the anus will be greatly reduced. Therefore, we advocate to preserve the greater omentum in NOSES IX.

Other Anastomosis Methods for Total Colectomy For patients diagnosed with lesions in the lower rectum, the sufficient length of the distal rectum cannot be preserved to complete the anastomosis between ileum and rectum. We may adopt other methods for anastomosis. The rectum can

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Fig. 22.69 Intraperitoneal dissection of rectum to the intersphincteric sulcus

Fig. 22.70 Complete transanal transection of the rectum

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Fig. 22.72 Transanal extraction of specimen

Fig. 22.73 Suture of terminal ileum to distal rectal stump

Fig. 22.71 Transanal placement of incision protector

Fig. 22.74 Ileum stump after the completion of anastomosis

be dissected intraperitoneally to the intersphincteric sulcus (Fig. 22.69), the rectum is completely transected extracorporeally through the anus (Fig. 22.70), and the proximal end of the rectal stump is sutured with fixation sutures for traction. A 60 mm incision protector is inserted (Fig. 22.71). The specimen is extracted out of the anus (Fig. 22.72), the anus is

closed, the pneumoperitoneum is reestablished, the terminal ileum is sent to the anus after the mesentery is divided, and the terminal ileum is sutured with the distal rectal stump extracorporeally (Fig. 22.73). After the completion of the anastomosis (Fig. 22.74), the second anoplasty is performed electively.

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References Han FH, Hua LX, Zhao Z, et al. Transanal natural orifice specimen extraction for laparoscopic anterior resection in rectal cancer. World J Gastroenterol. 2013;19:7751–7. Ngu J, Wong AS. Transanal natural orifice specimen extraction in colorectal surgery: bacteriological and oncological concerns. ANZ J Surg. 2016;86:299–302.

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Wolthuis AM, Penninckx F, D’Hoore A. Laparoscopic sigmoid resection with transrectal specimen extraction has a good short-term outcome. Surg Endosc. 2011;25:2034–8.

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Contents Indications and Contraindications of NOSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334 Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334 Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . Anesthesia Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Patient Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trocar Placement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Special Surgical Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Surgical Procedure, Techniques, and Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Exploration and Surgical Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dissection and Separation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Specimen Resection, Extraction, and Digestive Tract Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postoperative Abdominal Wall and Specimen Display . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Key Points, Difficulties, and Hot Spots Related to Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Dissection Sequence and Operation Essentials of Total Colectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Total Colectomy with Rectal Ampulla Preserved . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diagnosis and Treatment of Familial Adenomatous Polyposis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diagnostic Criteria for Lynch Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

346 346 347 347 347

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347

Abstract

Total colectomy is one of the most difficult and complex techniques in colorectal surgery involving complex surgical procedures and a wide resection range. Compared with conventional laparoscopic total colectomy, the main differences of NOSES X lie in the digestive tract reconstruction and the route of specimen extraction. The main X. Wang (*) Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China Z. Jiang Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China R. Yang Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China © People’s Medical Publishing House, PR of China 2023 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-99-2750-0_23

operating features of this procedure include complete laparoscopic total colectomy, specimen extraction from the vagina, and totally laparoscopic side-to-end anastomosis between the terminal ileum and rectum. Compared with NOSES IX, the procedure of NOSES X has a wider indication. In addition, this technique reduces the exposure of bowel within the abdominal cavity, which may reduce the risk of infection. The safe and orderly implementation of NOSES X requires the surgeons to have a solid anatomical understanding and clear surgical thinking. Keywords

Colorectal surgery · Transvaginal specimen extraction · NOSES · Laparoscopic total colectomy

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Indications and Contraindications of NOSES

Patient Positioning

Indications

The patient is placed in functional lithotomy position with both thighs slightly elevated, which facilitates to perform the operation for the surgeon (Fig. 23.2).

1. The patient has multiple malignant tumors in the colon and rectum, with the largest tumor having a circumferential diameter of less than 5 cm (Fig. 23.1). 2. Familial adenomatous polyposis, which is hard to be extracted through the anus. 3. Lynch syndrome-associated colorectal cancer. 4. Ulcerative colitis which is not sensitive to medical treatment and local mesenteric thickening, which makes it hard for specimen to be extracted from the anus. 5. This procedure is suitable for total colectomy with complete resection of the greater omentum.

Contraindications 1. Multiple primary colorectal cancer, and the circumferential diameter of tumor, is more than 5 cm. 2. Severely obese patients (BMI > 35 kg/m2), or patients with mesenteric thickening. 3. Tumor invades beyond the serosa.

Trocar Placement 1. Camera trocar (10 mm trocar) is located at the umbilicus, which takes the right and left colic and rectal field of vision into consideration. 2. The surgeon’s main trocar 1 (12 mm trocar) is located at the left upper quadrant, which facilitates the right hemicolectomy. 3. The surgeon’s main trocar 2 (12 mm trocar) is located at the McBurney’s point, which facilitates the left hemicolectomy and rectal resection. 4. The auxiliary trocar 1 (5 mm trocar) is located opposite. 5. The auxiliary trocar 2 (5 mm trocar) is located at the intersection between the transverse colon projection and the right midclavicular line (Fig. 23.3).

Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position Anesthesia Method General anesthesia or general epidural anesthesia.

Fig. 23.2 The patient’s position

Auxiliary Trocar 2 (5mm)

Camera Trocar (10mm)

Surgeon’s Main Trocar 2 (12mm)

Fig. 23.1 Extent of surgical resection

Fig. 23.3 Trocar placement (five-port method)

Surgeon’s Main Trocar 1 (12mm)

Auxiliary Trocar 1 (5mm)

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Surgical Team Position

Surgical Procedure, Techniques, and Key Points

The Right Hemicolectomy The surgeon stands on the left side of the patient; the assistant stands on the right side of the patient.

The schematic view of main surgical procedures of specimen extraction and digestive reconstruction in NOSES X (Fig. 23.6).

The Left Hemicolectomy and Rectal Resection The surgeon stands on the right side of the patient; the assistant stands on the left side of the patient. The camera holder stands on the same side of the surgeon or between two legs of the patient (Figs. 23.4 and 23.5).

Special Surgical Instruments Ultrasonic scalpel, 60 mm linear Endo GIA stapler, 25 mm circular stapler, vaginal suture line, uterine manipulator, and sterile protective sleeve.

Monitor

Exploration and Surgical Planning Based on comprehensive preoperative examination and surgical plan discussion, the exploration mainly includes three steps.

General Exploration After the laparoscope is placed into the umbilical port, the liver, gallbladder, stomach, spleen, colon, small intestine, greater omentum, and pelvic cavity are routinely examined for the presence of tumor seeding or ascites (Figs. 23.7 and 23.8). Exploration of the Tumor For multiple primary tumors, the evaluation of the largest tumor is most critical, and the circumferential diameter of the largest tumor is the most important factor for determining whether this NOSES procedure can be performed (Fig. 23.9).

Surgeon Assistant

Monitor Scrub Nurse

Evaluation of Anatomical Structures Total colectomy is very complex. It is necessary to observe the adjacent organs thoroughly. Abnormalities in blood vessels, abnormalities in vagina, and mesenteric thickness should be excluded, and the feasibility of this procedure should be evaluated again.

Camera Holder

Dissection and Separation

Fig. 23.4 Surgical team position (right hemicolectomy)

Camera Holder

Monitor

Surgeon Assistant

Monitor

Scrub Nurse

Fig. 23.5 Surgical team position (left hemicolectomy, rectal resection)

Management of the Root of the Ileocolic Artery and Vein The surgeon stands on the left side of the patient, and the patient is placed in the anti-Trendelenburg position slightly tilted to the left. After the surgical field is fully exposed, the surgeon opens the sheath of blood vessels below the root of the ileocolic artery and vein (Fig. 23.10) and on the surface of the superior mesenteric vein (Figs. 23.11 and 23.12). Dissection is continued upward on the surface of the superior mesenteric vein. The ileocolic artery is often accompanied by the ileocolic vein, and the ileocolic artery crosses the superior mesenteric vein to join the course of the ileocolic vein. Occasionally, they are separated, and the ileocolic artery is derived from the posterior of the superior mesenteric vein. After adequate isolation, the ileocolic vessels are ligated and transected at the root (Figs. 23.13 and 23.14).

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Fig. 23.6 The main surgical procedures of specimen extraction and digestive reconstruction in NOSES X

Fig. 23.7 Exploration of the liver’s surface

Fig. 23.8 Exploration of gallbladder and liver (visceral surface)

Management of the Root of Right Colic Artery and Vein Dissect upward along the superior mesenteric vein, then open the sheath of blood vessels to expose the right colic artery first. In most cases, the right colic artery is not accompanied by the vein, and they need to be managed separately.

However, in rare cases, the right colic artery is accompanied by the vein and can be managed simultaneously (Figs. 23.15, 23.16, and 23.17). The stump of the right colic artery is lifted, and dissection is performed upward in a medial to lateral pattern. During the dissection, the pancreatic capsule is visible and the Toldt’s fascia should be dissected on the surface

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Fig. 23.9 Exploration of the tumor location (marked with methylthioninium chloride preoperatively)

Fig. 23.10 The junction between superior mesenteric vein and ileocolic vessels

Fig. 23.11 Opening the mesentery at the root of the ileocolic vessels

of the pancreas (Figs. 23.18, 23.19, and 23.20). Henle’s trunk is usually located on the surface of pancreas. There are two smaller veins drain into the Henle’s trunk, respectively. The vein from the right is the right colic vein, which can be ligated at the root, and the vein from the superior is connected with the right gastroepiploic vein.

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Fig. 23.12 Dissection of mesentery along the Toldt’s fascia from medial to lateral

Fig. 23.13 Ligation of ileocolic vessels

Fig. 23.14 Transection of ileocolic vessels

Management of the Root of the Middle Colic Artery and Vein After the dissection of the right colic artery and vein, the inferior border of the pancreatic neck can be exposed. The mesentery is opened, then the middle colic vessels are isolated and double ligated at the root (Fig. 23.21). At this point, all vessels supplying the right colon have been managed.

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Fig. 23.15 Dissection of the mesentery on the surface of duodenum

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Fig. 23.19 Exposure of the pancreatic capsule

Fig. 23.16 Isolation of the right colic artery and vein Fig. 23.20 Dissection of the Toldt’s fascia on the surface of the pancreatic capsule

Fig. 23.17 Ligation of the right colic artery and vein

Fig. 23.21 Isolation of the middle colic artery and vein

Fig. 23.18 Transection of the right colic artery and vein

Dissection of the Right Mesocolon First, the stumps of right colic vessels are lifted, and blunt and sharp dissection is performed along the Toldt’s fascia downward and upward in a medial to lateral fashion. Dissection is then continued to the surface of duodenum, and the correct dissection plane should be smooth, flat, and clean. The identification of right ureter and the right gonadal vessels also indicates the correct space for dissection (Fig. 23.22).

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Management of the Terminal Ileum The surgeon grasps the terminal ileum and carefully divides the mesentery according to the status of the marginal vessels. End-to-end anastomosis between the ileum and rectum can be performed if the colon specimen can be completely extracted through the vagina. If it is difficult, side-to-end anastomosis between the ileum and rectum can be performed. The mesentery of the terminal ileum is divided to the wall of the ileum, and approximately 2–3 cm of the wall of ileum is isolated. The blood supply line should be checked carefully to ensure the blood supply of the anastomosis (Fig. 23.23). Dissection of the Right Paracolic Sulcus and Greater Omentum The greater curvature is lifted to expose the course of the gastroepiploic vessels. In the transparent thin area of the gastrocolic ligament, the ultrasonic scalpel is applied to open the gastrocolic ligament to enter the omental bursa (Figs. 23.24, 23.25, and 23.26), and the course of the pancreas can be seen. Along the course of the right gastroepiploic artery and vein, the gastrocolic ligament is dissected and transected (Figs. 23.27 and 23.28), whereafter the dissection is continued to the right to Henle’s trunk (Fig. 23.29). Subsequently, the posterior gastric wall and the right transverse mesocolon are dissected, and the

Fig. 23.24 Opening the gastrocolic ligament

Fig. 23.25 Gauze underneath the mesentery

Fig. 23.22 Complete dissection of Toldt’s fascia

Fig. 23.26 Management of the transverse mesocolon

Fig. 23.23 Dissection of the mesoileum

Fig. 23.27 Dissection and transection of the gastrocolic ligament

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Fig. 23.28 Exposure of the branch of right gastroepiploic vein

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Fig. 23.31 Dissection of the right paracolic sulcus

Fig. 23.29 Exposure of Henle’s trunk Fig. 23.32 Dissection along the Toldt’s fascia from medial to lateral

Fig. 23.30 Transection of the hepatocolic ligament

dissection planes are connected. After the hepatocolic ligament is transected (Fig. 23.30), the surgeon incises downward along the right paracolic sulcus to the attachment of cecum (Fig. 23.31) and gives direct access to the dissected mesentery of the terminal ileum. At this point, the dissection of the right colon has been completed.

Management of the Root of the Inferior Mesenteric Artery The surgeon stands on the right side of the patient, and the patient is placed in the anti-Trendelenburg position with right side tilted. The surgical field is adequately exposed. At this point, since the dissection of the mesentery of the terminal ileum is completed, the abdominal aorta and its bifurcation

Fig. 23.33 Isolation of the inferior mesenteric artery

are visible (Fig. 23.32). The posterior peritoneum is incised at the angle between the abdominal aorta and the inferior mesenteric artery. The lymphatic and adipose tissues are dissected at the root of the inferior mesenteric artery, and double ligation is performed at the root of vessels (Figs. 23.33 and 23.34).

Management of the Root of the Inferior Mesenteric Vein Dissection is performed along the left side of the abdominal aorta from the root of the inferior mesenteric artery to the

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Fig. 23.34 Double ligation of the inferior mesenteric artery

Fig. 23.37 Surface of the left mesocolon

Fig. 23.35 Dissection along the Toldt’s fascia from medial to lateral

Fig. 23.38 Placing a gauze beneath the mesocolon

Fig. 23.36 Ligation of the inferior mesenteric vein

Fig. 23.39 Dissection to the left along the gastroepiploic vessels

Treitz ligament in a medial to lateral fashion. The left mesocolon is lifted (Fig. 23.35) to transect the inferior mesenteric vein at the inferior border of the pancreas lateral to the Treitz ligament (Fig. 23.36).

can be observed, and the left gonadal vessels and the left adipose capsule of kidney are identified. A gauze is placed underneath the mesentery for protection and indication (Fig. 23.38).

Dissection of the Left Mesocolon The surgeon lifts the left mesocolon and the inferior mesenteric artery stump and continues dissecting along the Toldt’s fascia downward and upward in a medial to lateral fashion. The correct dissection plane should be smooth, flat, and clean (Fig. 23.37). The course and peristalsis of the left ureter

Management of the Left Greater Omentum and the Left Transverse Mesocolon The surgeon lifts the gastroepiploic vessels with the left hand and dissects along the gastroepiploic vessels to the left (Fig. 23.39). Gradually, dissection is continued to the gastrocolic ligament, then to the lower pole of spleen

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Fig. 23.40 Dissection to the left to the lower pole of spleen Fig. 23.42 Dissection of the left paracolic sulcus

Fig. 23.41 Dissection of the splenocolic ligament

(Fig. 23.40). The assistant pulls down the greater omentum to expose the left transverse mesocolon and the pancreatic tail. In most cases, this is the avascular area of mesentery. Occasionally, there are communicating branches between the splenic flexure, the jejunal mesentery vessels in the left side of Treitz ligament, and the vessels near the pancreatic tail. The surgeon applies the ultrasonic scalpel to dissect along the inferior border of pancreas, from the Treitz ligament and inferior mesenteric vein stump to the spleen and the paracolic sulcus lateral to the splenic flexure (Figs. 23.41, 23.42, and 23.43). When the dissection reaches the gauze underneath the left mesocolon, the left colon is mobilized completely (Fig. 23.44).

Dissection of Mesorectum and the Isolation of Rectum The extent of rectal resection depends on the nature of the lesion, and the rectal ampulla should be preserved if possible. The defecation reflex receptors are located in the rectal ampulla. Therefore, the preservation of rectal ampulla can maintain the integrity of defecation reflex pathway, which facilitates the maintenance and recovery of bowel function. After the dissection of posterior and right rectal wall

Fig. 23.43 Dissection upward along the left paracolic sulcus to the splenic flexure

Fig. 23.44 The inferior border of pancreas and the splenic flexure after dissection

according to the principle of TME (Fig. 23.45), the surgeon detaches the physiological sigmoid adhesions and dissects the peritoneum on the left of the rectum to the intended resection line (Fig. 23.46). The mesorectum on the right side of intended resection line on the rectum is transected. Occasionally, the diameters of the superior rectal vessels are too big, and the distal side of vessels can be ligated with

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Fig. 23.45 Dissection downward along the Toldt’s fascia

Fig. 23.46 Opening the left sigmoid mesocolon

vascular clips to avoid bleeding. Following this, the surgeon transects the mesorectum at the same level on the left side of the rectum, and the assistant lifts the rectum to further isolate the posterior rectal wall and get both sides connected.

Specimen Resection, Extraction, and Digestive Tract Reconstruction Specimen Resection With linear Endo GIA stapler, the rectum is transected at the intended resection line on the isolated area of rectum (Fig. 23.47), as well as the ileum (Fig. 23.48). Specimen Extraction The vagina has also been considered another ideal option to remove more bulky colorectal specimen when compared with anus, which presented several properties involving good elasticity, adequate blood supply, healing ability, and easy access (Wolthuis et al. 2014; Yagci et al. 2014; Torres et al. 2012). After the vaginal irrigation, the assistant introduces the bladder retractor through the vagina to indicate the posterior vaginal fornix. Under its indication, the surgeon applies

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Fig. 23.47 Transection of the rectum

Fig. 23.48 Transection of the small intestine

the ultrasonic scalpel to open the posterior vaginal fornix transversely for approximately 3 cm and extends the incision to 5–6 cm by longitudinal stretch (Fig. 23.49). The protective sleeve is introduced into the abdominal cavity through the main trocar. The assistant applies the oval forceps to clamp the distal end of protective sleeve and pull it out through the vagina (Fig. 23.50). At the same time, the surgeon and the assistant place the whole colon into the protective sleeve step-by-step (Fig. 23.51), and the assistant gently pulls the specimen out of the body through the protective sleeve inside the vagina (Fig. 23.52).

Digestive Tract Reconstruction The assistant inserts the anvil into the abdominal cavity through the vagina, evaluates the distance between the terminal ileum and the rectal stump, and selects the site of anastomosis in the ileum. An incision of approximately 2 cm is made on the ileum stump along the staple line (Fig. 23.53), through which the anvil is placed in the ileal cavity (Fig. 23.54). After the adjustment of position, the ileum stump is transected with the linear Endo GIA stapler (Fig. 23.55), and the resected stump can be extracted through the vagina. A small incision in the intended anastomosis site of the ileum is made to take out the anvil shaft (Fig. 23.56).

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Fig. 23.49 Opening the posterior vaginal fornix Fig. 23.52 Transvaginal extraction of specimen

Fig. 23.50 Placement of protective sleeve Fig. 23.53 Cutting open the ileum stump

Fig. 23.51 Placing the specimen into the protective sleeve

The assistant inserts the circular stapler through the anus and extends trocar to pierce one corner of the rectal stump (Fig. 23.57). The anvil is connected to the trocar of stapler (Fig. 23.58) to complete the side-to-end anastomosis between the ileum and the rectum, then the anastomosis is sutured to be reinforced (Fig. 23.59). Check the integrity of the anastomotic ring carefully. Air leak test is performed to confirm the integrity of the anastomosis (Fig. 23.60), and active bleeding should be excluded. Two drainage tubes are placed in the

Fig. 23.54 Inserting the anvil into the ileum

pelvic cavity through the trocars on the left and right lower quadrant (Figs. 23.61 and 23.62). Finally, the pneumoperitoneum is released and trocar sites are closed.

Suturing of the Vaginal Incision Fully expose the vaginal incision, clamp the anterior and posterior wall of the vaginal incision with two Allis forceps,

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Fig. 23.55 Closing the ileum

Fig. 23.56 Taking out the anvil shaft

Fig. 23.57 Inserting the stapler through the anus

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Fig. 23.59 Reinforcement and suture of anastomosis

Fig. 23.60 Air leak test

Fig. 23.61 Drainage tube is placed on the left side of the abdominal cavity

and perform interrupted suture with absorbable sutures (Fig. 23.63). After making sure that there is no leakage or bleeding, an iodoform gauze can be indwelled in the vagina to compress the posterior vaginal fornix, and the gauze should be extracted 48 h after operation.

Postoperative Abdominal Wall and Specimen Display See Figs. 23.64 and 23.65. Fig. 23.58 Side-to-end anastomosis between the ileum and rectum

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Fig. 23.62 Drainage tube is placed on the right side of the abdominal cavity Fig. 23.64 Specimen display

Fig. 23.63 Interrupted suture of vaginal incision

Key Points, Difficulties, and Hot Spots Related to Surgery The Dissection Sequence and Operation Essentials of Total Colectomy Total colectomy involves a wide extent of resection, complex technique, large surgical trauma, and long operating time. It is considered one of the most difficult procedures in colorectal surgery. Therefore, in order to complete the NOSES IX and NOSES X, the surgeons must have solid surgical skills for open total colectomy and extensive experience in laparoscopic operation. With regard to the dissection sequence of total colectomy, the clockwise direction of operation is recommended. In addition, we should perform this surgery step by step in avoidance of repeated operation in the same surgical field. In this way, the operation time can be shortened and the continuity of surgery can be ensured. Furthermore, the operation should follow the medial approach. For benign lesions of the colon (e.g., familial adenomatous polyposis without canceration), there is no need to dissect the

Fig. 23.65 Postoperative abdominal wall display

lymph nodes around the vessels. However, it is still necessary to carry out high ligation of the blood vessels. Dissection of the mesentery close to the wall of the colon will make the whole process more cumbersome, and the unclear vascular exposure is more likely to cause bleeding and dissection of the wrong plane. The dissection of transverse colon, splenic flexure, and hepatic flexure is the most difficult part of the whole procedure, because of the complex anatomical structure of the colon and the adjacent organs, including the liver, duodenum, pancreas, spleen, etc. All operations should be performed carefully to avoid the secondary damage to these organs and structures. In addition, the advantage of laparoscopy is manifested as the enlargement of tissue structure, which makes the local surgical field clearer, and the tissue structure easier to recognize. However, the holistic and overall view of the operation is often neglected, especially for the junior surgeons, and the difficulty of operation will be greatly increased. However, this happens to be a complex procedure that requires the mastering of the

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overall situation. In order to overcome this difficulty, we must have a solid anatomical understanding and a spatial thinking in anatomy.

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could improve the patients’ quality of life and are more likely to be adopted by surgeons and patients. However, these patients need intensive follow-up postoperatively to detect and manage the polyps under colonoscopy in time.

Total Colectomy with Rectal Ampulla Preserved Diagnostic Criteria for Lynch Syndrome The rectal ampulla is rich in defecation reflex receptors, which plays an important role in the defecation and defecation control. In the treatment of familial adenomatous polyposis, Lynch syndrome, and other diseases, the rectal ampulla is not preserved in most cases, which greatly reduces the quality of life of patients after surgery. Therefore, for patients with mild lesions, individualized treatment can be given, and the total colectomy can be performed with the rectal ampulla preserved. The indications of preserving the rectal ampulla include (1) no malignant lesions in the rectal ampulla and (2) a small number of adenomas in the rectal ampulla, which can be treated with colonoscopy. According to our observation results, this method can significantly improve the patient’s postoperative defecation and bowel control, as well as reduce the frequency of bowel movements. However, for patients with rectal ampulla preserved, postoperative colonoscopy also needs to be regularly carried out to detect the early lesion and prevent the occurrence of cancer.

Diagnosis and Treatment of Familial Adenomatous Polyposis Familial adenomatous polyposis is an autosomal dominant genetic disease, which is liable to occur in the youth, where symptoms generally appear from 15 to 25 years old and become most significant at around 30 years old. It is characterized by colorectal polypoid adenomas of various sizes. If not timely treated, almost all cases will develop malignancy before 40 years old. The diagnosis of familial adenomatous polyposis is relatively easy. The general diagnosis criterion is more than 100 adenomatous polyps in the colon. For patients with less than 100 adenomas, the diagnosis can be made in combination with the patient’s family history, colonic lesions, retinal pigment epithelium hypertrophy, and other manifestations. For patients with familial adenomatous polyposis, early resection is currently the best treatment option. In principle, total colectomy and proctectomy should be performed. In clinical practice, the surgical approaches for this disease are as follows: (1) total colectomy and proctectomy with permanent ileal stoma; (2) total colectomy with anastomosis between the ileum and rectum; and (3) total colectomy with rectum ampulla preserved, i.e., total resection of colon and partial resection of rectum with rectum ampulla preserved and anastomosis between the ileum and the remnant rectum. Anal function could be preserved with the latter two approaches, which

Lynch syndrome refers to individuals with mismatch repair genes (MMR) mutations that lead to colorectal cancer and other malignancies, including those who are already suffering from tumors and who have not yet developed tumors. In the past, it was known as the hereditary nonadenomatous colorectal cancer. Later, researchers found that in addition to colorectal cancer, Lynch syndrome can also occur in endometrial cancer, gastric cancer, ovarian cancer, urethral cancer, and a series of Lynch syndromerelated tumors. Similar to familial adenomatous polyposis, Lynch syndrome is also an autosomal dominant genetic disease, which has an early age of onset and is prone to cause multiple primary tumors. The diagnostic criteria for Lynch syndrome was first proposed in 1991, i.e., the famous Amsterdam Criteria: (1) Having at least three relatives with histologically confirmed colorectal cancer, one of whom is a first-degree relative of the other two, familial adenomatous polyposis should be excluded; (2) at least two successive generations are involved; and (3) at least one of the patients is diagnosed before the age of 50. Then, the Amsterdam Criteria II (1999) and the Revised Bethesda Guidelines (2004) were successively proposed to revise the diagnosis of Lynch syndrome. With the wide application of molecular diagnosis in the treatment of cancer, the original series of diagnostic criteria are only applied as screening criteria for high-risk groups of Lynch syndrome. Currently, MMR gene testing is recognized as the most reliable criteria for the diagnosis of Lynch syndrome. In addition, some medical institutions begin to screen Lynch syndrome by using microsatellite instability detection, immunohistochemistry, and BRAF gene mutation detection followed by diagnostic tests of specific MMR gene sequencing to the patients, which can maintain the accuracy and reduce the cost of diagnosis.

References Torres RA, Orban RD, Tocaimaza L, et al. Transvaginal specimen extraction after laparoscopic colectomy. World J Surg. 2012;36: 1699–702. Wolthuis AM, De B, v O A, D’Hoore A. Laparoscopic natural orifce specimen extraction-colectomy: a systematic review. World J Gastroenterol. 2014;20:12981–92. Yagci MA, Kayaalp C, Novruzov NH. Intracorporeal mesenteric division of the colon can make the specimen more suitable for natural orifce extraction. J Laparoendosc Adv Surg Tech A. 2014;24:484–6.

Section III NOSES for Gastrointestinal Cancer Su Yan and Gang Yu

Laparoscopic Distal Gastrectomy (Billroth I) with Transrectal Specimen Extraction (GC-NOSES I)

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Contents Indications and Contraindications of NOSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351 Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 352 Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . Anesthesia Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Patient Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trocar Placement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Special Surgical Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Surgical Procedure, Techniques, and Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Exploration of the Abdominal and Pelvic Cavity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Perigastric Lymph Node Dissection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Transection of the Distal Stomach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Transanal Specimen Extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Digestive Tract Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Key Points and Difficulties Related to Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 358 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361

Abstract

The tumor is located in the middle and lower third of the stomach, the stage is T3 or below, and the largest diameter of the tumor is less than 5 cm. After the perigastric lymph node dissection is completed, the specimen is placed in the specimen bag and can be extracted through the rectum. This procedure with specimen extraction through a natural orifice is referred to as NOSES I for gastric cancer, which is mostly applicable to male patients. This procedure does not require auxiliary incisions in the abdominal wall to extract the specimen out of the body. After the surgery, only a few tiny trocar scars are left on the abdominal wall, which makes this procedure a truly total laparoscopic radical gastrectomy. This procedure not only has a good cosmetic appearance on the abdominal wall, but also reduces the incidence of postoperative pain and infection S. Yan (*) Department of Gastrointestinal Surgery, Qinghai University Affiliated Hospital, Xining, Qinghai, P. R. China © People’s Medical Publishing House, PR of China 2023 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-99-2750-0_24

caused by additional auxiliary incisions. The surgeons should have clear understanding of the indications and contraindications of this procedure. Keywords

NOSES · Gastrectomy · Gastric cancer · Laparoscopy · Transrectal

Indications and Contraindications of NOSES Indications 1. Gastric cancer, stage CT1-3, N0-1, M0, and with lesions in the distal part of stomach. 2. The largest diameter of tumor 5 cm. 3. BMI  30 kg/m2.

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Contraindications 1. The tumor is too large to be pulled out through the rectum. 2. It is suspected that the tumor invades beyond the serosa or involves adjacent organs. 3. Patients with acute gastrointestinal obstruction or tumor perforation requiring emergency surgery. 4. Severely obese patients (BMI > 30 kg/m2), especially those with high visceral fat content. 5. Patients with history of pelvic surgery or rectal and anal deformities.

Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position Anesthesia Method General anesthesia or general epidural anesthesia.

Patient Positioning During the perigastric lymph node dissection for distal gastric cancer and digestive tract reconstruction, the patient is placed in the reverse-Trendelenburg position with legs open

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(Fig. 24.1a, b). During the transanal specimen extraction, the patient is placed in the Trendelenburg position (Fig. 24.2a, b).

Trocar Placement In principle, the trocar sites are no different from those of laparoscopic distal gastrectomy, the five-ports method is routinely adopted (Fig. 24.3), and the trocar sites should be adjusted appropriately according to the patient’s BMI and shape of abdomen. 1. Camera trocar (10 mm trocar) is located at the umbilicus or 1 cm above or below the umbilicus according to the abdominal type of the patient. 2. The surgeon’s main trocar (12 mm trocar) is located 1 ~ 2 cm below the costal margin of the left anterior axillary line. 3. The surgeon’s left-hand trocar (5 mm trocar) is located at the umbilical level of the left midclavicular line. 4. The assistant’s left-hand trocar (5 mm trocar) is located 1 ~ 2 cm under the costal margin of the right anterior axillary line. 5. The assistant’s main trocar (10 mm trocar) is located at the umbilical level of the right midclavicular line.

Fig. 24.1 (a) The patient’s position during radical gastrectomy for distal gastric cancer; (b) the patient is placed in the reverse-Trendelenburg position with legs open during lymph node dissection and digestive tract reconstruction

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Fig. 24.2 (a) The patient is placed in the Trendelenburg position during the transanal specimen extraction; (b) the surgeon can move to the side of the patient’s head during the transanal specimen extraction

Fig. 24.3 Trocar sites (five-ports method)

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Surgical Team Position

Surgical Procedure, Techniques, and Key Points

In China, most surgeons are accustomed to standing on the left side of the patient to complete the perigastric lymph node dissection and digestive tract reconstruction for distal gastric cancer (Fig. 24.3). The camera holder stands between the patient’s legs, and the assistant stands on the right side of the patient. In special circumstances, such as during the dissection of station 4sb lymph nodes, the surgeon can stand between the patient’s legs and the camera holder then stands on the right side of the patient. In addition, during the transanal specimen extraction, the assistant stands between the patient’s legs, and the surgeon can stand on the left side and on the side of the patient’s head to assist the assistant in extracting the specimen from the anus (Fig. 24.2a, b).

Exploration of the Abdominal and Pelvic Cavity

Special Surgical Instruments Ultrasonic scalpel, 60 mm linear Endo-GIA stapler, 3-0 barbed suture, 4-0 absorbable suture, sterile protective sleeve, etc.

After the laparoscope is placed into the umbilical port, explore the abdominal and pelvic cavity in a counterclockwise manner. First, observe the left lobe and right lobe of liver (Fig. 24.4a, b), then observe the right abdominal cavity and reach the right iliac fossa, and observe for the presence of pelvic adhesions; particularly observe for the presence of nodules and ascites in the rectouterine pouch (Fig. 24.4c). Observe the left iliac fossa and left abdominal cavity. After reaching the upper abdomen, observe for the presence of nodules and adhesions on the surface of spleen and the greater omentum. The circulating nurse is instructed to suction the gastric contents. After that, explore the location of the primary cancer and the perigastric lymph node metastases. Open the greater omentum if necessary, enter the omental cavity to explore whether the tumor invades beyond the posterior wall of the stomach, etc. If necessary, exfoliative cytology of the peritoneal cavity may be performed to exclude the presence of peritoneal metastases (Fig. 24.4d).

Fig. 24.4 (a) Exploration of the left lobe of the liver; (b) exploration of the right lobe of the liver; (c) exploration of pelvic cavity; and (d) exploration for the presence of peritoneal nodules

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Perigastric Lymph Node Dissection Dissection of the Greater Omentum and Dissection of Lymph Nodes of the Subpyloric Region First, lift the greater omentum cranial and ventrally and maintain a moderate tension, dissect the greater omentum along the avascular area of the attached border of transverse mesocolon, and dissect from the right of the hepatic flexure to the left of the lower pole of spleen and the splenic flexure (Fig. 24.5a). Then, move the greater omentum cranial, lift the right gastroepiploic mesentery cranial ventrally, dissect along the fusion fascia space between the transverse mesocolon and

Fig. 24.5 (a) Resection of the greater omentum along the border of the transverse colon; (b) transection of the right gastroepiploic vein at the root and dissection of station 6v lymph nodes; (c) transection of the right gastroepiploic artery at the root and dissection of station 6a lymph

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the right gastroepiploic mesentery from the right of the descending part of duodenum to expose the dorsal anterior fascia of the pancreatic head, expose the right gastroepiploic vein at the junction between the accessory right colic vein and the anterior pancreaticoduodenal vein, and perform ligation and transection at its root (Fig. 24.5b). Continue to dissect cephalad along the anterior fascia of the pancreatic head, expose the root of the right gastroepiploic artery originating from the gastroduodenal artery, ligate and transect the right gastroepiploic artery, and dissect the station 6 lymph nodes (Fig. 24.5c). Lift the duodenum ventrally, a window is created in the triangle formed

nodes; (d) transection of the duodenum; and (e) under the premise of ensuring the safety of resection margin, preserving duodenum long enough for billroth I gastroduodenal anastomosis

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by the superior border of the duodenum with the right gastric and anterior pyloric vessels, and transect the duodenum using a 60 mm linear Endo-GIA stapler with white cartridge (Fig. 24.5d, e).

Dissection of Lymph Nodes in the Superior Pancreatic Region Move the stomach to the right upper quadrant to fully expose the superior plane of the pancreas, search for the right gastric vessels along the gastroduodenal artery, ligate and transect the right gastric vessels at the root, and complete the dissection of station 5 lymph nodes (Fig. 24.6a). Dissect along the superior border of pancreas cephalad, dissect the vagal nerves on the surface of the common hepatic artery to the hepatic hilum, and dissect the station 8a lymph nodes (Fig. 24.6b). Resect the lymphatic and adipose tissues on the anteromedial surface of the proper hepatic artery, the left anterior wall of the portal vein can be seen posterior to the medial side, and complete the dissection of the station 12a lymph nodes (Fig. 24.6c–e). Dissect the station 11p lymph nodes along the surface of the splenic artery at the initial part of the left splenic artery of the left gastric mesentery until the retropancreatic space (Fig. 24.6f, g). Dissect the coronary vein right anterior to the left gastric artery and perform ligation and transection (Fig. 24.6h). Then dissect the station 9 lymph nodes at the root of the celiac artery, pull the left gastric artery cephalad ventrally (Fig. 24.6i), ligate and transect the left gastric artery at the root, and dissect stations 9 and 7 lymph nodes. At this point, continue to dissect cephalad, and the right diaphragmatic crus can be seen. Dissect along the surface of the retropancreatic Gerota’s fascia cephalad (Fig. 24.6j), and finally complete the dissection of lymph nodes in the superior pancreatic region (Fig. 24.6i–k). Dissection of Lymph Nodes in the Lesser Curvature of Stomach Adopt the posterior approach to lift the stomach cephalad ventrally to expose the rear of the omentum of the lesser curvature, perform sharp transection of the blood vessels that merge into the lesser curvature (Fig. 24.6l), thoroughly resect the adipose tissues anterior to the abdominal esophagus on the right side of the esophageal hiatus, and gradually isolate the lesser curvature caudally (Fig. 24.6m). Complete the dissection of stations 1 and 3 lymph nodes (Fig. 24.6n). Dissection of the Station 4sb Lymph Nodes The station 4sb lymph nodes are still within the extent of distal gastrectomy with D2 lymph node dissection. Gradually dissect the anterior fascia plane of the pancreas at the lower pole of spleen and the tail of pancreas cephalad to the splenic hilar region, and expose the left gastroepiploic vessels originating from the vessels of the lower pole of spleen. Ligate

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and transect the left gastroepiploic vessels at the root to complete the dissection of station 4sb lymph nodes (Fig. 24.7a), continue to dissect cranially to transect a short gastric vessel (Fig. 24.7b), and then isolate the greater curvature from left to right (Fig. 24.7c).

Transection of the Distal Stomach Transect the gastric body with two 60 mm linear Endo-GIA staplers with blue cartridge at 8 cm on the side of the greater curvature and 5 ~ 6 cm on the side of the lesser curvature from the upper edge of the tumor (Fig. 24.8a). Place the specimen in the specimen bag to complete the D2 lymph node dissection for distal gastric cancer (Fig. 24.8b).

Transanal Specimen Extraction The patient is placed in the Trendelenburg position. At about 5 ~ 6 cm above the peritoneal reflection, make an incision about 4 cm in length in the anterior rectal wall along the longitudinal axis of the bowel wall of the antimesenteric side of the rectum. The assistant inserts the grasping forceps from the anus and introduces it into the abdominal cavity through the incision in the anterior rectal wall. The surgeon hands one end of the specimen bag to the grasping forceps of the assistant. The surgeon grasps the bowel wall at the rectal incision with one hand, and pulls the bowel cephalad with the other hand to straighten the rectum. Meanwhile, the assistant slowly pulls the specimen bag out of the anus to complete the transrectal specimen extraction (Fig. 24.9a–c). After the specimen extraction, irrigate the pelvic cavity repeatedly, suture the incision in the anterior rectal wall with 3-0 V-loc barbed suture in a continuous manner, and make several interrupted sutures for embedding.

Digestive Tract Reconstruction A window is opened in the proximal greater curvature side 5 cm from the stump of the stomach, and another window is opened in the duodenal stump. A 60 mm linear Endo-GIA stapler with blue cartridge is inserted in the two windows to perform Billroth I anastomosis between the proximal greater curvature of the remnant stomach and the anterior wall of the duodenum (Fig. 24.10a). After firing the stapler, remove the stapler and see if there is active bleeding (Fig. 24.10b), and suture the common opening with 3-0 V-loc barbed suture in a continuous manner (Fig. 24.10c). Lift the remnant stomach ventrally, check for the presence of anastomotic tension, and complete the Billroth I gastroduodenal anastomosis (Fig. 24.10d).

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Fig. 24.6 (a) Transection of the right gastric vessels at the root and dissection of station 5 lymph nodes; (b) entering the superior retropancreatic space along the superior border of pancreas; (c) dissection of station 8a lymph nodes along the surface of the common hepatic artery; (d) exposure of portal vein and dissection of the station 12a lymph nodes; (e) surgical field after dissection of hepatic hilum; (f) dissection of the station 11p lymph nodes along the surface of splenic artery; (g) surgical

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field after dissection of the station 11p lymph nodes; (h) transection of the coronary vein at the root; (i) surgical field after the dissection of stations 9, 7, and 8a lymph nodes; (j) dissection cephalad along the right diaphragmatic crus; (k) surgical field after dissection of lymph nodes in the superior pancreatic region; (l) adopting the posterior approach for the dissection of stations 1 and 3 lymph nodes; (m) after the isolation of the lesser curvature; and (n) surgical field after the dissection of stations 1 and 3 lymph nodes

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Fig. 24.6 (continued)

Key Points and Difficulties Related to Surgery The key to Billroth I anastomosis for transanal distal gastric cancer specimen extraction is making an incision in the upper rectum, which requires strict compliance with the aseptic principle. Before making the incision in the rectum, the assistant should irrigate the rectum repeatedly with dilute iodine solution or chlorhexidine through the anus, and then introduce the specimen bag through the trocar site in the abdominal wall. Then the specimen bag is retained in the bowel lumen through the rectal incision, with some part of the specimen bag pulled out of the anus. The assistant inserts the grasping forceps through the anus; the surgeon places the gastric specimen into the specimen bag and assists the assistant to slowly extract the specimen out of

the anus. During the operation, specimen extrusion with excessive force is contraindicated, and the specimen extraction should be performed gently to prevent damage to the rectum. After the transanal specimen extraction, suture the incision in the rectum with 3-0 V-loc barbed suture in a continuous manner, and make several interrupted embedding sutures to ensure the integrity of the suture. After the suture, the surgeon should irrigate the abdominal and pelvic cavity again until it is clean. The tumor-free and aseptic principles should be strictly followed during the whole operation (Guan et al. 2020; Zhang et al. 2022; Dong et al. 2022). Rectum should be irrigated routinely before the specimen extraction. During the specimen extraction, rectal damage caused by excessive stretching of specimen bag is contraindicated. After specimen extraction, the rectal incision should be sutured, and the

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Fig. 24.7 (a) Left gastroepiploic vessels originating from the artery of the lower pole of spleen; (b) transection of a short gastric vessel; and (c) isolation of the greater curvature

Fig. 24.8 (a) Transection of the gastric body at 8 cm from the upper pole of the primary tumor; (b) surgical field after specimen extraction

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Fig. 24.9 (a) Transanal specimen extraction; (b) transanal specimen extraction, the specimen can be slowly pulled out of specimen bag; and (c) specimen display

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Fig. 24.10 (a) Anastomosis of proximal remnant stomach and the anterior wall of duodenum; (b) observing the integrity of anastomosis through the common opening; (c) closure of the common opening with

pelvic cavity should be irrigated again until clean. In addition, the rectal incision should be closed by mucosa-tomucosa and serosa-to-serosa suturing. If necessary, interrupted suture is required for reinforcement to ensure that the rectal incision is properly sutured. During the perigastric lymph node dissection, the patient should be placed in the anti-Trendelenburg position, where the head is elevated by approximately 30 ; during the transanal specimen extraction, the patient should be placed in the Trendelenburg position, where the head is lowered by approximately 30 .

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3-0 v-loc barbed suture in a continuous manner; and (d) completion of Billroth i gastroduodenal anastomosis

References Dong C, et al. Totally laparoscopic gastrectomy with natural orifice (vagina) specimen extraction in gastric cancer: Introduction of a new technique. J Minim Access Surg. 2022;18(3):484–6. Guan X, et al. International consensus on natural orifice specimen extraction surgery (NOSES) for gastric cancer (2019). Gastroenterol Rep (Oxf). 2020;8(1):5–10. Zhang ZC, et al. Development and future perspectives of natural orifice specimen extraction surgery for gastric cancer. World J Gastrointest Surg. 2022;14(11):1198–203.

Laparoscopic Distal Gastrectomy (Billroth I) with Transvaginal Specimen Extraction (GC-NOSES II)

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Contents Indications and Contraindications of NOSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 364 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 364 Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 364 Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . Anesthesia Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Patient Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trocar Placement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Special Surgical Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

364 364 364 364 366 366

Surgical Procedure, Techniques, and Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Exploration of the Abdominal and Pelvic Cavity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Perigastric Lymph Node Dissection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Transection of the Distal Stomach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Transvaginal Specimen Extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Digestive Tract Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

366 366 367 367 369 369

Analysis of Key Points and Difficulties Related to Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373

Abstract

The tumor is located in the middle and lower third of the stomach, the stage is T3 or below, and the largest diameter of the tumor is less than 5 cm. After the perigastric lymph node dissection is completed, the greater omentum and the distal stomach are placed in the specimen bag and can be extracted through the posterior vaginal fornix. This procedure with specimen extraction through a natural orifice is referred to as NOSES II for gastric cancer, which is mostly applicable to female patients with cosmetic requirements for the abdominal wall. This procedure does not require auxiliary incisions in the abdominal wall to extract the specimen out of the

body. After the surgery, only a few tiny trocar scars are left on the abdominal wall, which makes this procedure a truly total laparoscopic radical gastrectomy. This procedure not only has a good cosmetic appearance on the abdominal wall but also reduces the incidence of postoperative pain and infection caused by additional auxiliary incisions. The surgeons should have clear understanding of the indications and contraindications of this procedure. Keywords

NOSES · Gastrectomy · Gastric cancer · Laparoscopy · Transvaginal

S. Yan (*) Department of Gastrointestinal Surgery, Qinghai University Affiliated Hospital, Xining, Qinghai, P. R. China © People’s Medical Publishing House, PR of China 2023 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-99-2750-0_25

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Indications and Contraindications of NOSES

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Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position

Indications Anesthesia Method 1. Gastric cancer, stage CT1-3, N0-1, M0, with lesions in the distal part of stomach. 2. The largest diameter of tumor 5 cm. 3. BMI  30 kg/m2. 4. Female patients.

Contraindications 1. The tumor is too large to be pulled out through the vagina. 2. It is suspected that the tumor invades beyond the serosa or involves adjacent organs. 3. Patients with acute gastrointestinal obstruction or tumor perforation requiring emergency surgery. 4. Severely obese patients (BMI > 30 kg/m2), especially those with high visceral fat content. 5. Patients with history of pelvic or gynecological surgery or vaginal deformities.

General anesthesia or general epidural anesthesia.

Patient Positioning During the perigastric lymph node dissection for distal gastric cancer and digestive tract reconstruction, the patient is placed in the reverse-Trendelenburg position with legs open (Fig. 25.1a, b). During the transanal specimen extraction, the patient is placed in the Trendelenburg position (Fig. 25.2a, b).

Trocar Placement In principle, the trocar sites are no different from those of laparoscopic distal gastrectomy, and the five-ports method is

Fig. 25.1 (a) The patient’s position during radical gastrectomy for distal gastric cancer. (b) The patient is placed in the reverse-Trendelenburg position with legs open during lymph node dissection and digestive tract reconstruction

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routinely adopted (Fig. 25.3), and the trocar sites should be adjusted appropriately according to the patient’s BMI and shape of abdomen.

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1. Camera trocar (10 mm trocar) is located at the umbilicus or 1 cm above or below the umbilicus according to the abdominal type of the patient.

Fig. 25.2 (a) The patient is placed in the Trendelenburg position during the transvaginal specimen extraction. (b) The surgeon can move to the side of the patient’s head during the transvaginal specimen extraction

Fig. 25.3 Trocar sites (five-ports method)

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2. The surgeon’s main trocar (12 mm trocar) is located 1–2 cm below the costal margin of the left anterior axillary line. 3. The surgeon’s left-hand trocar (5 mm trocar) is located at the umbilical level of the left midclavicular line. 4. The assistant’s left-hand trocar (5 mm trocar) is located 1–2 cm under the costal margin of the right anterior axillary line. 5. The assistant’s main trocar (10 mm trocar) is located at the umbilical level of the right midclavicular line.

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between the patient’s legs, and the surgeon can stand on the left side or on the side of the patient’s head to assist the assistant in extracting the specimen from the vagina (Fig. 25.2a, b).

Special Surgical Instruments Ultrasonic scalpel, 60 mm linear Endo-GIA stapler, 3-0 barbed suture, 4-0 absorbable suture, sterile protective sleeve, etc.

Surgical Team Position

Surgical Procedure, Techniques, and Key Points In China, most surgeons are accustomed to standing on the left side of the patient to complete the perigastric lymph node dissection and digestive tract reconstruction for distal gastric cancer (Fig. 25.3). The camera holder stands between the patient’s legs, and the assistant stands on the right side of the patient. In special circumstances, such as during the dissection of station 4sb lymph nodes, the surgeon can stand between the patient’s legs and the camera holder then stands on the right side of the patient. In addition, during the transvaginal specimen extraction, the assistant stands

Exploration of the Abdominal and Pelvic Cavity After the laparoscope is placed into the umbilical port, explore the abdominal and pelvic cavity in a counterclockwise manner. Firstly, observe the left lobe and right lobe of liver (Fig. 25.4a, b), then observe the right abdominal cavity and reach the right iliac fossa, and observe for the presence of pelvic adhesions, particularly observe for the presence of nodules and ascites in the rectouterine pouch (Fig. 25.4c).

Fig. 25.4 (a) Exploration of the left lobe of the liver. (b) Exploration of the right lobe of the liver. (c) Exploration of pelvic cavity. (d) Exploration of primary lesion

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Observe the left iliac fossa and left abdominal cavity. After reaching the upper abdomen, observe for the presence of nodules and adhesions on the surface of spleen and the greater omentum. The circulating nurse is instructed to suction the gastric contents. After that, explore the location of the primary cancer and the perigastric lymph node metastases (Fig. 25.4d). Open the greater omentum if necessary, and enter the omental cavity to explore whether the tumor invades beyond the posterior wall of the stomach, etc. If necessary, exfoliative cytology of the peritoneal cavity may be performed to exclude the presence of peritoneal metastases.

Perigastric Lymph Node Dissection Dissection of the Greater Omentum and Dissection of Lymph Nodes of the Subpyloric Region and Station 4sb First, lift the greater omentum cephalad ventrally and maintain a moderate tension, dissect the greater omentum along the avascular area of the attached border of transverse mesocolon, dissect to the right to the hepatic flexure and to the left to the lower pole of spleen and the splenic flexure (Fig. 25.5a). The vessels of the lower pole of spleen are found along the lower pole of spleen and the tail of pancreas, and the left gastroepiploic vessels originating from the vessels of the lower pole of spleen are exposed. The left gastroepiploic vessels are ligated and transected at the root to complete the dissection of station 4sb lymph nodes (Fig. 25.5b). Then, move the greater omentum cephalad, lift the right gastroepiploic mesentery cephalad ventrally, dissect along the fusion fascia space between the transverse mesocolon and the right gastroepiploic mesentery to the right to the descending part of duodenum to expose the anterior fascia of the pancreatic head, expose the right gastroepiploic vein at the junction between the accessory right colic vein and the anterior pancreaticoduodenal vein, and perform ligation and transection at its root (Fig. 25.5c, d). Continue to dissect cephalad along the anterior fascia of the pancreatic head, expose the root of the right gastroepiploic artery originating from the gastroduodenal artery, ligate and transect the right gastroepiploic artery, and dissect the station 6 lymph nodes (Fig. 25.5d). The anterior pyloric vessels can be clearly observed by shifting the view to the superior pyloric region and lifting the right gastric vascular pedicle (Fig. 25.5f), dissect and expose the right gastric vascular pedicle (Fig. 25.5g). Lift the duodenum ventrally, a window is created in the triangle formed by the superior border of the duodenum with the right gastric and anterior pyloric vessels (Fig. 25.5h), and transect the

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duodenum using a 60 mm linear Endo-GIA stapler with white cartridge (Fig. 25.5i).

Dissection of Lymph Nodes in the Superior Pancreatic Region Move the stomach to the right upper quadrant to fully expose the superior plane of the pancreas, and search for the right gastric vessels along the gastroduodenal artery, ligate and transect the right gastric vessels at the root, and complete the dissection of station 5 lymph nodes (Fig. 25.6a). Dissect along the superior border of pancreas cephalad, dissect the vagal nerves on the surface of the common hepatic artery to the hepatic hilum, and dissect the station 8a lymph nodes (Fig. 25.6b, c). Resect the lymphatic and adipose tissues on the anteromedial surface of the proper hepatic artery, the left anterior wall of the portal vein can be seen posterior to the medial side, and complete the dissection of the station 12a lymph nodes (Fig. 25.6d, e). Expose the coronary vein superior and posterior to the common hepatic artery and perform transection (Fig. 25.6f), then dissect the station 9 lymph nodes surrounding the celiac artery along the surface of the Gerota’s fascia at the initial part of the common hepatic artery and the splenic artery cephalad (Fig. 25.6g), expose the root of the left gastric artery, dissect the station 7 lymph nodes (Fig. 25.6h), and dissect along the right diaphragmatic crus cephalad (Fig. 25.6i). Dissect the station 11p lymph nodes along the surface of the splenic artery at the initial part of the splenic artery until the retropancreatic space. After the dissection of the station 11p lymph nodes, the initial part of the splenic artery and splenic vein can be clearly seen, and the dissection of lymph nodes in the superior pancreatic region is completed (Fig. 25.6j). Dissection of Lymph Nodes in the Lesser Curvature Adopt the posterior approach to lift the stomach cephalad ventrally to expose the rear of the omentum of the lesser curvature, perform sharp transection of the blood vessels that merge into the lesser curvature, thoroughly resect the adipose tissues anterior to the abdominal esophagus on the right side of the esophageal hiatus, and gradually isolate the lesser curvature caudally (Fig. 25.7a). Complete the dissection of stations 1 and 3 lymph nodes (Fig. 25.7b).

Transection of the Distal Stomach Transect the gastric body with two 60 mm linear Endo-GIA staplers with blue cartridge at 8 cm on the side of the greater curvature and 5–6 cm on the side of the lesser curvature from the upper edge of the tumor (Fig. 25.8a). Place the specimen

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Fig. 25.5 (a) Resection of the greater omentum along the border of the transverse colon. (b) Transection of the left gastroepiploic vessels at the root and dissection of station 4sb lymph nodes. (c) Ligation and transection of the gastroepiploic vein at the root. (d) Ligation and transection of the right gastroepiploic artery at the root. (e) Exposure of the root of superior

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mesenteric vein and dissection of the station 14v lymph nodes. (f) Exposure of superior pyloric vessels. (g) Exposure of the right gastric vascular pedicle in the superior pyloric region. (h) Window is created in the superior pyloric region. (i) Transection of duodenum

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curvature of the remnant stomach and the anterior wall of the duodenum (Fig. 25.10a). After firing the stapler, remove the linear Endo-GIA stapler and see if there is active bleeding (Fig. 25.10b), and suture the common opening with 3-0 V-loc barbed suture in a continuous manner (Fig. 25.10c). Lift the remnant stomach ventrally, check for the presence of anastomotic tension, and complete the Billroth I gastroduodenal anastomosis (Fig. 25.10d).

Fig. 25.5 (continued)

in the specimen bag to complete the D2 lymph node dissection for distal gastric cancer (Fig. 25.8b).

Transvaginal Specimen Extraction First, after the vagina is thoroughly irrigated by the perineal assistant, the patient is placed in the Trendelenburg position. The small bowel is moved to the upper abdomen. Without any obstruction in the pelvic cavity, the uterus is suspended ventrally with the purse-string suture through the broad ligaments on both sides, so that the posterior vaginal fornix can be fully exposed. At the peritoneal reflection, the perineal assistant lifts the cervix ventrally with a uterine manipulator, and the chief surgeon applies the cautery hook to make a 4–5 cm incision along the posterior vaginal fornix (Fig. 25.9a), and the protective sleeve is taken out of the abdominal cavity through the incision (Fig. 25.9b). One end of the specimen bag is introduced into the posterior vaginal fornix, and the perineal assistant slowly pulls the specimen bag out of the body through the vagina with the grasping forceps. The operation should be gently performed to avoid bleeding of the posterior vaginal fornix (Fig. 25.9c, d). After the specimen extraction, the incision in the posterior vaginal fornix is continuously sutured with a 3-0 absorbable suture. Several interrupted stitches or continuous suture with V-loc barbed suture are performed for reinforcement (Fig. 25.9e, f). After the suture, the pelvic cavity is irrigated again, and the patient is placed in the reverse-Trendelenburg position again for the following digestive tract reconstruction.

Digestive Tract Reconstruction A window is opened in the proximal greater curvature side 5 cm from the gastric stump, and another window is opened in the duodenal stump. A 60 mm linear Endo-GIA stapler with blue cartridge is inserted in the two windows to perform Billroth I anastomosis between the proximal greater

Analysis of Key Points and Difficulties Related to Surgery The keys to Billroth I anastomosis for transvaginal distal gastric cancer specimen extraction are the operations before and after making the incision in the posterior vaginal fornix, which requires strict compliance with the aseptic principle. Before making the incision in the posterior vaginal fornix, the assistant should irrigate the vagina repeatedly with dilute iodine solution or chlorhexidine through the vagina, and then introduce the specimen bag through the trocar site in the abdominal wall. Then the specimen bag is retained in the vagina through the incision in the posterior vaginal fornix. The assistant inserts the grasping forceps through the vaginal incision, and the surgeon places the specimen into the specimen bag and helps the assistant to slowly extract the specimen out of the body. During the operation, specimen extrusion with excessive force should be avoided, and the specimen extraction should be performed gently to prevent damage to the vagina caused by tearing of the incision in the posterior vaginal fornix. After the transvaginal specimen extraction, suture the incision in the posterior vaginal fornix with 3-0 absorbable suture in a continuous manner and make several interrupted embedding sutures to ensure the integrity of the suture. After the suture, the chief surgeon should irrigate the pelvic cavity again until it is clean. The tumor-free and aseptic principles should be strictly followed during the whole operation (Guan et al. 2020; Zhang et al. 2022; Dong et al. 2022). The vagina should be irrigated routinely before the specimen extraction. During the specimen extraction, vaginal damage caused by excessive stretching of specimen bag should be avoided. After specimen extraction, the incision in the vagina should be sutured, and the pelvic cavity should be irrigated again until clean. In addition, the vaginal incision should be closed by mucosa-to-mucosa and adventitia-to-adventitia suturing. If necessary, interrupted suture or continuous suture with barbed suture is required for reinforcement to ensure that the incision in the posterior vaginal fornix is properly sutured. During the perigastric lymph node dissection, the patient should be placed in the antiTrendelenburg position, where the head is elevated by approximately 30 . During the transvaginal specimen extraction, the patient should be placed in the Trendelenburg position, where the head is lowered by approximately 30 .

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Fig. 25.6 (a) Exposure of the root of the right gastric vessels and dissection of the station 5 lymph nodes. (b) Entering the superior retropancreatic space along the superior border of pancreas to expose the common hepatic artery. (c) Dissection of station 8a lymph nodes along the surface of the common hepatic artery. (d) Exposure of the left anterior wall of the portal vein and dissection of the station 12a lymph nodes. (e) Surgical field after

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the dissection of lymph nodes in the hepatoduodenal ligament. (f) Exposure and transection of the coronary vein. (g) Dissection of the station 9 lymph nodes of the celiac artery along the surface of the Gerota’s fascia superior and posterior to the pancreas. (h) Surgical field after dissection of stations 7 and 9 lymph nodes. (i) Dissection along the right diaphragmatic crus cephalad. (j) Surgical field after dissection of the station 11p lymph nodes

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Fig. 25.6 (continued)

Fig. 25.7 (a) Adopting the posterior approach for the dissection of stations 1 and 3 lymph nodes. (b) After the isolation of the lesser curvature

Fig. 25.8 (a) Transection of the gastric body at 8 cm from the upper pole of the primary tumor. (b) Surgical field after specimen extraction

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Fig. 25.9 (a) Making a 4–5 cm incision in the posterior vaginal fornix. (b) Transabdominal introduction of specimen bag through the incision in the posterior vaginal fornix. (c) Transvaginal specimen extraction. (d)

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Specimen display. (e) Closure of incision in the posterior vaginal fornix by continuous suture. (f) Surgical field after the suture of posterior vaginal fornix

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Fig. 25.10 (a) Anastomosis of proximal remnant stomach and the anterior wall of duodenum. (b) Observing the integrity of anastomosis through the common opening. (c) Closure of the common opening with

References Dong C, et al. Totally laparoscopic gastrectomy with natural orifice (vagina) specimen extraction in gastric cancer: introduction of a new technique. J Minim Access Surg. 2022;18(3):484–6.

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3-0 V-loc barbed suture in a continuous manner. (d) Completion of Billroth I gastroduodenal anastomosis

Guan X, et al. International consensus on natural orifice specimen extraction surgery (NOSES) for gastric cancer (2019). Gastroenterol Rep (Oxf). 2020;8(1):5–10. Zhang ZC, et al. Development and future perspectives of natural orifice specimen extraction surgery for gastric cancer. World J Gastrointest Surg. 2022;14(11):1198–203.

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Contents Indications and Contraindications of NOSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376 Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376 Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . Anesthesia Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Patient Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trocar Placement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

376 376 376 376 376 377

Surgical Procedure, Techniques, and Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Exploration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dissection and Separation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Specimen Resection and Digestive Tract Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postoperative Specimens and Abdominal Wall Pictures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

377 377 377 379 384

Key Points, Difficulties, and Hotspots Related to Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385 Difficulties in Surgical Operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385 Values and Disputes of Transrectal Specimen Removal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 387 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 388

Abstract

At present, laparoscopic gastric tumor surgery requires an incision of about 4–6 cm in length to extract the specimen, which also partially offsets the minimally invasive advantages of laparoscopic gastric tumor surgery. With the continuous exploration of surgeons, NOSES came into being and broke through the limitations and restraints of abdominal wall incision in traditional laparoscopic surgery. Laparoscopic distal gastrectomy with transrectal specimen extraction is mainly applicable to male gastric cancer patients and some female patients having small specimen size of the tumor, within stage T3 and without serosal infiltrating. Except that the method of specimen extracting is different from that of traditional laparoscopic

surgery, the extent of gastrointestinal resection and lymph node dissection, as well as dissecting plane during the surgery are consistent with traditional laparoscopic surgery. The operating characteristics are as follows: perform radical resection of gastric cancer and digestive tract anastomosis under laparoscope with an incision in the upper rectum, and remove the specimen through the rectum and anus. This procedure requires the surgeon to fully understand the indications, and the doctor and patient’s acceptance on the risk of surgery should be evaluated. Keywords

NOSES · Gastrectomy · Gastric cancer · Laparoscopy · Transrectal

G. Yu (*) Department of General Surgery, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University Qingdao, Qingdao, Shandong, China © People’s Medical Publishing House, PR of China 2023 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-99-2750-0_26

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Indications and Contraindications of NOSES

Trocar Placement

Indications

Trocar sites of the operation should meet the needs of both radical gastrectomy for gastric cancer and transrectal specimen collection.

1. Gastric cancer, stage CT1-3N1-2M0, with lesions in the distal part of stomach. 2. The circumferential diameter of tumor is better 4 cm.

Contraindications 1. The tumor is too large to be pulled out through the anus. 2. The tumor invades the serosa or involves adjacent organs. 3. Patients with acute gastrointestinal obstruction or tumor perforation requiring emergency surgery. 4. Severely obese patients (BMI > 35 kg/m2). 5. Patients with history of pelvic surgery or rectal and anal deformities.

Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position Anesthesia Method General anesthesia or general epidural anesthesia.

Patient Positioning The patient should be placed in the supine position with legs opening and performed gastric cancer resection and digestive tract reconstruction operation (Fig. 26.1), which will be changed to the functional lithotomy position (Fig. 26.2) when removing the specimen through rectal incision.

Fig. 26.1 The patient’s position during gastric cancer resection

1. Camera trocar (10 mm trocar) 1 cm below the umbilicus. 2. The surgeon’s main trocar (12 mm trocar) is 2 cm below the costal margin of the left anterior axillary line. 3. The surgeon’s auxiliary trocar (5 mm trocar) is at the umbilical level of the left midclavicular line. 4. The assistant’s auxiliary trocar (5 mm trocar) is under the costal margin of the right anterior axillary line. 5. The assistant’s main trocar (12 mm trocar) is at the umbilical level of the right midclavicular line (Fig. 26.3).

Surgical Team Position Abdominal Exploration, Anatomical Separation, and Lymph Node Dissection The positions of the surgeon, assistant, and laparoscope holder should be on the left side, right side, and between the patient’s legs, separately (Fig. 26.4). Digestive Tract Reconstruction The surgeon and assistant can exchange positions. The monitor should be located on the side of the patient’s head. Specimen Extraction The positions of the surgeon, assistant, and laparoscope holder should be on the right side, left side, and the same side of the assistant, separately (Fig. 26.5). The monitor should be placed on the side of the patient’s foot.

Fig. 26.2 Functional lithotomy position during specimen extraction

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Surgical Instruments Ultrasonic knife, 60 mm linear cutting closure, 3-0 barbed suture, 4-0 absorbable suture, and sterile protector.

Surgical Procedure, Techniques, and Key Points Surgical Exploration

Fig. 26.3 Trocar placement (five-ports method)

Comprehensive Exploration On the basis of detailed preoperative examinations, the presence of ascites in the abdominal cavity and implant nodules on the surface of the diaphragmatic dome, paracolic sulci, peritoneum, pelvic floor, omentum, mesentery, and so forth should be comprehensively explored. Assess the condition of the primary tumor and the enlargement of the surrounding lymph nodes (Fig. 26.6). Tumor Exploration The tumor is located in the gastric antrum and did not infiltrate the serosal layer (Fig. 26.7).

Dissection and Separation

Fig. 26.4 Surgical team position during gastric cancer resection

Fig. 26.5 Surgical team position during specimen removal

Dissection of the Anterior Lobe of the Transverse Mesocolon and Separation of the Gastrocolic Ligament The greater omentum is flipped cephalad and transected from the left side of the transverse colon. After the lesser omental sac is entered, the dissection is turned to the right to the hepatic flexure, and continued to the posterior side of the anterior lobe of mesocolon. Next, the anterior lobe of the mesocolon is resected (Fig. 26.8).

Fig. 26.6 Comprehensive exploration of the abdominal cavity

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Fig. 26.7 Not infiltrating the serosa by tumor exploration

Fig. 26.8 The assistant’s cooperation on tensioning omentum by triangular stretch

Dissection of Group 6 Lymph Nodes The gastrocolic trunk (Henle’s trunk) is exposed and the right gastroepiploic vein is transected at the root, then the dissection is continued along the surface of the pancreatic head. The surgeon then incises the gastropancreatic ligament to expose the gastroduodenal artery. The right gastroepiploic artery is isolated and transected at the root, followed by the complete removal of Group 6 lymph nodes (Fig. 26.9). Dissection of Group 4sb Lymph Nodes The pancreatic tail is exposed to identify the splenic vessels. Attention should be paid to not injure the pancreas. The left gastroepiploic artery and vein are transected following the exposure of the origin of gastroepiploic vessels (Fig. 26.10). Dissection of Group 11p, 7, and 9 Lymph Nodes The separation is performed closely along the upper edge of the pancreas to expose the proximal end of splenic artery,

followed by dissection of group 11p lymph nodes (Fig. 26.11). After the celiac trunk is exposed, the left gastric artery and vein are separated and transected after clipping at the root. Subsequently, the group 7, 8, and 9 lymph nodes are dissected (Fig. 26.12).

Dissection of Group 5 and 12a Lymph Nodes The duodenum is transected with an Endo-GIA stapler at 2 cm from the distal of pylorus (Fig. 26.13). Then group 5 lymph nodes are dissected and group 12a lymph nodes are further dissected along the proper hepatic artery (Fig. 26.14). Dissection of Lymph Nodes in Lesser Curvature An ultrasonic scalpel is applied to cut closely along the stomach wall of lesser curvature and dissect the lymph nodes in lesser curvature and the right side of cardia (group 1 and 3 lymph nodes) (Fig. 26.15).

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Fig. 26.9 Treatment of the right gastroepiploic vein

Fig. 26.10 Root of the left gastroepiploic vein

Specimen Resection and Digestive Tract Reconstruction Specimen Resection Stomach is transected with an intracavitary Endo-GIA stapler at 5 cm from the proximal end of the tumor; a suitable stapler is selected according to the thickness of the stomach wall (Fig. 26.16); the resected specimen is placed in a specimen bag (Fig. 26.17).

Fig. 26.11 Dissection of group 11p lymph nodes along the splenic artery

Billroth II Anastomosis Windows are opened in the antimesenteric side of the jejunum 15–20 cm from the ligament of Treitz and at the point of gastric stump and greater curvature, respectively. A 60 mm linear

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Fig. 26.12 Isolation of the left gastric artery and common hepatic arteries, and dissection of group 7, 8, and 9 lymph nodes

Endo-GIA stapler is applied to perform the side-to-side anastomosis between the jejunum and the proximal gastric stump in an antecolic fashion. The common opening of stomach and jejunum is ligated with a 4-0 silk suture in an interrupted pattern (Figs. 26.18, 26.19, 26.20, 26.21, and 26.22).

Roux-en-Y Anastomosis of the Distal Gastric Jejunum The side-to-side anastomosis of the gastric jejunum and closing of the common opening of gastric jejunum is same as those of Billroth II. The proximal and distal jejunum are anastomosed with a 60 mm linear Endo-GIA stapler in a sideto-side fashion. The anastomosis position of afferent loop is Fig. 26.13 Transection of duodenum with an Endo-GIA stapler at 2 cm 7–10 cm from the ligament of Treitz and 40–45 cm from the to the distal of pylorus

Fig. 26.14 Transection of the right gastric artery at the root, and dissection of group 5 and 12a lymph nodes

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gastric jejunal anastomosis. The blocking position of afferent loop is about 3 cm from the gastric jejunum anastomosis (Figs. 26.23, 26.24, and 26.25).

Fig. 26.15 Dissection of group 1 and 3 lymph nodes

Transrectal Specimen Extraction After radical resection of gastric cancer and the digestive tract reconstruction, the patient is placed in the functional lithotomy position, then the perineal area and rectal cavity is disinfected with iodoform gauze. The laparoscopic monitor is moved to the side of patient’s foot, while the patient is placed in the right-leaning Trendelenburg position. The assistant stretches the sigmoid colon to fully expose the upper rectum, and then the surgeon makes an incision of 5–6 cm

Fig. 26.16 Amputation of the stomach at 5 cm from the proximal end of tumor

Fig. 26.17 Placing the specimen in the specimen bag

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Fig. 26.18 Opening a window at the point of gastric stump and greater curvature

Fig. 26.19 Measuring a 20 cm length of proximal jejunum from the Treitz ligament, a window opening in the antimesenteric intestinal wall

Fig. 26.20 Antecolic side-to-side gastric jejunal anastomosis

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Fig. 26.21 Closing up the common opening of the stomach and jejunum with a linear Endo-GIA stapler

Fig. 26.22 Quality check of sutures

Fig. 26.23 Side-to-side anastomosis of proximal and distal jejunum

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length in the anterior wall of the upper rectum (Fig. 26.26). The protective sleeve is inserted into the rectum after disinfecting with dilute iodine solution (Figs. 26.27 and 26.28), and the specimen is removed from the anus through the protective sleeve (Figs. 26.29 and 26.30). Finally, the bowel wall is sutured in continuous or intermittent pattern (Figs. 26.31 and 26.32), and the pelvic cavity is irrigated repeatedly.

Postoperative Specimens and Abdominal Wall Pictures Fig. 26.24 Intermittent sutures with 4-0 absorbable thread to close the common jejunal opening

See Figs. 26.33 and 26.34.

Fig. 26.25 Blocking the afferent loop at about 3 cm from the gastric jejunum anastomosis position of gastric jejunum

Fig. 26.26 Cutting open the anterior wall of the upper rectum after repetitive disinfection of the bowel cavity

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Fig. 26.27 Irrigation of pelvic cavity with dilute iodophor solution and normal saline

Fig. 26.28 Insertion of a protective sleeve

Key Points, Difficulties, and Hotspots Related to Surgery Difficulties in Surgical Operation With the development of laparoscopic technology and the improvement of minimally invasive surgical concepts, laparoscopy has been used as a conventional surgical method for

the surgical treatment of early gastric cancer (Lei et al. 2022). Because it shortens the surgical incision and has a good prognostic effect and significant advantages, it has gained wide recognition and comprehensive promotion (Rosa et al. 2022). The corresponding laparoscopic gastric cancer operation guidelines and laparoscopic gastric cancer quality control criteria have been formulated and updated. At the same time, as surgeons continue to explore, a series of new surgical methods have emerged. NOSES is an advancement that

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Fig. 26.29 Removing the specimen from the protective sleeve

Fig. 26.30 Anal appearance during specimen removal

combines laparoscopic technology with the NOTES concept. NOSES eliminates the auxiliary incision of the abdominal wall, which makes the advantages of laparoscopy more perfect (Guan et al. 2020; Zhang et al. 2022). Laparoscopic distal gastrectomy with transrectal specimen extraction is a procedure for radical resection of gastric cancer and digestive tract reconstruction completely under laparoscopy, with broader view of operation field as to easily determine the direction of the proximal and distal intestine during reconstruction, which can effectively avoid mistakes while operating with small auxiliary incision, such as intestine torsion and over-tension of the anastomosis. It has

obvious advantages in terms of the safety of the operation, and there are also many difficulties and disputes. Difficulties in surgery: (1) Full laparoscopic gastric cancer surgery and laparoscopic anastomosis require a certain amount of experience and excellent laparoscopic suture techniques, respectively. (2) The specimen removal through the anus requires good preoperative bowel preparation. Strictly tumor-free and aseptic principal is followed during the operation. (3) The cooperation of gastrointestinal surgery and anorectal surgery is needed in the early stage of development. The specimen removal should be performed in the Trendelenburg position, which needs to be preset or changed

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Fig. 26.31 3-0 continuous sutures with barbed suture for rectum incision

Fig. 26.32 Quality check of sutures and repetitive irrigation of the pelvic cavity

during the operation. (4) The specimen removal requires two groups of staffs to operate together, which also tests the cooperation of the team and increases labor costs. (5) The position of the monitor is needed to be moved during the operation, or prepare two sets of laparoscopic display equipment.

Values and Disputes of Transrectal Specimen Removal 1. Values ① The function of the abdominal wall is retained to the greatest extent, the postoperative pain is reduced,

the risk of incision hernia is reduced, and the physical trauma of the patient is reduced. ② Avoid the adverse psychological suggestion of auxiliary incision and reduce the psychological trauma of the patient. ③ Reduce possibilities of incision infection and tumor implantation. 2. Disputes ① Organs unrelated to the primary disease will be cut open. ② There is an increased risk of abdominal infection, tumor implantation, and spreading. ③ There may be serious complications such as intestinal leakage, bleeding, rectal stenosis, and abnormal bowel function, and once the intestinal leakage, bleeding, or rectal stenosis occur, the consequences are quite serious.

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Fig. 26.33 Specimen picture

Fig. 26.34 Appearance of abdominal wall after operation

References

meta-analysis of randomized controlled trials. World J Surg Oncol. 2022;20(1):405. Rosa F, et al. The role of surgery in the management of gastric cancer: state of the art. Cancers (Basel). 2022;14(22):5542. Zhang ZC, et al. Development and future perspectives of natural orifice specimen extraction surgery for gastric cancer. World J Gastrointest Surg. 2022;14(11):1198–203.

Guan X, et al. International consensus on natural orifice specimen extraction surgery (NOSES) for gastric cancer (2019). Gastroenterol Rep (Oxf). 2020;8(1):5–10. Lei X, et al. Short-and long-term outcomes of laparoscopic versus open gastrectomy in patients with gastric cancer: a systematic review and

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Contents Indications and Contraindications of NOSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 390 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 390 Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 390 Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . Anesthesia Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Patient Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trocar Placement (Fig. 27.3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

390 390 390 390 390 391

Surgical Procedure, Techniques, and Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Exploration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dissection and Separation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Specimen Resection and Digestive Tract Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postoperative Abdominal Wall and Specimen Display . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

391 391 392 395 396

Key Points, Difficulties, and Hotspots Related to Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 396 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 406

Abstract

Laparoscopic distal gastrectomy with transvaginal specimen extraction (GC-NOSES IV) is mainly applicable to female patients with tumors located in the middle and lower stomach. On the basis of strict adherence to the radical resection of tumor and digestive tract reconstruction in the conventional laparoscopic surgery for gastric cancer, this procedure adopts total laparoscopic operation, incision of the posterior vaginal fornix, and transvaginal specimen extraction. According to the International Consensus on Natural Orifice Specimen Extraction Surgery (NOSES) for Colorectal Cancer (2017), this is a resection extraction procedure. The resection, dissection, and reconstruction of NOSES for gastric cancer are performed in the upper abdomen, whereas the opening of posterior vaginal G. Yu (*) Department of General Surgery, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University Qingdao, Qingdao, Shandong, China © People’s Medical Publishing House, PR of China 2023 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-99-2750-0_27

fornix and the specimen extraction are performed in the lower abdomen. The patient’s position and the placement of laparoscope and the monitor should be changed during the operation. In addition, in the lower abdominal operation through the trocars placed for upper abdominal operation, the difficulty of operation will increase accordingly, and the surgeon should closely cooperate with the assistant to overcome the difficulty. The operating characteristics of this procedure are: (1) radical resection of gastric cancer, dissection of lymph nodes, and digestive tract reconstruction completely under laparoscopy (2) with no auxiliary incision on the abdominal wall, the function of abdominal wall is preserved, and the postoperative pain is reduced to the maximum extent. This procedure can not only ensure the radical resection of tumors but also reduce the damage to organs and tissues. Therefore, this is an ideal procedure that fully satisfies the requirements of functional surgery.

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Keywords

NOSES · Gastrectomy · Gastric cancer · Laparoscopy · Transvaginal

Indications and Contraindications of NOSES Indications 1. Female patients. 2. Gastric cancer, stage cT1-3N0-1M0, with lesions in the distal part of stomach. 3. The circumferential diameter of tumor is better 4 cm.

Fig. 27.1 Horizontal supine position with legs abduction

Contraindications 1. Female patients with fertility plan. 2. Locally advanced cancer (cT4N2-3M1). 3. The tumor is too large to be pulled out through the posterior vaginal fornix. 4. Severely obese patients (BMI > 30 kg/m2). 5. Patients with history of pelvic surgery or vaginal deformities. Fig. 27.2 Functional lithotomy position

Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position Anesthesia Method General anesthesia or general epidural anesthesia.

Patient Positioning The patient should be placed in the horizontal supine position with legs abduction (Fig. 27.1), which will be changed to the functional lithotomy position (Fig. 27.2) when removing the specimen through the posterior vaginal fornix.

Fig. 27.3 Trocar placement (five-ports method)

Trocar Placement (Fig. 27.3)

5. The assistant’s main trocar (12 mm trocar) is located at the umbilical level of the right midclavicular line.

1. Camera trocar (10 mm trocar) is located 1 cm below the umbilicus. 2. The surgeon’s main trocar (12 mm trocar) is located below the costal margin of the left anterior axillary line. 3. The surgeon’s auxiliary trocar (5 mm trocar) is located at the umbilical level of the left midclavicular line. 4. The assistant’s auxiliary trocar (5 mm trocar) is located under the costal margin of the right anterior axillary line.

Surgical Team Position Abdominal Exploration, Anatomical Dissection, and Lymph Node Dissection The positions of the surgeon, assistant, and camera holder should be on the left side, right side, and between the patient’s legs, separately (Fig. 27.4).

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Fig. 27.6 Surgical team position

Fig. 27.4 Surgical team position

Fig. 27.7 Changes in trocar function during specimen extraction

Surgical Instruments Ultrasonic scalpel, 60 mm linear Endo-GIA stapler, 3-0 barbed suture, 4-0 absorbable suture, and sterile protective sleeve. Fig. 27.5 Surgical team position

Surgical Procedure, Techniques, and Key Points Digestive Tract Reconstruction The positions of the surgeon, assistant, and camera holder should be on the right side, left side, and between the patient’s legs, separately (Fig. 27.5). Transvaginal Specimen Extraction The positions of the surgeon, assistant, and camera holder should be on the right side, left side, and the left side of the patient, separately (Fig. 27.6). In this step, the monitor should be placed on the side of the patient’s foot. The trocar function should be changed accordingly (Fig. 27.7).

Surgical Exploration Comprehensive Exploration On the basis of detailed preoperative examinations, the presence of ascites in the abdominal cavity and implant nodules on the surface of the diaphragmatic dome, paracolic sulci, peritoneum, pelvic floor, omentum, mesentery, and so forth should be comprehensively explored. The condition of the primary tumor and lymph nodes should also be assessed (Fig. 27.8).

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Tumor Exploration The tumor is located in the anterior wall of gastric antrum and does not invade beyond the serosal layer (Fig. 27.9).

Dissection and Separation Dissection of the Greater Omentum The greater omentum is flipped cephalad and transected from the left side of the transverse colon. The lesser omental sac is entered, and the incision is extended to the hepatic flexure of colon on the right side. Dissection is performed along the posterior region of the anterior lobe of the transverse mesocolon. The anterior lobe of the mesocolon is resected (Fig. 27.10). Dissection of Station 4sb Lymph Nodes The pancreatic tail is exposed to identify the splenic vessels. The splenic flexure is mobilized, and then the adhesion between the greater omentum and middle and lower pole of spleen is detached. Attention should be paid for the protection of the pancreatic tail. The left gastroepiploic artery and

Fig. 27.8 Exploration of the abdominal and pelvic cavity

Fig. 27.9 Exploration of the tumor

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vein are exposed and transected at the root after they derived into the branch of the lower pole of spleen, then station 4sb lymph nodes are dissected (Figs. 27.11, 27.12, and 27.13).

Dissection of Station 6 Lymph Nodes With the guidance of middle colic vessel, the fusion fascia space between the gastroduodenum and transverse mesocolon is entered, and the right gastroepiploic vein is transected (Figs. 27.14, 27.15, and 27.16). The dissection is continued along the surface of the pancreatic head to expose the gastroduodenal artery. The right gastroepiploic artery is isolated and transected at the root, and then station 6 lymph nodes are completely dissected (Fig. 27.17). Transection of the Duodenum See Fig. 27.18. Dissection of Stations 8a and 12a Lymph Nodes The surgeon then dissect along the superior border of pancreas to expose the common hepatic artery. The pancreas is gently pushed to the lower left, and the station 8a lymph nodes is dissected along the anterior and superior border of the common hepatic artery (Fig. 27.19). For the exposure of the portal vein, the fascia anterior to the portal vein is opened at the angle between the common hepatic artery, the gastroduodenal artery, and the superior border of pancreas. The capsule of the hepatoduodenal ligament is opened, and the anterior and left sides of the proper hepatic artery are isolated. Dissection is continued along the anterior of the portal vein, and the lymph nodes between the portal vein and the proper hepatic artery are removed. Since the right gastric vein has many variations, it should be carefully identified and ligated to avoid accidental damage, especially when the vein has a large diameter (Figs. 27.20 and 27.21). The duodenum should be transected first to facilitate the exposure of the right gastric artery and hepatoduodenal ligament, thereby the lymph node can be dissected easier (Figs. 27.22 and

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Fig. 27.10 Transection of the greater omentum and entry into the lesser omental sac

Fig. 27.11 Dissection and isolation of left gastroepiploic artery

Fig. 27.12 Transection of the left gastroepiploic artery at the root

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Fig. 27.13 Isolation of the greater curvature

Fig. 27.14 Dissection along the fusion fascia space

Fig. 27.15 Isolation of the right gastroepiploic vein

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27.23). The assistant pulls the common hepatic artery downwards to the right to facilitate the dissection of the lymphatic and adipose tissues medial to the proper hepatic artery and the portal vein, i.e., the station 12a lymph nodes (Fig. 27.24). The root of the right gastric vascular is ligated and transected.

Specimen Resection and Digestive Tract Reconstruction

Dissection of Stations 11p, 7, and 9 Lymph Nodes The pancreatic capsule is opened to perform dissection along the superior border of pancreas. The proximal end of the splenic artery is exposed, and station 11p lymph nodes are dissected. From left to right, the celiac trunk is exposed and the left gastric artery and vein are dissected and transected after being ligated at the root, and stations 7 and 9 lymph nodes are dissected (Figs. 27.25, 27.26, and 27.27).

Billroth II Anastomosis Windows are opened in the antimesenteric side of the jejunum 15–20 cm from the ligament of Treitz (Fig. 27.34) and at the point of gastric stump and greater curvature (Fig. 27.35). A 60 mm linear Endo-GIA stapler is applied to perform the side-to-side anastomosis between the jejunum and the proximal gastric stump in an antecolic fashion (Fig. 27.36). The common opening is sutured with a 4-0 absorbable suture in an interrupted pattern or 3-0 barbed suture in a continuous pattern (Fig. 27.37).

Dissection of Lymph Nodes in the Lesser Curvature and the Right Side of Cardia Ultrasonic scalpel is used to cut closely along the stomach wall of the lesser curvature (Fig. 27.28) and dissect the lymph nodes in lesser curvature and the right side of cardia (stations 1 and 3 lymph nodes) (Figs. 27.29, 27.30, and 27.31).

Fig. 27.16 Transection of the right gastroepiploic vein at the root

Specimen Resection See Figs. 27.32 and 27.33.

Roux-en-Y Anastomosis of the Gastric Jejunum The side-to-side anastomosis of the gastric jejunum and closing of the opening of gastric jejunum is the same as those of Billroth II. The proximal and distal jejunum are anastomosed with a 60 mm linear Endo-GIA stapler in a side-to-side fashion. The anastomosis position of afferent loop is 7–10 cm from the ligament of Treitz and 40–45 cm from the gastric jejunal anastomosis (Figs. 27.38 and 27.39). The blocking position of afferent loop is about 3 cm from the anastomosis position of gastric jejunum (Fig. 27.40). Transvaginal Specimen Extraction The vagina is disinfected repeatedly. After the uterus is suspended (Fig. 27.41), the posterior vaginal fornix is withstood with an abdominal spatula (Fig. 27.42) to facilitate the surgeon to make incision in the posterior vaginal fornix. Attention should be paid to ensure the incision is not exceeding the bilateral sacral ligaments (Fig. 27.43). A protective sleeve is introduced through the main trocar and inserted into

Fig. 27.17 Isolation of the right gastroepiploic artery for the dissection of station 6 lymph nodes

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Fig. 27.18 Transection of duodenum

Fig. 27.19 Dissection of station 8a lymph nodes

Fig. 27.21 Transection of the right gastric vein at the root

Postoperative Abdominal Wall and Specimen Display See Figs. 27.50, 27.51, and 27.52.

Key Points, Difficulties, and Hotspots Related to Surgery

Fig. 27.20 Isolation of the right gastric vein

the vagina through the incision (Fig. 27.44). The specimen is held by the oval forceps and extracted along the long axis of stomach (Figs. 27.45, 27.46, and 27.47). The abdominal cavity is irrigated repeatedly with distilled water, dilute iodine solution, and saline solution (Fig. 27.48). The incision of the posterior vaginal fornix is closed by continuous suture with 3-0 barbed suture (Fig. 27.49).

On the basis of strict adherence to the radical resection of tumor and digestive tract reconstruction in the conventional laparoscopic surgery for gastric cancer, gastric NOSES adopts total laparoscopic operation, incision of the posterior vaginal fornix, and transvaginal specimen extraction (Guan et al. 2020; Zhang et al. 2022). The key techniques and difficulties involve four aspects: (1) Aseptic operation: During the operation, the perineum and pelvic cavity should be disinfected repeatedly with iodoform gauze and dilute iodine solution, which conforms to the principle of aseptic operation. (2) Tumor-free operation: After the specimen resection, put it in a sterile specimen bag, place a sterile protective

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Fig. 27.22 Isolation of the right gastric artery

Fig. 27.23 Transection of the right gastric artery at the root

Fig. 27.24 Dissection of station 12a lymph nodes

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sleeve into the natural orifice when removing the specimen, and fully ensure the tumor-free principle of the operation. (3) The trocars established for the resection and reconstruction should be applied for specimen extraction. The number of trocars should not be increased to avoid the increase of operating difficulties. (4) The operation approach for resection and reconstruction is opposite to the operation approach of specimen extraction, for which the patient’s position need to be changed and the operation time need to be increased, which puts forward higher requirements for the cooperation between the surgeons and the assistants. Laparoscopic surgery with transvaginal specimen extraction has been widely performed in clinical practice, and the technique is relatively mature at present (Dong et al. 2022). Transvaginal NOSES has the common advantage of NOSES, which eliminates incision infection, incisional hernia, incision disruption, and other incision-related complications, shortens length of stay after operation, and reduces the degree and duration of postoperative pain. In general, the posterior vaginal fornix is anatomically devoid of large blood vessels and nerves, which makes it easier to remove larger specimens through the vagina. Therefore, this procedure has fewer complications and higher safety. Its main disadvantage is that it is only applicable to female patients excluding those with fertility needs. The surgical indications must be strictly followed. The location, size, and depth of tumor invasion should be evaluated before operation. In the selection of patients, the patient’s age, obesity degree, and marital and reproductive status should be taken into consideration.

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Fig. 27.25 Isolation of the left gastric vein

Fig. 27.26 Isolation of the left gastric artery for the dissection of station 7 lymph nodes

Fig. 27.27 Dissection of stations 9 and 11p lymph nodes

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Fig. 27.30 After dissection of the superior border of pancreas Fig. 27.28 Open the lesser curvature hierarchically with the ultrasonic scalpel

Fig. 27.29 Dissection of stations 1 and 3 lymph nodes in the lesser curvature

Fig. 27.31 After dissection of the hepatoduodenal ligament

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Fig. 27.32 Transection of the stomach at 5 cm from the proximal end of tumor

Fig. 27.33 Placing the resected specimen in the specimen bag

Fig. 27.34 Opening a window in the antimesenteric side of the jejunum

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Fig. 27.35 Opening the window at the point of gastric stump and greater curvature

Fig. 27.36 Side-to-side gastric jejunal anastomosis

Fig. 27.37 Closure of the common opening with intermittent suture

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Fig. 27.38 Side-to-side anastomosis of proximal and distal jejunum

Fig. 27.39 4-0 intermittent suture with 4-0 absorbable suture to close the common opening of jejunum

Fig. 27.40 Ligation for blocking the afferent loop at about 3 cm from the anastomosis position of gastric jejunum

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Fig. 27.41 Suspension of uterus

Fig. 27.42 Posterior vaginal fornix is withstood with the abdominal spatula after repeated disinfection of vagina

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Fig. 27.43 Opening the posterior vaginal fornix with the incision not exceeding the bilateral sacral ligaments

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Fig. 27.44 Placement of protective sleeve

Fig. 27.45 The gastric stump is held by the oval forceps and extracted along the long axis of stomach

Fig. 27.46 Transvaginal extraction of specimen

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Fig. 27.47 Extraction of specimen bag

Fig. 27.48 Repeated irrigation with distilled water, dilute iodine solution, and saline solution

Fig. 27.49 Incision of the posterior vaginal fornix closed by continuous suture with 3-0 barbed suture

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Fig. 27.50 Specimen resection

Fig. 27.52 Postoperative abdominal wall recovery

References Dong C, et al. Totally laparoscopic gastrectomy with natural orifice (vagina) specimen extraction in gastric cancer: introduction of a new technique. J Minim Access Surg. 2022;18(3):484–6. Guan X, et al. International consensus on natural orifice specimen extraction surgery (NOSES) for gastric cancer (2019). Gastroenterol Rep (Oxf). 2020;8(1):5–10. Zhang ZC, et al. Development and future perspectives of natural orifice specimen extraction surgery for gastric cancer. World J Gastrointest Surg. 2022;14(11):1198–203.

Fig. 27.51 Open the gastric wall for specimen observation

Laparoscopic Proximal Gastrectomy with Transanal Specimen Extraction (GC-NOSES V)

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Contents Indications and Contraindications of NOSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 407 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 407 Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 408 Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . Anesthesia Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Patient Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trocar Placement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

408 408 408 408 408 409

Surgical Procedure, Techniques, and Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Exploration and Surgical Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dissection and Separation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Specimen Resection and Digestive Tract Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postoperative Abdominal Wall and Specimen Pictures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Key Points, Difficulties, and Hotspots Related to Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 418 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 419

Abstract

Proximal gastrectomy is a standard procedure for early gastric cancer or benign lesions in the upper stomach. Proximal gastrectomy with transanal specimen extraction (GC-NOSES V) is mainly applicable to male and some female patients with early lesions in the upper stomach. On the basis of strict adherence to the radical resection of tumor and digestive tract reconstruction in the conventional laparoscopic surgery for gastric cancer, this procedure opens the rectum and extracts the specimen through the anus, which manifests the combination of minimally invasive surgery and function preservation surgery. This is a resection extraction NOSES procedure. The operating characteristics of this procedure are: (1) Radical resection of gastric cancer, dissection of lymph nodes, and digestive tract reconstruction completely under laparoscopy. The G. Yu (*) Department of General Surgery, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University Qingdao, Qingdao, Shandong, China © People’s Medical Publishing House, PR of China 2023 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-99-2750-0_28

operation is the same as that in the conventional laparoscopic surgery, and the operation difficulty is not increased. (2) With no auxiliary incision in the abdominal wall, the function of abdominal wall is preserved and the postoperative pain is reduced to the maximum extent. This procedure can not only ensure the radical resection of tumors but also reduce the damage to organs and tissues. Keywords

NOSES · Gastrectomy · Gastric cancer · Laparoscopy · Transanal

Indications and Contraindications of NOSES Indications 1. Upper gastric cancer, stage cT1-2N0M0. 2. The circumferential diameter of tumor is better 4 cm. 407

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Contraindications 1. Locally advanced cancer (cT3-4N1-3M0-1). 2. The tumor is too large to be pulled out through the anus. 3. Patients with acute gastrointestinal obstruction or tumor perforation requiring emergency surgery. 4. Severely obese patients (BMI > 30 kg/m2). 5. Patients with history of pelvic surgery or rectal and anal deformities.

Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position Anesthesia Method General anesthesia or general epidural anesthesia.

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4. The assistant’s auxiliary trocar (5 mm trocar) is located under the costal margin of the right anterior axillary line. 5. The assistant’s main trocar (12 mm trocar) is located at the umbilical level of the right midclavicular line (Fig. 28.3).

Surgical Team Position Abdominal Exploration, Anatomical Dissection, and Lymph Node Dissection The positions of the surgeon, assistant, and camera holder should be on the left side, right side, and between the patient’s legs, separately (Fig. 28.4). Digestive Tract Reconstruction The positions of the surgeon, assistant, and camera holder should be on the right side, left side, and between the patient’s legs, separately (Fig. 28.5).

Patient Positioning The patient should be placed in the horizontal supine position with legs abduction (Fig. 28.1), which will be changed to the functional lithotomy position (Fig. 28.2) when removing the specimen by opening the rectum.

Trocar Placement 1. Camera trocar (10 mm trocar) is located 1 cm below the umbilicus. 2. The surgeon’s main trocar (12 mm trocar) is located 2 cm below the costal margin of the left anterior axillary line. 3. The surgeon’s auxiliary trocar (5 mm trocar) is located at the umbilical level of the left midclavicular line. Fig. 28.2 Functional lithotomy position

Fig. 28.3 Trocar placement (five-ports method) Fig. 28.1 Horizontal supine position with legs abduction

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Fig. 28.6 Surgical team position

Fig. 28.4 Surgical team position

Surgical Procedure, Techniques, and Key Points Exploration and Surgical Planning Comprehensive Exploration On the basis of detailed preoperative examination, the liver, gallbladder, stomach, spleen, colon, small intestine, greater omentum, and pelvic cavity are routinely examined for the presence of tumor seeding, ascites, and other abnormalities (Fig. 28.7).

Dissection and Separation

Fig. 28.5 Surgical team position

Transanal Specimen Extraction The positions of the surgeon, assistant, and camera holder should be on the right side, left side, and the left side of the patient, separately (Fig. 28.6). In this step, the monitor should be placed on the side of the patient’s foot.

Surgical Instruments Ultrasonic scalpel, 60 mm linear Endo-GIA stapler, 3-0 barbed suture, 4-0 absorbable suture, and sterile protective sleeve.

Dissection of the Greater Omentum The greater omentum is flipped cephalad and transected from the left side of the transverse colon. The lesser omental sac is entered, and the incision is extended to the hepatic flexure of colon on the right side. Dissection is performed along the posterior region of the anterior lobe of the mesocolon. The anterior lobe of the mesocolon is resected (Figs. 28.8 and 28.9). Dissection of the Gastrosplenic Ligament The greater omentum is transected from the middle of colon to the splenic flexure. The left gastroepiploic artery and vein are transected at the root, and station 4sb lymph nodes are dissected. The patient is placed in the right-leaning antiTrendelenburg position, and the gastrosplenic ligament is exposed. Apply the ultrasonic scalpel to transect the short gastric artery close to the hilum of the spleen, and then station 4sa lymph nodes are dissected (Figs. 28.10, 28.11, 28.12, 28.13, 28.14, 28.15, and 28.16).

410 Fig. 28.7 Exploration of the abdominal and pelvic cavity

Fig. 28.8 Entering the lesser omental bursa

Fig. 28.9 Dissect to the right for the dissection of the greater omentum to the hepatic flexure

Fig. 28.10 Isolation of the left gastroepiploic vein

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Fig. 28.11 Transection of the left gastroepiploic vein

Fig. 28.12 Ligation of the left gastroepiploic artery

Fig. 28.13 Transection of the left gastroepiploic artery

Fig. 28.14 Ligation of the short gastric artery

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Fig. 28.15 Transection of the short gastric artery

Fig. 28.16 Dissection of station 4sa lymph nodes

Fig. 28.17 Protection of the right gastroepiploic vessel

Care Should Be Taken to Protect the Right Gastroepiploic Vessel During the Proximal Gastrectomy The right gastroepiploic vessel is the only blood supply to the remnant stomach. Total gastrectomy is necessary if damage occurs. Therefore, it is essential to protect the right gastroepiploic vessel (Fig. 28.17).

proximal to the tumor to pull the esophagus downwards. The surgeon then continues to dissect the esophagus upwards adequately, until the length of isolated esophagus is enough to obtain enough resection margin and to meet the need of anastomosis (Figs. 28.23 and 28.24).

Dissection of Stations 7, 8a, 9, and 11p Lymph Nodes The left gastric vein and artery are identified, isolated, and transected at the origin (Figs. 28.18 and 28.19). Stations 7, 9, and 11p lymph nodes are dissected (Fig. 28.20). Afterwards, the surgeon then perform dissection along the splenic artery to remove station 11d lymph nodes (Fig. 28.21), then perform dissection along the common hepatic artery and the proper hepatic artery to remove stations 8 and 12a lymph nodes (Fig. 28.22). Dissection of Stations 1 and 2 Lymph Nodes and Isolation of Esophagus Dissection is continued to the left side of the cardia, transect the anterior and posterior vagal trunk, and isolate the lower esophagus. Traction stitch is sutured in the esophagus

Specimen Resection and Digestive Tract Reconstruction Specimen Resection The esophagus is transected with a linear Endo-GIA stapler at 2 cm above the esophagogastric junction, and the stomach is transected with a linear Endo-GIA stapler at 5 cm from the distal end of the tumor. A suitable cartridge is selected according to the thickness of the stomach wall and the esophageal wall. The resected specimen is placed in a specimen bag (Figs. 28.25, 28.26, and 28.27). Digestive Tract Reconstruction (Gastroesophageal Overlap Anastomosis) Stitches are made on the left and right sides of the esophageal stump with the barbed suture. The ultrasonic scalpel is applied to open the middle of the esophageal stump.

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Fig. 28.18 Isolation and dissection of the left gastric vein, and transection at the root

Fig. 28.19 Isolation and dissection of left gastric artery

Fig. 28.20 Transection of the left gastric artery at the root and dissection of stations 7, 9, and 11p lymph nodes

Subsequently, with the guidance of the gastric tube, the surgeon inserts the two jaws of the linear Endo-GIA stapler into the esophageal lumen and the gastric cavity, respectively. After the anastomosis between the posterior wall of the esophagus and the anterior wall of the remnant stomach is created, the remaining opening is closed with barbed suture (Figs. 28.28, 28.29, 28.30, and 28.31).

Transrectal Specimen Extraction After radical resection of the gastric cancer and the digestive tract reconstruction, the patient is placed in the functional lithotomy position, and then the perineal area and rectal cavity is disinfected with iodoform gauze. The laparoscopic monitor is moved to the side of patient’s foot, while the patient is placed in the right-leaning Trendelenburg position. The assistant stretches the

414 Fig. 28.21 Dissection of station 11d lymph nodes along the splenic artery

Fig. 28.22 Dissection of stations 8 and 12a lymph nodes along the common hepatic artery and the proper hepatic artery

Fig. 28.23 Transection of the accessory left hepatic artery and dissection of station 3 lymph nodes

Fig. 28.24 Proximally dissection of esophagus

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Fig. 28.25 Transection of esophagus at 2 cm above the esophagogastric junction

Fig. 28.26 Transection of the stomach at 5 cm from the distal end of tumor

Fig. 28.27 Placing the specimen in the specimen bag

Fig. 28.28 Suture of the gastric wall with the esophageal wall

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Fig. 28.29 Anastomosis between the posterior wall of the esophagus and the anterior wall of the remnant stomach (overlap method)

Fig. 28.30 Placement of gastric tube

Fig. 28.31 Common opening of gastroesophageal anastomosis closed by continuous suture with 3-0 barbed suture

sigmoid colon to fully expose the upper rectum, and then the surgeon makes an incision of 5–6 cm length in the anterior wall of the upper rectum (Fig. 28.32). The protective sleeve is inserted into the rectum after disinfecting with dilute iodine solution (Figs. 28.33 and 28.34), whereafter the specimen is removed from the anus through the protective sleeve (Figs. 28.35 and 28.36). Finally, the bowel wall is sutured in continuous or intermittent pattern,

and the pelvic cavity is irrigated repeatedly (Figs. 28.37 and 28.38).

Postoperative Abdominal Wall and Specimen Pictures See Figs. 28.39 and 28.40.

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Fig. 28.32 Cutting open the anterior wall of the upper rectum after disinfection of the bowel cavity

Fig. 28.33 Repeated irrigation of pelvic cavity with dilute iodine solution and normal saline

Fig. 28.34 Insertion of sterile protective sleeve

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Fig. 28.35 Transanal specimen extraction (intraperitoneal picture)

Fig. 28.36 Transanal specimen extraction (extracorporeal picture)

Fig. 28.37 Continuous suture of rectal incision with barbed suture

Key Points, Difficulties, and Hotspots Related to Surgery Radical proximal gastrectomy, a function-preserving surgery for gastric cancer, is applicable to patients with early gastric cancer in the upper stomach (Guan et al. 2020; Zhang et al. 2022). Under the premise of ensuring adequate lymph node dissection, this procedure preserves more than 50% of gastric tissue and reduces reflux esophagitis after gastroesophageal anastomosis, which is of great significance for the

improvement of postoperative quality of life and maintenance of nutritional status. Total gastrectomy is recommended for patients with advanced tumors. Therefore, the surgeons should have clear understanding of indications of this procedure and accurately assess the tumor location, size, and depth of invasion before operation. In addition, for patients with gastric cancer, opening of the rectum is a damage to additional organs. There is an increased risk of intraperitoneal infection, tumor implantation, and spreading. Moreover, the possibility of serious complications such as intestinal leakage, rectal stenosis, and

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Laparoscopic Proximal Gastrectomy with Transanal Specimen Extraction (GC-NOSES V)

419

Fig. 28.38 Inspection of the quality of the rectal suture and repeated irrigation Fig. 28.40 Specimen picture

incision on bowel wall, and ensuring of aseptic and tumorfree operation are effective measures to prevent complications of transanal NOSES (Dong et al. 2022; Wang et al. 2019). Given that the number of cases is still small and the follow-up period is short, large-scale clinical studies are needed to assess the safety of opening the rectum for specimen extraction.

References

Fig. 28.39 Appearance of abdominal wall after operation

abnormal bowel function, etc., also exists. We believe that adequate preoperative bowel preparation, adequate anal dilation, gentle specimen extraction, precise suturing of the

Dong C, et al. Totally laparoscopic gastrectomy with natural orifice (vagina) specimen extraction in gastric cancer: introduction of a new technique. J Minim Access Surg. 2022;18(3):484–6. Guan X, et al. International consensus on natural orifice specimen extraction surgery (NOSES) for gastric cancer (2019). Gastroenterol Rep (Oxf). 2020;8(1):5–10. Wang YL, et al. Totally laparoscopic resection and natural orifice specimen extraction surgery (NOSES) in synchronous rectal and gastric cancer. Gastroenterol Rep (Oxf). 2019;8(1):79–81. Zhang ZC, et al. Development and future perspectives of natural orifice specimen extraction surgery for gastric cancer. World J Gastrointest Surg. 2022;14(11):1198–203.

Laparoscopic Proximal Gastrectomy with Transvaginal Specimen Extraction (GC-NOSES VI)

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Gang Yu

Contents Indications and Contraindications of NOSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422 Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422 Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . Anesthesia Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Patient Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trocar Placement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

422 422 422 422 423 423

Surgical Procedure, Techniques, and Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . General Exploration and Surgical Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dissection and Separation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Specimen Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Digestive Tract Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Transvaginal Specimen Extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postoperative Abdominal Wall and Specimen Display . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

423 423 424 425 427 427 427

Key Points, Difficulties, and Hotspots Related to Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 434

Abstract

At present, common laparoscopic gastric tumor surgeries require an auxiliary incision of about 4–6 cm in length to extract the specimen, which also partially offsets the minimally invasive advantages of laparoscopic surgery. Except that the method of specimen extraction is different from that of conventional laparoscopic surgery, the resection of tumor, lymph node dissection, and dissecting plane during the surgery of laparoscopic NOSES for gastric tumor are consistent with those of conventional laparoscopic surgery. Specimen extraction through a natural

orifice eliminates the auxiliary incision of the abdominal wall, which can not only ensure the radical resection of tumor but also reduce the damage to organs and tissues. Therefore, this is an ideal procedure that improves the psychological feelings of patients and fully satisfies the requirements of functional surgery. Laparoscopic proximal gastrectomy with transvaginal specimen extraction (GC-NOSES VI) is a gastric function preserving surgery that is mainly applicable to female patients with early cancer in the upper stomach and gastroesophageal junction. Under the premise of ensuring adequate lymph node dissection and strict adherence to the radical resection of tumor and digestive tract

G. Yu (*) Department of General Surgery, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University Qingdao, Qingdao, Shandong, China © People’s Medical Publishing House, PR of China 2023 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-99-2750-0_29

421

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G. Yu

reconstruction in the conventional laparoscopic surgery for gastric cancer, this procedure makes incision in the posterior vaginal fornix and adopts transvaginal specimen extraction, which puts forward higher requirements for the implementation of aseptic and tumor-free principles. This is a resection extraction NOSES procedure. Keywords

NOSES · Gastrectomy · Gastric cancer · Laparoscopy · Transvaginal

Indications and Contraindications of NOSES

Fig. 29.1 Horizontal supine position with legs abduction

Indications 1. Female patients. 2. Upper gastric cancer or gastroesophageal junction cancer, stage cT1-2N0-1M0. 3. The circumferential diameter of tumor is better
4 cm.

Contraindications 1. Female patients with fertility plan. 2. Locally advanced cancer (cT3-4N1-3M0-1), or the tumor is large. 3. Patients with acute gastrointestinal obstruction or tumor perforation requiring emergency surgery. 4. Severely obese patients (BMI > 30 kg/m2). 5. Patients with serious pelvic adhesion or vaginal deformities.

Fig. 29.2 Functional lithotomy position

Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position Anesthesia Method General anesthesia or general epidural anesthesia.

Patient Positioning

Fig. 29.3 Trocar sites (five-ports method)

The patient should be placed in the horizontal supine position with legs abduction (Fig. 29.1), which will be changed to the functional lithotomy position (Fig. 29.2) when removing the specimen through the posterior vaginal fornix.

2. The surgeon’s main trocar (12 mm trocar) is located below the costal margin of the left anterior axillary line. 3. The surgeon’s auxiliary trocar (5 mm trocar) is located at the umbilical level of the left midclavicular line. 4. The assistant’s auxiliary trocar (5 mm trocar) is located under the costal margin of the right anterior axillary line. 5. The assistant’s main trocar (12 mm trocar) is located at the umbilical level of the right midclavicular line (Fig. 29.3).

Trocar Placement 1. Camera trocar (10 mm trocar) is located 1 cm below the umbilicus.

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Laparoscopic Proximal Gastrectomy with Transvaginal Specimen Extraction (GC-NOSES VI)

Surgical Team Position Abdominal Exploration, Anatomical Dissection, and Lymph Node Dissection The positions of the surgeon, assistant, and camera holder should be on the left side, right side, and between the patient’s legs, separately (Fig. 29.4). Digestive Tract Reconstruction The positions of the surgeon, assistant, and camera holder should be on the right side, left side, and between the patient’s legs, separately (Fig. 29.5).

423

Transvaginal Specimen Extraction The positions of the surgeon, assistant, and camera holder should be on the right side, left side, and the left side of the patient, separately (Fig. 29.6). In this step, the monitor should be placed on the side of the patient’s foot. The trocar function should be changed accordingly (Fig. 29.7).

Surgical Instruments Ultrasonic scalpel, 60 mm linear Endo-GIA stapler, 3-0 barbed suture, 4-0 absorbable suture, and sterile protective sleeve.

Surgical Procedure, Techniques, and Key Points General Exploration and Surgical Planning On the basis of detailed preoperative examination, the liver, gallbladder, stomach, spleen, colon, small intestine, greater omentum, and pelvic cavity are routinely examined for the presence of tumor seeding or ascites (Figs. 29.8 and 29.9).

Fig. 29.4 Surgical team position

Fig. 29.6 Surgical team position

Fig. 29.5 Surgical team position

Fig. 29.7 Changes in trocar function during specimen extraction

424

G. Yu

Dissection and Separation Suspension of Liver and Dissection of Esophagus and the Right Diaphragmatic Crus to Enter the Gerota’s Space Firstly, the surgeon opens the hepatogastric ligament and sutures the hepatic side of the hepatogastric ligament as traction stitch to suspend the left lobe of liver. Dissection is performed between the gastroesophageal junction and the right diaphragmatic crus, and then the Gerota’s space is entered (Figs. 29.10 and 29.11). Fig. 29.8 Routine exploration

Fig. 29.9 Routine exploration Fig. 29.10 Suspension of liver

Fig. 29.11 Dissecting the space between the right side of the cardia and the right diaphragmatic crus

Dissection of the Greater Omentum and the Gastrosplenic Ligament The greater omentum is flipped cephalad and transected from the left side of the transverse colon. The incision is extended to the hepatic flexure of colon on the right side. Dissection is performed along the posterior region of the anterior lobe of the transverse mesocolon. Afterwards, the anterior lobe of the transverse mesocolon is resected and attention should be paid to the preservation of the right gastroepiploic vessel (Fig. 29.12). Then the patient is placed in the right-leaning position. The gastrosplenic ligament is exposed, and the greater omentum is transected from the middle of colon to the splenic flexure. Subsequently, the left gastroepiploic artery and vein are transected at the root, and station 4sb lymph nodes are dissected. Apply the ultrasonic scalpel to transect the short gastric artery close to the hilum of the

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425

Fig. 29.12 Preservation of the right gastroepiploic vessel

(Fig. 29.16). The celiac trunk is exposed and the left gastric artery and vein are dissected and transected after being ligated at the root. Stations 7 and 9 lymph nodes are dissected, whereafter the dissection is continued along the common hepatic artery for the excision of station 8a lymph nodes (Figs. 29.17, 29.18, and 29.19). Station 11d lymph nodes are further dissected along the splenic artery. Whether to dissect station 10 lymph nodes is determined according to the tumor location and whether splenic hilar lymph nodes are enlarged (Fig. 29.20).

Fig. 29.13 Tracking the origin of the left gastroepiploic vessel along the pancreatic tail

Dissection of Stations 1 and 2 Lymph Nodes and Isolation of Esophagus The surgeon transects the anterior and posterior gastric vagal nerves, and isolates the esophagus for enough length. When the dissected length of esophagus is insufficient, the diaphragm can be opened for 4–5 cm from the fornix of the esophageal diaphragmatic hiatus anteriorly, and the bilateral diaphragmatic crura can be transected in the middle and lower part of it to push the pleura aside laterally. A traction stitch is sutured in the esophagus above the tumor to pull the esophagus downwards as much as possible. The esophagus should be adequately dissected upwards in the posterior mediastinum to ensure that there is enough resection margin (Figs. 29.21 and 29.22).

Specimen Resection Fig. 29.14 Dissection of station 4sb lymph nodes

spleen, and station 4sa lymph nodes are dissected (Figs. 29.13, 29.14, and 29.15).

Dissection of Stations 7, 8a, 9, 11p, and 11d Lymph Nodes The dissection is performed along the superior border of pancreas. The proximal end of the splenic artery is exposed, and station 11p lymph nodes are dissected

The esophagus is transected with a linear Endo-GIA stapler at 2 cm above the esophagogastric junction and the stomach is transected with a linear Endo-GIA stapler at 5 cm from the distal end of the tumor. A suitable cartridge is selected according to the thickness of the stomach wall and the esophageal wall. After esophageal dissection is completed, the esophagus is transected with a linear Endo-GIA stapler (Fig. 29.23). The resected specimen is placed in a specimen bag (Figs. 29.24 and 29.25).

426 Fig. 29.15 Dissection of station 4sa lymph nodes

Fig. 29.16 Exposure of the proximal splenic artery along the superior border of pancreas

Fig. 29.17 Dissection of the left gastric vein

Fig. 29.18 Dissection of stations 7 and 9 lymph nodes

G. Yu

29

Laparoscopic Proximal Gastrectomy with Transvaginal Specimen Extraction (GC-NOSES VI)

Digestive Tract Reconstruction Digestive Tract Reconstruction with Instrumental Anastomosis: Anastomosis Between the Posterior Wall of the Esophagus and the Anterior Wall of the Remnant Stomach (Overlap Method) The two jaws of the linear Endo-GIA stapler are inserted into the windows of the posterior wall of the esophagus and the anterior wall of the remnant stomach, respectively. Then the

427

stapler is fired to complete the side-to-side esophagojejunal anastomosis (Figs. 29.26, 29.27, and 29.28). The remaining opening is sutured with 3-0 barbed suture (Fig. 29.29).

Digestive Tract Reconstruction with Manual Suture The anterior wall of the remnant stomach and the posterior wall of the esophagus are sutured with three stitches, whereafter the anterior wall of the remnant stomach and the posterior wall of the esophagus are opened for handsewn anastomosis (Fig. 29.30). The anastomosis of the posterior wall is sutured in an intermittent full-thickness pattern with absorbable suture, while the anterior wall is sutured in a continuous pattern with barbed suture (Fig. 29.31).

Transvaginal Specimen Extraction

Fig. 29.19 Effects of lymph node dissection at the superior border of pancreas

For transvaginal specimen extraction, the patient is placed in the functional lithotomy position, and the laparoscopic monitor is moved to the side of patient’s foot. The perineal area and vagina are disinfected with iodoform gauze. After replacing the patient in the right-leaning Trendelenburg position, the surgeon should suspend the uterus to expose the posterior vaginal fornix (Fig. 29.32). Use the abdominal spatula to withstand the posterior vaginal fornix. An incision for approximately 5 cm is made with the ultrasonic scalpel. Through the incision, the protective sleeve is inserted into the vagina (Figs. 29.33, 29.34, and 29.35) to remove the specimen from it (Figs. 29.36, 29.37, and 29.38). Finally, the posterior vaginal fornix is continuously sutured, and irrigation of the pelvic cavity is performed repeatedly (Figs. 29.39, 29.40, 29.41, and 29.42).

Postoperative Abdominal Wall and Specimen Display Fig. 29.20 Splenic hilar dissection

Fig. 29.21 Dissection of the left side of esophagus

See Figs. 29.43 and 29.44.

428 Fig. 29.22 Transection of the anterior and posterior gastric vagal nerves

Fig. 29.23 Transection of the esophagus at 3 cm from the proximal end of tumor

Fig. 29.24 Transection of the stomach at 5 cm from the distal end of tumor

Fig. 29.25 Placing the specimen in the specimen bag and temporarily placing it in the left lower abdomen

G. Yu

29

Laparoscopic Proximal Gastrectomy with Transvaginal Specimen Extraction (GC-NOSES VI)

Fig. 29.26 Opening of the esophageal stump

Fig. 29.27 Anastomosis between the posterior wall of the esophagus and the anterior wall of the remnant stomach

Fig. 29.28 Placement of gastric tube

Fig. 29.29 Remaining opening sutured in a continuous pattern with 3-0 barbed suture

429

430 Fig. 29.30 The posterior wall of the esophagus and the anterior wall of the remnant stomach are sutured with three stitches

Fig. 29.31 Remaining opening sutured in an intermittent pattern with 3-0 absorbable suture

Fig. 29.32 Suspension of uterus

Fig. 29.33 Posterior vaginal fornix is withstood with the abdominal spatula after repeated disinfection of vagina

G. Yu

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Laparoscopic Proximal Gastrectomy with Transvaginal Specimen Extraction (GC-NOSES VI)

Fig. 29.34 Open the posterior vaginal fornix with monopolar electrocoagulation

Fig. 29.35 Insertion of protective sleeve through the main trocar

Fig. 29.36 Extraction of specimen and specimen bag

Fig. 29.37 Transvaginal extraction of specimen

431

432

Fig. 29.38 Extraction of specimen bag

Fig. 29.39 Repeated irrigation with dilute iodine solution

Fig. 29.40 Repeated irrigation with normal saline

Fig. 29.41 Incision of the posterior vaginal fornix closed by continuous suture with 3-0 barbed suture

G. Yu

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Laparoscopic Proximal Gastrectomy with Transvaginal Specimen Extraction (GC-NOSES VI)

433

Fig. 29.42 Quality check of sutures

Fig. 29.44 Appearance of abdominal wall after operation

Fig. 29.43 Specimen display

Key Points, Difficulties, and Hotspots Related to Surgery Proximal gastrectomy is a gastric function preserving surgery. It is of great importance for the maintenance of nutritional status and the improvement of quality of life of patients after operation. However, the surgical indications must be strictly followed, and the procedure cannot be adopted at the cost of radical resection of tumors. This procedure is applicable to early cancer in the upper stomach. The greater proximal part of the stomach and the lower part of the esophagus should be resected. The distance between the resection margin of the esophagus and the tumor should be >3 cm, and the distance between the resection margin of the stomach and the tumor should be >5 cm. Stations 1, 2, 3, 4sa, 4sb, 7, 8a, 9, and 11p lymph nodes should be routinely dissected in D1 þ radical gastrectomy for proximal gastric cancer. Station 110 lymph nodes should be

dissected when the tumor invades the esophagus, and station 10 lymph nodes should be dissected when the tumor is located on the greater curvature side or the splenic hilar lymph nodes are enlarged. The location, size, and depth of tumor invasion should be evaluated before operation. In the selection of patients, the patient’s age, obesity degree, and marital and reproductive status should be taken into consideration. The aseptic and tumor-free principles should be followed throughout the operation. Opening the posterior vaginal fornix and specimen extraction through the narrow incision may increase the risk of intraperitoneal contamination and tumor implantation and spreading (Guan et al. 2020). Repeated irrigation with a large amount of dilute iodine solution, normal saline, and distilled water, as well as the use of specimen bag and protective sleeve can avoid specimen exposure and reduce the risk of tumor cell implantation. The resection, dissection, and reconstruction of NOSES for gastric cancer are performed in the upper abdomen, whereas the opening of posterior vaginal fornix and the specimen extraction are performed in the lower abdomen (Zhang et al. 2022). The patient’s position and the placement of laparoscope and the monitor should be changed during the operation. Operating in the lower abdominal through the trocars placed for upper abdominal operation without placing extra trocars increase the difficulty of operation. The surgeon should closely cooperate with the assistant to overcome the difficulty. Transvaginal NOSES is applied to female patients with gastric cancer. Since the posterior vaginal fornix is anatomically devoid of large blood vessels and nerves, it is a common route

434

for gynecological operation and specimen extraction (Dong et al. 2022). It is safer than rectum as a route of specimen extraction, and intestinal fistula, intraperitoneal infection, and other serious complications caused by transrectal specimen extraction can be avoided.

References Dong C, et al. Totally laparoscopic gastrectomy with natural orifice (vagina) specimen extraction in gastric cancer: Introduction of a new technique. J Minim Access Surg. 2022;18(3):484–6.

G. Yu Guan X, et al. International consensus on natural orifice specimen extraction surgery (NOSES) for gastric cancer (2019). Gastroenterol Rep (Oxf). 2020;8(1):5–10. Zhang ZC, et al. Development and future perspectives of natural orifice specimen extraction surgery for gastric cancer. World J Gastrointest Surg. 2022;14(11):1198–203.

Laparoscopic Total Gastrectomy with Transrectal Specimen Extraction (GC-NOSES VII)

30

Gang Yu

Contents Indications and Contraindications of NOSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 436 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 436 Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 436 Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . Anesthesia Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Patient Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trocar Placement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

436 436 436 436 436 438

Surgical Procedure, Techniques, and Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Exploration and Surgical Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dissection and Separation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Specimen Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Digestive Tract Reconstruction (Laparoscopic Roux-en-Y Esophagojejunal Anastomosis and Overlap Method) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Transanal Specimen Extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postoperative Specimen and Abdominal Wall Pictures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

438 438 438 441 441 441 441

Key Points, Difficulties, and Hotspots Related to Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 441 Difficulties in Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 443 Controversy over Transanal Specimen Extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 452

Abstract

Laparoscopic total gastrectomy is mainly applicable to gastric cancer patients with lesions invading the body of the stomach, the upper and middle part of the stomach, or the gastroesophageal junction. In the NOSES, specimen is extracted through the natural orifice, while the basic laparoscopic operational steps are not changed. Except that the method of specimen extraction is different from that of conventional laparoscopic surgery, the gastrointestinal tract resection, the extent of lymph node dissection, the dissection plane of surgery, and digestive tract reconstruction are consistent with those of G. Yu (*) Department of General Surgery, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University Qingdao, Qingdao, Shandong, China © People’s Medical Publishing House, PR of China 2023 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-99-2750-0_30

conventional laparoscopic surgery. Laparoscopic total gastrectomy with transanal specimen extraction (GC-NOSES VII) is a resection extraction NOSES procedure. The operating characteristics are as follows: radical resection of gastric cancer and digestive tract anastomosis under laparoscopy with an incision in the upper rectum, and specimen extraction through the anus. The procedure conforms to the concept of minimally invasive surgery. Under the premise of conforming to the basic principles of cancer surgery, the surgical damage can be reduced by optimizing the surgical approach, improving the operational procedure, preserving the structure and function of the abdominal wall, thereby reduce the influence on patients’ quality of life.

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Keywords

NOSES · Gastrectomy · Gastric cancer · Laparoscopy · Transrectal

Indications and Contraindications of NOSES Indications 1. Gastric cancer, stage cT1–3N1–2M0, with lesions invading the body of the stomach, the upper and middle part of the stomach, or the gastroesophageal junction. 2. The circumferential diameter of tumor is better 4 cm. 3. Male patients and some female patients who are not suitable for transvaginal specimen extraction.

Fig. 30.1 The patient’s position during gastric cancer resection and digestive tract reconstruction

Contraindications 1. The tumor is too large to be pulled out through the anus. 2. The tumor penetrates the serosa or involves adjacent organs. 3. Patients with acute gastrointestinal obstruction or tumor perforation requiring emergency surgery. 4. Severely obese patients (BMI > 30 kg/m2). 5. Patients with history of pelvic surgery or rectal and anal deformities.

Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position Anesthesia Method General anesthesia or general epidural anesthesia.

Patient Positioning The patient should be placed in the horizontal supine position with legs abduction for gastric cancer resection and digestive tract reconstruction operation (Fig. 30.1), which will be changed to the functional lithotomy position (Fig. 30.2) when removing the specimen through the anus.

Trocar Placement 1. Camera trocar (10 mm trocar) is located 1 cm below the umbilicus. 2. The surgeon’s main trocar (12 mm trocar) is located 2 cm below the costal margin of the left anterior axillary line. 3. The surgeon’s auxiliary trocar (5 mm trocar) is located at the umbilical level of the left midclavicular line.

Fig. 30.2 The patient’s position during specimen extraction

4. The assistant’s auxiliary trocar (5 mm trocar) is located under the costal margin of the right anterior axillary line. 5. The assistant’s main trocar (12 mm trocar) is located at the umbilical level of the right midclavicular line (Fig. 30.3).

Surgical Team Position Abdominal Exploration, Anatomical Dissection, and Lymph Node Dissection The positions of the surgeon, assistant, and camera holder should be on the left side, right side, and between the patient’s legs, separately (Fig. 30.4). Digestive Tract Reconstruction The positions of the surgeon, assistant, and camera holder should be on the right side, left side, and between the patient’s legs, separately (Fig. 30.5).

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Specimen Extraction The positions of the surgeon, assistant, and camera holder should be on the right side, left side, and the left side of the patient, separately (Fig. 30.6). The monitor should be placed on the side of the patient’s foot. At the same time, the function of trocars is changed (Fig. 30.7).

Fig. 30.3 Trocar placement (five-ports method)

Fig. 30.6 Surgical team position during specimen extraction

Fig. 30.4 Surgical team position

Fig. 30.7 Function of trocars during specimen extraction

Fig. 30.5 Surgical team position

Fig. 30.8 Exploration of the diaphragm

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Fig. 30.9 Exploration of the pelvic cavity and bowel

Dissection and Separation Dissection of the Anterior Lobe of the Transverse Mesocolon and Dissection of the Gastrocolic Ligament The greater omentum is flipped cephalad and transected from the left side of the transverse colon. The lesser omental sac is entered, and the incision is extended to the hepatic flexure of colon on the right side. Dissection is performed along the posterior region of the anterior lobe of the mesocolon. The anterior lobe of the mesocolon is resected (Fig. 30.12). Fig. 30.10 Exploration of the liver

Surgical Instruments Ultrasonic scalpel, 60 mm linear Endo-GIA stapler, and sterile protective sleeve.

Surgical Procedure, Techniques, and Key Points Surgical Exploration and Surgical Planning Comprehensive Exploration On the basis of detailed preoperative examinations, the presence of ascites in the abdominal cavity and implant nodules on the surface of the diaphragmatic dome, paracolic sulci, peritoneum, pelvic floor, omentum, mesentery, and so forth should be comprehensively explored (Figs. 30.8 and 30.9). Pay attention to explore the surface of liver for metastatic lesions (Fig. 30.10) and assess the condition of the primary tumor and the enlargement of the surrounding lymph nodes. If necessary, the position may be adjusted for thorough exploration. Tumor Exploration Gastric body tumors should not invade beyond the serosa (Fig. 30.11).

Perigastric Lymphadenectomy 1. Dissection of the station 6 lymph nodes: The gastric antrum is lifted upwards. The gastrocolic trunk (Henle’s trunk) is exposed and the right gastroepiploic vein is transected at the root (Figs. 30.13 and 30.14). The dissection is continued along the surface of the pancreatic head. The gastropancreatic ligament is opened to expose the gastroduodenal artery. The right gastroepiploic artery is isolated and transected at the root. Station 6 lymph nodes are completely dissected (Fig. 30.15). 2. Dissection of stations 4 and 10 lymph nodes: After entering the omental bursa, the pancreatic tail and the splenic vessel are exposed, the splenic vessel is located, the splenic flexure is mobilized, and the adhesion between the greater omentum and middle and lower pole of spleen is detached (Fig. 30.16). The pancreatic tail is protected and the root is exposed. The left gastroepiploic artery and vein are transected (Fig. 30.17), station 4sb lymph nodes are dissected, and splenic hilar lymph nodes are further dissected (Fig. 30.18). 3. Dissection of station 4sa lymph nodes: After pulling the stomach and the greater omentum to the left, the dissection is continued upwards. The short gastric vessels are transect for the dissection of station 4sa lymph nodes (Fig. 30.19).

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Fig. 30.11 Exploration of the tumor

Fig. 30.12 The assistant’s cooperation on tensioning omentum by triangular stretch

Fig. 30.13 Dissection along the fusion fascia space

4. Dissection of stations 8, 12 and 5 lymph nodes: The surgeon then exposes the common hepatic artery, pulls the pancreas to the lower left, and dissects the station 8a lymph nodes along the anterior and superior border of the common hepatic artery. The right gastric artery and the proper hepatic artery are adequately exposed along the gastroduodenal artery and the common hepatic artery. The

anterior and lateral sides of the proper hepatic artery are dissected upwards, and the station 12a lymph nodes are dissected (Fig. 30.20). The right gastric artery and vein are transected after being ligated at the root (Fig. 30.21) and the station 5 lymph nodes are dissected. The duodenum is transected with a linear Endo-GIA stapler at the distal end of pylorus and the station 5 lymph nodes are dissected

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(Figs. 30.22 and 30.23). The fascia anterior to the portal vein is opened at the angle among the common hepatic artery, the gastroduodenal artery, and the superior border of pancreas to expose the portal vein. The common

Fig. 30.14 Dissection, ligation, and transection of the right gastroepiploic vein

Fig. 30.15 Dissection, ligation, and transection of the right gastroepiploic artery

Fig. 30.16 Dissecting the greater omentum to the splenic flexure, taking the tail of the pancreas as a marker to locate the left gastroepiploic vessel

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hepatic artery is lifted toward the anterior abdominal wall. Subsequently, the surgeon dissects along the anterior of the portal vein and dissects the lymph nodes between the portal vein and the proper hepatic artery. Dissection is then continued upwards along the medial side of the portal vein to the hepatic hilum. Afterwards, the common hepatic artery is pulled downwards to the right, and the lymphatic and adipose tissues is dissected along the medial side of the proper hepatic artery and the portal vein (Fig. 30.24). Stations 8, 12, and 5 lymph nodes are dissected (Fig. 30.25). 5. Dissection of stations 11p, 7, and 9 lymph nodes: The greater omentum is placed below the liver. The assistant grasps and holds the plica gastropancreatica and turns the stomach upwards. The anterior pancreatic capsule is dissected. The dissection is performed closely along the superior border of pancreas to expose the proximal end of splenic artery, followed by dissection of the station 11p lymph nodes. From left to right, the celiac trunk is exposed and the left gastric artery and vein are dissected and transected after being ligated at the root, and stations 7 and 9 lymph nodes are dissected (Figs. 30.26 and 30.27). Dissection along the splenic artery to the distal end to transect the posterior gastric vessels is performed (Fig. 30.28), followed by the dissection of the station 11p lymph nodes. 6. Dissection of lymph nodes in the lesser curvature: Dissect closely along the lesser curvature layer by layer to dissect the lymph nodes (Fig. 30.29). 7. Dissection of Lower Esophagus and Dissection of Lymph Nodes in the Right and Left Sides of Cardia: Dissection is performed closely along the lesser curvature layer by layer, then the anterior and posterior vagal trunks are transected, and the lymph nodes in the right and left sides of cardia (stations 1 and 2 lymph nodes) are dissected (Figs. 30.30, 30.31, and 30.32).

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Fig. 30.17 Transection of the left gastroepiploic vessel at the root

antimesenteric side of the jejunum 40 cm from the esophagojejunal anastomosis, the proximal and distal jejunum are anastomosed with a linear Endo-GIA stapler in a side-to-side fashion, and the remaining opening of jejunum is closed with a 3.0 absorbable suture in an intermittent pattern (Figs. 30.43 and 30.44).

Transanal Specimen Extraction

Fig. 30.18 Further dissection of splenic hilar lymph nodes

Specimen Resection The surgeon transects the esophagus at 3 cm from the proximal edge of tumor, puts the specimen in the specimen bag, and temporarily places it in the left lower abdomen until the specimen is extracted through the anus (Figs. 30.33, 30.34, and 30.35).

Digestive Tract Reconstruction (Laparoscopic Roux-en-Y Esophagojejunal Anastomosis and Overlap Method) The surgeon makes a stitch on the left and right sides of the esophageal stump with the barbed suture. The ultrasonic scalpel is used to open the middle of the esophageal stump (Fig. 30.36), then the jejunum is transected at 20 cm from the Treitz’s Ligament (Figs. 30.37 and 30.38), so as to facilitate the creation of the overlap anastomosis between distal jejunum and esophagus (Fig. 30.39). The remaining opening is closed with barbed suture in a continuous pattern (Figs. 30.40, 30.41, and 30.42). After the esophagojejunal anastomosis is created, a window is opened in the

After radical resection of the gastric cancer and the digestive tract reconstruction, the patient is placed in the functional lithotomy position, then the perineal area and rectal cavity is disinfected with iodoform gauze. The laparoscopic monitor is moved to the side of patient’s foot, while the patient is placed in the Trendelenburg position. The assistant stretches the sigmoid colon to fully expose the upper rectum, and then the surgeon makes an incision of 5–6 cm in the anterior wall of the upper rectum (Fig. 30.45). The protective sleeve is inserted into the rectum through the trocar after further disinfecting with dilute iodine solution (Figs. 30.46 and 30.47), whereafter the specimen is removed from the anus through the protective sleeve (Figs. 30.48 and 30.49). Finally, the bowel wall is sutured in continuous or intermittent pattern (Figs. 30.50, 30.51, and 30.52).

Postoperative Specimen and Abdominal Wall Pictures See Figs. 30.53 and 30.54.

Key Points, Difficulties, and Hotspots Related to Surgery With the accumulation of surgical experience and the rapid development of instruments, the feasibility and safety of totally laparoscopic radical gastrectomy for gastric cancer

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Fig. 30.19 Transection of short gastric vessels and dissection of station 4sa lymph nodes

Fig. 30.20 Exposure of the gastroduodenal artery, common hepatic artery, proper hepatic artery, and right gastric artery

Fig. 30.21 Transection of the right gastric artery

have been improved continuously, and its application has received more and more attention (Lei et al. 2022). At the same time, with the surgeons’ constant exploration, NOSES become an advancement that combines laparoscopic technology with the NOTES concept (Guan et al. 2020; Zhang et al. 2022). Laparoscopic total gastrectomy with transanal specimen extraction (GC-NOSES VII) is an application of NOSES technique in laparoscopic total gastrectomy. It is a procedure for

Fig. 30.22 Status after the dissection of the subpyloric region

total gastrectomy and digestive tract reconstruction completely under laparoscopy with smaller auxiliary incision and broader view of operation field as to easily determine the direction of the bowel during reconstruction, which can effectively avoid mistakes, such as inadequate exposure, bowel torsion, and overtension of the anastomosis (Sun et al. 2019). It has obvious advantages in terms of the safety of the operation, but there are still many difficulties and controversies.

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Fig. 30.23 Transection of the duodenum at the distal end of pylorus

Fig. 30.24 Exposure of portal vein and dissection of station 12a lymph nodes

Fig. 30.25 Status after the dissection of stations 8, 12, and 5 lymph nodes

Difficulties in Surgery 1. In the totally laparoscopic radical gastrectomy, esophagojejunal anastomosis is a difficulty. This procedure requires a certain experience accumulation and the laparoscopic anastomosis requires excellent laparoscopic suture techniques. 2. The specimen extraction through the anus requires good preoperative bowel preparation. Strict tumor-free and aseptic principles should be followed during the operation.

3. The specimen extraction requires two surgical teams to operate together, which requires good cooperation of the team. 4. The position of the monitor should be adjusted during the operation, or prepare two sets of laparoscopic display equipment. 5. The number of trocars should not be increased, and the trocars placed for the operation in the upper abdomen should be applied for the operation in the lower abdomen as well, which puts forward higher requirements for the cooperation between the surgeons and the assistants.

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Fig. 30.26 Dissection and transection of the left gastric vein

Fig. 30.27 Dissection and transection of the left gastric artery and further dissection of stations 7, 9, and 11p lymph nodes

Fig. 30.29 Opening the lesser omentum

Fig. 30.28 Transection of the posterior gastric vessels Fig. 30.30 Dissection of the left side of esophagus

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Fig. 30.31 Dissection of the right side and the posterior region of esophagus and transection of the posterior vagal trunk

Fig. 30.32 Dissection of the lower esophagus to an appropriate length

Fig. 30.33 Intraoperative gastroscopy for the localization of the proximal edge of tumor and transection of the esophagus

Controversy over Transanal Specimen Extraction 1. Organs unrelated to the primary disease will be cut open. 2. There is an increased risk of abdominal infection, tumor implantation, and spreading. 3. There is an increased risk of serious complications such as leakage, bleeding, rectal stenosis, and abnormal bowel function, etc.

4. At present, NOSES is in the process of continuous improvement. The number of cases is still small, and more studies are needed for the observation of the longterm efficacy of NOSES. Therefore, doctors should strictly follow the indications to ensure the safety of patients, so as to maximize the benefits for patients.

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Fig. 30.34 Placing the specimen in the specimen bag and temporarily placing it in the left lower abdomen

Fig. 30.35 Status after the dissection of stations 10 and 11 lymph nodes

Fig. 30.36 Open the middle of the esophageal stump

Fig. 30.37 Transection of proximal mesojejunum

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Fig. 30.38 Transection of jejunum

Fig. 30.39 Overlap anastomosis of esophagus and jejunum

Fig. 30.40 Opening is closed by double suture in a continuous pattern with barbed suture

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Fig. 30.41 Status after esophagojejunal anastomosis

Fig. 30.42 Intraoperative gastroscopy to check the quality of anastomosis

Fig. 30.43 Side-to-side jejunal anastomosis

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Fig. 30.44 Opening closed in an intermittent pattern with absorbable suture

Fig. 30.45 Cutting open the anterior wall of the upper rectum after repeated disinfection of the bowel cavity

Fig. 30.46 Repeated disinfection of the bowel lumen with iodoform gauze

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Fig. 30.47 Insertion of protective sleeve

Fig. 30.48 Specimen extraction from the protective sleeve

Fig. 30.49 The specimen is extracted

Fig. 30.50 Repeated irrigation of pelvic cavity with dilute iodine solution and normal saline

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Fig. 30.51 Continuous double sutures with 3.0 barbed suture for rectum incision

Fig. 30.52 Irrigation of pelvic cavity with dilute iodine solution and normal saline again and rectal air leak test

Fig. 30.53 Specimen picture Fig. 30.54 Appearance of abdominal wall after operation

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References Guan X, et al. International consensus on natural orifice specimen extraction surgery (NOSES) for gastric cancer (2019). Gastroenterol Rep (Oxf). 2020;8(1):5–10. Lei X, et al. Short-and long-term outcomes of laparoscopic versus open gastrectomy in patients with gastric cancer: a systematic

G. Yu review and meta-analysis of randomized controlled trials. World J Surg Oncol. 2022;20(1):405. Sun P, et al. Natural orifice specimen extraction with laparoscopic radical gastrectomy for distal gastric cancer: a case report. World J Clin Cases. 2019;7(24):4314–20. Zhang ZC, et al. Development and future perspectives of natural orifice specimen extraction surgery for gastric cancer. World J Gastrointest Surg. 2022;14(11):1198–203.

Laparoscopic Total Gastrectomy with Transvaginal Specimen Extraction (GC-NOSES VIII)

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Contents Indications and Contraindications of NOSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 454 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 454 Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 454 Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . Anesthesia Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Patient Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trocar Placement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Surgical Procedure, Techniques, and Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Exploration and Surgical Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dissection and Separation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Digestive Tract Reconstruction (Total Laparoscopic Roux-en-Y Esophagojejunal Anastomosis) . . . . . . . . . Transvaginal Specimen Extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Key Points, Difficulties, and Hotspots Related to Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 460 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467

Abstract

Laparoscopic total gastrectomy with transvaginal specimen extraction (GC-NOSES VIII) is mainly applicable to female patients with tumors located in the middle and upper stomach and gastroesophageal junction. As with conventional laparoscopic surgery for gastric cancer, principles of radical resection and digestive tract reconstruction should be strictly followed. Except that the method of specimen extraction is different from that of conventional laparoscopic surgery, the gastrointestinal tract resection, the extent of lymph node dissection, and dissection plane of surgery are consistent with those of conventional laparoscopic surgery. This is a resection extraction NOSES procedure. The operating characteristics are as follows: radical resection of gastric cancer and digestive tract

reconstruction is performed under laparoscopy, then an incision is made in the posterior vaginal fornix to extract specimen. Total laparoscopic radical resection and digestive tract reconstruction provides a broader view of operation field as to easily determine the direction of the bowel during reconstruction. In this way, common mistakes while operating with small auxiliary incision, such as bowel torsion and over-tension of the anastomosis, can be effectively avoid. Transvaginal specimen extraction avoids the auxiliary incision in the abdominal wall, preserves the function of abdominal wall to the maximum, reduces postoperative pain, which facilitates early ambulation, and shortens recovery time, so as to minimize the physical and psychological effects of surgery. Keywords

G. Yu (*) Department of General Surgery, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University Qingdao, Qingdao, Shandong, China © People’s Medical Publishing House, PR of China 2023 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-99-2750-0_31

NOSES · Gastrectomy · Gastric cancer · Laparoscopy · Transvaginal

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Indications and Contraindications of NOSES

Trocar Placement

Indications

1. Camera trocar (10 mm trocar) is located 1 cm below the umbilicus. 2. The surgeon’s main trocar (12 mm trocar) is located below the costal margin of the left anterior axillary line. 3. The surgeon’s auxiliary trocar (5 mm trocar) is located at the umbilical level of the left midclavicular line. 4. The assistant’s auxiliary trocar (5 mm trocar) is located under the costal margin of the right anterior axillary line. 5. The assistant’s main trocar (12 mm trocar) is located at the umbilical level of the right midclavicular line (Fig. 31.3).

1. Gastric cancer, stage cT1-3N1-2M0, with lesions in the middle and upper part of the stomach or the gastroesophageal junction. 2. The circumferential diameter of tumor is better 4 cm.

Contraindications 1. The tumor is too large to be pulled out through the vagina. 2. The tumor invades beyond the serosa or invades adjacent organs. 3. Severely obese patients (BMI > 30 kg/m2). 4. Patients with serious cardiac, pulmonary, hepatic, renal, and other concomitant diseases that cannot tolerate the surgery.

Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position

Surgical Team Position Abdominal Exploration, Anatomical Dissection, and Lymph Node Dissection The positions of the surgeon, assistant, and camera holder should be on the left side, right side, and between the patient’s legs, separately (Fig. 31.4).

Anesthesia Method General anesthesia or general epidural anesthesia.

Patient Positioning The patient should be placed in the horizontal supine position with legs abduction for gastric cancer resection and digestive tract reconstruction operation (Fig. 31.1), which will be changed to the functional lithotomy position (Fig. 31.2) when removing the specimen through the vagina.

Fig. 31.2 The patient’s position during specimen extraction

Fig. 31.1 The patient’s position during resection and reconstruction

Fig. 31.3 Trocar placement (five-ports method)

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Fig. 31.6 Comprehensive exploration of the abdominal cavity

Fig. 31.4 Surgical team position during gastric cancer resection

Fig. 31.7 Comprehensive exploration of the abdominal cavity

Surgical Procedure, Techniques, and Key Points Surgical Exploration and Surgical Planning

Fig. 31.5 Surgical team position during specimen extraction

Digestive Tract Reconstruction The surgeon switches positions with the assistant. Specimen Extraction The positions of the surgeon, assistant, and camera holder should be on the right side, left side, and the left side of the patient, separately (Fig. 31.5). In this step, the monitor should be placed on the side of the patient’s foot.

Surgical Instruments Ultrasonic scalpel, 60 mm linear Endo-GIA stapler, 3-0 barbed suture, 4-0 absorbable suture, and sterile protective sleeve.

Comprehensive Exploration On the basis of detailed preoperative examinations, the presence of ascites in the abdominal cavity and implant nodules on the surface of the diaphragmatic dome, paracolic sulci, peritoneum, pelvic floor, omentum, mesentery, and so forth should be comprehensively explored. Pay attention to the exploration of the surface of the liver and bilateral ovaries for metastases, and the condition of the primary tumor and the enlargement of the surrounding lymph nodes should be assessed. If necessary, the position of patient or surgical team can be adjusted for thorough exploration (Figs. 31.6 and 31.7). Tumor Exploration Explore the size, location, and mobility of the tumor, invasion of the serosa, and enlargement of lymph nodes to determine the extent of surgical resection (Fig. 31.8).

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Dissection and Separation Dissection of the Anterior Lobe of the Transverse Mesocolon and Dissection of the Gastrocolic Ligament The greater omentum is flipped cephalad and transected from the left side of the transverse colon. The lesser omental sac is entered, and the incision is extended to the hepatic flexure of colon on the right side. Dissection is performed along the posterior region of the anterior lobe of the mesocolon. The anterior lobe of the mesocolon is resected (Fig. 31.9).

Fig. 31.8 Exploration of the tumor

Fig. 31.9 The assistant’s cooperation on tensioning omentum by triangular stretch Fig. 31.10 Dissection along the fusion fascia space

Fig. 31.11 Transection of the right gastroepiploic vein

Perigastric Lymphadenectomy 1. Dissection of station 6 lymph nodes: With the marker of middle colic vessel, the surgeon firstly enters into the fusion fascia space between the gastroduodenum and transverse mesocolon. The anterior superior pancreaticoduodenal vein is exposed, and the right gastroepiploic vein is transected above the junction between the anterior superior pancreaticoduodenal vein with the right gastroepiploic vein. The dissection is continued along the surface of the pancreatic head. The gastroduodenal artery is exposed. The right gastroepiploic artery is isolated and transected at the root. Station 6 lymph nodes are completely dissected (Figs. 31.10, 31.11, and 31.12). 2. Dissection of station 4sb lymph nodes: The pancreatic tail is exposed, the left gastroepiploic artery and vein are exposed and transected at the root, splenic hilar lymph nodes are further dissected along the splenic artery and

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Fig. 31.12 Transection of the right gastroepiploic artery

Fig. 31.13 Root of the left gastroepiploic vessel

Fig. 31.14 Exposure of left gastroepiploic vessel and dissection of station 4sb lymph nodes

vein distally until the branch vessels of splenic hilum are exposed, and station 4sb lymph nodes are dissected (Figs. 31.13, 31.14, and 31.15). 3. Dissection of stations 11p, 11d, 7, and 9 lymph nodes: The dissection is performed closely along the superior border of pancreas to expose the proximal end of splenic artery, followed by dissection of the station 11p lymph nodes. Station 11d lymph nodes are further dissected along the splenic artery. Whether to dissect the station 10 lymph nodes is determined according to the tumor

location and whether splenic hilar lymph nodes are enlarged. The celiac trunk is exposed, and the left gastric artery and vein are dissected and transected after being ligated at the root, and stations 7 and 9 lymph nodes are dissected (Figs. 31.16, 31.17, 31.18, 31.19, and 31.20). 4. Dissection of station 12 lymph nodes: The duodenum is transected with a linear Endo-GIA stapler at 2 cm from the distal end of pylorus (Fig. 31.21). The capsule of the hepatoduodenal ligament is opened and the anterior and left sides of the proper hepatic artery are isolated, and the root of

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Fig. 31.15 Dissection of station 4sa lymph nodes at the splenic hilum

Fig. 31.16 Dissection of station 11p lymph nodes proximal to the splenic artery

(Fig. 31.25). When the dissected length of esophagus is insufficient, the dissection can be performed in the posterior mediastinum or open the diaphragm for 4–5 cm from the fornix of the esophageal diaphragmatic hiatus anteriorly. During the dissection, attention should be paid to push the pleura aside laterally to prevent damage to the pleura. The esophagus is pulled downwards to dissect the esophagus adequately to ensure the safety of the proximal resection margin (Fig. 31.26).

Fig. 31.17 Dissection of station 7 lymph nodes around the left gastric artery

the right gastric vessel is ligated and transected (Fig. 31.22). The assistant pulls the common hepatic artery downwards to the right and dissects the lymphatic and adipose tissues medial to the proper hepatic artery and the portal vein, i.e., the station 12a lymph nodes (Figs. 31.23 and 31.24). 5. Isolation of esophagus: The ultrasonic scalpel is applied to dissect closely along the esophagus, transect the anterior and posterior gastric vagal nerves, and dissect enough length of esophagus to dissect the station 110 lymph nodes

Digestive Tract Reconstruction (Total Laparoscopic Roux-en-Y Esophagojejunal Anastomosis) Digestive Tract Reconstruction with Instrumental Anastomosis: Esophagojejunal Side-to-Side Anastomosis (Overlap Method) After esophageal dissection is completed, the esophagus is transected with a linear Endo-GIA stapler (Fig. 31.27). The jejunum is transected at 25 cm from the Treitz’s ligament (Fig. 31.28). Two windows are opened in the posterior wall of esophagus and the antimesenteric side of the distal jejunum, respectively. The surgeon then inserts two jaws of the linear Endo-GIA stapler into the windows and fires the

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stapler to complete the side-to-side esophagojejunal anastomosis (Figs. 31.29, 31.30, and 31.31). The remained opening is closed with a 3-0 barbed suture (Fig. 31.32).

Digestive Tract Reconstruction with Handsewn Suture The esophagojejunal anastomosis is completed by performing anastomosis first and followed by transection, i.e., lift the bowel at 25 cm from the Treitz’s ligament to

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esophageal hiatus to be sutured with the posterior wall of esophagus for 3 stitches, and open the lateral wall of the jejunum and the posterior wall of the esophagus for handsewn anastomosis (Figs. 31.33 and 31.34). The anastomosis of the posterior wall is full-thickness sutured in an intermittent pattern with absorbable suture (Fig. 31.35). The anterior wall is sutured in a continuous pattern with barbed suture (Fig. 31.36). After the esophagojejunal anastomosis is created, the proximal jejunum is transected at 3 cm from the anastomosis, a window is opened in the antimesenteric side of the jejunum 40 cm from the esophagojejunal anastomosis, the proximal and distal jejunum are anastomosed with a linear Endo-GIA stapler in a side-to-side fashion, and the common opening of jejunum is closed with a 3.0 absorbable suture in an intermittent pattern or 3.0 barbed suture in a continuous pattern (Figs. 31.37, 31.38, and 31.39).

Transvaginal Specimen Extraction

Fig. 31.18 Dissection of station 9 lymph nodes around the celiac trunk

Fig. 31.19 Dissection of station 11d lymph nodes along the splenic artery Fig. 31.20 After the dissection of stations 10 and 11d lymph nodes

After radical resection of gastric cancer and the digestive tract reconstruction, the patient is placed in the functional lithotomy position, followed by the disinfection of the perineal area and vagina with iodoform gauze. Move the laparoscopic monitor to the side of patient’s foot and replace the patient in the Trendelenburg position. After suspending the uterus to expose the posterior vaginal fornix, the surgeon makes an incision of 5–6 cm in the posterior vaginal fornix (Fig. 31.40). The protective sleeve is inserted through the main trocar after disinfected with dilute iodine solution (Fig. 31.41). The specimen is removed from the vagina through the protective sleeve (Figs. 31.42 and 31.43). Next, the pelvic cavity is irrigated repeatedly with dilute iodine solution and normal saline (Figs. 31.44 and 31.45). Lastly, the posterior vaginal fornix is closed with continuous suture (Fig. 31.46). The postoperative appearance of specimen and abdominal wall is displayed (Figs. 31.47 and 31.48).

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Fig. 31.21 Transection of duodenum

Fig. 31.22 Transection of the right gastric artery at the root

Fig. 31.23 Exposure of portal vein and dissection of station 12a lymph nodes

Key Points, Difficulties, and Hotspots Related to Surgery Laparoscopic total gastrectomy is applicable to patients with advanced gastric cancer in the upper and middle stomach and early gastric cancer invading the submucosal layer with lymph node metastasis. In principle, D2 lymph node dissection should be performed. Whether to perform splenic hilar

lymph node dissection should be determined based on the principles described in the Guideline for Laparoscopic Gastrectomy for Gastric Cancer (2016) and the Specifications for the Diagnosis and Treatment of Gastric Cancer (2018). Radical resection of gastric cancer, lymph node dissection, and digestive tract reconstruction completely under laparoscopy have high technical requirements (Guan et al. 2020; Zhang et al. 2022). The patient should be placed in the functional lithotomy position during specimen extraction,

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Fig. 31.24 Dissection of stations 8a and 12a lymph nodes

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Fig. 31.27 Transection of the esophagus at 3 cm from the proximal end of tumor

Fig. 31.25 Dissection of station 110 lymph nodes Fig. 31.28 Transection of the jejunum at 25 cm from the Treitz’s ligament

Fig. 31.26 Adequate dissection of the lower esophagus

and the operation should be performed on the side of the patient’s foot. During the operation, the patient’s position should be changed and the position of the monitor should be adjusted, and the operation time will be prolonged accordingly. Vaginal irrigation should be performed before transvaginal specimen extraction. Strict tumor-free and aseptic principles should be followed during the operation.

Fig. 31.29 The esophageal stump is sutured with two traction stitches

Esophagojejunal anastomosis is a difficulty of this procedure: (1) It is necessary to ensure the safety of the proximal resection margin and accurately locate the tumor. (2) Anastomotic tension should be avoided, adequate dissection of esophagus and jejunum should be ensured, and the mesenteric vessels should be transected if necessary. (3) The blood

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Fig. 31.30 Opening of the esophageal stump between the two traction stitches

Fig. 31.31 Anastomosis between the posterior wall of the esophagus and bowel wall

Fig. 31.32 Remaining opening is closed in a continuous pattern with 3-0 barbed suture

supply of the esophagus and jejunum should be ensured to reduce the risk of anastomotic leakage. (4) Tight suture must be ensured. Two 3-0 barbed sutures can be used for the reinforcement of suture. Totally laparoscopic esophagojejunal anastomosis mainly include stapled anastomosis and handsewn anastomosis (Sumer et al. 2015). Handsewn anastomosis can save the

cost of stapler, save the length of esophagus, and reduce the tension of the anastomosis. However, handsewn suture requires high suture technique, and it is only adopted by a small number of surgeons now. Linear Endo-GIA stapler is commonly used in the stapled anastomosis. Common methods for esophagojejunal anastomosis include: functional end-to-end (FETE) and side-to-side (overlap) anastomosis.

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Fig. 31.33 The posterior wall of the esophagus and the lateral wall of the jejunum are sutured

Fig. 31.34 Opening the anterior wall of the jejunum and the posterior wall of the esophagus for handsewn anastomosis

Fig. 31.35 Posterior wall of the anastomosis is sutured in an intermittent full-thickness pattern with absorbable suture

(1) Functional end-to-end esophagojejunal anastomosis: After esophageal dissection is completed, the esophagus is transected with a linear Endo-GIA stapler. The jejunum is transected at 25 cm from the Treitz’s ligament. Two windows are opened on the left side of esophagus and the antimesenteric side of the

distal jejunum, respectively. Two jaws of the linear Endo-GIA stapler are inserted into the windows, and the stapler is fired to complete the side-to-side esophagojejunal anastomosis. The common opening is then closed with a linear Endo-GIA stapler. This technique is only applicable to patients with gastric body

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Fig. 31.36 Continuous suture of anterior wall with 3-0 barbed suture

Fig. 31.37 Esophagojejunal anastomosis followed by transection of the proximal jejunum

Fig. 31.38 Side-to-side jejunal anastomosis

cancer, upper gastric cancer without esophagus invasion, and lower gastric cancer with gastric body invasion. When the tumor is located high up, the safety of the proximal resection margin may not be ensured, the tension of anastomosis is large, and there is a corner in the distal jejunum, which may increase the incidence of anastomotic complications. (2) Side-to-side esophagojejunal anastomosis: Compared with functional end-

to-end esophagojejunal anastomosis, this method adjusts the direction of distal jejunum after anastomosis, the jejunum is changed to become isoperistaltic, and the common opening is closed by manual suture. The esophageal stump still needs to be long enough, so the overlap method is recommended for patients with lesions invading less than 2 cm of the lower end of the esophagus.

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Fig. 31.39 Closure of the common opening

Fig. 31.40 Suspension of uterus

Fig. 31.41 Opening the posterior vaginal fornix with a cautery hook

Fig. 31.42 Specimen extraction through the protective sleeve

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Fig. 31.43 Transvaginal extraction of specimen

Fig. 31.44 Repeated irrigation with dilute iodine solution

Fig. 31.45 Repeated irrigation with normal saline

Fig. 31.46 Incision of the posterior vaginal fornix closed by continuous suture with 3-0 barbed suture

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References Guan X, et al. International consensus on natural orifice specimen extraction surgery (NOSES) for gastric cancer (2019). Gastroenterol Rep (Oxf). 2020;8(1):5–10. Sumer F, et al. Total laparoscopic subtotal gastrectomy with transvaginal specimen extraction is feasible in advanced gastric cancer. Int J Surg Case Rep. 2015;16:56–8. Zhang ZC, et al. Development and future perspectives of natural orifice specimen extraction surgery for gastric cancer. World J Gastrointest Surg. 2022;14(11):1198–203.

Fig. 31.47 Specimen display

Fig. 31.48 Appearance of postoperative abdominal wall

Robotic Gastric Tumor Resection with Transoral Specimen Extraction (GC-NOSES IX)

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Zhi-Wei Jiang

Contents Indications and Contraindications of NOSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 470 Indications (Figs. 32.1 and 32.2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 470 Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 470 Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . Anesthesia Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Patient Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trocar Placement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Surgical Procedure, Techniques, and Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Exploration and Surgical Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tumor Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Digestive Tract Reconstruction and Specimen Extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postoperative Abdominal Wall and Specimen Pictures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Key Points, Difficulties, and Hotspots Related to Surgery Precautions for Transoral Specimen Extraction in NOSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 475 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 476

Abstract

Gastrointestinal stromal tumor (GIST) is a common mesenchymal tumor of the digestive tract. Surgical resection is the first choice of treatment. With the deepening of the understanding of GIST and the improvement of the minimally invasive technique, the current surgery for GIST has entered the era of minimally invasive surgery from open surgery. Minimally invasive surgery has the advantages of minimal trauma and rapid recovery while ensuring the operation safety. At present, the main methods of minimally invasive surgery include endoscopic surgery, laparoscopic surgery, combined endoscopic and laparoscopic surgery, etc., and good therapeutic effects have been achieved. In recent years, Da Vinci robot system

has been popularized in China, which brings new opportunities and challenges for surgical operation. The following is a case of Da Vinci robotic gastroscopic gastric GIST resection performed by the surgical team led by Professor Jiang Zhiwei. The 50-year-old male patient presented with epigastric discomfort for 1 month. After endoscopic ultrasonography and abdominal CT examination, a mass of approximately 2 cm  2 cm in size was found in the anterior wall of the lesser curvature of the gastric body, which indicated the possibility of gastric GIST. The patient requested surgical treatment and hoped that the surgery would leave no obvious surgical scar in the abdominal wall. After excluding surgical contraindications, Da Vinci robotic gastroscopic gastric GIST resection was proposed.

Z.-W. Jiang (*) Department of General Surgery, Jiangsu Province Hospital of Traditional Chinese Medicine, Nanjing, Jiangsu, P. R. China © People’s Medical Publishing House, PR of China 2023 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-99-2750-0_32

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Keywords

NOSES · Gastric tumor resection · Gastric cancer · Robotic surgery · Transoral

Z.-W. Jiang

Patient Positioning The patient is placed in the anti-Trendelenburg supine position (Fig. 32.3).

Indications and Contraindications of NOSES

Trocar Placement

Indications (Figs. 32.1 and 32.2)

1. Camera trocar (12 mm trocar) is located below the umbilicus. 2. The assistant’s auxiliary trocar (12 mm trocar) is located at the umbilical level of the left midclavicular line. 3. Instrument trocar 1 (8 mm trocar) is located at the umbilical level of the right midclavicular line. 4. Instrument trocar 2 (8 mm trocar) is located 2 cm below the costal margin of the left anterior axillary line. 5. Instrument trocar 3 (8 mm trocar) is located 2 cm below the costal margin of the right anterior axillary line (Fig. 32.4).

1. Gastric tumor that can be resected locally. 2. The largest diameter of the lesion is less than 2.5 cm.

Contraindications 1. The largest diameter of the lesion is more than 2.5 cm. 2. Consistent with or highly suspicious of lymph node metastasis. 3. Consistent with esophageal diseases such as esophageal varices. 4. Patient does not understand and cannot accept the procedure.

Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position

Surgical Team Position The surgeon stands in front of the Da Vinci robotic platform and the assistant stands on the left side of the patient (Figs. 32.5 and 32.6).

Anesthesia Method

Surgical Instruments

General anesthesia or general epidural anesthesia.

Da Vinci robot and gastroscope.

Fig. 32.1 Gastroscopy and endoscopic ultrasonography: space-occupying lesion in the anterior wall of the lesser curvature of the gastric body, approximately 2 cm  2 cm in size

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Fig. 32.5 Layout of operating room Fig. 32.2 Contrast-enhanced CT of the upper abdomen: spaceoccupying lesion in the anterior wall of the lesser curvature of the gastric body, with intact capsule, approximately 2 cm  2 cm in size

Fig. 32.6 The assistant stands on the left side of the patient

Surgical Procedure, Techniques, and Key Points Fig. 32.3 The patient’s position

Exploration and Surgical Planning The surgical exploration and operation are initiated after the assembly of Da Vinci robotic surgical system.

General Exploration After the laparoscope is placed into the umbilical port, the liver, gallbladder, stomach, spleen, colon, small intestine, greater omentum, and pelvic cavity are routinely examined for the presence of tumor seeding or ascites.

Fig. 32.4 Trocar placement (five-ports method)

Tumor Exploration The liver is suspended by extracorporeal purse-string knot to expose the field of surgery (Fig. 32.7). The robotic camera combined with gastroscopy reveals that the exophytic gastric tumor is located in the anterior wall of the lesser curvature, with a size of 2 cm  2 cm (Fig. 32.8). No other abnormalities are noted in the abdomen.

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Fig. 32.7 Suspension of liver

Fig. 32.8 Tumor located in the anterior wall of the lesser curvature of the gastric body

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Fig. 32.10 Large vessels are ligated with titanium clip

Fig. 32.11 Isolated gastric wall of the lesser curvature

Fig. 32.9 Isolation of gastric wall around the tumor

Tumor Resection

Fig. 32.12 Lifting the gastric wall around the tumor

The surgeon applies the ultrasonic scalpel to isolate the gastric wall of the lesser curvature around the tumor (Fig. 32.9), ligates the great vessels with titanium clip (Fig. 32.10), and isolates the gastric wall of the lesser curvature adequately (Fig. 32.11). The intended resection gastric wall is lifted with the third arm of the robot

(Fig. 32.12). Afterwards, the surgeon applies the ultrasonic scalpel to open all layers of gastric wall at the intended resection line (Fig. 32.13) and perform complete circular resection of the tumor under direct vision (Figs. 32.14 and 32.15).

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Fig. 32.16 Placing the tumor in the specimen bag Fig. 32.13 Open all layers of gastric wall

Fig. 32.14 Complete circular resection of the tumor

Fig. 32.15 Complete resection of gastric tumor

Digestive Tract Reconstruction and Specimen Extraction Placement of Specimen in the Gastric Cavity The resected tumor is placed in the specimen bag (Fig. 32.16), and the opening of the bag is ligated with 0 suture (Fig. 32.17). The surgeon places the closed specimen bag into the gastric cavity through the incision in the gastric wall under laparoscopy (Fig. 32.18).

Fig. 32.17 Ligation of the opening of specimen bag with 0-suture

Fig. 32.18 Placing the specimen bag in the gastric cavity

Closing the Incision in the Gastric Wall Full-thickness suture of the incision in the gastric wall is performed upwards with 3-0 single stitch self-retaining knotless suture (Fig. 32.19), followed by continuous seromuscular layer embedding of the incision downwards with the same suture (Fig. 32.20). The tail of the suture is ligated with titanium clip to prevent falling off (Fig. 32.21). After the closure of the gastric incision, the surgeon should inspect the suture of incision under laparoscopy carefully (Fig. 32.22).

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Fig. 32.19 Full-thickness suture of incision in the gastric wall

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Fig. 32.22 Inspection of the incision in the gastric wall under laparoscopy

Fig. 32.20 Seromuscular layer embedding of incision in the gastric wall

Fig. 32.23 Gastroscopic inspection of gastric wall incision

Fig. 32.21 Ligation of the tail of the suture with titanium clip to prevent falling off

Gastroscopy-Assisted Specimen Extraction After the Da Vinci robotic operation is completed, the integrity of the suture of the incision in the gastric wall is inspected under gastroscopy (Fig. 32.23). Foreign body forceps is applied to grasp the ligature at the opening of the specimen bag and pull back to extract the specimen gently (Fig. 32.24).

Fig. 32.24 Specimen extraction with foreign body forceps

Inspection of specimen: The specimen is 2.5 cm  3.0 cm in size with safe resection margin. The specimen is sent for

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Fig. 32.25 The abdominal wall after operation

Fig. 32.26 Specimen display

analysis, the instruments are counted, incisions for trocars are sutured, and the operation is completed.

Postoperative Abdominal Wall and Specimen Pictures See Figs. 32.25 and 32.26.

Key Points, Difficulties, and Hotspots Related to Surgery Precautions for Transoral Specimen Extraction in NOSES With the widespread acceptance of minimally invasive concept and the rapid development of minimally invasive techniques, NOSES has gradually matured from the initial stage. In the gastrointestinal NOSES, transanal and transvaginal approaches

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are the main routes of specimen extraction. Colorectal specimens are mainly extracted through the anus, whereas gastric specimens are mainly extracted through the vagina. In addition to these two common ways of specimen extraction, some surgeons have started using transoral specimen extraction for NOSES. At present, some studies have reported the preliminary application of transoral specimen extraction in living animal models and clinical patients, including sleeve gastrectomy, liver biopsy, cholecystectomy, splenectomy, etc. Compared with transrectal and transvaginal specimen extraction, transoral specimen extraction reduces the auxiliary incision in the abdominal wall and shows the minimally invasive advantages of NOSES, including less abdominal wall dysfunction, good cosmetic appearance, rapid postoperative recovery, less incision complications, and less psychological disturbance, etc. In the transoral NOSES, the esophagus is the only route of specimen extraction, which also exhibits the particularity of transoral NOSES. Compared with rectum and vagina, the lumen of esophagus is long and narrow with low elasticity, which increases the difficulty in operation and puts forward higher requirements for the indications for specimen extraction. At the same time, the surgeons should also understand the anatomical characteristics of the esophagus. The lumen of the esophagus has three constrictions: at the start of the esophagus (15 cm from the incisor teeth), at where it is compressed by the left main bronchus (25 cm from the incisor teeth), and at the esophageal hiatus where it passes through the diaphragm (40 cm from the incisor teeth). Special attention should be paid to these constrictions during the specimen extraction. In addition, there are several points to be noted during specimen extraction. Firstly, since the protective sleeve cannot be placed in the esophageal lumen in advance, it is important to place the specimen in a closed protective sleeve before specimen extraction through the esophagus to completely isolate the specimen (particularly the tumor specimen) from the environment external to the protective sleeve, which is critical for the tumor-free operation. Secondly, in the process of specimen extraction, if resistance is encountered and the specimen cannot be extracted smoothly, perform gently to avoid damage to the esophageal wall. At the same time, gastroscopy should be used to facilitate the specimen extraction. In this way, the suture of the incision in the gastric wall can be inspected under direct vision to see whether there is bleeding, and the specimen can be extracted through the esophagus and mouth under the direct vision, which ensures the safety of the specimen extraction to the maximum extent. Thirdly, it is necessary to determine preoperatively whether the patient has esophageal varices, space-occupying lesions, or other conditions that are prone to cause esophageal bleeding and stricture, so as to comprehensively evaluate the risk factor of specimen extraction through the esophagus and mouth. The procedure is not recommended for those patients with high risk.

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Transoral NOSES also shows promising minimally invasive results, and this technique is a supplement and improvement of the NOSES system (Guan et al. 2020; Zhang et al. 2022; Hüscher et al. 2017). However, due to the particularity of the anatomical structure of the esophagus, the surgeons should strictly follow the surgical indications and master the technique of surgery. Only when the safety of operation is ensured can the minimally invasive advantages of this technique be manifested and the benefits for patients maximized.

Z.-W. Jiang

References Guan X, et al. International consensus on natural orifice specimen extraction surgery (NOSES) for gastric cancer (2019). Gastroenterol Rep (Oxf). 2020;8(1):5–10. Hüscher CG, et al. NOSE laparoscopic gastrectomies for early gastric cancer may reduce morbidity and hospital stay: early results from a prospective nonrandomized study. Minim Invasive Ther Allied Technol. 2017;26(2):71–7. Zhang ZC, et al. Development and future perspectives of natural orifice specimen extraction surgery for gastric cancer. World J Gastrointest Surg. 2022;14(11):1198–203.

Section IV NOSES for Hepato-Biliary-Pancreatic and Splenic Surgery Zheng Liu and Xiyue Hu

Laparoscopic Liver Tumor Resection with Transvaginal Specimen Extraction

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Feng Gao

Contents Indications and Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 480 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 480 Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 480 Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . Anesthesia Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Patient Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trocar Placement (Figs. 33.2 and 33.3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Special Surgical Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

480 480 480 480 481 481

Surgical Procedure, Techniques, and Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Exploration and Surgical Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dissection and Division . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Specimen Extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Images of the Postoperative Abdominal Wall and Specimen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

481 481 482 485 486

Key Points, Difficulties, and Hotspots Related to Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 486 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 488

Abstract

Laparoscopic liver tumor resection with transvaginal natural orifice specimen extraction is mainly applicable to female patients with a specimen diameter of less than 5 cm. The procedure for liver tumor resection is the same as that for conventional laparoscopic hepatectomy. However, specimen extraction is accomplished transvaginally via an incision at the posterior vaginal fornix, which helps avoid the abdominal incision made during conventional laparoscopic hepatectomy, hence achieving the “most minimally invasive of minimally invasive” surgeries. This surgical procedure is considered a type of natural orifice specimen extraction surgery (NOSES) and F. Gao (*) Department of Gastrointestinal Surgery, The Affiliated Hospital of Medical School of Ningbo University, Ningbo, Zhejiang, China Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, P. R. China © People’s Medical Publishing House, PR of China 2023 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-99-2750-0_33

requires that upper abdominal operations be converted to lower abdominal operations; the monitor and trocar placement should be adjusted where necessary. The main operative features of this procedure are that (1) upper abdominal liver tumor resection is performed under total laparoscopy, followed by wound assessment and placement of the specimen in a specimen retrieval bag; (2) transvaginal specimen extraction is performed without abdominal incision, thus avoiding pain at the incision site and accelerating patient recovery; and (3) this procedure is only applicable to female patients. Patients must be fully informed about this procedure, and their level of acceptance for this procedure must be assessed. A majority of surgeries using this procedure are similar to conventional laparoscopic hepatectomy, differing only in the method of specimen extraction. Therefore, as long as the surgeon is equipped with the surgical skills necessary for laparoscopic hepatectomy and adheres to the surgical

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indications for the technique, it is scientifically rational, safe, and feasible. Keywords

Liver tumor · Transvaginal specimen extraction · Laparoscopic hepatectomy · Natural orifice specimen extraction surgery (NOSES) · Female patients

Indications and Contraindications Indications 1. Female patients. 2. Benign or malignant liver tumors with an estimated specimen diameter of 5 cm or estimated specimen diameter of >5 cm (e.g., in cases of hemihepatectomy or extensive segmentectomy). 3. Patients with contraindications for laparoscopic liver surgery, such as those who cannot tolerate pneumoperitoneum; those who have dense abdominal adhesions, lesions adjacent to or directly invading major blood vessels, or lesions that cannot be safely operated under laparoscopy; or those with hilar invasion and portal vein tumor thrombosis. 4. Patients with a history of pelvic surgery or vaginal anomalies.

F. Gao

Trocar Placement (Figs. 33.2 and 33.3) 1. The camera port (10-mm trocar) is placed based on the tumor location, either at or slightly to the right of the umbilicus. 2. The surgeon’s main port (10-mm or 12-mm trocar) is placed according to the liver tumor location and the surgeon’s position. If the lesion is in the right liver, the port is placed on the right anterior axillary line or inferior to the xiphoid process. If the lesion is in the left liver, the port is placed on the left midclavicular line or inferior to the costal margin on the left anterior axillary line. 3. The surgeon’s auxiliary port (5-mm trocar) is placed according to the location of the liver tumor to be resected. 4. The assistant’s main port (5-mm or 10-mm trocar) is placed according to the location of the liver tumor to be resected. 5. The assistant’s auxiliary port (5-mm trocar) is placed according to the location of the liver tumor to be resected.

Fig. 33.1 Patient positioning

Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position Anesthesia Method General anesthesia or combined general and epidural anesthesia.

Patient Positioning The patient is placed in a supine position with the legs abducted and tilted either to the left or the right depending on tumor location. The patient is placed in a functional lithotomy position during specimen extraction, which facilitates the surgeon’s operations (Fig. 33.1).

Port (5mm)

Surgeon’s Main Port (12 mm) Port (5mm)

Port (5mm) Camera Port (10 mm)

Fig. 33.2 Trocar placement for left lateral segmentectomy

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Laparoscopic Liver Tumor Resection with Transvaginal Specimen Extraction

In general, the tumor location and the surgeon’s left and right working ports should form an isosceles triangle; the main working port must form a certain angle with the liver crosssection. For transvaginal specimen extraction, one or two lower abdominal working ports can be added, as required, based on the positions of the existing ports.

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the patient. The camera holder stands on the same side as the surgeon. The monitor is placed at the patient’s foot, and the functions of the trocar ports are adjusted accordingly.

Special Surgical Instruments Surgical Team Position 1. Laparoscopic exploration and liver resection. Based on the tumor location, the surgeon stands either to the left or right of the patient. The assistant stands opposite to the surgeon. The camera holder stands on the same side as the surgeon or between the patient’s legs (Fig. 33.4). 2. Transvaginal specimen extraction. The surgeon stands to the right of the patient. The assistant stands to the left of

Special instruments mainly include those for liver dissection and transection, such as the endo-stapler, ultrasonic scalpel, Cavitron ultrasonic surgical aspirator (CUSA), laparoscopic bipolar electrocauter, and barbed suture.

Surgical Procedure, Techniques, and Key Points Exploration and Surgical Planning Based on a detailed preoperative examination and surgical plan evaluation, the exploration is performed using the following three steps.

Port (5mm)

Surgeon’s Main Port (12 mm) Port (5mm)

Port (5mm)

Camera Port (10 mm)

Fig. 33.3 Trocar placement for right lobectomy

Fig. 33.4 Surgical team position

General Exploration Laparoscopic exploration is performed to detect tumor seeding on the pelvic cavity, colon, small intestine, spleen, greater omentum, and stomach (Figs. 33.5 and 33.6). Tumor Exploration The specific location and size of the liver and the tumor are examined (Fig. 33.7). Evaluation of Anatomical Structures The liver and tumor sizes are evaluated to determine whether transvaginal extraction is feasible (Figs. 33.8 and 33.9). This method is only applicable to female patients. Digital vaginal examination is performed to determine if the posterior fornix is suitable for incision and specimen extraction.

Fig. 33.5 Exploration of the greater omentum

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F. Gao

Fig. 33.6 Exploration of the colon, small intestine, and pelvic cavity

Fig. 33.9 Exploration of uterus and posterior vaginal fornix

Fig. 33.7 Exploration of the location and size of a primary liver tumor

Fig. 33.10 A rubber tape is looped through the back of the first porta hepatis and its ends are secured using a vascular clip

Fig. 33.8 Evaluation of liver tumor size Fig. 33.11 Tightening of the occlusion tape for the first porta hepatis

Dissection and Division Preplacement of Occlusion Tape at the First Porta Hepatis First, the hepatogastric ligament is opened, and the occlusion tape is placed in advance at the first porta hepatis. One of two methods of occlusion can be used. In the first method, an elastic rubber tape of approximately 15 cm in

length is looped through the back and around the hepatoduodenal ligament, and the ends of the rubber tape are secured using a vascular clip (Fig. 33.10). When occlusion of the first porta hepatis is required, the rubber tape is tightened by elevating it (Fig. 33.11), and it is clamped close to the hepatoduodenal ligament (Fig. 33.12). To remove the occlusion, the vascular clip can be transected

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Laparoscopic Liver Tumor Resection with Transvaginal Specimen Extraction

Fig. 33.12 Occlusion of the first porta hepatis

Fig. 33.13 While removing the occlusion, the vascular clip is transected using the ultrasonic scalpel to loosen the rubber tape

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Fig. 33.14 Transection of the round ligament using an ultrasonic scalpel

Fig. 33.15 Transection of the falciform ligament

using the ultrasonic scalpel to loosen the rubber tape (Fig. 33.13). The second method for occlusion involves extracorporeal occlusion via a cannula. The occlusion tape is placed around the hepatoduodenal ligament, inserted into the cannula, and the ends are pulled extracorporeally. The cannula is then tightened to occlude the first porta hepatis and loosened while removing the occlusion.

Mobilization and Transection of the Perihepatic Ligaments After preplacement of the occlusion tape at the porta hepatis, transection is performed on the perihepatic ligaments around the hepatic lobe in which the lesion is located and may include the round (Fig. 33.14), falciform (Fig. 33.15), coronary, and triangular ligaments (Fig. 33.16). The round ligament can be directly transected using the ultrasonic scalpel; however, if the intra-ligamental blood vessels are relatively thick, the ligament can be ligated using a vascular clip prior to transection. The falciform, coronary, and triangular ligaments can be directly transected using the ultrasonic scalpel (Figs. 33.17, 33.18, and 33.19).

Fig. 33.16 Transection of the right triangular ligament

Transection of the Liver Parenchyma Owing to the limitations on specimen size in transvaginal extraction (Figs. 33.20 and 33.21), this procedure is generally not suitable for standard hemihepatectomy; thus, surgeries where this procedure is used do not involve dissection and division of the first and second porta hepatis. If the tumor is located on the surface (Fig. 33.22), the

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Fig. 33.17 Transection of the hepatogastric ligament

F. Gao

Fig. 33.20 If the tumor location is deep and it cannot easily be visualized, a guidewire can be sutured around the tumor to facilitate the operation

Fig. 33.18 Transection of the left triangular ligament Fig. 33.21 Guidewire-assisted tumor resection

Fig. 33.19 Transection of the left coronary ligament

proposed resection line is marked 1 cm from the edge of the tumor (Fig. 33.23). Once the guidewire is secured using sutures, resection is performed gradually from the superficial to deep layers (Fig. 33.24). If the tumor is located in the left lateral segment, the resection line must be designed accordingly, and the surgical field must be kept clear during transection. The liver parenchyma is transected slowly

Fig. 33.22 A small tumor with a superficial location can be directly resected once the extent of resection is marked

using the ultrasonic scalpel; small incisions are taken while maintaining the correct direction. Major tubular tissues should be ligated using vascular clips prior to transection (Figs. 33.25 and 33.26). During liver transection, the

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Laparoscopic Liver Tumor Resection with Transvaginal Specimen Extraction

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Fig. 33.23 The extent of resection is marked 1 cm from the tumor

Fig. 33.26 Transection of the blood vessel after ligation

Fig. 33.24 Resection of the superficial tumor

Fig. 33.27 The main hepatic veins can be transected using an EndoGIA stapler

Management of the Liver Cross-Section After total tumor resection, complete hemostasis is performed at the liver cross-section. Minor bleeding can be stopped using bipolar electrocautery or an argon plasma scalpel. An active bleeding or bile leak site can be closed with 4-0 to 5-0 atraumatic sutures. The liver cross-section can also be covered with hemostatic materials (Figs. 33.28 and 33.29).

Specimen Extraction

Fig. 33.25 During resection, the major blood vessels are ligated using vascular clips

assistant should facilitate visualization of the transection plane and liver cross-section by promptly removing any blood using an aspirator. The hepatic veins can be transected using the Endo-GIA stapler (Fig. 33.27). Controlled and low central venous pressure can be employed to reduce bleeding at the liver cross-section.

After disinfecting the vagina again, the assistant introduces a small bladder retractor to indicate the position of the posterior vaginal fornix (Fig. 33.30). The surgeon then makes a transverse incision at the posterior fornix using an ultrasonic scalpel or electrocautery hook (Fig. 33.31). A sterile protective sleeve is introduced into the abdominal cavity via the trocar, and the specimen is placed into the protective sleeve. The protective sleeve is then clamped shut, and the assistant uses oval forceps to pull the sleeve out of the body via the posterior vaginal fornix (Fig. 33.32). The vaginal incision is

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F. Gao

Fig. 33.28 Management of minor bleeding at the liver cross-section with bipolar electrocautery

Fig. 33.31 Incision at the posterior vaginal fornix using an ultrasonic scalpel

Fig. 33.29 Liver cross-section after bipolar electrocautery

Fig. 33.32 Specimen extraction via the posterior vaginal fornix

Images of the Postoperative Abdominal Wall and Specimen See Figs. 33.34 and 33.35.

Key Points, Difficulties, and Hotspots Related to Surgery

Fig. 33.30 The bladder retractor is used to indicate the position of the incision

sutured laparoscopically (Fig. 33.33). The pelvic cavity is irrigated with normal saline or distilled water, and indwelling drainage tubes are placed. The trocar port is closed, and a count of all gauze and surgical instruments is performed before completion of the surgery.

Since the 1991 report on the laparoscopic resection of benign liver tumors was published by the American physician Reich (Reich et al. 1991), rapid advancements have been made in the laparoscopic resection of benign and malignant liver tumors. In China, following the successful completion of the first case of laparoscopic liver resection in 1994 (WP et al. 1994), steady progress has also been achieved in the techniques for laparoscopic liver resection. This progress is accompanied by continuous expansion in the extent of surgical resection, which has gradually increased from local or wedge resection to hemihepatectomy or further, including donor liver extraction in liver transplantation. The Louisville

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Laparoscopic Liver Tumor Resection with Transvaginal Specimen Extraction

Fig. 33.33 Suturing of the vagina after specimen extraction

Fig. 33.34 Postoperative abdominal wall

Fig. 33.35 Resected specimen

Statement of 2008 recommended laparoscopic liver surgery as a safe and effective procedure when performed by a surgeon experienced in hepatobiliary and laparoscopic surgeries (Buell et al. 2009). In recent years, clinical practice has also demonstrated that when compared with traditional open hepatectomy, laparoscopic hepatectomy is minimally

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invasive and is associated with milder systemic responses, less intraoperative bleeding, a shorter length of hospital stay, lower incidence of complications, and better cosmetic results (Dumronggittigule et al. 2022; Kabir et al. 2021; Shimada et al. 2002). A growing number of innovative surgical methods have also been reported, including single-port laparoscopic hepatectomy and posterior-approach laparoscopic hepatectomy (Cheng et al. 2011; Gaujoux et al. 2011). Surgeons have now turned their attention towards the minimization of trauma. The NOSES technique (Muhammad et al. 2022), which does not require auxiliary abdominal incisions, combines the advantages of laparoscopic hepatectomy with those of natural orifice specimen extraction. Thus, it can eliminate infection, pain, and other complications related to incisions and achieve the “most minimally invasive of minimally invasive” surgeries. For patients who meet the indications, laparoscopic liver resection with transvaginal specimen extraction is, without doubt, the ideal option for both the surgeon and the patient. The liver resection component of this procedure is similar to that of conventional laparoscopic hepatectomy. The only difference is that the selection of trocar placement should be adjusted to accommodate lower abdominal operations where possible or else additional working ports may be needed. The key points and difficulties of this procedure are as follows. First, strict adherence to the surgical indications should be ensured. This procedure is only suitable for female patients, excluding women of childbearing age who wish to bear children in the future. Furthermore, unlike the gastrointestinal tract, the liver has a harder and tougher texture, with poorer deformability. Therefore, this procedure requires accurate assessment of the specimen volume and is not suitable for large liver tumors or operations such as hemihepatectomy. Second, full compliance is required with the principles of aseptic surgery; thus, a gynecologist should be consulted preoperatively to determine the sepsis status of the vagina. During the operation, the perineum and vagina should be irrigated and disinfected with iodoform gauze and dilute iodine solution, as the incision protective sleeve is inserted through the abdominal trocar and extracted transvaginally. Third, the surgery should comply with the principles of tumor-free operation. The resected specimen should immediately be placed into the specimen retrieval bag, which should be clamped shut to prevent residual blood from spilling. During specimen extraction, any residual blood that may spill out of the specimen retrieval bag due to compression must immediately be aspirated. Finally, some large benign liver tumors (e.g., hemangiomas) that do not need to be kept intact can be cut into smaller pieces within the abdominal cavity and subsequently extracted transvaginally. This can help reduce the difficulty of specimen extraction.

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References Buell JF, et al. The international position on laparoscopic liver surgery: the Louisville statement, 2008. Ann Surg. 2009;250:825–30. Cheng KC, et al. Multimedia manuscript: laparoscopic resection of hepatocellular carcinoma at segment 7: the posterior approach to anatomic resection. Surg Endosc. 2011;25:3437. Dumronggittigule W, et al. Laparoscopic versus open hepatectomy for large hepatocellular carcinoma: a single center propensity-scorematching comparative analysis of perioperative outcomes and long-term survival. Surg Endosc. 2022; Gaujoux S, et al. Single-incision laparoscopic liver resection. Surg Endosc. 2011;25:1489–94. Kabir T, et al. Laparoscopic versus open resection of hepatocellular carcinoma in patients with cirrhosis: meta-analysis. Br J Surg. 2021;109:21–9.

F. Gao Muhammad S, et al. Laparoscopic natural orifice specimen extraction, a minimally invasive surgical technique for mid-rectal cancers: retrospective single-center analysis and single-surgeon experience of selected patients. J Int Med Res. 2022;50: 3000605221134472. Reich H, et al. Laparoscopic excision of benign liver lesions. Obstet Gynecol. 1991;78:956–8. Shimada M, et al. Minimally invasive hepatectomy: modulation of systemic reactions to operation or laparoscopic approach? Surgery. 2002;131:S312–7. WP Z, et al. Laparoscopic hepatic lobectomy for the treatment of hepatic hemangioma. Chin J Pract Surg. 1994;14(11):668.

Laparoscopic Hepatectomy with Transvaginal Specimen Extraction

34

Fan Wu and Hongguang Wang

Contents Indications and Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 490 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 490 Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 490 Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . Anesthesia Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Patient Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trocar Placement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Team Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Special Surgical Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

490 490 490 490 491 491

Surgical Procedure, Techniques, and Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Exploration and Surgical Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Images of Postoperative Abdominal Wall and Specimen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

492 492 492 496

Key Points, Difficulties, and Hotspots Related to Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 497 Glissonean Pedicle Transection with the Dorsocaudal Approach for Laparoscopic Left Hemihepatectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 497 Significance of ICG Liver Segment Staining in Laparoscopic Liver Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 498 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 500

Abstract

Laparoscopic hepatectomy with transvaginal natural orifice specimen extraction is a type of natural orifice specimen extraction surgery (NOSES) in the field of hepatobiliary surgery. At the time of writing, no international literature exists regarding this procedure. We have tried to perform intestinal anastomosis after removing the liver metastasis specimen through the severed intestinal tract in patients with simultaneous resection of liver metastasis from rectal cancer. However, for laparoscopic hepatectomy, we mainly use NOSES III. The main operative feature of this technique is the transvaginal

F. Wu · H. Wang (*) Department of Hepatobiliary Surgery, National Cancer Center, National Clinical Research Center for Cancer, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China © People’s Medical Publishing House, PR of China 2023 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-99-2750-0_34

extraction of liver surgical specimens. The liver is a parenchymatous organ, and surgical specimens generally vary in size. Due to the strong extensibility of the vagina, NOSES III has a broad range of indications and is suitable for liver surgery with relatively large specimen sizes; however, this procedure can only be performed in female patients. In this chapter, we illustrate the application of NOSES in liver surgery by describing a case of fluorescence-guided laparoscopic left hemihepatectomy. We introduce the operative details of Glissonean pedicle transection with the dorsocaudal approach for laparoscopic left hemihepatectomy, such as the placement of Trocar, the exposure of middle hepatic vein, the procedure of transvaginal specimen extraction, and the significance of fluorescent laparoscopy, to explore the application of NOSES operation in liver surgery.

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Keywords

NOSES (natural orifice specimen extraction surgery) · Hepatectomy · Fluorescent laparoscopy · Transvaginal · The dorsocaudal approach

Indications and Contraindications Indications 1. Female patients. 2. Benign or malignant liver tumors with an estimated specimen diameter of 5 cm or an estimated specimen diameter of >5 cm (e.g., hemihepatectomy or extensive segmentectomy). 3. Patients with contraindications for laparoscopic liver surgery, such as those who cannot tolerate pneumoperitoneum; those with dense abdominal adhesions; those with lesions adjacent to or directly invading major blood vessels; those with lesions that cannot be safely operated under laparoscopy; and those with hilar invasion and portal vein tumor thrombosis. 4. History of pelvic surgery or vaginal anomalies.

Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position Anesthesia Method General anesthesia.

Patient Positioning The patient is placed in a lithotomy position, with both thighs slightly flattened to facilitate the surgeon’s movements. The patient is placed in the reverse Trendelenburg position during liver surgery and in the Trendelenburg position during pelvic surgery. Fig. 34.1 Liver MRI: A significant ring-enhancing lesion observed in the arterial phase after enhancement

Fig. 34.2 Liver MRI: Slightly decreased enhancement in the venous phase

Trocar Placement Liver Surgery 1. Camera port (10-mm trocar): Our patient had a mesh from a previous midline incision in the lower abdomen. Thus, pneumoperitoneum was first established via the right-handed surgeon’s main port before a small incision was made superior to the umbilicus for the camera. In patients without meshes, the port can be placed inferior to or to the left of the umbilicus. 2. Left surgeon’s main and auxiliary ports (two 12-mm trocars): The main port is placed 2 cm lateral to the xiphoid process and inferior to the left costal margin. The auxiliary port is placed 8 cm inferior to and to the left of the main port. 3. Right surgeon’s main (12-mm trocar) and auxiliary (5-mm trocar) ports: The main port is placed 5 cm inferior to the right of the costal margin on the lateral edge of the rectus abdominis. The auxiliary port is placed inferior to the right costal margin on the anterior axillary line.

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Laparoscopic Hepatectomy with Transvaginal Specimen Extraction

Fig. 34.3 Trocar placement

Pelvic Surgery 1. The surgeon’s main port (5-mm trocar) is placed at one-third of the distance from the right anterior superior iliac spine to the umbilicus (i.e., at the McBurney’s point). 2. The surgeon’s auxiliary port (5-mm trocar) is placed 12 cm to the right at the level of the umbilicus. 3. The assistant’s port (5-mm trocar) is placed at one-third of the distance from the left anterior superior iliac spine to the umbilicus (i.e., opposite the McBurney’s point). The assistant’s forceps have relatively fewer uses and are mainly used to elevate tissues (Fig. 34.3).

Surgical Team Position For liver surgery, the two-surgeon technique is adopted, with one surgeon on each side of the patient; the camera holder stands between the patient’s legs. For pelvic surgery, the surgeon stands to the right of the patient, the assistant stands to the left of the patient, and the camera holder stands on the same side as the surgeon. The second assistant stands between the patient’s legs during specimen extraction (Fig. 34.4).

Special Surgical Instruments Fluorescence laparoscope, ultrasonic scalpel, Cavitron ultrasonic surgical aspirator (CUSA), BiClamp, 60 mm linear Endo-GIA stapler (white and blue staples), vaginal suture thread, uterine manipulator, and sterile protective sleeve.

Fig. 34.4 Surgical team position

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Surgical Procedure, Techniques, and Key Points Surgical Procedure Exploration and Surgical Procedure In our patient, the decision to perform left hemihepatectomy according to the results of the exploration was made on the basis of detailed preoperative examination and surgical plan evaluation.

General Exploration Laparoscopic observation is performed in the abdominal and pelvic cavity to detect the presence of tumor seeding on the liver, gallbladder, stomach, spleen, colon, small intestines, greater omentum, and pelvic cavity. In our patient, marked pelvic adhesions were observed resulting from previous surgeries (Fig. 34.5).

Mobilization of the Left Perihepatic Ligaments The round, falciform, and left triangular ligaments of the liver are transected using an ultrasonic scalpel, followed by careful dissection at the second porta hepatis using an electrocautery hook. Using the ultrasonic scalpel, the liver tissue between the left lateral lobe and left caudate lobe is incised at the ventral aspect of the Arantius ligament, in preparation for extra-Glissonian dissection of the left hepatic pedicle (Figs. 34.7, 34.8, and 34.9).

Tumor Exploration The specific location and size of the liver tumor are examined (Fig. 34.6).

Placement of Occlusion Tape at the Porta Hepatis The lesser sac is opened, and a pair of atraumatic forceps is gradually and gently passed from the right to the left posterior to the hepatoduodenal ligament while avoiding important structures such as the left lateral lobe, caudate lobe, and esophageal veins. Using too much force for dissection may result in injury. The occlusion tape is retracted to the right (Fig. 34.10), then extracorporeally through the 5 mm trocar

Fig. 34.5 Exploration of the liver and greater omentum

Fig. 34.7 Transection of the left triangular ligament

Fig. 34.8 Mobilization of the second porta hepatis Fig. 34.6 Exploration of tumor location (arrow indicates tumor)

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Fig. 34.9 Incision of liver tissues between the left lateral lobe and left caudate lobe at the ventral aspect of the Arantius ligament

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Fig. 34.11 Placement of the occlusion cannula

Fig. 34.10 Placement of the occlusion tape at the first porta hepatis

port on the left abdomen. The occlusion cannula is placed after removing the trocar (Fig. 34.11).

Extra-Glissonian Dissection of the Left Hepatic Pedicle To mobilize the space to the right of the left hepatic pedicle, blunt dissection can be performed after the hilar plate is descended; this dissection gradually proceeds along the space between Laennec’s capsule and the left hepatic pedicle. For patients in whom this space can be easily identified, dissecting forceps or an aspirator can be used to gently squeeze and dissect the space between the liver parenchyma and Glisson’s sheath of the left hepatic pedicle. The finer branches of the portal vein are coagulated and transected. Mobilization is carried out from the right anterior region to the left posterior region (Fig. 34.12); the tunnel posterior to the left hepatic pedicle is penetrated up to the Arantius ligament anterior to the caudate lobe. Guidewires are used to assist left hepatic pedicle transection using the Endo-GIA stapler (Fig. 34.13); this is usually performed via the right surgeon’s right-hand main port. The articulating joint of the

Fig. 34.12 Extra-Glissonian dissection of the left hepatic pedicle

Endo-GIA stapler should remain as far from the root of the left portal vein branch as possible, leaning towards the left or cephalad aspect. This helps avoid clamping of the stapler close to the root and involving the right hepatic pedicle, which may result in postoperative complications such as obstructive jaundice.

Negative Staining of the Right Hemi-liver A solution is prepared with 5 mL of indocyanine green (ICG) in 500 mL of sterilized water, and 5 mL of this solution is

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Fig. 34.13 Transection of the left hepatic pedicle with a 60 mm intracavitary Endo-GIA stapler

Fig. 34.14 Indocyanine green-negative staining of the right hemi-liver

injected intravenously. Visible uptake of the stain in the right hemi-liver occurs after approximately 1 min (Fig. 34.14), and the left hemi-liver is transected based on the extent of staining. The surgeon on the right morcellates the liver parenchyma using the CUSA to expose the intrahepatic bile duct structures. The surgeon on the left transects the smaller ducts using the ultrasonic scalpel, whereas the larger ducts are ligated using Hem-o-lok clips prior to transection (Fig. 34.15).

Gradual Transection of the Left Hemi-liver Along the Middle Hepatic Vein The main trunk of the middle hepatic vein is gradually exposed by following the branches of the hepatic vein, which are transected. Transection of the liver tissues on the dorsal aspect of the middle hepatic vein is prioritized so that the entire length of the vein can gradually be visualized (Fig. 34.16). Transection is continued along the liver tissues on the ventral aspect of the middle hepatic vein (Fig. 34.17)

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Fig. 34.15 Morcellation of the liver parenchyma using the Cavitron ultrasonic surgical aspirator according to the negative staining to expose the bile duct structures

Fig. 34.16 The branches of the middle hepatic vein are transected to expose the middle hepatic vein

to expose the left hepatic vein, which is then transected using an intracavitary Endo-GIA stapler to complete left hemihepatectomy (Fig. 34.18).

Liver Wound Hemostasis and Placement of the Specimen in a Retrieval Bag Complete hemostasis of the liver wound is performed. Owing to the large size of the left hemihepatectomy specimen, a specimen retrieval bag of the appropriate size is fashioned out of a sterile protective sleeve. The specimen is placed into the retrieval bag, and the bag is placed in the lower right abdomen (Fig. 34.19). Lower Abdominal Surgeries For the pelvic surgeries, the patient is placed in a Trendelenburg position, and trocars are placed in the lower right abdomen, right abdomen, and lower left abdomen. Our patient had undergone several previous

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Fig. 34.17 Transection is continued along the liver tissues on the ventral aspect of the middle hepatic vein

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Fig. 34.19 The left hemihepatectomy specimen is placed into the specimen retrieval bag, and the bag is placed in the lower right abdomen

Fig. 34.20 The uterus is suspended to visualize the posterior vaginal wall

Fig. 34.18 The left hepatic vein is visualized and transected to complete left hemihepatectomy

surgeries, and adequate dissection of pelvic adhesions was required. The uterus is suspended for visualization of the posterior vaginal fornix (Fig. 34.20). The assistant disinfects the vagina again and indicates the position of the posterior vaginal fornix using the small bladder retractor. A 2 mL intravenous injection of the ICG stock solution is administered to help observe the vasculature at the

Fig. 34.21 Incision of the posterior vaginal wall

posterior vaginal wall. A transverse incision is made at the posterior vaginal fornix using an electrocautery hook while avoiding the blood vessels (Figs. 34.21 and 34.22).

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Fig. 34.22 Oval forceps are introduced transvaginally to clamp the string at the top of the specimen retrieval bag and gradually retract it extracorporeally

Fig. 34.23 A gauze is used to push the bottom of the specimen bag for transvaginal specimen extraction

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Fig. 34.25 Liver wound treatment and drainage tube placement

Fig. 34.26 Postoperative abdominal wall (the orange region represents the mesh location)

transvaginally and drag it extracorporeally while rotating the specimen using their fingers to identify its smallest diameter. The assistant at the top of the operating table uses a gauze to push the bottom of the specimen bag and works together with the other assistant to gradually extract the left hemihepatectomy specimen transvaginally (Fig. 34.23). Hemostasis is performed on the vaginal incision, which is then closed with continuous sutures using barbed thread (Fig. 34.24). The liver wound is treated, and drainage tubes are placed. The liver wound is reinspected, and subsequently, hemostatic gauze and drainage tubes are placed to complete the surgery (Fig. 34.25). Fig. 34.24 Suturing of the vaginal incision

The assistant positioned at the bottom of the operating table lubricates and dilates the vagina. The assistant then uses oval forceps to clamp the specimen retrieval bag

Images of Postoperative Abdominal Wall and Specimen See Figs. 34.26 and 34.27.

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Fig. 34.27 Resected specimen

Key Points, Difficulties, and Hotspots Related to Surgery Glissonean Pedicle Transection with the Dorsocaudal Approach for Laparoscopic Left Hemihepatectomy Laparoscopic liver resection has been extensively carried out in China since 2010. From the earliest irregular resection to anatomical resection, clinicians and researchers have constantly strived to identify the most optimal surgical approaches and methods, so as to achieve homogenization and standardization of surgical procedures. Laparoscopic left hemihepatectomy may soon become a standardized procedure for laparoscopic liver resection. Prioritizing the management of the hepatic pedicle meets the requirements of anatomical liver resection and can prevent the spread of tumor cells via the hepatic portal vein when the tumor is compressed. The authors have a greater preference for the extra-Glissonian method for dissection of the left hepatic pedicle, as this method requires less time; this is consistent with the opinions of foreign experts (Machado et al. 2016). The intra-Glissonian method of mobilizing the left branch of the hepatic portal and left hepatic artery is not difficult but takes a longer duration than that taken in the extra-Glissonian method. However, for patients with hilar bile duct stones, only the intra-Glissonian method can be employed for the division of the left hepatic pedicle. Mobilization along the left margin of the left hepatic pedicle is generally carried out on the ventral aspect of the Arantius ligament, and transection is performed in the middle section once the left hepatic pedicle is fully mobilized. This facilitates the inferior retraction and transection of the left hepatic pedicle. The hepatic portal veins of Spiegel’s lobe mainly originate from the transverse and umbilical portions

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of the left hepatic portal vein and are located at the inferior end of the Arantius ligament. Thus, there is little chance of damaging these vessels when transection is performed at the middle section. Some researchers believe that to protect the hepatic pedicle of Spiegel’s lobe, transection of the Arantius ligament should be avoided where possible. However, other researchers performed mobilization along the dorsal aspect of the Arantius ligament, incised part of the liver parenchyma in the caudate lobe, and extended a Goldfinger dissector rightwards from the left hepatic pedicle to the point of incision, where a loop is created using the thread to transect the left hepatic pedicle and the Arantius ligament. It is generally believed that the latter method can be performed in cases where the tumor involves the Arantius ligament and mobilization of the ventral aspect is not possible. To mobilize the space to the right of the left hepatic pedicle, blunt dissection is performed after the hilar plate is descended and gradually continued along the space between Laennec’s capsule and left hepatic pedicle. Laennec’s capsule was first described by the French physician, Laennec, and has been drawing increasing attention in the recent years. It has been posited that there is a natural gap between Laennec’s capsule and the Glissonean pedicle that can be used to mobilize the hepatic pedicle, which would result in decreased bleeding (Sugioka et al. 2017). However, because the Laennec’s capsule is relatively thin, complete dissection of this space is difficult to achieve in patients with recurrent inflammation or in whom this space is not easily identifiable. In such cases, dissection can be performed using the CUSA close to the left hepatic pedicle, which generally involves separating a small amount of liver parenchyma and requires rapid mobilization. For both methods for mobilization of the left hepatic pedicle, we recommend occluding the first porta hepatis in order to minimize blurring of the surgical field because of bleeding. Several approaches can be used for the visualization of the middle hepatic vein in laparoscopic anatomical left hemihepatectomy, the most common of which include the cephalad and caudal approaches. The cephalad approach is mainly performed by the operating surgeon, with the assistant playing a smaller role. For the traditional caudal approach, the middle hepatic vein is exposed from the ventral aspect. The biggest drawback of this method is that the liver parenchyma is relatively thick at the ventral aspect of the middle hepatic vein; thus, this approach will involve a greater depth of surgical field and a larger wound when visualizing the middle hepatic vein. Moreover, when the right surgeon uses the right hand as the main operating hand, the “tenting sign of the hepatic vein” may cause deflection of the transection plane towards the direction of resection, thus preventing continued mobilization of the middle hepatic vein while also resulting in excessive preservation of liver parenchyma.

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Our approach, which involves two surgeons and liver parenchyma transection using the CUSA for the dorsocaudal approach, involves the caudal approach, but with a preference for the dorsal aspect. Compared to the traditional caudal approach, our approach is more advantageous for the visualization of the middle hepatic vein in the following ways: (1) The liver parenchyma at the dorsal aspect of the middle hepatic vein is relatively thin, and transection of only a small amount of liver parenchyma is required to expose the main trunk of the middle hepatic vein. (2) There are no branches originating at the posterior wall of the middle hepatic vein, and few blood vessels traverse the dorsal aspect, thus reducing the amount of bleeding. (3) The Arantius ligament is located slightly to the left of the dorsal aspect of the middle hepatic vein. The boundary is clear, is almost a straight line, and has a short path, which means that the entire course of the middle hepatic vein can quickly be visualized. In contrast, the liver parenchyma on the ventral aspect is curved and involves a long dissection path. Thus, the speed of hepatectomy is relatively slow without the requirement for exposure of the main trunk of the middle hepatic vein. In this case, the surgeon is required to check whether each blood vessel that appears on the dissection path originates at the middle hepatic vein, which can cause immense psychological stress. (4) In the two-surgeon method, the second surgeon operates the ultrasonic scalpel. The direction of this ultrasonic scalpel is not parallel to that of the middle hepatic vein; it tends to be directed on the side to be preserved, which makes the surgeon less susceptible to the “tenting sign” when performing liver transection. The transection of the liver parenchyma on the ventral aspect of the middle hepatic vein corresponds with the actual plane between the right and left livers, where there are virtually no ductal structures, facilitating rapid liver transection. (5) This surgical method involves two surgeons and liver parenchyma transection using the CUSA, which is advantageous as simultaneous operations can be performed by the two surgeons without the requirement for repeated insertion and removal of instruments by a single surgeon, thereby saving time and significantly improving the surgical efficiency in liver transection. Based on the authors’ surgical experience, the time taken for liver parenchyma transection alone is generally 20–60 min, with the shortest time being 12 min, and the overall operative time is 120–240 min (171  41 min), which is significantly shorter than the operative time reported in the literature, indicating that our method significantly improved surgical efficiency. When performing Glissonean pedicle transection using the dorsocaudal approach for laparoscopic left hemihepatectomy, the following points should also be noted: (1) This method is particularly advantageous when performing left hemihepatectomy with caudate lobe preservation. If caudate lobe resection is needed, the subhepatic inferior vena cava should serve as the landmark for dorsal

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liver transection, rather than the Arantius ligament. (2) Complete visualization of the middle hepatic vein requires cooperation of the anesthesia team. Adequate control of the central venous pressure is required to avoid substantial cribriform bleeding, which impedes surgery. (3) The CUSA must be used correctly; it should not directly face the vascular wall, as this may result in small ruptures in the blood vessels, causing more bleeding from the wound. (4) Patients with intrahepatic bile duct stones can be examined using endoscopic ultrasound or choledochoscopy to determine the presence of bile duct stones at the point of transection, in order to prevent staple failure when transecting the left hepatic pedicle using the Endo-GIA stapler. In summary, Glissonean pedicle transection using the dorsocaudal approach for laparoscopic left hemihepatectomy is simple, can be performed rapidly, causes little bleeding, and involves a clear surgical field. Therefore, it is expected to become a standard approach and surgical method in laparoscopic left hemihepatectomy.

Significance of ICG Liver Segment Staining in Laparoscopic Liver Surgery Laparoscopic techniques have continued to advance, and it is now possible to perform laparoscopic anatomical resection of liver segments 1–8 according to Makuuchi’s criteria (Ishizawa et al. 2012). The key challenges in laparoscopic anatomical liver resection include adequate staining of the tumor-bearing liver segment and selection of the liver transection plane. In the recent years, ICG fluorescence-guided anatomical liver resection has garnered growing surgical interest. By injecting ICG, we can achieve precise and long-lasting intraoperative fluorescence staining of the liver surface and parenchyma. This solves the methylene blue-related problems of short-lived and easily eluted staining, where it is difficult to clearly differentiate the ischemic lines caused by liver surface adhesions or cirrhosis based on the extent of staining. Moreover, ICG staining does not require occlusion of the hepatic artery. Fluorescence labeling, which can last for >8 h, within the liver parenchyma provides real-time guidance for the selection of the liver transection plane during the surgery. Under ICG liver segment staining, surgeons can complete laparoscopic anatomical liver resection in a true sense, as it naturally exposes the uneven interfaces between the liver segments and allows for passive visualization of the main hepatic veins and their branches, rather than requiring active isolation of the hepatic veins. Laparoscopic anatomical liver resection guided by fusion ICG fluorescence imaging enables the surgeon to obtain a rapid and direct understanding of the three-dimensional (3D) region of staining within the liver parenchyma, without requiring the integration of two separate images to further comprehend the anatomy of the liver.

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Methods and selection of ICG liver segment staining. ICG fluorescence liver segment staining can be performed using the positive and negative staining methods. (1) Positive staining: The target hepatic pedicle portal vein is punctured under guidance of transcutaneous or endoscopic ultrasound or identified and punctured after the dissection of the first porta hepatis (intra- or extra-Glissonian) or liver splitting, followed by the injection of 0.125–0.250 mg of ICG. The ICG solution is prepared as follows: One 25-mg vial of ICG is dissolved in 10 mL of water for injection; 1 mL of the prepared solution is then combined with 100 mL of water for the operative injection. Subsequently, 5–10 mL of the ICG solution is injected based on the volume of the target liver segment. The puncture can be performed using the smallest scalp needle connected to an extension tube. One side of the plastic wings on the scalp needle is trimmed off before the needle is placed into the abdominal cavity via the 12 mm trocar. Prior to puncture, the air in the extension tube must be expelled, and the tube should be filled with ICG; prior to administering the stain, the plunger of the syringe must be withdrawn to check for blood. (2) Negative staining: The target hepatic pedicle is identified based on extra-Glissonean dissection of the Glissonean pedicle. Identification of the hepatic pedicles with a higher bifurcation usually requires incision of the liver parenchyma according to the anatomical landmarks on the liver surface, and identification of the bifurcation of higher-lying hepatic pedicles by tracing them from lower-lying hepatic pedicles. After occlusion, 2.5 mg of ICG is injected via a peripheral vein. The ICG solution is prepared as follows: One 25-mg vial of ICG is dissolved in 10 mL of water for injection, and 1 mL of this solution is used for injection. There is currently no standard method or concentration and dose of ICG for the staining of different liver segments. Furthermore, the various technical indicators of staining also undergo constant optimization. In general, the dose of ICG should be reduced where possible to avoid excessive fluorescence staining, which will overload the contrast at the interface between liver segments and increase the difficulty of identification. Based on our preliminary experiences, the selection of methods for ICG fluorescence liver segment staining should adhere to the following principles: (1) When possible, the positive staining method should be selected for single liver segments or subsegments. As long as the appropriate concentration and dose of ICG is injected after successful puncture, staining of the target liver segment lasts for a long time after ICG uptake by hepatocytes, and the extent of staining will not change over time. (2) For cases of multiple segmentectomy, lobectomy, or hemihepatectomy, the higher number of target hepatic pedicles significantly increases the difficulty of puncture. Moreover, the ICG dose for positive staining is difficult to determine when the target liver segment is relatively large, which can also lead to uneven staining

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caused by interrupted blood flow due to factors such as liver rotation or compression. Therefore, when possible, the negative staining method should be selected for multiple segmentectomy, lobectomy, or hemihepatectomy. During negative staining, the target hepatic pedicle should be identified and occluded using the extra-Glissonian approach. This is because adopting the intra-Glissonian approach of dissecting and occluding the portal vein of the target hepatic pedicle will cause the ICG to re-enter the target hepatic pedicle via the hepatic artery or the communicating branches between the hepatic hilar plates. Thus, the target liver segment will be re-stained after a transient absence of staining, which would mean that negative staining has failed. At the time of writing, the authors have treated >40 cases of liver cancer using laparoscopic ICG liver segment staining, and the success rate of staining is 30 kg/m2). 6. History of pelvic surgery or deformities of vagina, rectum, anus, etc. 7. Female patients with fertility plan are not applicable for transvaginal specimen removal.

Fig. 36.1 The patient’s position during tumor resection and gastrointestinal reconstruction

Anesthesia, Patient Positioning, Trocar Positioning, and Surgical Team Positioning Anesthesia General anesthesia with or without epidural anesthesia. Fig. 36.2 The patient’s position during specimen extraction

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Fig. 36.3 Positions of trocars

(c) Trocar C for the operating surgeon (5 mm): On the intersection of the umbilicus level and the midline of the left clavicle. (d) Trocar D for the assistant surgeon (5 mm): Below the costal margin of the right anterior axillary line. (e) Trocar E for the assistant surgeon (5 mm): On the intersection of the umbilicus level and the midline of the right clavicle (Fig. 36.3).

Fig. 36.4 The position of the surgeons when the specimen is resected and the digestive tract is reconstructed

Position of Surgeons 1. The stage of abdominal cavity exploration, dissection, and lymph node dissection: The surgeon stands on the left side of the patient, the assistant stands on the right side of the patient, and the camera holder stands between the legs of the patient (Fig. 36.4). Digestive tract reconstruction stage: The surgeon and assistant exchange positions. 2. The stage of specimen extraction: The surgeon stands on the right side of the patient, the assistant stands on the left side of the patient, and the camera holders stands on the same side of the assistant (Fig. 36.5). At this time, the display position is changed and placed on the tail side of the patient. At the same time, the function of each trocar is changed (Fig. 36.6).

Fig. 36.5 The position of the surgeons when the specimen is extracted

Surgical procedures, Skills, and Key Points Comprehensive Exploration

Specific Instruments Dissecting device (ultrasonic scalpel), endoscopic stapler (straight linear cutter, 60 mm), and sterile plastic sleeve.

On the basis of detailed preoperative examination, a comprehensive exploration of whether there is abdominal effusion in the abdominal cavity, and whether there are planting nodules on the surface of the diaphragm, paracolonic groove, peritoneum, pelvic floor, omentum, and mesenteric. Exploring the

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Fig. 36.9 Dissect the ligamentum hepatoduodenale Fig. 36.6 The function of each trocar when he specimen is extracted

Fig. 36.10 Cut the right gastric artery Fig. 36.7 Exploring the liver and diaphragm

Fig. 36.11 Dissect along the upper edge of the pancreas Fig. 36.8 Exploring tumors, abdominal intestines, and omentum

surface of the liver for metastases, assessing the condition of the primary tumor, and surrounding lymph node enlargement (Figs. 36.7 and 36.8).

Dissection and Detachment 1. Dissecting the ligamentum hepatoduodenale (Fig. 36.9), dissecting along the upper edge of the pancreas, revealing the common hepatic artery, proper hepatic artery,

gastroduodenal artery, and right gastric artery, and dissecting the lymph nodes adjacent to the common hepatic artery (Figs. 36.10 and 36.11). 2. Separate the lower edge of the pancreatic neck, clarify the position of the superior mesenteric vein and the portal vein (Fig. 36.12), and establish the posterior pancreatic tunnel (Fig. 36.13). 3. Disconnect the pancreatic neck with ultrasonic scalpel and scissors (Figs. 36.14 and 36.15), and pay attention to finding the main pancreatic duct. 4. Use a 60 mm linear cutting closure device to cut off at approximately 1/3 of the stomach (Fig. 36.16).

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Fig. 36.12 Dissect along the lower edge of the pancreas to reveal the superior mesenteric vein

Fig. 36.15 Disconnect pancreas (scissors)

Fig. 36.16 Cut off the stomach Fig. 36.13 Penetrate the posterior pancreatic tunnel

Fig. 36.17 Cut off the jejunum Fig. 36.14 Disconnect pancreas (ultrasonic scalpel)

5. Lift the transverse colon, determine the position of the jejunum and Treitz ligament, and cut off the jejunum at a distance of 10–15 cm from the Treitz ligament (Fig. 36.17). Close to the jejunum, separate to the left edge of the Treitz ligament, and protect the inferior mesenteric vein. Separate the duodenal mesentery (Fig. 36.18). 6. Make a Kocher incision, separate along the outside of the duodenum (Figs. 36.19 and 36.20), remove the gallbladder (Fig. 36.21), cut off the gastroduodenal

Fig. 36.18 Separation of the duodenal mesentery

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Fig. 36.19 Separation of the duodenum through a reverse Kocher incision

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Fig. 36.22 Cut off the gastroduodenal artery

Fig. 36.23 Cut off the common bile duct Fig. 36.20 Make a Kocher incision and separate along the outer side of the descending duodenum

Fig. 36.24 Dissect pancreatic uncinate process

Fig. 36.21 Resection of the gallbladder

artery and common bile duct (Figs. 36.22 and 36.23), and the uncinate process of the pancreas is severed along the upper mesenteric vessel (Fig. 36.24). At this time, the excised specimen is free, and the specimen is placed in the specimen bag and temporarily placed in the left lower abdomen (Fig. 36.25).

Digestive Tract Reconstruction The digestive tract reconstruction adopts Child’s method: The pancreaticojejunostomy adopts the end-to-side anastomosis of the pancreatic duct to the jejunum mucosa. End-toside bile duct jejunostomy was performed at 10 cm from the pancreaticojejunostomy. The gastrointestinal anastomosis was performed side-to-side anastomosis with a 60 mm linear cutting closure device.

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Fig. 36.25 Put the specimen in the specimen bag

Fig. 36.27 End-to-side anastomosis of pancreatic duct to jejunum mucosa

Fig. 36.26 Place the support tube into the main pancreatic duct and fix it

Fig. 36.28 The state after pancreaticojejunostomy

1. Anastomosis of pancreatic duct to jejunum mucosa (Figs. 36.25, 36.26, 36.27, and 36.28). 2. Bile duct jejunum anastomosis (Figs. 36.29 and 36.30). 3. Gastrojejunostomy (Fig. 36.31).

Natural Orifice Specimen Extraction Transanal Specimen Extraction After specimen resection and gastrointestinal reconstruction were completed, the surgical position was changed to a functional lithotomy position. Use iodophor to disinfect the perineal area and rectal cavity. Adjust the laparoscopic monitor to the side of the patient’s feet, and adjust the body position to head low and feet high. The assistant pulls the sigmoid colon to fully expose the upper rectum and cuts about 5–6 cm in the anterior wall of the upper rectum (Fig. 36.32). After repeated disinfection with dilute iodophor solution, the incision protector is placed (Fig. 36.33), and the specimen is extracted from the anus through the incision protector (Figs. 36.34 and 36.35). The rectal wall was sutured continuously with barbed thread, and the rectal incision was

Fig. 36.29 Bile duct jejunum anastomosis

double-reinforced (Fig. 36.36). Wash the pelvic cavity with dilute iodophor solution and normal saline again, and check whether the rectal incision is sutured tightly.

Transvaginal Specimen Extraction Change the patient’s posture to a functional lithotomy position with head low, foot high and right incline 30 , and adjust the laparoscopic display on the patient’s foot. Expose and disinfect the perineum, and repeatedly disinfect the vagina with iodophor gauze. Rinse the pelvic cavity thoroughly with

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Fig. 36.30 The state after bile duct jejunal anastomosis

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Fig. 36.33 The incision protector is placed

Fig. 36.31 Gastrojejunostomy

Fig. 36.34 Specimen extraction

Fig. 36.32 Flush the pelvic cavity, disinfect the rectal cavity, and incise the anterior wall of the upper rectum

Fig. 36.35 Appearance of the perineum during specimen extraction

distilled water, dilute iodophor solution (1000 mg/L), and physiological saline before and after the incision of the posterior fornix of the vagina, after the incision, after the specimen is extracted, and after the suture is completed (Fig. 36.37). Suspend the uterus, lift the posterior fornix of the vagina with an intestinal pressure plate, and cut it horizontally for about 5 cm (Figs. 36.38 and 36.39). Put a sterile protective cover through the vagina or abdomen, wipe the surface with iodophor gauze and lubricate, extract the specimen with oval forceps, pay attention to maintaining the

pressure of the pneumoperitoneum, and then extract the incision protective cover (Fig. 36.40). Continuously suture the incision of the posterior fornix of the vagina with a 3-0 barbed thread to ensure that the suture is tight (Fig. 36.41).

Photographs of Specimens and Abdominal Wall After Surgery See Figs. 36.42, 36.43, and 36.44.

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Fig. 36.36 Double continuous suture of rectal incision with barbed thread

Fig. 36.37 Disinfecting the perineum and pelvis

Fig. 36.38 Properly separate the anterior rectal space

4. Analysis of Key Points, Difficulties, and Hot Spots Related to Surgery The feasibility, safety, and short-term and long-term treatment effects of LPD have been recognized by more and more surgeons, and it has gradually become a research hot spot of pancreaticoduodenectomy. The successful implementation of

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Fig. 36.39 Cut the posterior fornix of the vagina

Fig. 36.40 Insert the incision protective cover and extract the specimen through the vagina

Fig. 36.41 Suture the incision of the posterior fornix of the vagina

laparoscopic pancreaticoduodenectomy with transvaginal specimen extraction has broadened the scope of application of NOSES, and once again verified that the NOSES conforms to the concept of minimally invasive surgery. On the premise of conforming to the basic principles of surgery, by optimizing the surgical approach, improving the surgical operation and preserving the structure and function of normal tissues and organs, and reducing trauma, it can reduce the impact on the quality of life of the patient.

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Fig. 36.44 Appearance of abdominal wall after operation

Fig. 36.42 Photograph of specimen

enables the pancreatic duct and jejunal mucosa to accurately align, and guides the growth of the jejunal mucosa and the pancreatic duct. 2. Good preoperative preparation is required for specimen extraction through natural orifice, and strict tumor free and aseptic operation should be paid during the operation. The specimen extraction requires two groups of personnel to perform reverse operations, which also tests the team’s cooperation. It requires intraoperative adjustment of the monitor position or two sets of laparoscopic display devices. The number of trocars is not increased when the specimen is extracted, and the lower abdomen surgery is performed with the trocars designed for upper abdomen surgery, which will increase the difficulty of the operation. Therefore, higher requirements are put forward for the cooperation between the surgeon and the assistant.

Controversy over Transanal Specimen Extraction

Fig. 36.43 Photograph of specimen (open view)

Difficulties in Surgery 1. Digestive tract reconstruction is the key and difficult point of LPD, among which pancreatic-jejunal anastomosis is the most complicated and most likely to cause postoperative complications. This patient used the pancreatic duct to jejunal mucosa anastomosis. During the pancreaticojejunostomy, the plastic tube was used as the support tube, which not only fully drains pancreatic juice but also

1. Cut open the organs unrelated to the primary disease. 2. Increase the risk of abdominal infection and tumor cell implantation and dissemination. 3. There is a risk of complications such as rectal leakage, bleeding, intestinal stenosis, and abnormal bowel function. 4. At present, NOSES is in the process of continuous improvement. There are no reports of large cases, and more colleagues are needed to conduct research to observe its long-term effects. Therefore, surgeons should strictly grasp the indications to ensure the safety of patients and maximize the benefits of patients.

Section V NOSES for Urinary Tumor Surgery Nianzeng Xing and Sujun Han

Laparoscopic Uterus, Fallopian Tube, and Ovary Sparing Cystectomy with Transvaginal Specimen Extraction

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Nianzeng Xing, Sujun Han, and Liyuan Wu

Contents The Indication and Contraindication of NOSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 520 Indication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 520 Contraindication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 520 Anesthesia, Disinfection, Body Position, the Position of the Trocar, and the Position of the Operator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Disinfection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trocar Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Position of the Surgeon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Operation Steps, Skills, and Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 520 Surgical Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 522 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 523

Abstract

The classic range of radical cystectomy in women includes the bladder, uterus, fallopian tube, ovary, anterior vaginal wall, and urethra. But there has been controversy over whether to remove the uterus and double attachments. Some scholars believe that if bladder cancer with the tumor does not infiltrate the surrounding tissue, the female reproductive organs should not be removed during surgery. As we all know, transvaginal specimen extraction was convenient for female patients. Specimen extraction through the vagina can avoid minilaparotomy and its accompanying side effects, such as postoperative pain, wound infection, and even wound dehiscence. Further experience with this approach should reduce the operation time. In recent years, this technique has been widely used in gynecological and colorectal surgery. To summarize the

experience of laparoscopic cystectomy with preservation of uterus and double adnexa without auxiliary incision to remove specimens from posterior vaginal vault. And whether radical cystectomy for women preserves for female genital organs, our indications are: (i) age of the patient < 60 years; (ii) cystoscopic biopsy proved no tumor infiltration in the triangle region and bladder neck; (iii) preoperative imaging evaluation: tumor did not invade the uterus, appendage, and vagina, and had no other lesions in the genitals; (iv) preoperative cystoscopic biopsy was pathologically diagnosed as non-invasive urothelial cancer. To sum up, laparoscopic uterus, fallopian tube, and ovary sparing cystectomy with transvaginal specimen extraction for bladder cancer is safe and feasible. Keywords

Laparoscope · Natural orifice specimen extraction surgery (NOSES) · Bladder cancer · Female · Surgical techniques N. Xing (*) · S. Han · L. Wu Department of Urology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China © People’s Medical Publishing House, PR of China 2023 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-99-2750-0_37

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The Indication and Contraindication of NOSES Indication 1. Patient’s age was 5 cm, which is difficult to be retracted via the natural lumen 2. Tumor invasion beyond serosa, which has the risk of tumor implantation when retracted via the natural lumen 3. Severe obesity (BMI > 35 kg/m2), or mesocolon hypertrophy, which could produce difficulty during specimen retraction via the natural lumen

Key Surgical Points Anterior Rectal Resection Combined with Right Hemicolectomy Complex NOSES Surgery 1. Trocar Locations The patient takes the modified lithotomy position. Trocars are implanted as 5-port method: 10 mm trocar implanted beneath the umbilicus as observation port, 12 mm trocar at the McBurney’s point, 10 mm trocar at the level of umbilicus or higher through left midclavicular line as primary operating port, and 5 mm trocars at reverse McBurney’s point and the level of umbilicus or higher through right midclavicular line as auxiliary operating port. 2. Surgical Techniques Dissection and excision of the right colon are performed first. The surgeon stands on the left side of the patient, while the assistant is on the right side and the camera holder between the legs of patient. The right colon is dissected via the caudal approach, following the principle of complete mesocolon excision (CME). The anterior lobe of the mesentery is cut open from the fold at the junction of the ileocolic mesentery, and then right Toldt’s space is entered (Fig. 73.9). Dissection along the Toldt’s space is further made, with outside to the lateral peritoneum, inside to the front of the superior mesenteric vein (SMV), and

Fig. 73.9 Cut open the junction of ileocolic mesentery

Fig. 73.10 Ligation at the root of supplying vessels

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lumen separately, and then the endoscopic linear stapler is embedded to accomplish the lateral-lateral ileum-colon anastomosis. After that, the orifice is closed using an endoscopic linear stapler again. Checking that the anastomosis is satisfactory and there is no blood oozing, the resected right half of the colon is placed in the right upper abdomen and the resection of rectum then continues. The operator changes to the right side of the patient, with the assistant standing to the left side and the endoscopy holder to the cephalic side. The rectum is dissected and resected via the middle approach, following the principle of total mesorectum excision (TME). Lymph nodes around the root of inferior mesentric artery (IMA) are removed. By ligating the inferior mesentric artery under the origin of left colic artery (LCA), the left colic artery is routinely preserved, and meanwhile, the inferior mesentric vein is highly ligated approximate to the lower edge of the pancreas. The mesorectum is dissected along with the presacral avascular space downward to the pelvic floor in low rectal cancer or at least 5 cm below the tumor in middle rectal cancer. During the dissection, attention is paid to avoid any injuries to the hypogastric nerves and pelvic nerve plexus on both lateral sides, the neurovascular bundle (NVB) on both anterolateral sides, and the posterior vaginal wall (female) or seminal vesicle gland (male) on the front. After completion of the mesorectal dissection, the intestinal wall about 3 cm long is denudated within 5 cm below the tumor, and trimming of the sigmoid mesentery is made down to the planed transection line of the sigmoid colon, which is approximately 10 cm proximal to the tumor. Then, the sigmoid colon is transected with the endoscopic stapler. 3. Specimen Extraction The rectal and sigmoid colic lumen is irrigated and sterilized with diluted iodophor solution, then the long-handled toothed oval forceps are inserted via the anus to clamp the residual end of the sigmoid colon and pull the sigmoid colon and rectal tumor reversely out of the anus. After irrigating and sterilizing the reversed lumen with diluted iodophor solution again, the distal stapled end of the sigmoid colon is opened, and an aseptic plastic protective sleeve with inside and outside full lubrication is inserted into the pelvis via the trocar. The oval forceps are inserted via the opened sigmoid colon to pull one end of the plastic protective sleeve out of the anus. The appropriate stapler anchor is put into the abdomen cavity via the plastic protective sleeve. After that, the oval forceps are inserted again, clamping the ileal end of the right colon specimen, and pull the specimen out of the anus via the protective sleeve. Then, the rectum is transected 2 cm below the lower edge of tumor using a curved cutter stapler under

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direct vision, and the rectal tumor and specimens are removed. 4. Reconstruction of Digestive Tract The pelvic cavity is washed thoroughly with a large amount of diluted iodophor solution and distilled water. A purse suture of the proximal sigmoid end is first made in stapled situation. Once the purse suture has been accomplished, the stapled end is cut and removed, and the stapler anchor is implanted. The anchor is embedded appropriately with the tightening of the purse suture. After washing the pelvic cavity again, the circumferential stapler is inserted via the anus, piercing through the center of residual stapled rectum. A sigmoid colon-rectum end-to-end anastomosis is therefore accomplished under vision. The pelvic floor is reconstructed by suturing the colonic mesentery to the lateral peritoneum together. At last, drainage tubes are placed in the abdominal cavity as needed.

Subtotal Colectomy Complex NOSES Surgery 1. Trocar Locations The patient is placed in modified lithotomy position, and trocars are implanted as 5-port method: 10 mm trocar implanted beneath the umbilicus as observation port, 12 mm trocar at the McBurney’s point, 10 mm trocar at the level of the umbilicus or higher through left midclavicular line as primary operating port, and 5 mm trocars at reverse McBurney’s point and the level of umbilicus or higher through right midclavicular line as assistant ports. 2. Surgical Techniques The dissection is initiated in counterclockwise order after abdominal and pelvic exploration. The chief surgeon stands on the right side of the patient, the assistant on the left side, and the endoscopy holder on the same side with the chief surgeon or on the cephalic side. Then the dissection of rectum and left colon is carried out. After that, the chief surgeon changes to the left side of the patient, the assistant to the right and the endoscopy holder between the legs of patient to continue the dissection of right colon and ileocecal segment. The dissection of rectum follows TME principle and proceeds to the pelvic floor. The dissection of left and right colon follows CME principle, and the corresponding blood-supply vessels are ligated and transected at root. When the dissection of the whole colon and rectum is completed, the ileum is cut about 15 cm from the proximal part of ileocecal valve with an endoscopic linear stapler and the sigmoid colon is also transected 10 cm from the proximal edge of rectal tumor using the endoscopic linear stapler. 3. Specimen Extraction The specimen extraction is completed step-by-step with the order as eversion of rectum and tumor first, and then extraction of the sigmoid colon and proximal specimen in transection and drag-out way.

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The rectal lumen distal to the stapled end of the sigmoid colon is irrigated and sterilized with diluted iodophor solution routinely before the extraction of specimen. After that, the long-handled toothed oval forceps are inserted via the anus, clamping the inner stapled end of the sigmoid colon, to pull reversely and extract the sigmoid colon and rectal tumor out of the anus. Washing and sterilizing the lumen with diluted iodophor solution is made again (Fig. 73.11). Then the stapled end of sigmoid colon is opened, through which the long-handled toothed oval forceps are inserted to pull one end of the sterilized plastic protective sleeve out of the anus. The appropriate stapler anchor is put into the abdomen through the protective sleeve. Following that, the colic specimen is extracted out of the abdomen by clamping the proximal stapled sigmoid colic end with long-handled toothed oval forceps via the protective sleeve (Fig. 73.12). Under direct vision, the rectum is closed and severed 2 cm distal to the lower

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edge of the rectal tumor with a curved stapler and then the rectal tumor specimen is removed. 4. Reconstruction of Digestive Tract The pelvic cavity is thoroughly flushed with a large amount of diluted iodophor solution and distilled water successively. A purse suture of the ileum stump is first made in a stapled situation (Fig. 73.13). Once the purse suture has been accomplished, the stapled end is cut and removed, and the stapler anchor is implanted and well embedded by tightening the purse suture. After washing the pelvic cavity again, the circumferential stapler is inserted into the rectum via the anus, piercing through the center of residual stapled rectum. An ileum-rectum end-to-end anastomosis is therefore made under vision. Thorough washing of the pelvic cavity is made again, followed by pelvic floor reconstructed by suturing the ileal mesentery or intestinal wall to the lateral peritoneum (Fig. 73.14). One or two abdominal drainage tubes are

Fig. 73.11 Washing rectum with diluted iodophor solution Fig. 73.13 Making purse suture in stapled situation

Fig. 73.12 Extraction colic specimen via protective sleeve

Fig. 73.14 Reconstruction of pelvic floor

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retained according to the situation before the ending of surgery.

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harming the interests of patients but also driving the surgeons into passive situations.

Application of Reverse Puncture Technique to Place Anvil for Laparoscopic Colorectal The concept of complex NOSES surgery is a combination of Resection with NOSES Notifications

two or more extraction techniques to take out the specimen step-by-step and in phases, without violation of the aseptic and tumor-free principles, in order to accomplish the transformation from NOSES infeasible to NOSES possible in situations as surgical specimens could not be taken out in one time via natural orifice, or could not be taken out with one single extraction technique. Since the operation of complex NOSES involves repeated transection and trimming of the specimen and multiple opening and reconstruction of the intestinal lumen in vivo, the demands of aseptic and tumor-free principles to the surgeons and cooperation skills within the surgical teams are extremely high. In order to reduce the risk of contamination of the abdominal cavity by intestinal contents once the lumen is opened, it is necessary to do full bowel preparation before the operation, as well as several manipulation skills are recommended during the operation. The use of the iodophor solution gauze is necessary to isolate and protect the residual intestinal end before opening it. Blockage of the lumen 10 cm proximal to the residual end with noninvasive vascular forceps is also useful to avoid the downstream of intestinal contents, anytime when the proximal intestine or colon is planned to be opened. And skillful use of the aspirator to remove any potential overflowing intestinal fluid and feces is also very important. In addition, thorough flushing and irrigation of the abdomen cavity with a large amount of diluted iodophor solution and distilled water play critical roles in the elimination of the potential pollution after the procedure of luminal opening. In our opinion, the risk of intestinal content pollution and tumor planting or metastasis could be minimized or even avoided, as long as full bowel preparation is made before operation, principles of aseptic and tumor-free are strictly observed during operation, proficient cooperation and coordination of operation are carried out between members, and surgical instruments and materials such as specimen bag, aseptic protective sleeve, strap, iodophor gauze, aspirator, and irrigator are skillfully used. However, a strict selection of patients and indications is required, due to the difficulty of surgical techniques and complexity of manipulation. The surgeons’ cognition of the concept and mastery of the technique of complex NOSES should also be taken into consideration. It is critical to mind that NOSES should never be carried out for the sake of surgeon’s will, thus to induce severe complications and cause poor prognosis, not only

With the deepening of the understanding of minimally invasive concepts, the laparoscopic technique has been rapidly popularized in the field of colorectal cancer. High-level evidence-based medical evidence indicates that the short-term efficacy of laparoscopic colorectal cancer surgery is better than that of open surgery. There is also a good guarantee for long-term efficacy. In recent years, NOSES surgery has embarked on the stage of surgical history. NOSES is called “the most minimally invasive surgery.” While ensuring the curative effect of tumor, it completely eliminates the abdominal incision, greatly reduces the pain of surgery, and improves the patient’s medical experience. A key technical difficulty in NOSES surgery is how to place the stapler anvil into the proximal bowel and fix it. From January 2016 to June 2018, the Center applied the reverse puncture technique to fix the stapler to the anvil in 61 cases in Qilu Hospital of Shandong University and achieved good short-term results. The summary report is as follows.

Data and Methods General Data From January 2016 to June 2018, the general surgery department of Qilu Hospital of Shandong University completed a total of 61 cases of laparoscopic abdominal incision-free radical resection of colorectal cancer, which were performed by the reverse puncture technique and inserted into the anvil from the anus. All operations were performed by the gastrointestinal surgery team of the center, and all patients were diagnosed with adenocarcinoma by pathology before surgery. Patients with large tumors, obesity, and locally advanced tumors are not suitable for this operation. Operative Technique (a) Preparation of the Patients Preoperative intestinal preparation was routinely performed, prophylactic use of antibiotics was performed during the induction period of anesthesia, endotracheal intubation was used for general anesthesia to ensure a good state of muscle relaxation during the operation, catheter was routinely indwelled, and gastric tube was placed when it is necessary. The patient was placed in the lithotomy position with the left leg elevated and the right leg slightly flat, a pneumoperitoneum was established,

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and the trocar was placed in accordance with conventional laparoscopic colorectal surgery. (b) Surgical Procedures The mesenteric membrane was cut horizontally from the sacral promontory, the abdominal aorta was identified within the Toldt’s fascia, and the abdominal aorta was extended to the head to find the root of the inferior mesenteric artery. The blood vessels were isolated to the distal end along the root of the inferior mesenteric artery, the lymph nodes were dissected, and the deep left ureter and gonadal vessels were protected. Determine the position of proximal distal bowel cut off, isolate the distal bowel, cut open the distal bowel, disinfect and place the anvil from the anus, and remove it from the distal bowel. The proximal bowel was cut open, the anvil was placed into the proximal bowel lumen, and the reverse puncture technique was used to puncture the anvil shaft. A linear stapler was placed close to the anvil shaft. One of the two methods was used to remove the specimen extra- corporeally: eversionresection (Figs. 73.15, 73.16, 73.17, 73.18, 73.19, 73.20, 73.21, 73.22, 73.23, 73.24, 73.25, 73.26, 73.27, 73.28, and 73.29) or resection-extraction (Figs. 73.30, 73.31, 73.32, 73.33, 73.34, 73.35, 73.36, 73.37, 73.38, 73.39, 73.40, and 73.41). Subsequently, the circular stapler was placed from the anus, anastomosis was completed under laparoscopy, and the abdominal drainage tube was indwelled. (c) Summary of Technical Points Principles: (1) The bowel and blood vessels should be completely resected before specimen extraction; (2) after disinfection, an incision is made in the isolated part of the distal bowel and the anvil is inserted transanally, through the incision to the abdominal cavity; (3) reverse puncture of the anvil from the proximal bowel and closure of the proximal bowel; (4) the specimen is extracted from the

Fig. 73.15 Cut open the distal bowel (a)

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anus; and (5) during the extraction process, the protective sleeve should be applied to protect the specimen from the natural orifice.

Follow-Up Patients or their family members were followed up in the form of gastrointestinal surgery clinic, telephone, and letter, starting from the date of operation and ending on August 31, 2018. Postoperative complications, survival status, and tumor recurrence and metastasis were recorded.

Results All patients were successfully operated, and no conversion to laparotomy or other emergency occurred during the operation.

Fig. 73.16 Cut open the distal bowel (b)

Fig. 73.17 Insert the anvil through the anus

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Fig. 73.18 Place the anvil through the reverse puncture technique (a)

Fig. 73.21 Sponge forceps clamp the closed end of the bowel

Fig. 73.19 Place the anvil through the reverse puncture technique (b)

Fig. 73.22 Pull out the specimen by anal eversion (a)

Fig. 73.20 Close and transect the distal bowel with Endo-GIA stapler

Fig. 73.23 Pull out the specimen by anal eversion (b)

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Fig. 73.24 Pull out the specimen by anal eversion (c)

Fig. 73.27 Bowel anastomosis

Fig. 73.25 Contour close and transect the bowel specimen

Fig. 73.28 Interrupted suture

Fig. 73.26 Anal placement of a circular stapler

Fig. 73.29 Place pelvic drainage tube

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Fig. 73.30 Cut open the distal bowel (a)

Fig. 73.33 Place the anvil into the proximal bowel

Fig. 73.31 Cut open the distal bowel (b)

Fig. 73.34 The anvil passes through the bowel

Fig. 73.32 Remove the anvil

Fig. 73.35 Close the proximal bowel

Postoperative follow-up results showed that by the end of December 2018, the median follow-up time of the patients was 13.9 months, during which there was no delayed anastomotic fistula, intestinal obstruction, serious cardiopulmonary complications, etc. Bacteriological examination: No abdominal infection, pelvic abscess, and other infectious complications developed. Functional study: All patients did not have obvious urination dysfunction, sexual dysfunction, or obvious defecation disorders. In terms of oncology treatment, liver metastasis occurred in 1 patient 18 months after surgery, and no tumorrelated death occurred in 61 patients.

Discussion At present, exploration and development of minimally invasive surgery with smaller trauma is the development trend of colorectal cancer treatment. Inspired by NOTES technique, NOSES are gradually introduced and applied in laparoscopic colorectal cancer surgery to avoid additional abdominal incision. Research has confirmed that colorectal cancer surgery with NOSES can effectively avoid abdominal incision and related complications, and can reduce postoperative pain and psychological pressure of patients (Wang et al. 2022), which

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Fig. 73.36 Pull the specimen out through the anus

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Fig. 73.39 Anastomosis

Fig. 73.40 Interrupted suture Fig. 73.37 Close the distal bowel

Fig. 73.41 Place pelvic drainage tube Fig. 73.38 The stapler passes through the distal bowel

is known as minimally invasive. However, this is still in the development stage and there are many conceptual issues and technical bottlenecks to be solved and improved. Among them, the operation of fixation of the anvil in the proximal bowel under complete laparoscopic operation is the key technique and core problem of the NOSES operation, which has put forward high requirements for the surgeon’s mastery of operational skills and team coordination ability. At present, there are many methods of anvil fixation applied in clinical practice, including fixed extrusion method, snare ligation method, manual purse-string suture method, etc., each of

which has its own advantages and disadvantages. Through the practice and exploration of 61 patients, we put forward the reverse puncture technique for the introduction of anvil and share it with everyone. There are many means of laparoscopic colorectal surgery with NOSES. The 2018 NOSES expert consensus unified the ten kinds of different ways of operation and unified the naming. The 2018 NOSES expert consensus standardized the terminology and approach for ten different types of operations, thereby promoting the standardized development of NOSES. While obtaining specimens through the vaginal route is feasible, it is not the preferred method. This is due

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to the potential for additional damage to the female reproductive organs, and the lack of sufficient evidence from evidence-based medicine regarding its impact on female fertility. With vaginal incision combined with the traditional ideas and the limitation of ethics, transanal specimen extraction is still the current choice of NOSES method. Tumor-free is the core issue for NOSES. Early colorectal tumor specimens can be removed extracorporeally after bowel extraction or eversion, but in both methods the tumor is compressed. There is a risk for the tumor cells to flow back into the blood if the tumor is compressed while the blood supply still exists. What is more, how to incise the proximal bowel wall and insert the anvil extracorporeally is another problem. Reverse puncture technique perfectly solves the above problems. Before the specimen is extracted, the anvil is introduced into the proximal bowel and the proximal bowel is transected, which avoids the problem of tumor cells contaminating the proximal bowel. Also, the specimen is completely placed in the protective sleeve before extraction. With the protective sleeve, the external environment will not be contaminated even with certain extrusion. At the same time, it avoids the problem of vascular damage caused by traction of the mesentery. Asepsis is another core issue for NOSES. Before the specimen is extracted, the distal bowel is fully disinfected and then completely transected. After the anvil is fixed in the proximal bowel, the closure device is placed close to the puncture hole to transect and ligate the bowel, which reduces the probability of abdominal infection. NGU bacteriological culture of the abdominal lavage fluid in the NOSE operation was found only 20% positive, but none of the patients showed complications related to bacterial infection. Peng Jian in China cultivated abdominal lavage fluid of 96 cases of colorectal NOSE operation, and the bacterial positive rate was 34.4% (Ouyang et al. 2020). No patients had symptoms of abdominal and pelvic cavity-related bacterial infection. It is worth noting that, in 2008, Hu Sanyuan et al. removed the gallbladder of the pig through the stomach and vagina through NOTES method in the animal experiment, and the bacterial positive rate of abdominal lavage solution was also 20%, indicating that the total laparoscopic NOSES did not cause abdominal contamination or lead to infection. In summary, reverse puncture technique is a new method for proximal bowel insertion in the NOSES, which can better guarantee the aseptic and tumor-free principles in the NOSES, and it is a technique worth popularizing. As another surgical revolution after laparoscopy, NOSES is in its early stages, but undeniably a trend favored by surgeons and patients with colorectal tumors. In time, NOSES is expected to reach the highest level of minimally invasive surgery – scarless surgery.

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Robotic Radical Resection for Lower Rectal Carcinoma with Transanal Pullout of Rectum Eversion and Extracorporeal Resection Technique (A Modified NOSES I) With the rapid development of surgical technology, the minimally invasive surgery has obtained a widespread application in colorectal carcinoma resection. In recent years, natural orifice specimen extraction surgery (NOSES) has been applied in colorectal surgery. NOSES not only obtains radical oncological resection, but also minimizes the postoperative pain. Laparoscopic radical resection with transanal specimen eversion and extracorporeal resection (NOSES I) is well suitable for lower rectal carcinoma. The advantage of this method is that the specimen is transected after being everted transanally, which helps to evaluate the definite distance of distal resection margin and reduce the possibility of positive resection margin. Six different methods of NOSES I have been reported. The key procedure of this method is the introduction of anvil into the bowel lumen of sigmoid colon. However, how to complete this step aseptically is still the focus. Based on the clinical experience of colorectal resection with Da Vinci robotic surgery system, we developed a modified NOSES I as robotic radical resection for lower rectal carcinoma with transanal pullout of rectum eversion and extracorporeal resection technique. The procedures of operation are as follows: After the establishment of pneumoperitoneum, the inferior mesenteric artery (IMA) and inferior mesenteric vein (IMV) are dissected. Depending on the type of IMA, the left colonic artery is either divided or preserved after the removal of lymph nodes (Fig. 73.42). After division of the artery, the space above Toldt’s fascia is separated and extended, avoiding injury of the inferior mesenteric nerve plexus, the left ureter, and gonadal vessels. The splenic flexure should be mobilized to facilitate the eversion. According to the TME principles, the rectum should be dissected to the end of the mesorectum, posteriorly to the anococcygeal ligament, left and right to the septum between sphincter internus and externus, and anteriorly to the transection of lower segment of vagina for female or seminal vesicle for male. Then the mesentery of sigmoid colon is divided and the rectum is isolated at the intended resection line at 10 cm above the proximal edge of the tumor. After full dilation of the anus, the rectum is lavaged by dilute iodine solution. Then the sponge forceps is transanally introduced into sigmoid colon lumen from the contralateral side of the tumor and sutured to the isolated rectum (Fig. 73.43). The rectum is slowly pulled down and gently everted out transanally (Fig. 73.44). After the everted rectum is washed with dilute iodine solution for three times, the rectum is cut open at the intended resection line where the sponge forceps is sutured. The anvil is placed into the

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Fig. 73.42 The types of IMA. Left colonic artery is either divided or not, depending on the type of IMA after removal of lymph nodes

Fig. 73.44 The rectum is everted outside transanally Fig. 73.43 The sponge forceps is sutured to the intended resection line of dissected rectum

proximal colon with a string suture fixed, and then the proximal colon is returned back to the pelvic cavity (Fig. 73.45). Subsequently, the distal rectum is transected with a linear stapler according to the directly measured length (Fig. 73.46).

An end-to-end anastomosis of sigmoid colon and rectum is performed by circular stapler under the observation of Da Vinci laparoscopy (Fig. 73.47). This modified NOSES I technique is different from NOSES IA and IB which have been described before. In

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Fig. 73.45 The anvil is introduced into the lumen of sigmoid colon after the rectum is cut open Fig. 73.47 An end-to-end anastomosis of sigmoid colon and rectum is performed with circular stapler

Fig. 73.46 Distal rectum is transected with linear stapler according to the directly measured length

NOSES IA or IB, the incision of sigmoid colon and introduction of anvil are performed intracorporeally. Differently, the key steps of modified NOSES I, i.e., the transection of the rectum and the introduction of the anvil into sigmoid colon lumen, are performed extracorporeally under direct vision. These steps ensure the aseptic operation and remarkably reduce the risk of intraperitoneal infection caused by intestinal flora. Also, the result of related clinical research has been proved the safety and advantage of this procedure (Liu et al. 2020). This technique can also reduce the risk of anastomotic leakage due to the absence of “dog ears” during digestive

tract reconstruction. However, the limitation of this technique is that this procedure is only applicable in these following conditions: (1) The sigmoid colon should be long enough to allow the eversion of the rectum; (2) the sigmoid mesocolon should be long and thin enough; (3) the infiltration depth of tumor should not exceed the muscularis propria; and (4) the tumor volume is relatively small. There is a risk for the tumor cells to shed off after eversion if the tumor volume is too large and the local infiltration is deep. Above all, robotic radical resection for lower rectal carcinoma with transanal pullout of rectum eversion and extracorporeal resection technique is a feasible NOSES procedure due to the decreased risk of abdominal infection and anastomotic leakage. Colorectal surgeons can use this technique on selected patients based on clinicopathological parameters.

References Liu D, Luo R, Wan Z, Zhu W, He P, Ye S, Tang C, Lei X, Li T. Clinical outcomes and prognostic factors of robotic assisted rectal cancer resection alone versus robotic rectal cancer resection with natural orifice extraction: a matched analysis. Sci Rep. 2020;10(1):12848. Ouyang Q, Peng J, Xu S, Chen J, Wang W. Comparison of NOSES and conventional laparoscopic surgery in colorectal cancer: bacteriological and oncological concerns. Front Oncol. 2020;10:946. Wang S, Tang J, Sun W, Yao H, Li Z. The natural orifice specimen extraction surgery compared with conventional laparoscopy for colorectal cancer: a meta-analysis of efficacy and long-term oncological outcomes. Int J Surg. 2022;97:106196.

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Qingchao Tang, Haipeng Chen, Xishan Wang, Junhong Hu, Dan Ma, and Chuangang Fu

Contents How to Perfectly Follow the Aseptic and Tumor-Free Principles in NOSES . . . . . . . . . . . . . . . . . . . . . . . . . . . 932 NOSES for Total Laparoscopic Left Hemicolectomy with Inferior Mesenteric Vein Preserved . . . . . 933 Skills and Experience Sharing on the Use of Gauze in NOSES Operation of Colorectal Cancer . . . . Action One “Block” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Action Two “Pad” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Action Three “Press” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Action Four “Steady” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Action Five “Support” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Action Six “Blunt Dissection” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Action Seven “Protect” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Action Eight “Mark” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Action Nine “Sterilize” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Action Ten “Suction” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Action Eleven “Spread” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Action Twelve “Withstand” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Operating Points of Aseptic and Tumor-Free Operation in NOSES for Rectal Cancer . . . . . . . . . . . . . . . 940

Q. Tang Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China H. Chen Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China X. Wang (*) Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China J. Hu Department of General Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China Department of Anorectal Surgery, First Affiliated Hospital, Zhengzhou University, Zhengzhou, Henan, China D. Ma Department of General Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing, P. R. China C. Fu Department of Gastrointestinal Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China © People’s Medical Publishing House, PR of China 2023 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-99-2750-0_74

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Q. Tang et al. Application of “Reverse Parallel Division of Sigmoid Mesocolon” and “Wang’s Isolation” for the Isolation of Mesorectum in NOSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 941 Division of the Sigmoid Mesocolon (Reverse Parallel Division) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 941 Isolation of the Mesorectum (Wang’s Isolation) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 942 Application of OrVilTM and NOSES in Total Laparoscopic Gastrectomy for Female . . . . . . . . . . . . . . . . 943 New Method of Modified NOSES I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 949 Surgical Procedure of a Modified NOSES I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 949 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 949 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 950

Abstract

Aseptic and tumor-free operations are essential to the success of NOSES. Standardized aseptic and tumor-free procedures ensure the safety and effectiveness of NOSES and are important in reducing the incidence of postoperative complications and ensuring the long-term oncological prognosis of patients. This chapter covers the experience and wisdom of various Chinese experts in the aseptic and tumor-free operation of NOSES, as well as some other related tips that may improve the quality of operation during NOSES. The topics discussed in this chapter include: (1) how to perfectly follow the aseptic and tumor-free principles in NOSES, (2) NOSES for total laparoscopic left hemicolectomy with inferior mesenteric vein preserved, (3) tips on the use of gauze in NOSES, (4) points of aseptic and tumor-free operation in NOSES for rectal cancer, (5) “Wang’s Isolation” for the isolation of mesorectum, (6) application of OrVil and NOSES in total laparoscopic gastrectomy for female patients, and (7) new method of modified NOSES I. These techniques are applicable to different surgical methods, but the purpose is consistent. Hopefully, the technical details and mindset provided in the following content will inspire readers to optimize their operations and further explore the possibilities of NOSES beyond current standard procedures. Keywords

NOSES · Aseptic and tumor-free principle · Inferior mesenteric vein preservation · OrVil · Mesorectum · Laparoscopic gastrectomy · Gauze

How to Perfectly Follow the Aseptic and TumorFree Principles in NOSES NOSES has been understood and adopted by more and more doctors; however, how to follow the aseptic and tumor-free principle during the procedure has always been challenging. Our operating skills and experience in the aseptic and tumorfree operation of NOSES are introduced as follows.

1. During conventional operation, the used gauze is removed from the abdominal cavity through the trocar, which has the following potential risks: (1) The risk of tumor seeding when the gauze passes through the trocar. In addition, once the trocar is contaminated, there is risk for the other laparoscopic instruments, such as ultrasonic scalpel, forceps, etc., to be contaminated by tumor cells as well. Tumor seeding may occur when the abdominal and pelvic organs are contacted with such instruments; (2) When the used gauze is removed through the trocar, the gauze is squeezed and the fluid absorbed by the gauze may return to the abdominal cavity, which is prone to cause infection and tumor cell dissemination in the abdominal and pelvic cavity (Fig. 74.1a); (3) Repeated removal of gauze through the trocar may damage the airtightness of the trocar and the abdominal wall. At the same time, it is prone to cause loosening of the trocar, which may interfere with the surgical operation; (4) Repeated removal of gauze through the trocar is prone to damage the gauze, and the replacement of instruments may interfere with the smooth operation of surgery; and (5) Removal of gauze through the trocar may damage the gauze, which interferes with the counting of gauze after operation, and may cause residual gauze left in the body (Fig. 74.1b). 2. Specimen extraction through the trocar has the above risks as well. To solve this problem, the “sleeve in sleeve,” i.e., resected glove fingers, specimen retrieval bag, or protective sleeve for ultrasonic scalpel, etc., is applied for the extraction of resected specimen (Fig. 74.1c, d). In most cases, the specimen is extracted through the protective sleeve together with the used gauze (Fig. 74.2). 3. Iodoform gauze can be applied to sterilize the rectal stump and other potentially wcontaminated sites. The proximal bowel can also be closed with a ligating band to avoid intraluminal dissemination of tumor cells. 4. After the digestive tract reconstruction, the abdominal and pelvic cavity is adequately irrigated with dilute iodine solution or 42
C distilled water. 5. For patients who meet the indications, intraperitoneal chemotherapy drugs such as lobaplatin and raltitrexed are applicable.

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Aseptic and Tumor-Free Operation and Other Key Techniques Sharing on NOSES

Fig. 74.1 Sharing on details of aseptic and tumor-free techniques of NOSES. (a) Removing gauze through the trocar may contaminate the abdominal cavity. (b) Gauze is damaged when passing through the

NOSES for Total Laparoscopic Left Hemicolectomy with Inferior Mesenteric Vein Preserved In standard D3 lymph node dissection for left-side colon cancer surgery, the inferior mesenteric artery and vein are generally ligated from their origin. However, the incidence of colonic ischemia after ligation of the inferior mesenteric artery ranges between 0.45% and 24%. In these patients, extended resection of the colon is inevitable. In order to prevent this problem, we present a method to perform the D3 lymph node dissection with the inferior mesenteric vein preserved in selected patients. As the principle of radical resection is still followed, this method has several advantages, including avoiding excess mobilization of the transverse colon, maximizing the length of the residual bowel, maintaining the blood supply of distal sigmoid colon, ensuring anastomotic blood supply, and reducing anastomotic tension. Meanwhile, intracorporeal anastomosis and natural orifice specimen extraction techniques are applied. The main surgical procedures are as follows.

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trocar. (c) Extraction of resected specimen with resected glove finger. (d) Unprotected resected specimen stump

After the laparoscope is placed into the camera trocar, the condition of the abdominal and pelvic cavity and tumor location are examined. The surgeon applies the ultrasonic scalpel to open the retroperitoneum at the root of the inferior mesenteric artery and incises the retroperitoneum to the Treitz ligament along the lateral side of the abdominal aorta. The dissection is continued to enter the space anterior to Toldt’s fascia, and then the root of the inferior mesenteric artery is exposed. Following this, the left colic artery is isolated and transected. No. 253 lymph nodes are dissected while preserving the distal sigmoid artery and superior rectal artery. Attention should be paid to protect the nerves. Afterward, dissection is performed upwards to the lateral side of the Treitz ligament. At the inferior border of the pancreas, the inferior mesenteric vein is isolated, and the surrounding lymphatic tissue is dissected. Once the left colic vein is identified, it is ligated and transected. Since the venous wall is thin and without vascular sheath, this operation should be performed extremely carefully (Fig. 74.3). The surgeon lifts the left mesocolon and applies the ultrasonic scalpel to perform sharp and blunt dissection along the Toldt’s fascia downwards and upwards in a medial to lateral fashion. Transverse mesocolon is divided along the inferior

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Fig. 74.2 (a) Placing the used gauze into the protective sleeve. (b) Placing the specimen into the protective sleeve. (c) Tightening the inner opening of the protective sleeve. (d) The protective sleeve is extracted out of the body together with the used gauze and specimen inside

pancreatic edge from right to left. The left paracolic sulcus is incised cephalad until reaching the previous dissection plane. After dividing the splenocolic and gastrocolic ligaments from left to right, the splenic flexure and the distal third of the transverse colon are completely mobilized. The great omentum is divided toward the bowel wall, and according to the en bloc principle, the left part of it is removed along with the splenic flexure. The left branch of the middle colic artery is ligated and divided. Subsequently, the extent of resection below the tumor is assessed, and the resection line should be approximately 10 cm from the tumor margin. Side-to-side or end-to-end method can be adopted to create the intracorporeal colocolonic anastomosis (Fig. 74.4). The specimen can be extracted via rectum in male patient or via the vagina in female patient (Fig. 74.5).

Skills and Experience Sharing on the Use of Gauze in NOSES Operation of Colorectal Cancer NOSES for radical resection of colorectal cancer is a surgery that applies conventional laparoscopic instruments, TEM, and other instruments to complete the abdominal laparoscopic surgery without auxiliary incision. Studies have confirmed that NOSES is safe and feasible, and does not affect the radical resection of tumors or organ function. Compared with the method of specimen extraction through the abdominal auxiliary incision, the transvaginal or transanal approach

seems to be more suitable and more easily accepted by the majority of colorectal surgeons. NOSES has the advantage of being convenient for all levels of hospitals and doctors to carry out on the basis of existing laparoscopy, but it also puts forward higher requirements for surgeons’ skills in laparoscopic operation. Professor Wang Xishan led the team to fully explore and summarize the operation and coordination skills of surgeon, assistant, and camera holder in the process of innovative series of radical colorectal cancer NOSES. Among them, the use of gauze has distinctive features and important practical significance in the series of NOSES operations. According to the different uses and the specific operation methods of gauze, the skills in the use of gauze are summarized into the following ten actions. Preparation of gauze: After cutting the small gauze into one-half or one-quarter size, the burred edge is rolled into the inside of the gauze strip to avoid shedding of the gauze thread and affecting the operation or its remaining in the abdominal cavity.

Action One “Block” Applicable Scene 1. After laparoscopic exploration and before the NOSES operation, small gauze strips are used to block the small intestine, omentum, and accessories to the nonsurgical area to fully expose the main operating field.

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Fig. 74.3 The surgery procedure of D3 lymph node dissection and preserving IMA/IMV. (a) Exposure of the Treitz Ligament and IMV. (b) Isolation of the LCA, preservation of the sigmoid artery and superior rectal artery, and dissection of station 253 lymph nodes. (c) Ligation and transection of the LCA. (d) Isolation of the IMV to the inferior boarder

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of the pancreas, and dissection of the surrounding lymphatic tissue. (e) Isolation of the LCV. (f) Ligation of the LCV. (g) Transection of the LCV. (h) Status after dissection of lymph nodes with preservation of the IMV. IMA inferior mesenteric artery, IMV inferior mesenteric vein, LCA left colic artery, LCV left colic vein, RV renal vein

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Fig. 74.4 Intracorporeal colocolonic anastomosis type. (a) Side-to-side anastomosis. (b) End-to-end anastomosis

Fig. 74.5 Specimen extraction approach. (a) In the male patient, the specimen extracted via the rectum. (b) In the female patient, the specimen extracted via the vagina

2. During the process of NOSES, when the small intestine or omentum slides into the surgical field due to the position or mesenteric hypertrophy, the small gauze strips can be used to increase the local friction and temporarily block and expose the field of vision.

Method of Operation While pushing the small intestine and the omentum, the surgeon and the assistant turn the mesentery fully to the nonsurgical direction and put the gauze strip through the main trocar. In the direction of the small intestine and the omentum, the gauze strip can be rolled out in a linear fashion and pushed as a whole, and sometimes the gauze strip can be curled for a partial push of a certain point (Fig. 74.6).

Action Two “Pad” Applicable Scene 1. While performing operations such as withstanding and supporting on the easily punctured tissue, such as in the

Fig. 74.6 Using gauze strips to push the small intestine to the upper abdomen

posterior mesenteric area, the gauze is placed in between the operating instrument and the tissue to prevent the sharp end of the instrument from piercing the thin tissue. 2. After controlling the bleeding at the small bleeding points, the small gauze can be placed in the part to further achieve the effect of hemostasis or can be used as a marker to check the hemostasis effect.

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Method of Operation The surgeon and the assistant roll the gauze strip into a gauze roll, and then apply the atraumatic forceps to the tissue to be supported or pulled to increase the local contact area, thereby reducing the local pressure to avoid stabbing the tissue (Fig. 74.7).

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Action Four “Steady” Applicable Scene The assistant steadies the anvil and bowel to the local area with gauze band clamps to keep the position of the bowel and anvil stable so that the surgeon can smoothly take the anvil shaft out while the stapler anvil retained in the proximal bowel is punctured in NOSES.

Action Three “Press” Applicable Scene When pulling on some brittle tissues that are prone to be damaged by the clamp device, such as the expansion of the space anterior to Toldt’s fascia, the pulling of the inner connective tissue and the surface of the autonomic nerve should be gently performed. The tension of the dissection space can be established by clamping the gauze and pressing the tissue for drawing.

Method of Operation For example, in the NOSES-I and the NOSS-IV procedures, the assistant holds the long atraumatic forceps in the left hand and winds the gauze strip around the anvil. The bowel which contains the anvil is steadied to the low point of the left paracolonic groove. The right hand assists the surgeon to adjust the anvil shaft to the intended puncture point at the sigmoid colon stump and maintain a certain tension. The surgeon applies an ultrasonic scalpel to make a hole to take out the anvil shaft for anastomosis (Fig. 74.9).

Method of Operation The gauze strips are crimped into a mass and clamped with grasping forceps to establish the tension by friction, and the space is exposed for dissection (Fig. 74.8).

Action Five “Support”

Fig. 74.7 Applying a gauze pad to the posterior wall of the rectum

Fig. 74.8 Clamping the small gauze to hold the tissue and pull to the right side to form tension

Applicable Scene 1. In the treatment of rectal mesenteric vessels during NOSES for rectal cancer, in order to protect the dorsal tissue or the bowel that is slipped in, the gauze can be used as a support on the dorsal side of the tactile, which can not only facilitate the operation of blood vessel dissection but also protect the dorsal tissue. 2. After the treatment of blood vessels through the medial approach of right hemicolectomy, the gauze strip is placed underneath the ascending colon and the surface of the pancreas as a support, which facilitates to merge with the medial side when the paracolic sulcus is opened, and merge with the lower side when the vessels at the root of mesentery are processed in the posterior transverse colon space.

Fig. 74.9 Assistant uses gauze steadying anvil to assist puncture

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Method of Operation The surgeon and the assistant roll out the small gauze strip under the laparoscope to the lowest point of the plane of the adequately dissected space or crimped into a mass to be fully supported locally. The position of the gauze can be determined before the incision is made on the opposite side. During the incision, the direction of the gauze can be repositioned and adjusted and attention should be paid to the protection of other tissues on the back of the gauze (Fig. 74.10).

Action Six “Blunt Dissection” Applicable Scene In the avascular area of natural tissue space such as the space anterior to Toldt’s fascia, dissection can be performed by blunt dissection or combined blunt and sharp dissection. Gauze can be used to increase the contact area to push the tissue to the operating side, which can achieve the purpose of blunt dissection and reduce tissue damage.

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Method of Operation In NOSES, the ureter is accurately localized by the nourishing blood vessels and ureteral peristalsis of ureter surface flexion. Adequately dissect the mesentery up and down along the space anterior to Toldt’s fascia, and the gauze strip is spread into a line at the lowest point of the dissected mesenteric space to cover the ureter, thus achieving the marking effect. When the mesentery is opened on the opposite side, the position of the gauze is accurately found and the course of the ureter is determined. Operate on the inside of the ureter when cutting the peritoneum to protect the ureter (Fig. 74.12).

Action Eight “Mark” Applicable Scene 1. In the radical NOSE surgery of rectal cancer, isolation of the rectal mesentery can be marked with gauze strips to keep the dissection of mesorectum on the same level. 2. In the radical NOSE surgery of colon cancer, gauze can be placed on the surface of the pancreas as a marker.

Method of Operation The small gauze strips are crimped into a mass, and the grasping forceps clamp the gauze mass to form a blunt end, and the blunt dissection is performed by the frictional force of the gauze end in the tissue gap, and the gauze contact surface is large, which can prevent the scratch of the tissue caused by the direct application of surgical instrument (Fig. 74.11).

Action Seven “Protect” Applicable Scene In the NOSES radical resection of colorectal cancer, it is important to expose the ureter and protect it. The gauze can be placed on the surface of the dissected ureter to protect it, which can facilitate accurate positioning and avoid damage during the contralateral operation.

Fig. 74.10 Supporting the gauze to the dorsal side of the mesentery

Fig. 74.11 Clamping the gauze mass for blunt dissection in the space anterior to Toldt’s fascia

Fig. 74.12 Placing the gauze yarn on the surface of the ureter for protection

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Method of Operation After isolating one side of the mesorectum to the border of the intestinal wall, the gauze is wrapped around the intestinal wall to the opposite side along the same plane, and the contralateral mesorectum is dissected after finding the gauze on the opposite side to determine the dissecting level (Fig. 74.13).

Action Nine “Sterilize” Applicable Scene The biggest feature of NOSES is the avoidance of the auxiliary incision of the abdomen and the specimen extraction through the natural orifice. Therefore, in the NOSES series, more attention should be paid to the aseptic technique. Apply iodoform gauze strips in time for sterilizing exactly when cutting the natural orifice in different NOSES procedures. Among them, several cases commonly used in NOSES include transecting the proximal bowel before the placement of stapler anvil, cutting open the distal rectum or posterior vaginal fornix and before the placement of the protective sleeve.

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the aspirator sucking colonic fat sag, mesentery, omentum, and other tissues during and after the NOSES operation, suction under the guidance of gauze pellet can be applied.

Method of Operation After the anastomosis is completed in the NOSES for rectal cancer, the gauze is crimped into a mass and placed into the pelvic floor. The surgeon performs cleaning and rinsing through the main trocar, and the assistant sucks the liquid out of the gauze with a suction device. The surgeon and the assistant move the gauze to the natural depressions such as the left and right colonic sulcus and the mesenteric root to absorb the irrigating liquid from the gauze, thereby achieving the purpose of maintaining the pneumoperitoneum and protecting the tissue during the suction process (Fig. 74.15).

Action Eleven “Spread” Applicable Scene Fully expose the surgical area to reduce collateral damage to the tissue.

Method of Operation When the bowel is resected, the iodoform gauze should be introduced into the proximal and distal intestines, and the assistant applies the suction device to clean the intestinal secretions in time to avoid inflow into the abdominal cavity. In the transvaginal treatment for NOSES, the vagina should be disinfected before surgery. In the intraoperative vaginal incision, the surgeon sends the iodoform gauze into the vaginal cavity and performs vaginal bimanual examination to take out the gauze through the vagina (Fig. 74.14).

Action Ten “Suction” Applicable Scene In order to avoid the loss of pneumoperitoneum that may affect the operation and avoid the tissue damage caused by

Fig. 74.14 Using small iodoform gauze to disinfect the posterior vaginal incision and extract it through the vagina

Fig. 74.13 Gauze markings around the sides of the rectal mesangial area

Fig. 74.15 The suction device draws the flushing liquid on the surface of the gauze

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Method of Operation For example, in a right hemicolectomy, we need to pull the transverse colon toward the cephalic side to fully expand and expose the mesenteric plane. When we clamp tissue with forceps, we often cause collateral damage to the tissue because the force application area is small. However, when we apply forceps to clamp the gauze to push the transverse colon to the cephalic side, the force application area is increased, which is not prone to cause collateral damage (Fig. 74.16).

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front of the duodenum, the mesentery is often very thin, and it is prone to be damaged by the forceps. Instead, the assistant can clamp the gauze with forceps and withstand the mesentery with gauze, which gives the surgeon more space to operate (Fig. 74.18). In summary, the application of gauze in the series of NOSES is extensive and diverse. Many hospitals that carry out NOSES in China have their own strengths. The above is a systematic summary of the 12 commonly used operations. I hope this chapter can provide ideas for the majority of doctors who carry out NOSES surgery and help to promote the popularization and standardization of NOSES.

Action Twelve “Withstand” Applicable Scene Fully expose the surgical area to reduce collateral damage to the tissue. Method of Operation For example, when dissecting in the presacral space, the surgeon applies forceps in the left hand to clamp the gauze and withstand the mesorectum to facilitate the dissection (Fig. 74.17). In right hemicolectomy, when dissecting in

Operating Points of Aseptic and Tumor-Free Operation in NOSES for Rectal Cancer NOSES for rectal cancer is gradually maturing. At present, there are many surgical methods available. In terms of the way of specimen extraction, the specimen can be extracted by pull-through or eversion. In terms of the route of specimen extraction, the specimen can be extracted through the rectum, anus, or vagina. The core issue of NOSES is how to realize the complete extraction of resected specimen and avoid bacterial contamination of abdominal cavity by the intestinal contents and tumor cell dissemination. Although many methods have been reported in the literatures, it is difficult for them to meet the abovementioned requirements. Our team started to perform NOSES in the rectum and sigmoid colon since October 2014, and we have conducted a prospective randomized controlled trial in our center to prove the safety of NOSES (Zhou et al. 2020). The operating points of aseptic and tumor-free operation during surgery are summarized as follows.

Fig. 74.16 Using forceps to clamp the gauze to push the transverse colon to the cephalic side

1. Adequately irrigate the distal rectum. After closing the bowel above the tumor, the perineum group irrigates the rectum repeatedly with chlorhexidine (0.05%

Fig. 74.17 Clamping the gauze to withstand the mesorectum and dissect the presacral space

Fig. 74.18 Clamping the gauze to withstand the mesentery of right colon

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3.

4.

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chlorhexidine acetate) and dries it with dry gauze, which can effectively reduce the intestinal contamination during anastomosis. Perform specimen extraction with self-made protective sleeve. The protective sleeve is cut from the laparoscopic protective sleeve. According to the retained length of distal rectum, the protective sleeve is cut at 25–35 cm from one end. One end of the protective sleeve is ligated and the other end is an open opening with a ligating band (Fig. 74.19). Irrigate and lubricate the sleeve with approximately 5 mL of liquid paraffin during the preparation. The self-made protective sleeve is simple and economical, which can effectively reduce the risk of damage to the distal bowel wall and intra-abdominal contamination of intestinal contents. In addition, there is a ligating band at one end, which can be tightened to avoid contamination caused by compression of lumen during specimen extraction. Perform adequate disinfection when opening the bowel lumen. Before opening the bowel lumen in the abdominal cavity, protect the adjacent area with clean gauze and disinfect the bowel lumen with iodoform gauze immediately after making the incision. Insertion of protective sleeve and anvil. Insert the protective sleeve through the main trocar, pull it out of the anus to establish an aseptic route, and then insert the anvil through the anus. The aseptic and tumor-free principles are followed throughout the operation, which can effectively reduce the contamination. Start the extraction of specimen from the proximal bowel. The distal end of the resected specimen is the side of the tumor. The distance between the resection margin and the tumor is short. In addition, with the presence of tumor, and mesenteric fat is abundant in the rectal ampulla, the diameter of the bowel is usually larger than that of the proximal stump. Pulling this side out is often difficult, and the traction process is prone to cause tumor rupture, which interferes with the accuracy of pathological examination. Therefore, the larger side

Fig. 74.19 Self-made protective sleeve

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should be avoided to be clamped during extraction, and the smaller proximal bowel should be clamped and pulled out through the protective sleeve. 6. Open the bowel lumen for suction if necessary. For specimen with a long resected bowel and residue gas or liquid in the bowel lumen, the part left in the body may develop bowel dilatation after part of the bowl has been extracted out of the body, which makes it difficult for the subsequent extraction of the part in the body. In this case, a small incision can be made on the side of bowel that has been pulled out, from which the outer cannula of the suction device is inserted to the dilated part of the bowel to release the gas and liquid, and the collapsed bowel can be pulled out smoothly. 7. Adequately irrigate the abdominal cavity after specimen extraction. After the specimen extraction, the abdominal cavity should be irrigated with a large amount of distilled water to reduce bacterial contamination. In our center, bacterial culture of the last batch of irrigation fluid of 48 patients undergoing NOSES showed negative results.

Application of “Reverse Parallel Division of Sigmoid Mesocolon” and “Wang’s Isolation” for the Isolation of Mesorectum in NOSES Colorectal NOSES requires a series of total laparoscopic procedures, including resection of colorectal tumors, regional lymph node dissection, division of mesocolon, isolation of mesorectum, digestive tract reconstruction, and extraction of resected specimen. The division of sigmoid mesocolon and the isolation of mesorectum are the important steps in this procedure. The experience in the division of sigmoid mesocolon and the isolation of mesorectum in colorectal NOSES are introduced as follows.

Division of the Sigmoid Mesocolon (Reverse Parallel Division) The division of the sigmoid mesocolon should meet the following requirements: (1) to ensure the safety of the proximal resection margin; (2) to ensure the extent of regional lymph node dissection; (3) to ensure adequate length of bowel; and (4) to ensure the blood supply of the anastomosis. The blood supply of the colorectal wall comes from the marginal vessels. Protection of the marginal vessels is the key to guarantee the blood supply for the bowel. By adopting the “reverse parallel division,” the division of sigmoid mesocolon is simple and easy to operate, safe, and facilitates the observation of the course of the marginal vessels during operation.

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First, the assistant pulls the sigmoid colon to the left, inserts a gauze underneath the sigmoid mesocolon (Fig 74.20a), evaluates the extent of division, determines the intended resection line, and then performs the division of sigmoid mesocolon by “reverse parallel division” (Fig 74.20b). The length of the preserved sigmoid mesocolon varies with the different NOSES procedures, for example, in the NOSES II and III, the preserved length of sigmoid mesocolon must be longer to facilitate the specimen extraction through the anus or vagina, so as to ensure the tensionfree of anastomosis. By adopting the “reverse parallel division,” the course of sigmoid mesocolic arteries and veins can be directly observed. The surgeon divides along the course of vessels, and then ligates and transects several sigmoid colon vessels (Fig. 74.20c). Attention should be paid to protect the branches of the vessels of the sigmoid colon to ensure the blood supply of the distal bowel (Fig. 74.20d). Division is further continued to the intended resection line to cut the mesentery, and then proceeds towards the wall of the sigmoid colon (Fig. 74.20e). Vascular clips are not recommended to be used near the bowel wall to avoid affecting the anastomosis (Fig. 74.20f). Apply ultrasonic scalpel to dissect to the bowel wall and isolate 2–3 cm of the bowel.

Isolation of the Mesorectum (Wang’s Isolation) Laparoscopic isolation of the mesorectum has always been a difficulty in the radical resection of lower rectal cancer,

Fig. 74.20 Procedures of mesenteric division. (a) Inserting a gauze underneath the sigmoid mesocolon. (b) Dividing the sigmoid mesocolon by “reverse parallel division.” (c) Ligation and transection of vessels of the sigmoid mesocolon; d. Paying attention to protect the branches of

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especially the isolation of the left rectal wall and thick mesentery. It is necessary not only to ensure the safety of distal resection margin but also to meet the requirements of various operations of NOSES for colorectal cancer. The experience in the mesorectal isolation is named by the author as “Wang’s isolation,” which is introduced as follows. Firstly, the surgeon determines the tumor location and isolates approximately 3 cm of bowel wall at 5 cm below the distal edge of tumor. The mesocolon is isolated following the sequence of “anterior ! right ! left ! posterior.” Prepare to isolate the bowel wall when the mesorectum is fully dissected to 2–3 cm below the intended resection line. At the peritoneal reflection, the ultrasonic scalpel is applied to open the adipose connective tissue of the anterior rectal wall (Fig. 74.21a, b). Dissection is performed along the course of the bowel wall on the left and right sides. The surgeon pulls the right mesorectum, and the assistant pulls the rectum upward to the left. Meanwhile, the mesentery is dissected from the bowel wall with the ultrasonic scalpel (Fig. 74.21c), and the dissection is gradually extended posteriorly to the midline of the posterior wall (Fig. 74.21d). During the dissection of the left wall, the assistant pulls the mesentery to the left, and the surgeon pulls the rectum upward to the right. The division of mesentery is performed in parallel to the bowel wall (Fig. 74.21e–g), gradually extend to the posterior rectal wall, and eventually rendezvous with the right side (Fig. 74.21h). In general, the bowel should be isolated for 3 cm. Isolation of rectal wall by

the vessels of the sigmoid colon to ensure the blood supply of the distal bowel. (e) Reversely dividing the mesentery followed by division of the wall of the sigmoid colon. (f) Isolation of the wall of the sigmoid colon

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Fig. 74.21 Procedures of mesorectum isolation (Wang’s isolation). (a) Dissection of the anterior rectal wall (male). (b) Dissection of the anterior rectal wall (female). (c) Isolation of the right rectal wall. (d) Dissection of the posterior rectal wall. (e) Placing small gauze

underneath the rectum for marking. (f) Isolation of the left mesentery in parallel to rectum. (g) Isolation of the left rectal wall. (h) Complete isolation of rectum

“Wang’s isolation” has less bleeding and clearer anatomical structure. This method has more advantage in the isolation of the left rectal wall and thick mesentery. The extent of isolation may vary slightly based on the requirements of different NOSES procedure. The reverse parallel division of sigmoid mesocolon and “Wang’s isolation” of mesorectum in the NOSES for colorectal cancer is convenient, safe, reliable, and easy to be popularized in clinical practice. It is especially suitable for beginners and obviously shortens the learning curve. This is also a perfect embodiment of “full understanding of the 3D anatomical structure” advocated by Professor Wang Xishan.

the digestive tract reconstruction. However, in the totally laparoscopic gastrectomy, specimen resection and digestive tract reconstruction are both performed with laparoscopy, and only one small abdominal incision is required to extract the specimen, which makes this procedure less invasive than the former one. Nevertheless, there are still two problems to be solved in this procedure. Firstly, abdomen incisions are still required, which brings about a series of problems such as pain, scar, and delayed recovery. Secondly, there are two key points in the Roux-en-Y reconstruction method: the esophago-jejunostomy (or gastrojejunostomy) and the jejuno-jejunostomy. Currently, these two anastomoses are mostly created with linear staplers, which are prone to cause anastomotic stenosis and often need manual suture. Laparoscopic suture is timeconsuming and laborious, and suture with Da Vinci robot system is very expensive. In order to overcome the shortcomings of the procedures mentioned above, we applied the OrVilTM system, a newly emerged double stapling and transoral anvil delivery system, to perform the esophago-jejunal (or gastro-jejunal)

Application of OrVilTM and NOSES in Total Laparoscopic Gastrectomy for Female At present, in laparoscopy-assisted gastrectomy (Roux-enY method), gastric resection is commonly performed under laparoscopy, while a large abdominal incision is needed for

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anastomosis. Multiple clinical studies has been conducted to support the usage of OrVilTM in intracorporeal anastomosis (Chen et al. 2018; Lu et al. 2016). This system has the following advantages. Firstly, it can create a circular anastomosis, which may reduce the risk of anastomosis stenosis and facilitates the treatment of tumors located near the gastric cardia. Secondly, it greatly simplifies the operation to create the esophago-jejunal (or gastro-jejunal) anastomosis by delivering the anvil through the mouth. After the esophago-jejunostomy (or gastro-jejunostomy), a 21 mm circular stapler is applied to perform the jejuno-jejunal anastomosis in the bowel approximately 40 cm distal to the esophago-jejunal (or gastro-jejunal) anastomosis. At this point, the totally laparoscopic digestive tract reconstruction is finished. Afterwards, the transvaginal-NOSES method is adopted to extract the specimen. An incision is made in the posterior vaginal fornix to remove the specimen, and then a barbed suture is applied to close the incision. In conclusion, by performing total laparoscopic gastrectomy with the OrVilTM and transvaginal-NOSES, the extraabdominal incision is avoided, thus the minimally invasive outcome is greatly improved. Moreover, the risk of anastomotic stenosis is lowered, and the surgical operation is simplified. So far, we are the first center to adopt and report this new gastric surgical procedure at home and abroad. Operational Steps in Detail 1. Nasotracheal intubation should be applied to induce anesthesia, since the anvil of the OrVilTM system should be placed into the oral cavity. 2. Laparoscopic five-ports method of gastric resection and lymph node dissection, which is the same as those of the conventional surgical method (omitted in this chapter). 3. The digestive tract is reconstructed with Roux-en-Y method, that is, totally laparoscopic esophagojejunostomy (or gastro-jejunostomy) and jejunojejunostomy.

1. Esophago-jejunal (or gastro-jejunal) anastomosis is created with a 25 mm OrVilTM anvil (Medtronic). The delivery tube is inserted into the esophagus transorally and then gently advanced to the esophageal (gastric) stump. An incision is created in the midpoint of stump to allow the bulb tip to go through. Subsequently, the delivery tube is further advanced until the anvil shaft has passed through the incision and is grasped intracorporeally (Figs. 74.22, 74.23, 74.24, 74.25, 74.26, 74.27, 74.28, 74.29, 74.30, 74.31, 74.32, 74.33, 74.34, and 74.35). 2. The jejuno-jejunal anastomosis is performed with 21 mm circular stapler (Figs. 74.36, 74.37, 74.38, 74.39, 74.40, 74.41, 74.42, and 74.43).

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Fig. 74.22 Cutting one of the OrVilTM anvil retaining sutures

Fig. 74.23 Taking anvil shaft out of the stump under the guidance of delivery tube

Fig. 74.24 The jejunum is transected at 25 cm below the Treitz ligament with a linear Endo-GIA stapler, and the closure staple line is resected with ultrasonic scalpel

3. Specimen is removed from the incision in the posterior vaginal fornix (Figs. 74.44, 74.45, 74.46, 74.47, 74.48, and 74.49).

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Fig. 74.25 Disinfection of the intestinal lumen of jejunal stump Fig. 74.28 The body of stapler is inserted through the upper left Trocar site

Fig. 74.26 Lubrication of the intestinal lumen with paraffin oil cotton balls Fig. 74.29 Inserting the body of stapler into the intestine lumen for about 10 cm

Fig. 74.27 Expansion of the upper left Trocar site

Fig. 74.30 Extending the trocar of stapler and penetrate the intestinal wall in the antimesenteric side

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Fig. 74.31 Connecting the trocar of stapler with the OrVilTM anvil

Fig. 74.32 Confirming that the mesentery is not twisted and has no tension

Fig. 74.33 Firing the stapler

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Fig. 74.34 Pulling out the anvil

Fig. 74.35 Closing the jejunal stump with linear Endo-GIA stapler

Fig. 74.36 Making an incision in the intestine at 40 cm distal to the anastomosis with an ultrasonic scalpel

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Fig. 74.37 Inserting a 21 mm anvil Fig. 74.40 Inserting the stapler body into the intestine lumen

Fig. 74.38 Using the barbed suture for purse-string suture

Fig. 74.41 Connecting trocar with the anvil of the stapler

Fig. 74.39 The closure staple line of proximal jejunum is resected

Fig. 74.42 Firing the stapler

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Fig. 74.43 Closing the proximal jejunum stump with linear Endo-GIA stapler

Fig. 74.46 Extraction of specimen from the vagina

Fig. 74.44 Opening the posterior vaginal fornix

Fig. 74.47 Closing the posterior vaginal fornix with barbed suture

Fig. 74.45 The specimen is placed in the protective sleeve

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Fig. 74.48 Specimen appearance (the stomach is cut open)

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in the intended resection line proximal to the tumor (Fig. 74.50a). The sponge forceps is inserted through the anus to grasp the distal rectum, which is then pulled and everted out of the abdominal cavity through the anus (Fig. 74.50b). Dilute iodine solution is used for the repeated irrigation of the everted rectum (Fig. 74.50c), and then pursestring forceps is used to clamp the rectum at 1–2 cm distal to the tumor under direct vision (Fig. 74.50d). After the rectum is transected and the specimen is removed, the sponge forceps is inserted into the abdominal cavity through the anus to pull the distal end of the sigmoid colon out of the abdominal cavity (Fig. 74.50e). Following this, the purse-string forceps is used to clamp the distal end of the sigmoid colon, the sigmoid wall is incised, and the blood supply to the distal end of the sigmoid colon is verified (Fig. 74.50f). Subsequently, the anvil is inserted into the distal sigmoid colon and the purse-string suture is tightened (Fig. 74.50g). The distal sigmoid colon with the anvil is returned to the abdominal cavity, and then the sigmoid rectal end-to-end anastomosis is performed after tightening the purse-string suture at the rectal stump (Fig. 74.50h). No auxiliary incision is made in the abdominal wall (Fig. 74.50i).

Discussion

Fig. 74.49 Postoperative abdominal wall appearance

New Method of Modified NOSES I Surgical Procedure of a Modified NOSES I The proximal sigmoid mesentery is fully dissected while protecting the peri-intestinal vascular arch. The bowel is isolated at the site 2–3 cm distal to the lower edge of the tumor and 10 cm proximal to the tumor. The bowel is divided

The emergence of a new surgical procedure is always accompanied by doubts. For NOSES I (eversion method), many researchers have questioned how to ensure blood supply to the distal sigmoid colon after it is pulled out of the abdominal cavity through the anus and how to reduce the tension of the anastomosis. Since 2015, the authors have carried out more than 80 cases of this procedure (Hu et al. 2019) and only 1 patient encountered the insufficient sigmoid colon to be pulled out of the abdominal cavity; after mobilizing the splenic flexure of the colon, the distal sigmoid colon was able to be pulled out for the anvil placement. Figure 74.50f shows evidence of a sufficient blood supply to the distal sigmoid colon. Of course, the indications for the anvil placement extracorporeally, tumor eversion resection, and NOSES should be strictly controlled in order to ensure the safety and continuously improvement of this procedure. In summary, modified NOSES I has advantages in reliving postoperative pain, accelerating recovery, reducing medical costs, and improving the postoperative cosmetic appearance of the abdominal wall. However, prospective randomized controlled trials with a large sample size are required to verify the long-term tumor-free survival and overall survival in the future.

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Fig. 74.50 (a) The bowel loop is divided at 10 cm proximal to the tumor. (b) A purse-string forceps is inserted through the anus to hold the end of the rectal stump, which is then pulled and everted out of the abdominal cavity through the anus. (c) Dilute complex iodine is used to wash the everted rectum serval times. (d) Under direct vision, the pursestring forceps is used to clamp the rectum at 1–2 cm below the tumor. (e)

References Chen X, Luo J, Zhu Y, Chen Y, Hu Y, Lin T, Liu H, Li T, Zhao M, Chen H, Li G, Yu J. Surgical safety of laparoscopic total gastrectomy with intracorporeal esophagojejunostomy via transoral anvil versus mini-laparotomy anastomosis: a propensity score matching analysis. Zhonghua Wei Chang Wai Ke Za Zhi. 2018;21(8):887–95. Hu JH, Li XW, Wang CY, Zhang JJ, Ge Z, Li BH, Lin XH. Short-term efficacy of natural orifice specimen extraction surgery for low rectal cancer. World J Clin Cases. 2019;7(2):122–9.

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The sponge forceps is inserted via the anus to pull the distal sigmoid colon out of the abdominal cavity through the anus. (f) The blood supply to the distal end of the sigmoid colon is verified. (g) The anvil is inserted into the sigmoid colon, and the purse-string is secured onto the anvil shaft. (h) Rectal sigmoid end-to-end anastomosis. (i) There is no auxiliary incision in the abdominal wall Lu X, Hu Y, Liu H, Mou T, Deng Z, Wang D, Yu J, Li G. Short-term outcomes of intracorporeal esophagojejunostomy using the transorally inserted anvil versus extracorporeal circular anastomosis during laparoscopic total gastrectomy for gastric cancer: a propensity score matching analysis. J Surg Res. 2016;200(2):435–43. Zhou ZQ, Wang K, Du T, Gao W, Zhu Z, Jiang Q, Ji F, Fu CG. Transrectal natural orifice specimen extraction (NOSE) with oncological safety: a prospective and randomized trial. J Surg Res. 2020;254:16–22.

Section XII International Consensus on Natural Orifice Specimen Extraction Surgery Xishan Wang and Zheng Liu

International Guideline on Natural Orifice Specimen Extraction Surgery (NOSES) for Colorectal Cancer (2023 Version)

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Zheng Liu, Xu Guan, Mingguang Zhang, Xiyue Hu, Ming Yang, Junge Bai, Jun Li, Shaojun Yu, Kefeng Ding, Qing-Si He, Liang Kang, Dan Ma, Chuangang Fu, Junhong Hu, Ye Wei, Dong-Hui Sun, Gang Yu, Songbing He, Changyou Wang, Yanwei Gao, Gui-Yu Wang, Hongliang Yao, Jian Peng, Yangchun Zheng, Bo Jiang, Taiyuan Li, Zhiguo Xiong, Xuejun Sun, Zhenning Wang, William Meng, William Tzu-Liang Chen, Ming-Yin Shen, John H. Marks, Charles A. Ternent, Darcy D. Shaw, Jim S. Khan, Petr V. Tsarkov, Inna Tulina, Sergey Efetov, Joaquim Manuel da Costa Pereira, Fernanda Nogueira, Ricardo Escalante, Joel Leroy, Avanish Saklani, Audrius Dulskas, Cuneyt Kayaalp, Atsushi Nishimura, Kay Uehara, Woo-Yong Lee, Sang-Hoo Kim, Suk-Hwan Lee, Xishan Wang, Committee of Colorectal Cancer Society Chinese Anti-Cancer Association, and International NOSES Alliance

Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Z. Liu · X. Wang (*) Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China X. Guan Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Department of Colorectal Surgery, National Cancer Center, National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China M. Zhang · X. Hu · M. Yang · J. Bai Department of Colorectal Surgery, National Cancer Center, National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China J. Li · S. Yu · K. Ding Department of Colorectal Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China Q.-S. He Department of General Surgery, Shandong University Qilu Hospital, Jinan, Shandong, P. R. China L. Kang Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China © People’s Medical Publishing House, PR of China 2023 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-99-2750-0_75

D. Ma Department of General Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing, P. R. China C. Fu Department of Gastrointestinal Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China J. Hu Department of General Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China Department of Anorectal Surgery, First Affiliated Hospital, Zhengzhou University, Zhengzhou, Henan, China Y. Wei Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China D.-H. Sun Department of Gastric and Colorectal Surgery, Jilin University First Hospital, Changchun, Jilin, P. R. China G. Yu Department of General Surgery, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University Qingdao, Qingdao, Shandong, China S. He Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China

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Contents Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 955 Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Classification According to the Route of Specimen Retrieval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Classification According to the Specimen Extraction Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Classification According to the Resected Organ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Technology Requirement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 957 Surgical Operating Platform . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 957 Auxiliary Tools for Specimen Extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 957 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 957 Technical Difficulties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 958 Clinical Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 959 Prospects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 959 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 960

C. Wang Affiliated Hospital of North China University of Science and Technology, Tangshan, Hebei, China Y. Gao Inner Mongolia Autonomous Region People’s Hospital, Huhhot, Inner Mongolia Autonomous Region, China G.-Y. Wang Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, P. R. China H. Yao Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China J. Peng Department of Geriatric Surgery, Xiangya Hospital, Central South University, Changsha, China National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China Y. Zheng Department of Gastrointestinal Surgery, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Cancer Hospital Affiliate to School of Medicine, UESTC, Chengdu, China B. Jiang Anal and Colorectal Surgery, Shanxi Cancer Hospital, Affiliated Cancer Hospital of Shanxi Medical University, Taiyuan, China T. Li Department of General Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, China Z. Xiong Department of Gastrointestinal Surgery, Hubei Provincial Cancer Hospital, Wuhan, China X. Sun Department of General Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China Z. Wang Department of Gastrointestinal Surgery, The First Affiliated Hospital of China Medical University, Shenyang, China

W. Meng Minimally Invasive Surgery Centre and Endoscopy Centre, Matilda International Hospital, Hong Kong, China W. T.-L. Chen Department of Colorectal Surgery, China Medical University Hsinchu Hospital, Taichung, Taiwan Department of Surgery, China Medical University Hospital, Taichung, Taiwan, China M.-Y. Shen Colorectal Surgery Division, China Medical University Hsinchu Hospital, Zhubei, Taiwan, China Department of Surgery, China Medical University Hospital, Taichung, Taiwan, China J. H. Marks Division of Colorectal Surgery, Lankenau Medical Center, Wynnewood, PA, USA Lankenau Medical Center, Medical Office Building West, Wynnewood, PA, USA C. A. Ternent Section of Colon and Rectal Surgery, Creighton University School of Medicine, Omaha, NE, USA D. D. Shaw Colorectal Surgery Associates, Kansas City, MO, USA Kansas City University, Kansas City, MO, USA J. S. Khan Anglia Ruskin University Chelmsford, Chelmsford, UK Department of Colorectal Surgery, Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Portsmouth, UK P. V. Tsarkov · I. Tulina Clinic of Colorectal and Minimally Invasive Surgery, Department of Surgery ICM, I.M. Sechenov First Moscow State Medical University, Moscow, Russia

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Keywords

Laparoscopic resection has been widely accepted for the surgical management of colorectal cancer, which is associated with improved outcomes and fewer complications when compared to open surgery (Izquierdo et al. 2018; Liu et al. 2019; Shen and Chen 2020). Despite these advantages, current laparoscopic approach requires an extra incision at the abdominal wall for specimen extraction, which is associated with postoperative pain, and increased wound complications including infection, hernia formation, and scarring (Kayaalp and Yagci 2015a; Anania et al. 2021). Natural orifice specimen extraction surgery (NOSES) has recently gained widespread attention as an alternative approach without a requirement for any additional incisions or extensions (China NOSES Alliance et al. 2019; Wang 2018a). Although the safety and feasibility of NOSES have been confirmed by published studies, many questions remain open for discussion (Guan et al. 2020). The Committee of Colorectal Cancer Society Chinese Anti-Cancer Association (CACA) and the International NOSES Alliance were edited to provide more evidence for the promotion of NOSES. The following introduces the details of this guideline from several aspects.

Colorectal cancer · Guideline · Treatment · Surgery · Holistic integrative medicine · Natural orifice specimen extraction surgery

Definition

Abstract

Purpose: In recent years, natural orifice specimen extraction surgery (NOSES) has gained widespread attention as an alternative approach. Although the safety and feasibility of NOSES have been well documented, many questions remain open for discussion. The aim of this guideline is to provide more evidence for the promotion of NOSES. Methods: This guideline has been prepared by the CACA Committee of Colorectal Cancer Society and the International NOSES Alliance, based on the latest evidence. Results: The guideline on NOSES for colorectal cancer includes the definition, classification, technology requirement, indications, technical difficulties, and clinical research. Conclusion: The guideline provides a full introduction of the theoretical and technical aspects of NOSES for colorectal cancer which will beneficial to development of NOSES.

S. Efetov Colorectal Surgery Department, Sechenov First Moscow State Medical University, Moscow, Russia Clinic of Faculty Surgery N2, Surgical Department N2, University Clinical Hospital N4, I.M. Sechenov First Moscow State Medical University, Moscow, Russia J. M. da Costa Pereira · F. Nogueira Department of Surgery, Hospital de Braga, Braga, Portugal R. Escalante Universidad Central de Venezuela, Centro Medico Loira, Caracas, Venezuela J. Leroy Hanoi High Tech & Digestive Center, St. Paul Hospital, Digestive Colorectal, Hano, Vietnam A. Saklani Department of GI Surgical Oncology, Tata Memorial Hospital, Mumbai, India A. Dulskas Department of Abdominal and General Surgery and Oncology, National Cancer Institute, Vilnius, Lithuania Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania C. Kayaalp Department of Gastrointestinal Surgery, Inonu University, Malatya, Turkey Gastrointestinal Surgery, Yeditepe University Medical School, Istanbul, Turkey

NOSES is defined as follows: Surgical specimen resection is performed intra-abdominally, and then the specimen is extracted through an incision in a hollow organ communicating with the outside of the body, such as the anus, vagina, or mouth (Guan et al. 2020). To date, there have been many reported case studies in which specimens from colorectal surgery were removed from the rectum, anus, vagina, and mouth (Brincat et al. 2022a). In addition to colorectal surgery, it can also be applied to the fields of gastrointestinal, hepatobiliary, urinary, gynecologic surgery, etc. As the A. Nishimura Department of Surgery, Institute of Gastroenterology, Nagaoka Chuo General Hospital, Nagaoka, Niigata, Japan K. Uehara Department of Surgery, Division of Surgical Oncology, Nagoya Graduate School of Medicine, Nagoya, Japan W.-Y. Lee Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea S.-H. Kim IRCAD China, Wuxi, China S.-H. Lee Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea Committee of Colorectal Cancer Society Chinese Anti-Cancer Association International NOSES Alliance

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technology continues to mature, this technique has now been successfully implemented in the treatment of inflammatory bowel disease, diverticulitis, and malignancy (Zhang et al. 2022a; Wang et al. 2020; Nishimura et al. 2022; Lu et al. 2020; Kudsi et al. 2021).

Classification Classification According to the Route of Specimen Retrieval In current clinical practice, NOSES are classified into three types according to the route of specimen extraction: transanal-NOSES (Ta-NOSES), transvaginal-NOSES (Tv-NOSES), and transoral-NOSES (To-NOSES) (China NOSES Alliance 2017; Abu Gazala and Wexner 2017). Two principles should be followed when selecting the route of specimen extraction, namely, the function preservation in oncology surgery principle (FPOSP) and the surgical risk–benefit balance principle (SRBBP) (Wang 2018b). For example, Ta-NOSES is most appropriate for colorectal surgery, Tv-NOSES is most appropriate for gynecologic surgery, and To-NOSES is most appropriate for gastric surgery. At the same time, the route of specimen extraction also requires consideration of various factors, including specimen size, BMI, mesentery thickness, tumor stage, tumor location, and organ type. From the perspective of specimen size, Tv-NOSES is suitable for larger specimens because of the good ductility of vagina, followed by Ta-NOSES. To-NOSES is only suitable for smaller size specimens. The effect of transanal specimen extraction on anal sphincter function and postoperative defecation function is the core issue of Ta-NOSES. In recent years, studies regarding Ta-NOSES have gradually increased, but abnormal postoperative anal function or sphincter injury has not been reported (Wolthuis et al. 2011). In addition, a multicenter study in China showed that only very few patients treated with Ta-NOSES presented different degrees of postoperative anal dysfunction (Guan et al. 2022a). Therefore, with the aim to prevent anal sphincter injury, we should strictly follow the indications of NOSES and perform gentle operation during transanal specimen extraction. Tv-NOSES has also been considered another ideal option to remove more bulky colorectal specimen when compared with anus, which presented several properties involving good elasticity, adequate blood supply, healing ability, and easy access (Yagci et al. 2014; Torres et al. 2012). The optimal vaginal incision should be chosen at the posterior fornix of the vagina, where it is the most safely and easily exposed laparoscopically. Numerous studies have shown that Tv-NOSES does not lead to postoperative sexual dysfunction in patients (Nishimura et al. 2013). However, transvaginal

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specimen extraction presents the following limitations: First, this technique is only confined to female patients; second, opening the vaginal wall may increase the risk of postoperative complications and sexual dysfunction; and third, transvaginal-NOSES is also limited by ethics (Zhao et al. 2023). To-NOSES is an important part of the NOSES classification, which is also a supplement of the theoretical system of NOSES. Currently, studies have reported the application of To-NOSES in a small number of patients with upper abdominal tumors, especially for gastric tumors, showing good minimally invasive advantages (China Natural Orifice Specimen Extraction Surgery Alliance 2019). However, due to the narrow anatomical structure of the esophagus, To-NOSES should be performed by strictly following the indications.

Classification According to the Specimen Extraction Method According to the specimen extraction method, NOSES can be divided into three types: (1) Transanal specimen eversion and extra-abdominal resection technique – this technique is mainly used for lower rectal resection; (2) translumenal specimen extraction and extra-abdominal resection technique – this technique is mainly used for middle rectal resection; and (3) intra-abdominal specimen resection and translumenal extraction technique – this technique is mainly used for upper rectal resection and colectomy. To further refine the classification, ten NOSES approaches, from NOSES I to NOSES X, were proposed for the treatment of colorectal cancer, including five approaches for rectal resection and five approaches for colon cancer (Table 75.1). Furthermore, the NOSES I used to lower rectal cancer includes seven methods: NOSES IA and NOSES IB are transanal specimen eversion and extra-abdominal resection technique; NOSES IC is Park technique; NOSES ID is intersphincteric resection (ISR) technique; NOSES IE is Bacon technique; NOSES IF is non-disconnected specimen eversion; and NOSES IG is conformal resection surgery.

Classification According to the Resected Organ According to the classification of resected organs, NOSES can be divided into colorectal cancer NOSES (CRC-NOSES), gastric cancer NOSES (GC-NOSES), small bowel tumor NOSES (ST-NOSES), hepatobiliary tumor NOSES (LT-NOSES), pancreatic tumor NOSES (PT-NOSES), urologic tumor NOSES (UT-NOSES) and gynecological tumor NOSES (UT-NOSES), and gynecologic tumor NOSES (GT-NOSES). The nomenclature is characterized by the abbreviation of the surgical organ name plus the

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Table 75.1 Natural orifice specimen extraction surgery (NOSES) techniques for colorectal cancer Abbreviation NOSES I (A-G) NOSES II (A/B) NOSES III (A/B) NOSES IV NOSES V NOSES VI (A/B) NOSES VII NOSES VIII (A-C) NOSES IX NOSES X

Full name Laparoscopic lower rectal cancer resection with transanal specimen extraction Laparoscopic middle rectal cancer resection with transanal specimen extraction Laparoscopic middle rectal cancer resection with transvaginal specimen extraction Laparoscopic upper rectal cancer resection with transanal specimen extraction Laparoscopic upper rectal cancer resection with transvaginal specimen extraction Laparoscopic left colectomy with transanal specimen extraction

Orifice Anus

Tumor location Lower rectum

Anus

Middle rectum

Vagina

Middle rectum

Anus

Laparoscopic left colectomy with transvaginal specimen extraction

Vagina

Laparoscopic right colectomy with natural orifice specimen extraction

Natural orifice Anus Vagina

Upper rectum/distal sigmoid colon Upper rectum/distal sigmoid colon Left colon/proximal sigmoid colon Left colon/proximal sigmoid colon Right colon

Laparoscopic total colectomy with transanal specimen extraction Laparoscopic total colectomy with transvaginal specimen extraction

abbreviation of “NOSES,” which together form a scientific and standardized surgical nomenclature.

Technology Requirement Surgical Operating Platform The basic surgical operating platform for NOSES is the conventional two-dimensional (2D) laparoscopic platform (Wang 2018b). Therefore, for surgeons with experience in laparoscopic surgery, the learning curve of NOSES will be short. In addition to 2D laparoscopic equipment, NOSES can also be performed by using other advanced equipment, such as high-definition 3D laparoscopy, the da VinciVR robotic platform, single-port laparoscopy, etc., which will provide better minimally invasive effect for NOSES (Kang et al. 2012; Feng et al. 2015). The high-definition 3D laparoscope makes the operation field clearer and more realistic, which helps the surgeon to complete a variety of difficult surgical operations in a relatively easy way. The da VinciVR robot provides a more stable operation with automated tremor filter, enabling a delicate and fine surgical dissection (Tsarkov et al. 2019). However, single-port laparoscopy is not routinely recommended to perform NOSES in the consideration of “chopstick effect” of this technique.

Auxiliary Tools for Specimen Extraction Compared with conventional laparoscopic surgery, NOSES requires an auxiliary tool to assist in the removal of the

Vagina Anus

Total colon Total colon

specimen through the natural cavity to avoid contact with the natural cavity and to ensure aseptic and tumor-free operation. Soft tools have better elasticity and are not limited by the size of the specimen, which can be expanded according to the width of natural orifice. According to the current literature and clinical practice, various tools used to facilitate the specimen extraction include double ringed wound protectors, transluminal endoscopic operation ports, self-made plastic sleeves, sterile specimen bags, etc. (Wolthuis et al. 2014a; Cai and Hong 2016). Furthermore, there are also combined application of hard and soft tools in the clinic to further ensure the aseptic and tumor-free operation during the specimen extraction. Accordingly, reasonable usage of auxiliary tools is recommended, but the choice of tools needs to be considered in the context of the patient’s specific condition and the surgeon’s experience and habits.

Indications In clinical practice, an important prerequisite of performing NOSES is to select appropriate patient (Izquierdo et al. 2018). Since the NOSES is performed in laparoscopic platform, the indication of NOSES should follow the indications of conventional laparoscopic surgery (Wang 2021): (1) The surgical team should have extensive experience in laparoscopic surgery and be skilled in performing intracorporeal digestive tract reconstruction; (2) not indicated for locally advanced cancer; (3) not indicated for acute bowel obstruction or perforation; (4) thorough abdominal exploration is required; and (5) preoperative marking of lesion(s) should be considered.

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The specific indications of NOSES mainly include the following: The depth of tumor invasion should be T2 or T3; the maximum circumferential diameter of the specimen should be less than 5 cm for transanal NOSES and should be less than 7 cm for transvaginal NOSES. In clinical work, the indications can be flexible, depending on the thickness of the mesentery and the anatomy of the natural orifice. Besides, the following conditions are also the indications of NOSES: benign tumor, Tis, large-sized T1 tumor, unable to be resected transanally, or failure of local excision (Guan et al. 2019).

Technical Difficulties The major technical difficulties of NOSES are intracorporeal digestive tract reconstruction and specimen extraction (Zhang et al. 2022a). Digestive tract reconstruction should follow the basic principles: (1) On the premise of guaranteeing radical resection of tumor, select a safe and feasible method of digestive tract reconstruction according to the extent of colorectal resection; (2) the anastomosis should be provided with sufficient blood supply without tension and stenosis (Sparreboom et al. 2018); (3) FPOSP should be followed, so as to reduce unnecessary tissue damage and protect gastrointestinal physiological function; and (4) for low and ultralow sphincterpreserved surgery, if the risk of anastomotic leakage is high or the patient is treated with neoadjuvant chemoradiotherapy, protective ileostomy should be performed. There are three different ways of intracorporeal digestive tract reconstruction, end-to-end anastomosis, functional end-to-end anastomosis, and functional side-to-side anastomosis (Slieker et al. 2013; Zhang et al. 2022b; Zhang et al. 2022c). Anastomosis could be performed with a stapled technique or sutured technique. Before anastomosis, the blood supply of the bowel wall, the tension of the anastomosis, and the direction of mesentery should be checked. The anastomotic leakage, bleeding or not, and patency should be examined after anastomosis. The examination methods included air or water test and intraoperative colonoscopy. If the anastomosis is not exact, it can be strengthened and sutured under laparoscopy. For middle and low rectal anastomosis, the transanal suture for reinforcement can also be performed. After the completion of digestive tract reconstruction, a tube should be placed beside the anastomosis for drainage. Specimen extraction through the natural orifice is the most characteristic core step in NOSES. The principles of specimen extraction are summarized as follows: (1) The indications of all kinds of specimen extraction should be strictly followed; (2) selection of the specimen extraction route should follow the FPOSP and SRBBP, with the purpose of minimizing the damage for patient caused by specimen

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extraction; and (3) the operative normalization of specimen extraction should be fully mastered, and aseptic and tumorfree principles should be followed strictly. There are three methods of specimen extraction: specimen extraction through the stump of rectum; specimen extraction through the incision on rectum; and specimen extraction through the incision on vagina. (1) Specimen extraction through the stump of rectum is the most widely used and the most minimally invasive method and is the first choice of colorectal NOSES (Wang et al. 2022a). In order to consider the safety and feasibility of the specimen extraction, the requirements of operation are as follows: The anus must be fully expanded before specimen extraction; rectal end must be irrigating with a large amount of iodine water; sterile protective sleeve should be placed before specimen extraction to avoid contact between the specimen and the natural orifice; and the specimen should be handled gently and slowly during specimen extraction to avoid the damage of specimen integrity by violent pulling. If the resistance during specimen extracting is hard, the anesthesiologist can give appropriate muscle relaxants to reduce the tension of anal sphincter. (2) Specimen extraction through the incision on rectum is another transanal procedure, which is primarily used for right or left hemicolectomy or transverse colectomy of male. There are two obstacles in specimen extraction through the incision of rectum: first, how to extract the specimen through the anus. The key operative point is the same as the techniques of specimen extraction through the stump of rectum; second, how to choose the site of rectal incision and what are the operative specifications. It is recommended that the rectal incision should be chosen on the anterior wall of the middle rectum above the peritoneal reflection. The length of incision is about 3 cm, and the incision direction should be parallel to the direction of rectum. The contralateral rectal wall should not be damaged during incising. It is recommended that continuous suture should be performed from the distal to the proximal. After suturing, air or water injection test or intracorporeal colonoscopy should be performed to examine whether the rectal incision is fully sutured. (3) Specimen extraction through the incision on vagina: The posterior fornix is recommended for vaginal incision because it is easy to find and expose under laparoscopy and has a well-healing ability. Moreover, there is no important vessel and nerve around posterior fornix. The incision of posterior fornix has little influence on the patient’s sexual function (Zhang et al. 2022d; Zheng et al. 2022). The vagina can be incised laparoscopically or extracorporeally, which can be chosen by the surgeon according to their operation habit. The recommended length of vaginal incision is 3–5 cm, and the direction should be transverse. The depth of incision is the full thickness of the vaginal wall. After the specimen is extracted, the vagina needs to be rinsed laparoscopically. The vaginal can be incised laparoscopically

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or extracorporeally. Most of the suture methods are continuous full-thickness suture with barbed thread from one end of the vaginal incision to another. After suture, digital vaginal examination is required to check whether the incision is sutured properly. Aseptic and tumor-free operations are the core steps for a high-quality NOSES. In order to ensure that aseptic and tumor-free operations can be performed normatively in NOSES, following points are recommended. First, the operator must have a good concept of aseptic and tumorfree operations; second, adequate bowel and vaginal preparation must be carried out before the operation; and third, certain surgical skills must be acquired and the overall coordination of the surgical team must be emphasized. The use of iodine gauze, close cooperation of the first assistant with aspirator, transanal irrigation with iodine water, flushing the operative area with large amounts of iodine and distilled water, and the use of protective sleeve for specimen extraction are a series of operational techniques that can reduce the risk of contamination of the abdominal cavity and the occurrence of tumor implantation. It is recommended that patients with colorectal cancer at high risk of recurrence, especially those whose tumor has invaded beyond the serosa, those with lymph node metastases, those with positive or suspicious positive cytological examination in abdominal washout fluid, and those whose tumor has been excessively squeezed or whose tumor has been ruptured during surgery, should be treated with intraperitoneal chemotherapy.

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transvaginal specimen extraction surgery revealed that transvaginal NOSES have the advantages mentioned above while having limited adverse effects on females’ sexual function (Stipa et al. 2015; Kayaalp and Yagci 2015b; Zhang et al. 2022e). Nowadays, the robotic platform is becoming widely accepted in colorectal surgeries. Several small-scale studies have demonstrated the advantages of NOSES in robotic colorectal surgery, mainly including less morbidity, reduced postoperative pain, shorter hospital stay, and similar longterm survival (Aslaner et al. 2022; Liu et al. 2020; Feng et al. 2021; Yao et al. 2021). Although these studies are heterogeneous, they still provided evidence supporting the application of NOSES in robotic surgery. Despite the clinical research summarized above, highlevel evidence is still required to reveal the applicability of NOSES in different settings. This guideline recommends that the following indicators be included in data collection and clinical studies on NOSES, to evaluate the efficacy of this innovative technique comprehensively: (1) surgery and specimen quality; (2) intraoperative and postoperative complications; (3) pain assessment and postoperative accelerated recovery, along with conversion rate to standard specimen extraction site; (4) cosmetic effects; (5) psychological effects; (6) quality of life; (7) natural orifice functional results; (8) long-term oncological outcomes; (9) both institutional and surgeon learning curve; and (10) health economics benefits. In addition, this guideline also recommends that more clinical studies be carried out to explore the precise selection and further expansion of the indications of NOSES.

Clinical Research With the application and promotion of NOSES, research on colorectal NOSES has gradually increased in recent years. Systematic reviews, meta-analyses, and large-scale retrospective studies which included thousands of patients have confirmed the safety and efficacy of colorectal NOSES (Wolthuis et al. 2014b; Brincat et al. 2022b; Wang et al. 2022b; Guan et al. 2022b; Xu et al. 2022). According to these studies, compared with conventional laparoscopic surgery, NOSES brought benefits in terms of postoperative complications, incision-related complications, bowel function recovery, hospital stay, cosmetic scores, and postoperative pain control. An intracorporeal sutured anastomosis after NOSES may have some benefits over a stapled anastomosis in terms of cost and potential time, particularly in the scenario of transrectal stump extraction. Meanwhile, the pathological outcomes, anastomotic complications, intraabdominal infection, pelvic floor function, intraoperative blood loss, and long-term oncological outcomes of NOSES remained comparable with those of laparoscopic surgery. Also, reviews and retrospective studies concerning

Prospects With the establishment of a theoretical system and the promotion in clinical practice, NOSES has gradually grown to be a series of well-developed surgical procedures in the past decade. Numerous clinical reports have revealed the broad application prospects of NOSES. When performing NOSES, following the indications and technical details in this guideline will help surgeons carry out this procedure in a safer and more standardized way. Meanwhile, it should be noted that more high-level clinical evidence is still needed to demonstrate the safety, advantages, and health economic benefits of NOSES. It is expected that more multicenter clinical studies will be conducted all around the world to further support the implementation of NOSES. Authors’ Contributions All authors contributed to the study conception and design. All authors read and approved the final manuscript.

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Availability of Data and Materials All data generated or analyzed during this study are included in this published chapter. Declarations Ethics Approval and Consent to Participate: There are no ethics issues in the present guideline. All authors agree to participate in the above research. Not applicable. Competing Interests No conflicts of interest. Author Xishan Wang is a member of the Editorial Board for Holistic Integrative Oncology. The chapter was handled by the other Editor and has undergone rigorous peer review process. Author Xishan Wang was not involved in the chapter’s peer review or in decisions related to this manuscript. Funding This study was supported by National Key R&D Program for Young Scientists (Grant Number: 2022YFC2505700) and the Sanming Project of Medicine in Shenzhen (Grant Number: No. SZSM201911012).

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Nishimura A, Kawahara M, Kawachi Y, Hasegawa J, Makino S, Kitami C, Nakano T, Otani T, Nemoto M, Hattori S, Nikkuni K. Totally laparoscopic resection of right-sided colon cancer using transvaginal specimen extraction with a 10-mm-long abdominal incision. Tech Coloproctol. 2022;26(9):755–60. https://doi.org/10. 1007/s10151-022-02636-7. Epub 2022 May 23 Shen MY, Chen WT. Natural Orifice Specimen Extraction (NOSE) with single-stapling anastomosis for left colon cancer. J Minim Invasive Surg. 2020;23(4):201–3. https://doi.org/10.7602/jmis.2020.23.4.201. Slieker JC, Daams F, Mulder IM, et al. Systematic review of the technique of colorectal anastomosis. JAMA Surg. 2013;148(2):190–201. Sparreboom CL, van Groningen JT, Lingsma HF, Dutch Colorectal Audit Group, et al. Different risk factors for early and late colorectal anastomotic leakage in a nationwide audit. Dis Colon Rectum. 2018;61(11):1258–66. Stipa F, Burza A, Curinga R, et al. Laparoscopic colon and rectal resections with intracorporeal anastomosis and trans-vaginal specimen extraction for colorectal cancer. A case series and systematic literature review [J]. Int J Color Dis. 2015;30(7):955–62. Torres RA, Orban RD, Tocaimaza L, et al. Transvaginal specimen extraction after laparoscopic colectomy. World J Surg. 2012;36: 1699–702. Tsarkov PV, Efetov SK, Tulina IA, Kitsenko YE, Picciariello A, Kim VD, Solodovnikova AK. Robotic transvaginal natural orifice specimen extraction sigmoidectomy with extended D3 lymph node dissection for cancer – a video vignette. Color Dis. 2019;21(6):732–3. Wang XS. Current challenges and prospects of NOSES in China. Chin J Colorec Dis (Electronic Edition). 2018a;7(1):2–7. Wang XS. Natural orifice specimen extraction surgery. Berlin: Springer; 2018b. Wang X. Natural orifice specimen extraction surgery-gastrointestinal tumor. 2nd ed. Beijing: People’s Medical Publishing House; 2021. Wang X, Efetov SK, Liu Z, Medkova YS, Kitsenko YE, Picciariello A, Tulina IA, Tsarkov PV. Transrectal specimen extraction after laparoscopic right hemi-colectomy with extended D3 lymph node dissection (anterior medial to lateral approach) – a video vignette. Color Dis. 2020;22(4):471–2. https://doi.org/10.1111/codi.14929. Epub 2020 Jan 6 Wang S, Tang J, Sun W, et al. The natural orifice specimen extraction surgery compared with conventional laparoscopy for colorectal cancer: a meta-analysis of efficacy and long-term oncological outcomes. Int J Surg. 2022a;97:106196. Wang S, Tang J, Sun W, et al. The natural orifice specimen extraction surgery compared with conventional laparoscopy for colorectal cancer: a meta-analysis of efficacy and long-term oncological outcomes [J]. Int J Surg. 2022b;97:106196.

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Xu Guan, Zheng Liu, Amjad Parvaiz, Antonio Longo, Avanish Saklani, Ali A. Shafik, Jian-Chun Cai, Charles A. Ternent, Lin Chen, Cuneyt Kayaalp, Fatih Sumer, Fernanda Nogueira, Feng Gao, Fang-Hai Han, Qing-Si He, Ho-Kyung Chun, Chang-Ming Huang, Hai-Yang Huang, Rui Huang, Zhi-Wei Jiang, Jim S. Khan, Joaquim Manuel da Costa Pereira, Joseph W. Nunoo-Mensah, Jung Tack Son, Liang Kang, Keisuke Uehara, Ping Lan, Le-Ping Li, Han Liang, Bing-Rong Liu, Juan Liu, Dan Ma, Ming-Yin Shen, Mohammad Rashidul Islam,

Original Source: Guan X, Liu Z, Parvaiz A, et al. International consensus on natural orifice specimen extraction surgery (NOSES) for gastric cancer (2019). Gastroenterol Rep (Oxf). 2020;8(1):5–10. Published 2020 Jan 24. doi:10.1093/gastro/goz067 Xu Guan and Zheng Liu contributed equally with all other contributors. X. Guan Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Department of Colorectal Surgery, National Cancer Center, National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China Z. Liu · H.-Y. Huang · X. Wang (*) Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China A. Parvaiz Poole Hospital NHS Trust, Poole, UK A. Longo European Center of Coloproctology and Pelvic Diseases-Multimedica Hospital, Milan, Italy A. Saklani Department of GI Surgical Oncology, Tata Memorial Hospital, Mumbai, India

L. Chen Department of General Surgery, Chinese People’s Liberation Army General Hospital, Beijing, P. R. China C. Kayaalp Department of Gastrointestinal Surgery, Inonu University, Malatya, Turkey Gastrointestinal Surgery, Yeditepe University Medical School, Istanbul, Turkey F. Sumer Department of Gastrointestinal Surgery, Inonu University, Malatya, Turkey F. Nogueira · J. M. da Costa Pereira Department of Surgery, Hospital de Braga, Braga, Portugal F. Gao Department of Gastrointestinal Surgery, The Affiliated Hospital of Medical School of Ningbo University, Ningbo, Zhejiang, China Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, P. R. China F.-H. Han Department of Gastroenterological Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China

A. A. Shafik Department of Colorectal Surgery, Cairo University, Cairo, Egypt

Q.-S. He Department of General Surgery, Shandong University Qilu Hospital, Jinan, Shandong, P. R. China

J.-C. Cai Department of Gastrointestinal Surgery, Zhongshan Hospital of Xiamen University, Xiamen, Fujian, P. R. China

H.-K. Chun · J. T. Son Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea

C. A. Ternent Section of Colon and Rectal Surgery, Creighton University School of Medicine, Omaha, NE, USA

C.-M. Huang Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, P. R. China

© People’s Medical Publishing House, PR of China 2023 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-99-2750-0_76

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Narimantas Evaldas Samalavicius, Kai Pan, Petr V. Tsarkov, Xin-Yu Qin, Ricardo Escalante, Sergey Efetov, Seung Kyu Jeong, Suk-Hwan Lee, Dong-Hui Sun, Li Sun, Tatiana Garmanova, Yan-Tao Tian, Gui-Yu Wang, Guo-Jun Wang, Guo-Rong Wang, Xiao-Qiang Wang, William Tzu-Liang Chen, Woo-Yong Lee, Su Yan, Zu-Li Yang, Gang Yu, Pei-Wu Yu, Dan Zhao, Yun-Shi Zhong, Jian-Ping Wang, Xishan Wang, and The International Alliance of NOSES

R. Huang · G.-Y. Wang Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, P. R. China

K. Pan Department of Gastrointestinal Surgery, Shenzhen People’s Hospital & Second Clinical Medical College of Jinan University, Shenzhen, Guangdong, P. R. China

Z.-W. Jiang Department of General Surgery, Jiangsu Province Hospital of Traditional Chinese Medicine, Nanjing, Jiangsu, P. R. China

P. V. Tsarkov Clinic of Colorectal and Minimally Invasive Surgery, Department of Surgery ICM, I.M. Sechenov First Moscow State Medical University, Moscow, Russia

J. S. Khan Anglia Ruskin University Chelmsford, Chelmsford, UK Department of Colorectal Surgery, Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Portsmouth, UK J. W. Nunoo-Mensah King’s College Hospital, London, UK L. Kang · P. Lan · J.-P. Wang (*) Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China K. Uehara Department of Surgery, Division of Surgical Oncology, Nagoya University School of Medicine, Nagoya, Japan L.-P. Li Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, P. R. China H. Liang Department of Gastric Cancer, Tianjin Medical University Cancer Institute & Hospital, Tianjin, P. R. China B.-R. Liu Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, P. R. China J. Liu Department of Obstetrics and Gynecology, Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, P. R. China D. Ma Department of General Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing, P. R. China M.-Y. Shen Colorectal Surgery Division, China Medical University Hsinchu Hospital, Zhubei, Taiwan, China Department of Surgery, China Medical University Hospital, Taichung, Taiwan, China

X.-Y. Qin Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, P. R. China R. Escalante Universidad Central de Venezuela, Centro Medico Loira, Caracas, Venezuela S. Efetov Colorectal Surgery Department, Sechenov First Moscow State Medical University, Moscow, Russia Clinic of Faculty Surgery N2, Surgical Department N2, University Clinical Hospital N4, I.M. Sechenov First Moscow State Medical University, Moscow, Russia S. K. Jeong Department of Surgery, Yang Hospital, Seoul, South Korea S.-H. Lee Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea D.-H. Sun Department of Gastric and Colorectal Surgery, Jilin University First Hospital, Changchun, Jilin, P. R. China L. Sun · D. Zhao Department of Gynecologic Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China T. Garmanova Clinic of Colorectal and Minimally Invasive Surgery, Sechenov First Moscow State Medical University, Moscow, Russia Y.-T. Tian Department of Colorectal Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China

M. R. Islam Department of Surgery, Shaheed Suhrawardy Medical College, Dhaka, Bangladesh

Department of Pancreatic and Gastric Surgery, National Cancer Center/ National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China

N. E. Samalavicius Department of Surgery, Klaipeda University Hospital, Klaipeda, Lithuania

G.-J. Wang Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, P. R. China

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 965 Definition and Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Naming of GC-NOSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Indications and Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 966 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 966 Relative Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 967 Surgical Devices for GC-NOSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 967 Gastrectomy and Digestive Tract Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 967 Aseptic Operation and Tumor-Free Operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 968 Requirements of Surgical Procedures for Specimen Extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Principles of Specimen Extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Requirements for Transoral Specimen Extraction Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Requirements for Transvaginal Specimen Extraction Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Requirements for Transrectal Specimen Extraction Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Clinical Research and Technical Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 969 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 970

Abstract

Keywords

At present, natural orifice specimen extraction surgery (NOSES) has attracted more and more attention worldwide, because of its great advantages including minimal cutaneous trauma and postoperative pain, fast postoperative recovery, short hospital stay, and positive psychological impact. However, NOSES for the treatment of gastric cancer (GC) is still in its infancy, and there is great potential to improve its theoretical system and clinical practice. Especially, several key points including oncological outcomes, bacteriological concerns, indication selection, and standardized surgical procedures are raised with this innovative technique. Therefore, it is necessary to achieve an international consensus to regulate the implementation of GC-NOSES, which is of great significance for healthy and orderly development of NOSES worldwide.

Gastric cancer · Natural orifice specimen extraction surgery · Transanal specimen extraction · Transvaginal specimen extraction · Transoral specimen extraction · Consensus

G.-R. Wang · X.-Q. Wang Department of General Surgery, Shanxi Provincial People’s Hospital, The Third Affiliated Hospital, Medical College, Xi’an Jiao Tong University, Xi’an, Shaanxi, P. R. China W. T.-L. Chen Department of Colorectal Surgery, China Medical University Hsinchu Hospital, Taichung, Taiwan Department of Surgery, China Medical University Hospital, Taichung, Taiwan, China W.-Y. Lee Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea S. Yan Department of Gastrointestinal Surgery, Qinghai University Affiliated Hospital, Xining, Qinghai, P. R. China

Introduction Natural orifice specimen extraction surgery (NOSES) has attracted more and more attention because of its great minimally invasive effect. Furthermore, the safety and efficacy of NOSES has also been gradually recognized, especially in the field of gastrointestinal surgery (Wolthuis et al. 2014; Guan et al. 2017; Park et al. 2011; China Natural Orifice Specimen

Z.-L. Yang Department of Gastrointestinal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China G. Yu Department of General Surgery, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University Qingdao, Qingdao, Shandong, China P.-W. Yu Department of General Surgery, Center of Minimal Invasive Gastrointestinal Surgery, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, P. R. China Y.-S. Zhong Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, P. R. China The International Alliance of NOSES

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Extraction Surgery Alliance 2017). In recent years, laparoscopic and robotic gastric cancer (GC) resection with NOSES obviously shows an upward trend, but many theoretical and technical issues have failed to reach unification (Sumer et al. 2016; Sumer et al. 2018; Stanek et al. 2017; Hüscher et al. 2017). Faced with this situation, the International Alliance of NOSES organized dozens of experts from gastrointestinal surgery, gynecology, endoscopy, and colorectal surgery to draft and formulate this international consensus. This consensus comprehensively elaborates the key issues of GC-NOSES and further provides a significant industry guideline for its clinical practice.

Definition and Classification Definition The definition of NOSES is as follows: The surgical specimen resection is performed intra-abdominally, and the specimen is extracted by opening a hollow organ that communicates with the outside of body, including the anus, vagina, or mouth. The main features of GC-NOSES involve specimen extraction from a natural orifice and complete intraabdominal digestive tract reconstruction, which avoid the additional incision on abdominal wall (Guan et al. 2019). Currently, NOSES can be applied in the fields of gastrointestinal surgery, hepatobiliary surgery, urinary surgery, and gynecologic surgery (Wang 2019).

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Classification According to different specimen extraction routes, GC-NOSES is divided into three categories including transoral specimen extraction, transanal specimen extraction, and transvaginal specimen extraction (Fig. 76.1) (China Natural Orifice Specimen Extraction Surgery Alliance 2019).

Naming of GC-NOSES In order to make GC-NOSES more standardized and unified, this consensus systematically proposes nine specific surgical procedures for GC-NOSES, which are mainly based on tumor location and the way of specimen extraction (China Natural Orifice Specimen Extraction Surgery Alliance 2019). The specific abbreviations and full names of GC-NOSES are shown in Table 76.1.

Indications and Contraindications Indications Compared with conventional laparoscopic surgery, the indications of GC-NOSES are stricter. First, the indications of GC-NOSES should meet the requirements of conventional laparoscopic gastrectomy. Second, surgeons should be capable of performing total laparoscopic digestive reconstruction of gastrectomy and have wealth of experience to strictly

Fig. 76.1 Specimen extraction routes for gastric cancer. (a) Transoral specimen extraction; (b) transanal specimen extraction; (c) transvaginal specimen extraction

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Table 76.1 The abbreviations and full names of natural orifice specimen extraction surgery for gastric cancer (GC-NOSES) Abbreviation GC-NOSES I GC-NOSES II GC-NOSES III GC-NOSES IV GC-NOSES V GC-NOSES VI GC-NOSES VII GC-NOSES VIII GC-NOSES IX

Full name Laparoscopic distal gastrectomy (Billroth I) with transrectal specimen extraction Laparoscopic distal gastrectomy (Billroth I) with transvaginal specimen extraction Laparoscopic distal gastrectomy (Billroth II) with transrectal specimen extraction Laparoscopic distal gastrectomy (Billroth II) with transvaginal specimen extraction Laparoscopic proximal gastrectomy with transrectal specimen extraction Laparoscopic proximal gastrectomy with transvaginal specimen extraction Laparoscopic total gastrectomy with transrectal specimen extraction Laparoscopic total gastrectomy with transvaginal specimen extraction Laparoscopic partial gastrectomy with transoral specimen extraction

Orifice Rectum

Table 76.2 Indications for GC-NOSES Specimen extraction route Transoral specimen extraction

Vagina Rectum Vagina

Transrectal specimen extraction

Rectum Vagina Rectum Vagina Mouth

comply with the basic requirements of aseptic and tumor-free principles (China Natural Orifice Specimen Extraction Surgery Alliance 2019). Otherwise, GC-NOSES is not recommended. Meanwhile, GC-NOSES has its specific indications. According to different ways of specimen extraction, the indications are distinguishing. The details are shown in Table 76.2.

Relative Contraindications Relative contraindications include locally advanced GC, acute bowel obstruction, bleeding and perforation derived from cancer, obese patients (BMI  30 kg/m2), patients with a history of pelvic surgery, anal stenosis, vaginal malformation, etc. In addition, female who have not completed their family should not be recommended to perform transvaginal specimen extraction (China Natural Orifice Specimen Extraction Surgery Alliance 2019).

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Transvaginal specimen extraction

Indications (1) Benign or T1 tumor cannot be completely resected under endoscopy; (2) the maximum diameter of specimen should be less than 2 cm; and (3) T2/T3 tumor (China Natural Orifice Specimen Extraction Surgery Alliance 2019) (1) Benign or malignant tumor cannot be extracted through mouth (male patient); (2) T2/T3 tumor; (3) the maximum diameter of specimen should be less than 3 cm; and (4) BMI < 30 kg/m2 (China Natural Orifice Specimen Extraction Surgery Alliance 2019) (1) Benign or malignant tumor cannot be extracted through mouth (female patient); (2) T2/T3 tumor; (3) the maximum diameter of specimen should be from 3 cm to 5 cm; and (4) BMI < 30 kg/m2 (China Natural Orifice Specimen Extraction Surgery Alliance 2019)

GC-NOSES gastric cancer-natural orifice specimen extraction surgery, BMI body mass index

laparoscope makes the operation field clearer, which helps the surgeon to perform complex surgical operations much easier. The da VinciVR robot manipulator provides a more stable operation environment avoiding subtle jitter of human hands during a delicate and fine surgical dissection (Zhang et al. 2015). Furthermore, a protective tool is recommended during specimen extraction to avoid direct contact between specimen and natural orifice in order to ensure the aseptic and tumor-free operation. In current clinical practice, specimen extraction tools are mainly divided into soft and hard devices. The former includes double-ringed wound protective devices, self-made plastic sleeves, and sterile specimen bags, whereas the latter include anoscope and transluminal endoscopic operation ports (Guan et al. 2019).

Gastrectomy and Digestive Tract Reconstruction Surgical Devices for GC-NOSES The basic surgical platform required by GC-NOSES is conventional two-dimensional (2D) laparoscopic platform (Sumer et al. 2018). Therefore, for surgeons with experience of laparoscopic surgery, the learning curve of GC-NOSES will be obviously reduced. In addition to 2D laparoscopic platform, GC-NOSES can be performed by using other minimally invasive devices, such as highdefinition 3D laparoscopy, and the da VinciVR robotic platform (Guan et al. 2019). The high-definition 3D

The gastrectomy and gastrointestinal reconstruction of GC-NOSES should follow the basic principles of open surgery and conventional laparoscopic surgery (Jeong et al. 2011). First, the resection range of gastrectomy cannot be intentionally reduced because of specimen extraction through narrow orifice. Second, based on different tumor location, the methods of gastrectomy and reconstruction should be carefully selected to preserve gastrointestinal function. Finally, the anastomosis should be provided with sufficient blood supply, no tension, and no stenosis.

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Aseptic Operation and Tumor-Free Operation Bacteriological concerns have been raised because of the breach in peritoneal sterility in some procedures of GC-NOSES (Sumer et al. 2016). Previous studies have fully confirmed the potential of bacterial contamination during NOSES by examining the bacterial positive rate of intraoperative pelvic fluid culture. In order to solve this problem, this consensus recommends that prophylactic antibiotics administration, mechanical bowel preparation, intraoperative peritoneal irrigation, and placement of pelvic or abdominal drains should be applied to reduce the bacterial load of NOSES. The oncological safety is another major concern in procedures of GC-NOSES. Tumor dissemination mainly arises from compression between specimen and narrow natural orifice, with the potential for compromise in oncological safety (Sumer et al. 2015). In clinical practice, lots of clinical experience techniques were summarized to prevent tumor dissemination, including the use of sterile protection devices when taking specimen, avoiding over-pulling, and compression of lesions during specimen extraction. Previous findings showed that transluminal specimen extraction provided the same degree of protection as transabdominal specimen extraction by comparison of peritoneal tumor cytology test (Leroy et al. 2011).

Requirements of Surgical Procedures for Specimen Extraction

X. Guan et al.

lumen and poor elasticity of the esophageal tract, the transoral route is only appropriate for highly selected patients with small-size tumors (Huscher et al. 2013).

Preoperative Preparation Endoscope should be preoperatively performed to exam if there are varices or stenosis in the esophageal wall. Transoral specimen extraction should be forbidden if varices or abnormal stenoses were detected in the esophagus. Operative Essentials It is essential that aseptic and tumor-free principles should be strictly followed during specimen extraction. Here, this consensus recommends that gastric specimen should be completely sealed within a retrieval bag intraperitoneally before transoral extraction, so as to avoid direct exposure of tumor to natural orifice. Furthermore, the whole process of specimen extraction should be guided under close observation of endoscope. Complication Prevention and Therapy The most common complications of transoral specimen extraction are rupture and bleeding of the esophageal wall. The esophagus is characterized with narrow lumen, and poor elasticity, which increases the difficulty of specimen extraction as well as the risk of esophageal wall injury. In order to avoid the injury during specimen extraction, this consensus recommends that full assessments should be carried out preoperatively. If esophageal rupture or bleeding occurs during specimen extraction, timely endoscopic therapy is needed.

The Principles of Specimen Extraction Specimen extraction is the most characteristic surgical procedure in NOSES. The requirements for technical skills of NOSES are obviously higher in specimen extraction than those of open surgery and conventional laparoscopic surgery. The main principles of specimen extraction recommended in this consensus include: (1) strict adherence to the indications of GC-NOSES; (2) full compliance with the aseptic and tumor-free principles during the specimen extraction; (3) comprehensive preoperative assessments for anatomy and physiology of natural orifice; and (4) prompt conversion to transabdominal specimen extraction if specimen is hard to be extracted from natural orifice (China Natural Orifice Specimen Extraction Surgery Alliance 2019).

Requirements for Transoral Specimen Extraction Procedures The transoral route is considered to be the ideal way for specimen extraction for GC. However, due to the narrow

Requirements for Transvaginal Specimen Extraction Procedures The transvaginal route is only performed in female patients with larger specimens that cannot be extracted through transoral route. This route is currently the most common way in GC-NOSES (Zhang et al. 2015).

Preoperative Preparation Before transvaginal specimen extraction, the accessibility and elasticity of vagina should be carefully assessed. It is essential to make clear whether there is pelvic inflammation or adhesions around the posterior fornix for patients who have history of pelvic surgery. Operative Essentials The transvaginal specimen extraction consists of the following four steps. (1) Intracorporeal specimen transfer: The gastric specimen is located at the upper abdomen after resection, and it needs to be transferred to the pelvic cavity from which the specimen will be extracted out of the body.

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Before specimen transfer, the specimen should be completely sealed within a retrieval bag in order to avoid intraperitoneal tumor dissemination. (2) Opening posterior fornix: The posterior fornix could be clearly exposed under laparoscopy. Because of its good elasticity and healing ability, the posterior fornix is considered the preferred site for vaginal incision (Franklin Jr et al. 2013). Opening vaginal incision could be performed either intracorporeally or extracorporeally. The length of vaginal incision is recommended to be 3–5 cm; vaginal incision should be made transversely from the middle to both sides. (3) Transvaginal specimen extraction: After opening the posterior fornix, the specimen is transvaginally extracted from the pelvic cavity and is gently extracted extracorporeally. The transvaginal specimen extraction should be performed under close observation with laparoscope. (4) Closing posterior fornix: Vaginal incision can be closed either intracorporeally or extracorporeally with absorbable sutures. A knotless suture is often sewed from one side of incision to the other side with continuous stitch. Alternatively, the vaginal incision can be stitched extracorporeally with an interrupted full-thickness suturing technique. After closure, it is necessary to perform a digital examination to check the intact of vaginal incision.

Complication Prevention and Therapy Making an incision on the posterior fornix may increase the risks of chronic dyspareunia and affect sexual function and quality of life although this may not occur very frequently. Therefore, this consensus recommends careful evaluation for these patients with appropriate quality of life and validated sexual function during follow-up. In addition, transvaginal specimen extraction may increase the risks of secondary pelvic infection and incisional tumor dissemination. Hence, it is necessary to fully comply with aseptic and tumor-free principles during extraction.

Requirements for Transrectal Specimen Extraction Procedures Although transrectal specimen extraction has not yet been widely accepted in GC-NOSES, this measure is only recommended to male patients who could fully accept the risk of this procedure.

Preoperative Preparation Before transrectal specimen extraction, it is necessary to check the anatomical structure of the rectum so as to evaluate the feasibility of this operation.

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Operative Essentials The transrectal specimen extraction consists of the following four steps. (1) Intracorporeal specimen transfer: The specimen should be sealed within a retrieval bag to avoid intraperitoneal tumor dissemination during specimen transfer; the specimen is transferred from the upper abdominal cavity to the pelvic cavity. (2) Proctotomy: The location of rectal incision is recommended to be 5–10 cm above the peritoneal reflection, where may facilitate specimen extraction and incision closure. A 3–5 cm longitudinal incision is recommended to be made on the anterior wall of the rectal wall. Here, hook monopolar cautery is advised to use for rectal incision to minimize injury. (3) Transrectal specimen extraction: After specimen transferred to the pelvic cavity, the specimen is extracted through rectal incision and is gently withdrawn extracorporeally. Violent withdrawal will cause specimen stuck outside rectal incision. The whole operation should be performed under laparoscopic guidance. (4) Closure of rectal incision: The rectum should be closed longitudinally, and a knotless suture should be made from the distal end to the proximal end with a continuous full-thickness suture, followed by inversion of the suture line with seromuscular stitches. After stitching, an air test is required to detect whether the incision is sutured intactly. The endoscopic examination may be conducted, if necessary. Complication Prevention and Therapy The main complications of the transrectal specimen extraction are anal sphincter injury and proctotomy leak. In recent years, there has been a gradual increase in reports of transrectal NOSES, but anal disfunction or sphincter injury is rarely reported. This consensus suggests that the anus should be fully expanded before specimen extraction to reduce the risk of sphincter injury. Proctotomy leak is another serious complication. Once proctotomy leak is detected, adequate drainage should be performed as early as possible. As for patients with delayed healing or nonhealing, a diverting colostomy or ileostomy should be considered. Alternatively, a re-resection followed by anastomosis would still be an option.

Clinical Research and Technical Training At present, the research related to GC-NOSES is mostly single-centered, small-sampled, and retrospective, with poor quality and low evidence level (Zhang et al. 2015; Jeong et al. 2011; Sumer et al. 2015; Leroy et al. 2011; Huscher et al. 2013; Lirici et al. 2016). Therefore, large-sampled, multicentered randomized clinical trials comparing NOSES vs with transabdominal specimen extraction for GC are very

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necessary, which will address the risks and benefits in GC-NOSES, especially abdominal infection, anastomotic leak, and natural orifice injury and dysfunction, etc. In addition, in consideration of the potential advantages of NOSES, it is recommended to carry out assessment and research on the quality of life, social-psychological, and health-economic effects on patients with undergoing GC-NOSES. More importantly, in order to ensure the healthy and orderly development of GC-NOSES, standardized procedures should be established in clinical practice. It is, therefore, essential that NOSES-oriented academic organizations should be established, and academic activities and surgeon trainings for GC-NOSES should be done to further standardize clinical practice of GC-NOSES in future.

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