Natural Orifice Specimen Extraction Surgery: Gastrointestinal Tumor [2 ed.] 9789811579257, 9811579253

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Xishan Wang Editor

Natural Orifice Specimen Extraction Surgery Gastrointestinal Tumor Second Edition

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Natural Orifice Specimen Extraction Surgery

Xishan Wang Editor

Natural Orifice Specimen Extraction Surgery Gastrointestinal Tumor Second Edition

Editor Xishan Wang Department of Colorectal Surgery Cancer Institute & Hospital, Chinese Academy of Medical Sciences Beijing China

ISBN 978-981-15-7924-0    ISBN 978-981-15-7925-7 (eBook) https://doi.org/10.1007/978-981-15-7925-7 Jointly published with People’s Medical Publishing House, PR of China

© People’s Medical Publishing House, PR of China 2021 This work is subject to copyright. All rights are reserved by the Publishers, whether the whole or part of the material is concerned, specifically the rights of translation, 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, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publishers remains 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

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.

Lead the way with skill, win the future with virtue.

Be appreciative of others’ achievements; be critical with one’s own deficiencies.

The courage to question oneself makes one a real surgeon.

The moment our effort paid off marked our achievements as a thing of the past. Now is the time to set sail for the next destination.

The perfection of the human body makes up for the shortage of medicine and our self-righteousness.

——Xishan Wang 王锡山

Foreword by Jie He

According to the latest data from National Cancer Center, the prevalence of gastrointestinal cancer in China is ranked the highest among malignant tumors, and its morbidity and mortality are still rising year by year. The prevention and treatment of gastrointestinal cancer in China is faced with serious challenges. As the main treatment of gastrointestinal tumors, surgery has made considerable progress and improvement in recent years, especially in minimally invasive treatment. Professor Xishan is a leading figure in the field of colorectal cancer in China. It is witnessed by all that he has been engaging in the prevention, diagnosis, and treatment of colorectal cancer in China. At the same time, as the academic leader of colorectal surgery in our hospital, he has achieved significant achievements in recent years. In 2019, over 3000 colorectal surgeries have been carried out in our hospital, and the number of colorectal tumor surgeries ranked first in China. In order to establish the brand of our department, he puts forward the two subject characteristics of “minimally invasive of minimally invasive, difficulty of difficulty,” which are the embodiment of his innovative consciousness and pioneering spirit. NOSES is the best manifestation of “minimally invasive of minimally invasive.” At present, up to 300 cases of NOSES are carried out in our hospital annually, which is leading both in China and in the world. Surely, the innovation of any technique must be based on standardization, and the innovation of cancer treatment should be doubly cautious. As a new minimally invasive technique, the standardization of NOSES is not only applicable to individuals but also requires the whole surgical field to have its own standards. At present, Prof. Xishan has further improved the theoretical system of NOSES.  Over the last three years, he has written several monographs on NOSES in Chinese and foreign languages, which objectively demonstrate the feasibility and great social value of NOSES and again illustrate the broad application prospect of NOSES. In addition, a series of academic activities, such as hundreds of Chinese NOSES lecture tours and

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NOSES seminars, have been carried out with the Chinese NOSES Alliance and the Chinese Cancer Center as the academic platform. Over 10,000 medical staff have been trained, which plays a great role in promoting the standardization of NOSES. Within just a few years, NOSES has developed from a single procedure to a complete theoretical system, from a single organ to applicable to abdominal and pelvic organs, and from several single centers to national and even the world. All these developments reflect the strong vitality of NOSES.  I also believe that the publication of the second edition of the English monograph on NOSES for gastrointestinal cancer will have a profound impact on the international promotion of NOSES. It will inject new vitality to bringing the Chinese original minimally invasive technology to the world stage and lead the international minimally invasive surgery into a new era.

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 Tracy L. Hull

I would like to thank Prof. Xishan Wang for the opportunity to write a preface for the second edition of the NOSES book on gastrointestinal tumors (English version). Minimally invasive surgery, represented by laparoscopic and robotic surgery, has been widely accepted and developed in the field of gastrointestinal surgery. In the quest to avoid abdominal incisions, NOSES has been developed as a form of minimally invasive surgery and is becoming more popular in many sections of the world. Other similar variations related to minimally invasive surgery include NOTES and TaTME. Compared to NOSES, NOTES seems to offer a more cosmetically pleasing effect but lacks high-level evidence-based supporting studies. TaTME has received a lot of attention around the world. Compared to NOSES, TaTME seems to be more technically demanding and less adaptable. TaTME has received significant scrutiny worldwide and time will tell if it remains a safe and feasible platform for rectal resection particularly due to concerns of increased local recurrence rates in rectal cancer. Unlike NOTES and TaTME, NOSES may be technically easier to adapt. A database of NOSES procedures established by Prof. Xishan Wang has over 6000 patients from more than 200 hospitals. In August 2019, I was honored to be invited to Beijing to participate in the third International NOSES Symposium. Fifty international experts who specialize in NOSES-based surgery from 16 countries participated in a comprehensive symposium. Besides talks about the benefits of this platform, current technical bottlenecks and challenges were discussed. This was highlighted by a live demonstration of surgery utilizing the NOSES techniques. Prof. Wang and his team showcased their technical skills and then invited us to visit their patients the following days as they recovered in the hospital. These patients were up and walking in the halls and progressing quickly in their recovery. 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 NOSES books and monographs that have been translated into English, Korean, Russian, Japanese, and other languages for global promotion. In addition, he also organized nearly 100 NOSES training

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courses and lectures, which trained over 10,000 surgeons. The development and achievements of these efforts have played an important role in promoting the standardized treatment and safe technique of NOSES in the world. Presently, few surgeons in the USA perform NOSES surgery. Through the efforts of surgeons like Prof. Wang, more clinicians worldwide (including the USA) will be exposed to this platform and embrace its utility in performing surgery in a safe and truly minimally invasive fashion. Tracy L. Hull President, American Society of Colon and Rectal Surgeons President, Society of Pelvic Surgeons Section Chief, IBD of Department of Colorectal Surgery The Cleveland Clinic Foundation

Foreword by Tracy L. Hull

Foreword by Antonio Longo

With the fast development of minimally invasive surgery in the treatment of gastrointestinal disease, novel surgical techniques and methods to reduce surgical trauma have been introduced and become highly concerned issues in current clinical practice. Natural orifice specimen extraction surgery (NOSES), by avoiding abdominal incision, has been considered as a well-­ established surgical approach. Currently, NOSES represents the least invasive option in surgical treatment of gastrointestinal diseases. Furthermore, more and more research results are published in support of the application of NOSES with acceptable short- and long-term outcomes. In 2018, an international academic organization, the International Alliance of NOSES, was established with the aim of improving the clinical practice of NOSES worldwide. I am honored to be a member of this international organization. After that, we published one consensus of NOSES for colorectal cancer together, which systematically integrated technical variations of

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Foreword by Antonio Longo

NOSES for colorectal cancer. In 2019, under the leadership of Prof. Wang, a new consensus of NOSES for gastric cancer was published by dozens of international surgical experts, providing a theoretical basis for healthy growth of NOSES involved in the field of gastrointestinal surgery. As far as I know, many surgeons in Europe have performed NOSES in the treatment of colorectal disease. However, the general surgeon does not have the habit of working transanally, which may discourage the population from NOSES. Furthermore, the potential pitfalls of NOSES raised with this new technique still attract long-standing concerns, especially in terms of bacteriological results and oncological outcomes. In my opinion, the development of more specialized surgical devices will be a good direction for NOSES. The specialized surgical devices for NOSES could be used to reduce the difficulty of surgery and the risk of complications. In order to better standardize the development of NOSES technology, Prof. Wang and many experts have published several NOSES monographs to elaborate standard surgical techniques of NOSES. Two years ago, I have read the book NOSES—Colorectal Cancer written by Prof. Wang; this book fully presented all kinds of the NOSES techniques in the treatment of CRC, which has benefited me a lot. Compared to open surgery and conventional laparoscopic surgery for gastrointestinal tumor, NOSES has numerous technical variations regarding specimen extraction and intraperitoneal bowel reconstruction. Today, I feel very surprised and excited to hear that Prof. Wang is about to publish the second edition NOSES—Gastrointestinal Tumor. This new book summarizes a wide variety of novel techniques and experience regarding NOSES in the treatment of gastrointestinal tumor. I firmly believe that they could be available to be recommended to a broader surgical community and allow more patients to benefit in the world. Antonio Longo Director, European Center of Coloproctology and Pelvic Diseases

Foreword by Ho-Kyung Chun

Clinical researchers at the Johns Hopkins University were the first to report the use of natural orifice transluminal endoscopic surgery (NOTES) in 2004. Developed through animal experiments, it has become more advanced minimally invasive surgery than laparoscopic and robotic surgery, and it is an ideal procedure with the best minimally invasive effect. In the summer of 2007, the Korean NOTES Study Group was established, and academic conference has been held twice a year to discuss the development and application of laparoscopic and endoscopic techniques in NOTES. These activities have played an important role in the promotion of NOTES technique in Korea. However, the NOTES technique still has many problems, including high technical difficulty, high dependency on device platform, and limited indicated population. Therefore, it will take a long time for this technique to be widely applied in clinical practice.

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On the basis of conventional laparoscopic surgical techniques, NOSES combines the “incision-­free” concept of NOTES and the technique of specimen extraction through natural orifice. NOSES has both high feasibility of laparoscopic surgery and the good minimally invasive effect of NOTES. By avoiding auxiliary incision in the abdominal wall, this technique has light pain, quick recovery, good cosmetic effect of abdominal wall, less psychological disturbance, and many other advantages. These advantages are essential to the physical and psychological health of patients, especially those with cancer. In the summer of 2012, I visited Prof. Wang Xishan for the first time and have learnt that he had performed the first case of laparoscopic NOTES for rectal cancer worldwide in 2010. I was amazed at the carrying out of this highly difficult minimally invasive technique under the condition of limited technical equipment, which inspired my great admiration for Prof. Wang Xishan’s innovative spirit. When I met Prof. Wang Xishan again in Beijing in 2016, he mentioned that he had started carrying out colorectal NOSES procedures in 2013. In just three years, Prof. Wang has successfully completed more than 300 colorectal NOSES procedures. He also had them classified and integrated to form a complete technical and theoretical system. I was very pleasantly surprised by his achievement, which helps me gain a new understanding of the NOSES technique. By now, Prof. Wang Xishan has published many monographs on NOSES, which play an important role in the promotion and development of NOSES. To facilitate the development of NOSES in Korea, I was honored to translate Professor Wang Xishan's monograph of NOSES for Colorectal Cancer into Korean. Since its publication, this book has been highly evaluated in the surgical field of Korea. It has also played an important role in the standardization of colorectal NOSES technique in Korea. Now, I am glad to hear that Prof. Wang Xishan and dozens of international experts have collaboratively written the second edition of English monograph of NOSES for Gastrointestinal Cancer, which covers all NOSES techniques for gastrointestinal cancer. Many new techniques have been launched in an innovative manner, and the previous techniques have been improved and perfected, which injects new vitality into NOSES. I believe that the publication and distribution of this edition will play a positive role in promoting the standardized development of NOSES technique for gastrointestinal tumor in the field of minimally invasive surgery worldwide. Ho Kyung Chun President, International Society of University Colon & Rectal Surgeons (ISUCRS) President, Asia Pacific Federation of Coloproctology (APFCP) President, Eurasian Colorectal Technologies Association (ECTA)

Foreword by Ho-Kyung Chun

Introduction of Chief Editor

The Main Academic Title The Chairman of Colorectal Cancer Committee of Chinese Medical Doctor Association; the Chairman of Colorectal Cancer Committee of Chinese Anti-Cancer Association; the President of International Alliance of NOSES; the President of China Alliance of NOSES; the Chairman of Youth Committee of Colorectal Cancer Committee of Chinese Anti-Cancer Association; the Vice Chairman of Tumor Metastasis Committee of Chinese Anti-Cancer Association; the Vice Chairman of MDT Committee of Chinese Medical Doctor Association; the Standing Committee of Surgeon Committee of Chinese Medical Doctor Association; the Chief Editor of Chinese Journal of Colorectal Diseases (Electronic Edition); President of Russian-Chinese Society of Colorectal Surgeons; Honorary Member of Russian School of Colorectal Surgery.

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Scientific Research and Clinical Achievements Totally, he has published 116 SCI papers; edited and participated in 18 monographs and 31 audiovisual materials related to colorectal cancer treatment; taken charge of more than 10 projects, including three projects of the National Natural Science Foundation, the National City cancer early diagnosis and early treatment; and presided over National Major Project of Precision Medicine titled “the application of precision medicine in colorectal cancer diagnosis and treatment.”

Novel Techniques He is proficient in minimally invasive surgery for colorectal cancer as well as combined organ resection for difficult cases. Currently, he has 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 500 cases of NOSES for colorectal cancer; this number ranked first in China. He established evaluation standard to determine low, ultra-low anastomosis surgery based on the tumor location to the dentate line instead of the anal verge; put forward the “risk investment theory” to make sphincter preserving surgery a more scientific and standardized treatment system; carried out a variety of difficult surgeries, such as hemicolectomy combined with pancreaticoduodenectomy; and proposed the distinction of concepts between combined organ resection and multiple organ resection. According to the different invasion manner (cancerous invasion or inflammatory invasion), he 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 sacrococcygeal route, radical colectomy with the omentum preserved, and total colectomy with the rectal ampulla preserved. These clinical works play an important role of improving the current treatment status of colorectal cancer.

Student Training At present, there are a total of 95 graduate students, including one professor, 10 associate professors, 8 master tutors, 9 students in the national academic community as academic part-time, and 15 students in the provincial academic community as academic part-time; some of these students were sent abroad including Britain, the USA, and Japan, to study further.

Introduction of Chief Editor

Introduction of Associate Editor

Atsushi Nishimura MD Chief of Department of Surgery of Nagaoka Chuo General Hospital Board Certified Surgeon in Japan Surgical Society Board Certified Surgeon in Gastroenterology Councilor of Japan Society for Endoscopic Surgery Qualified Surgeon of Endoscopic Surgical Skill Qualification System

Cuneyt Kayaalp Professor Chief of Gastrointestinal Surgery Department of Inonu University Member of Turkish Surgical Society, Society of Surgery Days, Turkish Laparoscopic Endoscopic Surgery Association, Turkish HBP Surgery Society, Turkish Gastrointestinal Surgery Society Vice president of Turkish Bariatric Metabolic Surgery Association President of MAGIC (Malatya Gastro-Intestinal Chirurgie) xvii

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Joaquim Manuel da Costa Pereira Professor Director Surgical Service and of Colorectal Unity of Hospital de Braga. Director of Courses of Advanced Colorectal Laparoscopic Surgery of Portuguese Society of Minimally Invasive Surgery. Director of Courses of Intestinal Anastomosis of Portuguese Society of Minimally Invasive Surgery. Director of Courses of Laparoscopic Suture of Portuguese Society of Minimally Invasive Surgery. Member of Direction of Portuguese Society of Coloproctology. Honorary Consultant Surgeon of Vigo University Hospital

Joel Leroy MD, FRCS, Professor of Surgery Founder and Chairman Hanoi High Tech and Digestive Center, Saint Paul Hospital Chairman of Colorectal Department HDC, Digestive Colorectal Surgeon Professor Honoris Causa Hanoi Medical University

Introduction of Associate Editor

Introduction of Associate Editor

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Petr V. Tsarkov MD, Professor, PhD, FASCRS (Hon) Director of Clinic of Colorectal and Minimally Invasive Surgery, Chief of Research Educational Clinical Center of Colorectal and Endoscopic Surgery of Sechenov First Moscow Medical State University Founding Member of Russian Coloproctology Association International Society of University Colorectal Surgeons (ISUCRS) President Eurasian Colorectal Technologies Association (ECTA) Member of European Society of Coloproctology (ESCP) Honorary Fellow of American Society of Colon and Rectal Surgeons (ASCRS) Member of European Association of Endoscopic Surgery (EAES) Founding Member and Board Chairman of Russian Society of Colorectal Surgeons (RSCRS)

William Tzu-Liang Chen MD, Associate Professor of Surgery Vice-Superintendent of International Medicine Center, Chairman of Department of Surgery, Director of Minimally Invasive Center of China Medical University Hospital Member of American Society of Colon and Rectal Surgeons Member of Society of American Gastrointestinal Endoscopic Surgeons Board Member of Endo-laparoscopic Surgeons of Asia Board Member of Asia-Pacific Endo-laparoscopic Surgeons Board Member of Asian Endoscopic Task Force

Preface

At the completion of the second edition of the English book on NOSES, I am overwhelmed with emotions. When the first edition of the Chinese book on NOSES was published, I was very excited and wrote as follows: “NOSES is the integration of idea and technology, the collision of inspiration and practice, the mutual assistance of trust and motivation, the agreement of norms and innovation, and the progress of development and wishes.” After several years of accumulation and development, the Chinese book on NOSES has been rapidly updated from the first edition of NOSES for Colorectal Tumors to the third edition of NOSES for Abdominal and Pelvic Tumors, and many foreign language translations have been published successively. I hereby share with you some of my rational reflections on this technique. The direction for the future development of gastrointestinal surgery must be innovation. The revolution and innovation of medicine relies on the progress of physics, mechanical engineering, material science, and other related disciplines, as well as the development of various instruments and energy platforms such as laparoscopy and Da Vinci robot. The perfection of the human body also makes up for the arrogance and self-righteousness of medicine. Open surgery has been the mainstay of surgical treatment for hundreds of years. In the past 30 years, the once controversial laparoscopic surgery has been widely accepted and popularized. Similarly, we are making continuous progress and improvement in the development of NOSES. At present, the techniques of laparoscopic organ resection and digestive tract reconstruction by gastrointestinal surgeons are very mature. However, how to select a rational approach to achieve better specimen extraction still warrants consideration. Since incisions for specimen extraction are inevitable, why do not we choose the more concealed, scarless, and less painful approaches. The advent of NOSES happens to meet these requirements. With regard to NOSES, we must answer three questions: (1) What is it? (2) Why we do this? (3) How to do this? Firstly, we must answer “What is NOSES?.” NOSES is a kind of operation in which all operative procedures are performed in the abdominal cavity, and the specimen is extracted through the natural orifice. This operation can be performed on all organs in the abdomen and pelvis. NOSES originated from the concepts of incision-free, Like-NOTES, etc. This book illustrates the concepts of NOSES, NOTES, and taTME and their mutual relations, which facilitates the development, improvement, and perfection of these techniques. Secondly, we must answer “Why we do NOSES?” This should be discussed from two perspectives of both doctors and patients. For patients, “incision-free” is a novel idea, which can relieve or even eliminate postoperative pain, reduce abdominal wall dysfunction, provide good cosmetic appearance, and give them positive social psychosocial suggestions. With these advantages, NOSES facilitates the establishment of self-confidence, accelerates postoperative rehabilitation, and helps the patients to have a better return to society. For doctors, they should keep “two senses and two pursuits” in the process of practicing medicine. “Two senses” are the “sense of accomplishment” and the “sense of guilt.” “Two pursuits” of surgeons are “full understanding of the 3D anatomical structure” and “every movement is the crystallization of wisdom.” Doctors would feel the sense of happiness and fulfillment when their patients have good feelings and quick recovery. Thus, NOSES has a positive impact on both doctors and patients, which indicates that it is a better surgical procedure with good prospects. xxi

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Preface

Finally, we must answer “How to do NOSES?” Surgeons should explore new clinical techniques in a pragmatic manner and carry out the clinical practice of a series of procedures in a healthy, scientific, and orderly way. The members of Chinese NOSES Alliance have done a great deal of work for this purpose. Their hard work is far more than a mere pursuit of personal development. At the height of industry progress and national rejuvenation, they are striving to get the voice of Chinese surgeons heard in the global medical world. They appreciate other people’s achievements with an open mind and critically review their own limitations. With the broad mind and wide vision of the members of Chinese NOSES Alliance, NOSES is destined to have the characteristics of “standardization, innovation, pragmatism, truth-seeking, and advancing.” We have accommodated the opinions and suggestions of all aspects and recognize NOSES as the direction and goal of future development. On this basis, NOSES has developed rapidly and vigorously. With the increased diversity of involved tissues and organs, the number of hospitals, specialists, and operation cases of NOSES in China is increasing year by year. The overall complications have not been increased significantly, which sufficiently demonstrated the safety and feasibility of NOSES. The International NOSES Alliance has been established, and each province has set up the secondary branch of the Alliance successively, which provides a strong organizational guarantee for the healthy development of NOSES. In order to standardize the clinical development of NOSES, with the efforts of all members of this alliance, the Chinese Consensus on NOSES and the International Consensus on NOSES were formulated successively to make NOSES reasonable and evidence based. In addition, a series of academic activities, such as international NOSES academic conference, Chinese NOSES lecture tour, NOSES seminar, NOSES live surgical demonstration, and expert symposium, have been carried out with the Chinese NOSES Alliance and the Chinese Journal of Colorectal Diseases as the academic platform. These have greatly promoted the clinical popularization of NOSES and benefited more patients. The successive publications of NOSES books in English, Korean, Japanese, and Russian have significantly promoted the international popularization and exchange of NOSES. We firmly believe that all specialties will publish their respective NOSES monographs in the near future. The successful publications of many NOSES monographs are not possible without the wisdom and hard work of all the editors and the guidance and help of Academician He Jie, Prof. Zheng Shu, Prof. Zheng Minhua, Academician Chen Xiaoping, Academician Fan Daiming, and Academician Guo Yinglu. It is also inseparable from the support and dedication of Prof. Petr V. Tsarkov, Prof. Atsushi Nishimura, Prof. Cuneyt Kayaalp, Prof. Ho-Kyung Chun, Prof. Joaquim Manuel da Costa Pereira, Prof. William Tzu-Liang Chen, and other international colleagues for the promotion of NOSES. I would like to extend our sincere gratitude to all of them. NOSES is not just a great work of doctors, but also the gospel of patients. NOSES not only belongs to China, but also belongs to the world.

Beijing, China

Xishan Wang

Contents

Part I General Statement 1 Overview of NOSES���������������������������������������������������������������������������������������������������   3 Xishan Wang 2 Perioperative Preparation of NOSES�����������������������������������������������������������������������  25 Xishan Wang, Yinggang Chen, Lei Yu, and Rui Huang 3 Laparoscopic Abdominal Pelvic Anatomical Landmarks and Essentials of Surgical Exploration�����������������������������������������������������������������������������������������������  33 Haipeng Chen, Xu Guan, and Xishan Wang Part II NOSES for Colorectal Cancer 4 Laparoscopic Lower Rectal Cancer Resection with Transanal Specimen Extraction (CRC-NOSES IA, IB, and IB+, Eversion Method)������������������������������  43 Xishan Wang, Enrui Liu, and Haipeng Chen 5 Laparoscopic Ultralow Rectal Cancer Resection with Transanal Specimen Extraction: Park Method (CRC-NOSES IC)�����������������������������������������������������������  67 Xishan Wang, Yinghu Jin, and Zheng Jiang 6 Laparoscopic Ultralow Rectal Cancer Resection with Transanal Specimen Extraction: Intersphincteric Resection Method (CRC-NOSES ID) ���������������������  81 Xishan Wang, Meng Wang, and Zheng Jiang 7 Laparoscopic Ultralow Rectal Cancer Resection with Transanal Specimen Extraction: Bacon Method (CRC-NOSES IE)���������������������������������������������������������  95 Bo Jiang and Yi Feng 8 Laparoscopic Lower Rectal Cancer Resection with Rectal Eversion and Extra-­Abdominal Resection: Tsarkov Method (CRC-NOSES IF)����������������� 109 Sergey Efetov, Inna Tulina, and Petr V. Tsarkov 9 Laparoscopic Middle Rectal Cancer Resection with Transanal Specimen Extraction (CRC-NOSES II)������������������������������������������������������������������������������������� 121 Xishan Wang, Ziming Yuan, and Zhixun Zhao 10 Laparoscopic Middle Rectal Cancer Resection with Transvaginal Specimen Extraction (CRC-NOSES III)����������������������������������������������������������������������������������� 139 Xishan Wang, Qian Zhang, and Haipeng Chen 11 Laparoscopic Upper Rectal Cancer Resection with Transanal Specimen Extraction (CRC-NOSES IV) ����������������������������������������������������������������������������������� 157 Xishan Wang, Song Wang, and Peng Sun

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12 Laparoscopic Upper Rectal Cancer Resection with Transvaginal Specimen Extraction (CRC-NOSES V)������������������������������������������������������������������������������������� 171 Xishan Wang and Zhixun Zhao 13 Laparoscopic Left Hemicolectomy with Transanal Specimen Extraction (CRC-­NOSES VI A)��������������������������������������������������������������������������������������������������� 187 Xishan Wang and Zheng Jiang 14 Laparoscopic Left Hemicolectomy with Transrectal Specimen Extraction (CRC-­NOSES VIB)����������������������������������������������������������������������������������������������������� 205 Haipeng Chen, Zhaoxu Zheng, and Xishan Wang 15 Laparoscopic Left Hemicolectomy with Transvaginal Specimen Extraction (CRC-­NOSES VII) ����������������������������������������������������������������������������������������������������� 221 Xishan Wang, Zheng Liu, and Zhao Lu 16 Laparoscopic Right Hemicolectomy with Transvaginal Specimen Extraction (CRC-NOSES VIIIA)������������������������������������������������������������������������������������������������� 237 Xishan Wang, Xu Guan, and Haiyang Huang 17 Laparoscopic Right Hemicolectomy with Transrectal Specimen Extraction (CRC-­NOSES VIIIB)������������������������������������������������������������������������������������������������� 255 Xiyue Hu and Haitao Zhou 18 Laparoscopic Right Hemicolectomy with Transcolonic Specimen Extraction (CRC-NOSES VIIIC)������������������������������������������������������������������������������������������������� 269 Jian Peng 19 Laparoscopic Total Colectomy with Transanal Specimen Extraction (CRC-NOSES IX)������������������������������������������������������������������������������������������������������� 283 Xishan Wang and Zheng Jiang 20 Laparoscopic Total Colectomy with Transvaginal Specimen Extraction (CRC-­NOSES X)��������������������������������������������������������������������������������������������������������� 303 Xishan Wang, Zheng Jiang, and Runkun Yang 21 Transanal Total Mesorectal Excision (taTME) ������������������������������������������������������� 319 Liang Kang Part III NOSES for Gastrointestinal Cancer 22 Laparoscopic Distal Gastrectomy (Billroth I) with Transrectal Specimen Extraction (GC-NOSES I)����������������������������������������������������������������������������������������� 335 Su Yan 23 Laparoscopic Distal Gastrectomy (Billroth I) with Transvaginal Specimen Extraction (GC-NOSES II) ��������������������������������������������������������������������������������������� 345 Su Yan 24 Laparoscopic Distal Gastrectomy (Billroth II) with Transrectal Specimen Extraction (GC-NOSES III)��������������������������������������������������������������������������������������� 355 Gang Yu 25 Laparoscopic Distal Gastrectomy (Billroth II) with Transvaginal Specimen Extraction (GC-NOSES IV)��������������������������������������������������������������������������������������� 369 Gang Yu

Contents

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26 Laparoscopic Proximal Gastrectomy with Transrectal Specimen Extraction (GC-NOSES V)����������������������������������������������������������������������������������������������������������� 387 Gang Yu 27 Laparoscopic Proximal Gastrectomy with Transvaginal Specimen Extraction (GC-NOSES VI) ��������������������������������������������������������������������������������������������������������� 401 Gang Yu 28 Laparoscopic Total Gastrectomy with Transrectal Specimen Extraction (GC-NOSES VII)��������������������������������������������������������������������������������������������������������� 415 Gang Yu 29 Laparoscopic Total Gastrectomy with Transvaginal Specimen Extraction (GC-NOSES VIII)������������������������������������������������������������������������������������������������������� 431 Gang Yu 30 Robotic Gastric Tumor Resection with Transoral Specimen Extraction (GC-NOSES IX) ��������������������������������������������������������������������������������������������������������� 447 Zhiwei Jiang 31 Laparoscopic Small Intestinal Tumor Resection with Transrectal Specimen Extraction ������������������������������������������������������������������������������������������������������������������� 455 Haitao Zhou 32 Laparoscopic Small Intestinal Tumor Resection with Transvaginal Specimen Extraction ������������������������������������������������������������������������������������������������������������������� 465 Xishan Wang and Haipeng Chen Part IV Special and Extended Resection Surgery with NOSES 33 Laparoscopic Extended Lower Rectal Cancer Resection with En Bloc Lateral Lymph Node Dissection (Wang’s Approach) ����������������������������������������������������������� 475 Xishan Wang, Zhaoxu Zheng, and Haipeng Chen 34 Laparoscopic Right Hemicolectomy and Sigmoidectomy with Transvaginal Specimen Extraction��������������������������������������������������������������������������������������������������� 491 Xishan Wang and Haipeng Chen 35 Laparoscopic Right Hemicolectomy and Rectal Cancer Resection with Transrectal Specimen Extraction��������������������������������������������������������������������� 507 Guiyu Wang, Tianyi Ma, and Qian Zhang 36 Laparoscopic Rectal Cancer Resection Combined with Liver Metastasis Resection with Transanal Specimen Extraction������������������������������������������������������� 523 Chuangang Fu 37 Laparoscopic Right Hemicolectomy Combined with Pancreaticoduodenal Resection with Natural Orifice Specimen Extraction��������������������������������������������� 539 Gang Yu Part V Complications and Management of NOSES 38 Complications and Management of NOSES for Gastrointestinal Tumor������������� 559 Yinggang Chen, Yantao Tian, and Qian Liu

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Part VI Collection of Expert Experience on NOSES 39 Experience Sharing in NOSES for Colorectal Cancer ������������������������������������������� 567 Qingchao Tang, Haipeng Chen, and Xishan Wang 40 Totally Laparoscopic Colectomy for Colorectal Cancer with Natural Orifice Specimen Extraction Combined with Reduced-Port Surgery: Japanese Experience��������������������������������������������������������������������������������������������������� 587 Atsushi Nishimura, Mikako Kawahara, Yasuyuki Kawachi, Shigeto Makino, Chie Kitami, and Keiya Nikkuni 41 Laparoscopic-Assisted Natural Orifice Specimen Extraction Colectomy Using a Cai Tube for Left-Sided Colonic Carcinomas��������������������������������������������� 595 Jianchun Cai and Shuzhen Xu 42 Laparoscopic Total Colectomy Combined with NOSES: Turkish Experience����������������������������������������������������������������������������������������������������� 601 Cuneyt Kayaalp 43 Operating Points of Aseptic and Tumor-­Free Operation in NOSES for Rectal Cancer ������������������������������������������������������������������������������������������������������� 605 Chuangang Fu 44 Application of Reverse Puncture Technique to Place Anvil for Laparoscopic Colorectal Resection with NOSES����������������������������������������������������������������������������� 607 Qingsi He and Hui Qu 45 New Method of Modified NOSES I��������������������������������������������������������������������������� 615 Junhong Hu 46 Laparoscopic Resection of Tumors of Left Colon, Sigmoid Colon, and Upper Rectum with Transanal Specimen Extraction (NOSES IV and VI): Portuguese Experience������������������������������������������������������������������������������������������������������������������� 617 Joaquim Manuel da Costa Pereira and Carlos Costa Pereira 47 NOSES in Colorectal Surgery: Vietnamese Experience����������������������������������������� 623 Joel Leroy, Frederic Bretagnol, and Dan Nguyen 48 Robotic Radical Resection for Lower Rectal Carcinoma with Transanal Pullout of Rectum Eversion and Extracorporeal Resection Technique����������������� 635 Taiyuan Li and Lei Xiong 49 Application of OrVil™ and NOSES in Total Laparoscopic Gastrectomy for Female ������������������������������������������������������������������������������������������������������������������� 639 Dan Ma 50 Experience Sharing of Key Points in NOSES for Colorectal Cancer��������������������� 645 Xuejun Sun 51 Experience and Skill Sharing on NOSES in the Left and Right Colon����������������� 647 Guiyu Wang 52 Natural Orifice Specimen Extraction in Laparoscopic Anterior Resection (NOSE-­LAR): Taiwanese Experience����������������������������������������������������������������������� 651 Ming Li Leonard Ho and William Tzu-Liang Chen 53 Reduced Port Laparoscopic Anterior Resection with Transrectal Specimen Extraction and Single-Stapled Anastomosis: Taiwanese Experience��������������������� 657 Sheng-Chi Chang, Ming Li Leonard Ho, and William Tzu-Liang Chen

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54 Robotic Single Stapling Coloanal/Colorectal Anastomosis with Transanal Specimen Extraction for Anterior Resection of Rectosigmoid Tumor������������������� 661 Hongliang Yao 55 Conformal Sphincter-Preserving Operation + NOSES I (CSPO + NOSES I) for Extremely Low Rectal Cancer����������������������������������������������������������������������������� 663 Wei Zhang and Zheng Lou 56 Laparoscopic Complex NOSES Surgery of Colorectal Tumor������������������������������� 667 Yangchun Zheng and Yuanyi Rui  Appendix A: International Consensus on Natural Orifice Specimen Extraction Surgery (NOSES) for Colorectal Cancer������������������������������������������������������������������������� 673  Appendix B: International Consensus on Natural Orifice Specimen Extraction Surgery (NOSES) for Gastric Cancer (2019)������������������������������������������������������������������� 683 Postscript����������������������������������������������������������������������������������������������������������������������������� 691 Content Summary��������������������������������������������������������������������������������������������������������������� 693

Contributors

Frederic  Bretagnol High Tech Digestive Center, Saint Paul University Hospital, Hanoi, Vietnam Jianchun  Cai Department of Gastrointestinal Surgery, Zhongshan Hospital of Xiamen University, Xiamen, 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 William  Tzu-Liang  Chen Department of Colorectal Surgery, China Medical University Hsinchu Hospital, Taichung, Taiwan Yinggang  Chen Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Shenzhen Center, Shenzhen, China Joaquim  Manuel  da Costa  Pereira Department of Surgery, Hospital de Braga, Braga, Portugal Sergey  Efetov Colorectal Surgery Department, Sechenov First Moscow State Medical University, Moscow, Russia 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 Xu Guan  Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Qingsi He  Department of General Surgery, Shandong University Qilu Hospital, Jinan, China Ming Li Leonard Ho  Department of General Surgery, Sengkang General Hospital, Singapore, Singapore Haiyang  Huang Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Rui  Huang Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China Hanqing  Hu  Department of Colorectal Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China Junhong  Hu  Department of General Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China

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Xiyue Hu  Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Bo Jiang  Anal and Colorectal Surgery, Shanxi Cancer Hospital, Affiliated Cancer Hospital of Shanxi Medical University, Taiyuan, China Jun Jiang  Diagnostic Imaging Department, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Zheng  Jiang Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Zhiwei  Jiang Department of General Surgery, Jiangsu Province Hospital of Traditional Chinese Medicine, Nanjing, China Yinghu  Jin Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China Liang Kang  Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, 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 Chie Kitami  Nagaoka Chuo General Hospital, Niigata, Japan Joel Leroy  High Tech Digestive Center, Saint Paul University Hospital, Hanoi, Vietnam Taiyuan  Li Department of General Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, China Enrui Liu  Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Hengchang  Liu Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Qian Liu  Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Zheng Liu  Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Zheng Lou  Department of Colorectal Surgery, Changhai Hospital, Navy Medical University, Shanghai, China Zhao Lu  Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Chenxi Ma  Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Dan  Ma Department of General Surgery, Xinqiao Hospital, The Third Military Medical University, Chongqing, China Tianyi  Ma Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China

Contributors

Contributors

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Xiaolong  Ma Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Shigeto Makino  Nagaoka Chuo General Hospital, Niigata, Japan Dan Nguyen  High Tech Digestive Center, Saint Paul University Hospital, Hanoi, Vietnam Keiya Nikkuni  Nagaoka Chuo General Hospital, Niigata, Japan Atsushi Nishimura  Nagaoka Chuo General Hospital, Niigata, Japan Jian  Peng  Hepatobiliary and Enteric Surgery Research Center, Xiangya Hospital, Central South University, Changsha, Hunan, China Carlos Costa Pereira  Department of Surgery, Hospital de Braga, Braga, Portugal Tianyu  Qiao Department of Pancreatic Stomach Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Hui Qu  Department of General Surgery, Shandong University Qilu Hospital, Jinan, China Jichuan  Quan Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Yuanyi  Rui  Department of Gastrointestinal Surgery, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Cancer Hospital Affiliate to School of Medicine, UESTC, Chengdu, China Peng Sun  Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Shenzhen Center, Shenzhen, China Xuejun  Sun Department of General Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China Qingchao Tang  Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China Yantao  Tian  Department of Colorectal Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China Petr V. Tsarkov  Clinic of Colorectal and Minimally Invasive Surgery, Sechenov First Moscow State Medical University, Moscow, Russia Inna Tulina  Clinic of Colorectal and Minimally Invasive Surgery, Sechenov First Moscow State Medical University, Moscow, Russia Guiyu Wang  Department of Colorectal Cancer Surgery, Cancer Hospital of the University of Chinese Academy of Sciences, Hangzhou, China Meng Wang  Department of Colorectal Cancer Surgery, Cancer Hospital of the University of Chinese Academy of Sciences, Hangzhou, China Song Wang  Department of Colorectal Cancer Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China Xishan  Wang Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Lei  Xiong Department of General Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, China

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Shuzhen  Xu Department of Gastrointestinal Surgery, Zhongshan Hospital of Xiamen University, Xiamen, China Ming Yang  Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Runkun Yang  Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China Su  Yan  Department of Gastrointestinal Surgery, Affiliated Hospital of Qinghai University, Qinghai University, Xining, 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 of Shandong University (Qingdao), Qingdao, China Lei Yu  Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China Ziming Yuan  Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China Hongmei  Zhang Diagnostic Imaging Department, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Mingguang Zhang  Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Qian Zhang  Department of Colorectal Cancer Surgery, Cancer Hospital of the University of Chinese Academy of Sciences, Hangzhou, China Wei Zhang  Department of Colorectal Surgery, Changhai Hospital, Navy Medical University, Shanghai, China Zhixun  Zhao 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 Haitao  Zhou Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Meng  Zhuang Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China

Contributors

Part I General Statement

1

Overview of NOSES Xishan Wang

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. In most cases, laparoscopic surgery has replaced the conventional open surgery as a regular treatment procedure. Meanwhile, more recently, robotic surgery has been enthusiastically adopted by patients and surgeons alike. Moreover, natural orifice transluminal endoscopic surgery (NOTES) has overturned the conventional concept and pushed minimally invasive technique to the extreme of “no incision.” Furthermore, various minimally invasive techniques, and the evolved modalities of the surgical armamentarium of many different laparoscopic techniques, including 3D laparoscopic surgery, single-port laparoscopic surgery, hand-assisted laparoscopic surgery, and transanal minimally invasive surgery, are widely being used in the clinical practice. From here, we can see that the field of surgery has fully entered a new era with multiple surgical techniques and a wide variety of academic perspectives. 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 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, then present a detailed surgical monograph of NOSES. X. Wang (*) Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China

1  M  inimally 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 the 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 the 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

© People’s Medical Publishing House, PR of China 2021 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-15-7925-7_1

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X. Wang

Table 1.1  Classification of incisions

NOTES, like-NOTES, etc. Although the terminology is different, all techniques are aimed at achieving a common goal, namely the pursuit of minimally invasive effects, avoidance of abdominal wall incisions, and reduction of abdominal ≥2 cm, dysfunction. However, this complex nomenclature may con0.55; left ventricular ejection fraction  35 kg/m2).

2

 nesthesia, Patient Positioning, A Trocar Placement, and Surgical Team Position

2.1

Anesthesia Method

General anesthesia or general epidural anesthesia.

2.2

2.3

Patient Positioning

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

© People’s Medical Publishing House, PR of China 2021 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-15-7925-7_4

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The Middle Rectum

5cm

The Lower Rectum

5cm

The Upper Rectum

X. Wang et al.

5cm

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Fig. 4.1  Tumor location suitable for NOSES I

Fig. 4.2  Colonoscopy: tumors of ulcerated and protuberant type, 3–5 cm from the dentate line, maximum diameter of 3 cm

Fig. 4.3  Rectal MRI: female, T3, with tumors 2.0 cm from the dentate line, the maximum diameter of 2.7 cm

rectal operation easier, especially when the lower rectal wall 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, in the meantime, facilitates 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. 4.5).

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Fig. 4.4  The Patient’s position

2.4

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. 4.5  Trocar sites (Five-ports method)

Surgeon

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. 4.6).

2.5

Assistant

Fig. 4.6  Surgeons’ positions

Monitor

Surgical Procedures, Techniques, and Key Points

The schematic view of main surgical procedures of specimen extraction and digestive reconstruction in NOSES IA (Fig. 4.7). The schematic view of the main surgical procedures of specimen extraction and digestive reconstruction in NOSES IB (Fig. 4.8). The schematic view of main surgical procedures of specimen extraction and digestive reconstruction in NOSES IB+ (Fig. 4.9).

3.1 Scrub Nurse

Special Surgical Instruments

Ultrasonic scalpel, linear Endo-GIA stapler, Contour curved stapler, circular stapler, sterile protective sleeve.

3

Camera Holder

Surgical Team Position

Exploration and Surgical Planning

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

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Fig. 4.7  The main surgical procedures of specimen extraction and digestive reconstruction in NOSES IA

3.1.1 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 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 (Figs. 4.10 and 4.11). 3.1.2 Tumor Exploration Low rectal tumors are often undetectable under laparoscope, which is located below the peritoneal reflection (Fig.  4.12). The surgeon can perform the digital rectal examination with the right hand to rendezvous with the forceps in the left hand for determining the location and size of the tumor to confirm whether the patient is suitable for this procedure (Fig. 4.13).

3.1.3 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 (Figs. 4.14 and 4.15).

3.2

Dissection and Separation

3.2.1 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 first point of the incision should be selected at 3–5 cm below the sacral promontory. The peritoneum here is weak (especially for obese patients), where is an optimal selection as the initial dissection (Figs. 4.16 and 4.17).

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CRC-NOSES IB

Fig. 4.8  The main surgical procedures of specimen extraction and digestive reconstruction in NOSES IB

3.2.2 I solation and Ligation of Inferior Mesenteric Artery and Vein The inferior mesenteric artery and vein are exposed by retracting the mesosigmoid to the left (by the assistant). Then, a peritoneal window is created just to the left of the pedicle using blunt dissection, so that the pedicle is dissected both medially and laterally. The surgeon then applies grasping forceps to draw the pedicle ventrally, and expands the window using the tip of forceps or ultrasonic scalpel (Fig. 4.18). Meanwhile, The medial to lateral view allows the clear visibility of the left ureter, and the gonadal vessels (Figs. 4.19, 4.20, and 4.21). The connective tissue surrounding the root of the inferior mesenteric artery will be clear. Then, separate and dissect the connective tissue at the root. After being fully isolated, double ligation is performed to the inferior mesenteric artery and vein (Figs. 4.22 and 4.23). The isolated length of the root of the blood vessel should be long enough to ligate.

3.2.3 Dissection of the Mesorectum Following the transection of the inferior mesentery vessels, the assistant should gently draw the mesentery near the stump of the pedicle to the left ventral side using the grasping forceps from the left upper quadrant cannula, for the clear exposure of the operating field. Then, the dissection of sigmoid mesocolon is continued medially to lateral beneath the divided vessels until the level of the right common iliac artery (Fig. 4.24). To better identify and protect the ureter and gonadal vessels, a gauze is placed underneath the sigmoid mesocolon (Fig. 4.25). Then, the pelvic portion of the operation is ready to begin. We separate the posterior mesorectum by pushing it anteriorly. Dissection of the presacral space from the proximal to the distal is adopted. Hypogastric nerves and the distally pelvic nerve plexus are carefully identified and protected (Fig. 4.26). The presacral space between the fascia propria of the rectum and the presacral fascia is expanded by both sharp and blunt dissection

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Fig. 4.9  The main surgical procedures of specimen extraction and digestive reconstruction in NOSES IB+

Fig. 4.10  Exploration of the liver and stomach

Fig. 4.11  Exploration of the greater omentum

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Fig. 4.12  Exploration of the tumor location Fig. 4.14  Evaluate the length of sigmoid colon and thickness of mesentery

Fig. 4.13  Combination of laparoscope with digital rectal examination Fig. 4.15  Evaluate the length of the marginal vascular

Cooperating skills: The assistant needs to lift the anterior rectal wall upwards and towards the abdominal wall with forceps in the left hand, so that the complete course of rectum will be showed in the pelvic cavity. The assistant should lift 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. 4.16  The first cutting point

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Experience sharing: After cutting the mesentery, the scalpel’s head will generate heat, then push up and down with the cutter head, follow by the vision of the white cellular tissue after entering in the space anterior to Toldt’s fascia, which proves that the correct space has been entered (Fig 4.17).

Fig. 4.17  Entering the Toldt’s space

Smart usage of the small gauze: Combine the "point dissection" of ultrasonic scalpel with the "sphere dissection" of small gauze, and integrate “point and sphere” to expand the space.

Fig. 4.18  The peritoneal window is expanded by blunt dissection

together (Figs. 4.27 and 4.28). The dissection of the mesorectum proceeds distally into the pelvis to about the level of coccyx; both sides of the anal levator become visible (Fig. 4.29).

Ureter

Fig. 4.19  The left ureter is exposed

3.2.4 D  issection of the Right Side of the Rectum Based on sufficient separation of the posterior mesorectum, the dissection of right side of the rectum is much easier. The bladder (male patient) or the uterus (female patient) is lifted up ventrally using grasping forceps from the left lower quadrant cannula. The rectum also is placed to the left side of the pelvis under slight tension by the use of grasping forceps

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Smart usage of the small gauze: Place small gauze behind and on the left lateral side of theinferior mesenteric artery and vein, which can not only be served as a protective sign, but alsoprevent subtle bleeding (Fig 4.20).

Fig. 4.20  A gauze is placed on the back of mesosigmoid

Operating skills: The sigmoid mesocolon has avascular area, and is thin and transparent. Change the direction of the camera, gauzesbehind the avascular zone of sigmoid mesocolon can be observed (Fig 4.21). Gauze

Fig. 4.21  The small gauze can be clearly seen through mesosigmoid

Operating skills: The nerve bundles on both sides of the artery should be pushed as far as possible to the posteriorabdominal wall, and the anterior fascia of the abdominal aorta should not be cut open as to not damage the nerve. Inferior Mesenteric Artery

Fig. 4.22  Isolation of the root of the inferior mesenteric artery

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a

b

Fig. 4.23 (a) Ligation and transection of the inferior mesenteric artery, (b) Ligation and transection of the inferior mesenteric vein

Operating skills: The surgeon may also usepeanut gauze ball to perform blunt dissectionalong theToldt’s fascia.

Left Ureter

Common Iliac Artery

Fig. 4.24  The sigmoid mesocolon is dissected medial to lateral

Right Inferior Hypogastric Nerve

Fig. 4.25  A gauze is placed underneath sigmoid mesocolon Fig. 4.26  Right hypogastric nerves and its branches are exposed

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Fig. 4.27  The presacral space is expanded from the middle to right side

Fig. 4.28  The presacral space is expanded from the middle to left right

Operating skills: The presacral separation must be performed along the correct space. Too deepseparation may injury Levator Ani Muscles of Both Sides

presacral vein causing bleeding, while too superficial separation willlead to incomplete mesorectal excision.

Fig. 4.29  Dissection of mesorectum proceeds distally to the level of the levator ani muscles

from the left upper quadrant. Then the surgeon should dissect the right side of the rectum down to the peritoneal reflection (Fig.  4.30), and continually incise the peritoneal reflection from the right side to the left side (Fig. 4.31).

3.2.5 D  issection of the Sigmoid Colon and the Left Rectal Wall The lateral attachments of the sigmoid colon are dissected free, and the sigmoid colon is completely mobilized (Fig.  4.32). The assistant draws the sigmoid colon to the right side. The gauze over the ureter could be identified through mesosigmoid (Fig. 4.33). The dissection is then preceded laterally, the ureter and/or the gonadal vessels are identified with the great care from any possible injuries. Splenic flexure is not required to be separated in most of the

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Fig. 4.30  Dissection of the right side of rectum

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cases of lower rectal cancer resection. As the surgeon continues dissecting the left side of the rectum down to the peritoneal reflection (Figs. 4.34 and 4.35), the assistant facilitates the dissection by drawing the mesorectum to the right side of pelvic.

3.2.6 Isolation of the Bowel Below the Tumor 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 them easier to be identified and dissected. We continually separate the anterior wall of the rectum distally. 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, injury to the rectal wall should be avoided. Similarly, the mesorectum is dissected on the left side, exposing the rectal wall, and connecting the right and left resection lines posteriorly (Figs. 4.36 and 4.37).

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3.2.7 Dividing the Sigmoid Mesocolon The sigmoid colon is drawn to the left side to unfold the sigmoid mesocolon. A gauze is placed underneath the sigmoid mesocolon (Fig. 4.38). The scope of surgical resection and proposed proximal intestinal resection line is measured

The gauze behind the mesocolon

Fig. 4.33  The mesosigmoid is dissected lateral to medial

Ureter

Fig. 4.31  The peritoneal reflection is incised from right side to left side

Fig. 4.34  The left side of the mesorectum is incised from up to down

Operating skills: Do not detach the lateral adhesion band of the sigmoid colon in advance, because it can fix the sigmoid colon.

Fig. 4.32  The lateral adhesions of sigmoid colon are detached free

4  Laparoscopic Lower Rectal Cancer Resection with Transanal Specimen Extraction (CRC-NOSES IA, IB, and IB+, Eversion Method)

Experience Sharing: Strive for the dissection surfaces on both sides of the rectum to be at the same level, and be able to get connected in the posterior wall of the rectum. The surgeon should perform the digital rectal examination again to confirm that the isolated bowel is 2-3 cm length beyond the distal edge of the tumor.

Fig. 4.35  Completely opening the peritoneal reflection

Fig. 4.36  Isolation of the right side of the rectal wall Fig. 4.38  A gauze is placed underneath the sigmoid mesocolon

Levator Ani Muscle

Left Rectum Wall

Fig. 4.37  Isolation of the left side of the rectal wall Fig. 4.39  The sigmoid mesocolon is incised up to the bowel edge

visually (Fig.  4.39). The sigmoid mesocolon is incised upward until the bowel edge. The sigmoid vessels are ligated followed by dissection (Fig. 4.40). The vascular clip is not recommended to be used in the vicinity of the bowel wall. The exposed length of bowel wall of the sigmoid colon is proposed to be appropriately 2–3 cm (Fig. 4.41).

3.3

 pecimen Resection and Digestive S Tract Reconstruction

NOSES I, Method A:

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Fig. 4.40 Ligation and transection of vessels of the sigmoid mesocolon Fig. 4.42  The anvil is introduced into the bowel lumen

Anvil

Fig. 4.41  Isolation of bowel wall of the sigmoid colon Fig. 4.43  The anvil is delivered into the sigmoid colon

3.3.1 Specimen Resection Followed by gentle dilation of the anal canal, the sterile plastic sleeve is inserted into the rectum, certifying that the upper edge of the sleeve should be more than 5 cm above the upper edge of the tumor. The anvil is then introduced into the bowel lumen through the sleeve, till to the proposed resection line of the sigmoid colon (Figs. 4.42 and 4.43). Proximal bowel division is performed through the right lower quadrant cannula using a linear Endo-GIA stapler (Fig. 4.44), leaving the anvil inside of the sigmoid colon. A large clamp is reintroduced into the bowel lumen through the anal canal to grab the rectal stump and to gently evert it extracorporeally (Figs. 4.45 and 4.46). After everting the specimen out of the body, the tumor location can be clearly visible. Then, the everted rectal specimen is flushed with the cytotoxic solution (e.g., 1% povidone-iodine, 500 ml). The distal rectal resection is performed using the curved cutter stapler, certifying 1–2 cm of lower tumor margin preserved, and the specimen is then removed (Fig.  4.47). After removing the specimen, the rectum stump can be delivered back to the pelvic cavity.

Fig. 4.44  Transection of the sigmoid colon

3.3.2 Digestive Tract Reconstruction After the anal dilation, the rectal irrigation is performed with dilute iodophor solution (e.g., 1% povidone-iodine, 500 ml). Then, the center rod of the anvil head is extracted from the proximal bowel lumen (Fig.  4.48). The circular stapler is

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Operating skills: During the eversion of the specimen, the surgeon can push the specimen from the inside of the abdominal cavity toassist the specimen eversion. Clamping Position of Oval Forceps

Fig. 4.45  Specimen is transanally everted out

Fig. 4.46  Display of pelvic cavity after specimen eversion

Fig. 4.48  The center rod of the anvil head is extracted from sigmoid colon

Fig. 4.49  The circular stapler is introduced transanally Fig. 4.47  Removing the rectal specimen

NOSES I, Method B: introduced transanally and an end-to-end anastomosis is then performed with a great care, to certify the surrounding tissues not being caught in the anastomotic site (Figs.  4.49, 4.50 and 4.51).

3.3.3 Specimen Extraction Following the gentle anus dilation, proximal bowel division is performed through the right lower quadrant cannula using

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a linear Endo-GIA stapler at the isolated intended resection line in the bowel (Fig. 4.52). Povidone gauze is used to disinfect both of the stumps. A large clamp is reintroduced into the bowel lumen through the anal canal to grab the rectal stump and to gently drag it out extracorporeally (Fig. 4.53). After eversion, make an incision on the rectal wall (Fig. 4.54), then the anvil is introduced into the pelvic cavity from the incision on the rectal wall (Fig.  4.55). The everted rectal specimen is flushed extraabdominally with the cytotoxic solution (e.g., 1% povidone-iodine, 500 ml), and the distal rectal resection is performed using the curved cutter stapler with 1–2 cm lower tumor margin preserved (Figs. 4.56 and 4.57). After removal of the specimen, the rectal stump is delivered back to the pelvic cavity.

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being caught in the anastomotic site (Fig. 4.62). The integrity of the proximal and the distal rings are verified. An air test is performed to check the anastomotic leakage. Two drainage tubes of the anastomotic area are routinely performed on both sides of the pelvic cavity. For patients treated with ultralow anus preserving surgery, the anastomosis can also be reinforced and sutured through the anus. NOSES I, Method B+:

3.3.4 Digestive Tract Reconstruction Open the bowel wall of the sigmoid stump and disinfect it with iodoform gauze (Fig. 4.58). The anvil is then introduced into the bowel lumen of the sigmoid colon (Fig. 4.59). The sigmoid incision is closed with the linear Endo-GIA stapler (Fig. 4.60). The center rod of the anvil head is extracted from the proximal bowel lumen (Fig. 4.61). An end-to-end anastomosis is then performed very carefully, to certify the surrounding tissues not

Fig. 4.52  The division of sigmoid colon

Fig. 4.50  An end-to-end anastomosis is performed

Fig. 4.53  The specimen is everted transanally

Experience sharing: The 8-figure suture can be conducted in the ‘danger triangle of the anastomosis’ to reduce the incidence of postoperative anastomotic leakage (Fig 4.51).

Fig. 4.51  “Danger triangle of the anastomosis”

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Fig. 4.54  Opening the rectal wall Fig. 4.56  Fully exposure of the distal resection margin of the tumor

a

Experience sharing: This method can avoid the contact and squeeze between the anvil and the tumor, and achieve the requirements of aseptic surgery and tumor-free surgery to the greatest extent.

b

Fig. 4.55 (a) The anvil is introduced into pelvic cavity from the rectal incision, (b) The anvil is introduced into pelvic cavity from the rectal incision

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Fig. 4.60  Closing the incision on sigmoid colon wall

Fig. 4.57  Removing the specimen

Fig. 4.61  Take out the center rod of anvil

Fig. 4.58  Disinfect the incision on the wall of the sigmoid colon

Fig. 4.62  An end-to-end anastomosis is performed

Fig. 4.59  The anvil is introduced into the bowel lumen of the sigmoid colon

3.3.5 S  pecimen Resection and Digestive Tract Reconstruction Following the gently anus dilation, proximal bowel division is performed through the right lower quadrant cannula using a linear Endo-GIA stapler at the isolated intended resection

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line in the bowel (Fig. 4.63), and both of stumps were disinfected with iodoform gauze. After full anal dilation and rectal irrigation, a large clamp is reintroduced into the bowel lumen through the anal canal to grab the rectal stump and to gently drag it out extracorporeally (Figs. 4.64 and 4.65). An incision is made on the bowel wall of the everted rectal stump below the distal edge of the tumor by at least 2 cm. Then the assistant inserts the oval forceps into the pelvic cavity from the rectal incision, to hold the stump of the sigmoid colon and gently drag it out extracorporeally (Fig. 4.66). The surgeon opens the stump of sigmoid colon extracorporeally (Fig. 4.67). The anvil is then inserted into the bowel lumen of the sigmoid colon and fixed with a purse-string suture (Fig. 4.68). The stump of sigmoid colon is returned back to the pelvic cavity with the oval forceps. The rectal wall is then transected at 1–2 cm below the distal edge of tumor with the curved stapler (Fig. 4.69). The circular stapler is inserted transanally, and an end-to-end anastomosis is performed (Fig. 4.70). The “danger triangle of the anastomosis” of anastomosis should be firmly sutured (Fig. 4.71). Air test is performed to confirm the integrity of the anastomosis. The pelvic cavity should be irrigated with

normal saline, and two drainage tubes are placed through the left and right lower abdomen trocar, respectively (Fig. 4.72).

Fig. 4.63  The division of sigmoid colon is performed

Fig. 4.66  The stump of sigmoid colon is extracted through the rectal incision

Fig. 4.64  A large clamp is reintroduced into the bowel lumen

Fig. 4.67  The sigmoid colon stump is opened extracorporeally

3.3.6 Postoperative Abdominal Wall and Specimen Display (Figs. 4.73 and 4.74)

Fig. 4.65  The specimen is everted transanally

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Fig. 4.68  The anvil is fixed with a purse-string suture

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Fig. 4.71 “Danger triangle of the anastomosis” are sutured for reinforcement

Fig. 4.69  The division of lower rectum is performed Fig. 4.72  The drainage tube is placed

Fig. 4.70  An end-to-end anastomosis is performed Fig. 4.73  The display of abdominal wall

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 tandard of Rectal Segmentation S and Concept of Low and Ultralow Anastomosis in Anus-Preserving Surgery

At present, the standards of rectal segmentation are not consistent. The traditional segmentation method is based on the peritoneal reflection, which divides the rectum into upper and lower segments; because the peritoneum covers the upper half or third of the rectum, according to the relationship between the peritoneum and the rectum, the rectum can also be divided into intraperitoneal rectum and extraperitoneal rectum. The distances from anterior peritoneum reflection to the anal margin for the male and female are 7–9 cm and 5–7.5  cm, respectively. Surgeons are more concerned about the anus-­preserving problem of rectal cancer. Usually, the rectum can be divided into the upper rectum 10–15 cm, the middle rectum 6–10  cm and the lower rectum 3–6  cm according to the distance from the lower edge of the tumor to the anal margin. The lower third of the rectum is customarily defined as the lower rectum, and another more intuitive method is that the lower rectum is the palpable part during the digital rectal examination. The author here recommends that the rectal segmentation as well as the low and ultralow anastomosis is judged by the dentate line as a constant anatomical landmark, which is the junction of endoderm and ectoderm of the primitive rectum at the embryonic stage. The dentate line and the range of about 1.5 cm above it are of great significance for the function of controlling the stool. Unified judgment criteria are

Fig. 4.74  The display of rectal specimen

The Upper Rectum

The Middle Rectum

The Lower Rectum

5cm

4.1

not only convenient for measurement, but also for collaboration among hospitals to summarize statistical analysis data. The specific rectal segmentation recommendations are as follows: within 5 cm from the dentate line as the lower rectum, from 5 to 10  cm from the dentate line as the middle rectum, and above 10 cm from the dentate line as the upper rectum (Fig. 4.75). Similarly, using the dentate line as a reference standard, we have proposed the concepts of low and ultralow anastomosis in anus preserving surgeries for rectal cancer, which means that the anastomosis positions are 2–5 cm and within 2 cm above the dentate line, respectively (Fig. 4.76). Of course, although the sign of the dentate line is constant, it does not exist on the body surface, so the surgeon is required to gently expose the dentate line with the anal retractor to observe the anastomosis so that the anastomosis

5cm

 ey Points, Difficulties, and Hotspots K Related to Surgery

5cm

4

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Dentate Line

Fig. 4.75  Rectal segmentation

Fig. 4.76  Schematic diagram of low and ultralow anastomosis of rectum

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can be checked for exactness and also the position of the anastomosis can be accurately determined. Generally, for upper and middle rectal cancer, anal sphincter preserving surgery can be performed. However, for rectal cancer less than 5 cm from the dentate line, whether performing anus-­ preserving surgery depends on the specific conditions of the patient, such as the height, weight, gender, pathological type, local invasion condition and other factors, which are not easy to be determined before surgery, and only can be judged scientifically and rationally by detailed preoperative ­examinations and evaluation. Even so, sometimes the specific surgical method for the patient is still needed to be determined during the surgery.

4.2

 echnique Application of Artery T “Vascular Bridging” on the Rectum in Low and Ultralow Anastomosis Anus-Preserving Surgeries for Rectal Cancer

The blood supply of the anastomosis during radical surgery of rectal cancer is an important factor affecting the anastomosis healing. During the digestive tract reconstruction after radical surgery of rectal cancer, changes will happen in the blood supply of the distal and proximal intestinal canals. It is important to determine whether the superior rectal artery should be preserved to provide sufficient blood supply to anastomosis during the operation. The change of the blood supply of the bowel is closely related to the surgeon’s operations and anatomy of mesentery vascular. The blood supply of the colorectal wall comes directly from the marginal vessels. Protection of the marginal vessels is the key to determining the blood supply for the bowel. Among them, the Sudeck’s point between the lowermost branch of the sigmoid artery and the superior rectal artery is a key point that should be paid special attention during radical resection of rectal cancer. Techniques of the artery “vascular bridging” on the rectum: When dissecting the lymph nodes at the root of the inferior mesenteric artery, ligate at the root of the inferior mesenteric artery inside the vascular sheath, isolate the ­superior rectal artery, and ligate the superior rectal artery at the point above the lowermost branch of the sigmoid artery to preserve the anastomotic branches between superior rectal artery, its branches, and the sigmoid marginal vessels, achieving the purpose of “vascular bridging” with superior rectal arteries, which ensure the blood supply for the proximal bowel of the anastomosis (Fig.  4.77). The superior rectal artery “vascular bridging” technique is safe and feasible during radical resection of rectal cancer,

Fig. 4.77  Display of artery vascular bridging on the rectum

which can effectively solve the problem of anastomotic blood supply failure caused by the discontinuity in the marginal vessel during the digestive tract reconstruction. For the low rectal cancer patient with the long bowel and short marginal vessels, the probability of anus preservation may be increased.

4.3

 ros and Cons of Diverting Stoma P During Ultralow Anus-Preserving Surgery

Anastomotic leakage is one of the most serious complications in low and ultralow rectal anastomosis anus-preserving surgeries. Diverting stoma can keep the rectal anastomosis relatively clean, reduce the pressure in the intestinal canal to protect the anastomosis and reduce the incidence of anastomotic leakage. However, determinants of anastomotic leakage mainly include blood supply, tension, local infection, and nutritional status of the whole body. Diverting stoma do not fundamentally change these factors. In addition, the diverting stoma itself may also have various complications, such as fistula retraction, stoma hernia, infection, necrosis, etc. In addition, the patient with diverting stoma needs to undergo a second operation for stoma reversal, for which risks of complications such as anastomotic leakage, ­intestinal obstruction, and incision infection still exist. This increases the patient’s surgical trauma and medical costs to a certain extent. According to the author’s experience, regular diverting stoma on terminal ileum or transverse colon is not recommended for patients who underwent low and ultralow rectal anus-preserving surgeries. Only patients with the high-risk

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factors possibly causing postoperative anastomotic leakage, such as preoperative long-term intestinal obstruction leading to bowel edema, extremely poor nutritional status, severe systemic infection, severe intestinal congestion and edema caused by neoadjuvant radiotherapy before surgery and other

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conditions, diverting stoma can be selectively performed. At the same time, for patients undergoing stoma, anal dilation or rectal irrigation should be given regularly to keep the intestine irritated and avoid anastomotic stenosis due to disuse, or intestinal closure for scar formation.

5

Laparoscopic Ultralow Rectal Cancer Resection with Transanal Specimen Extraction: Park Method (CRC-NOSES IC) Xishan Wang, Yinghu Jin, and Zheng Jiang

X. Wang (*) · Z. Jiang Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Y. Jin Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China

1  Indications and Contraindications of NOSES 1.1  Indications (Figs. 5.1, 5.2 and 5.3)

Middle Rectum

5 cm

Upper Rectum

5 cm

1 . Lower rectal tumor or benign tumor. 2. The extent of invasion is more than 1/2 of the rectal circumference, which makes it hard for the specimen to be everted out of the anus. 3. Protuberant type tumor and the circumferential diameter of the tumor should be less than 3 cm. 4. The distance from the distal edge of the tumor to the dentate line should be 2–3 cm.

Lower Rectum

5 cm

The special anatomical location of lower rectal cancer makes anus preserving surgery more challenging. At present, the double stapling technique is usually used in the anastomosis for rectal cancer, which increases the chance of anus preservation. However, due to the limitation of the size of stapler, it is difficult for the stapler to transect and close the rectum at the level of the pelvic floor muscle surface for obese patients or patients with a narrow pelvis. Parks proposed transabdominal resection for rectal cancer with transanal coloanal anastomosis in 1982. Many scholars have confirmed that this approach provides anus preserving opportunity for more rectal cancer patient without affecting the long-term efficacy. It also makes up for the deficiency of double stapling technique in anus preserving surgery for lower rectal cancer. NOSES IC, i.e., laparoscopic ultralow rectal cancer resection with transanal specimen extraction and single-layer sigmoid-anal anastomosis, is not only a sublimation of the traditional Parks procedure but also an improvement of the theoretical system of NOSES for the lower rectum. The characteristics of this procedure are distinct: (1) Under the premise of ensuring the radical resection of rectal cancer, this procedure gives full play to the minimally invasive advantage of NOSES with small postoperative injury, light pain, and quick recovery; (2) In the transanal specimen extraction and manual single-layer sigmoid-anal anastomosis, both ends are sutured with absorbable sutures. The good tissue compatibility of absorbable suture reduces the disadvantage of poor tissue compatibility of the staple, thereby reduce the anastomotic inflammatory reaction and reduce the possibility of anastomotic stenosis. (3) This procedure can protect the internal and external anal sphincter to the greatest extent to preserve the anal function and ensure the postoperative bowel control function.

Fig. 5.1  Tumor location suitable for NOSES I

© People’s Medical Publishing House, PR of China 2021 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-15-7925-7_5

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Fig. 5.2  Colonoscopy: Tumors of ulcerated and protuberant type, 3–5 cm from the dentate line, maximum diameter of 2.5 cm

1.2  Contraindications 1 . Patients with severe local tumor infiltration. 2. Circumferential diameter of the tumor is more than 3 cm, which makes it hard to be extracted through the anus. 3. Mucinous adenocarcinoma or signet ring cell carcinoma, with uncertain distal resection margin status. 4. Severely obese patients (BMI > 35 kg/m2).

2  A  nesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position 2.1  Anesthesia Method General anesthesia or general epidural anesthesia.

2.2  Patient Positioning 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).

2.3  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

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

rectal operation easier, especially when the lower rectal wall 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, in the meantime, facilitate 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).

2.4  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. 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).

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

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Fig. 5.4  The patient’s position

3.1  Exploration and Surgical Planning

Surgeon's Auxiliary Trocar (5 mm)

Camera Trocar (10 mm)

Surgeon's Main Trocar (12 mm)

Based on the detailed preoperative examination and surgical plan discussion, surgical exploration mainly includes three steps: Assistant's Main Trocar (5 mm) Assistant's Auxiliary Trocar (5 mm)

Fig. 5.5  Trocar sites (Five-ports method)

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

3.1.1 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). 3.1.2 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.

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a

b

Monitor

Camera Holder

Surgeon

Assistant Assistant

Scrub Nurse Monitor

Scrub Nurse

Assistant

Surgeon

Fig. 5.6 (a) Surgeons’ positions (Abdominal operation); (b) Surgeons’ positions (Perineal operation)

CRC-NOSES IC

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

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Fig. 5.10  The first cutting point of the incision Fig. 5.8  Exploration of the pelvic cavity

Fig. 5.11  Entering the Toldt’s space Fig. 5.9  The surgical field is fully exposed

3.1.3 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.

3.2  Dissection and Separation 3.2.1 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 upwards 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).

3.2.2 I solation 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 (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 upwards, which could prevent additional injury to surrounding tissues.

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Fig. 5.12  Exposure of the inferior hypogastric nerves

Fig. 5.13  Dissection to the root of the inferior mesenteric artery

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Fig. 5.15  Isolation of the inferior mesenteric artery

Fig. 5.16  Ligation and transection of the inferior mesenteric artery

Fig. 5.14  Dissection of lymph nodes at the root of mesentery

Fig. 5.17  Exposure of the inferior mesenteric vein

3.2.3 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 downwards 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 downwards along with the space (Fig. 5.23).

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Fig. 5.18  Ligation and transection of the inferior mesenteric vein

Fig. 5.19  Dissection of the sigmoid mesocolon downwards from medial to lateral

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Fig. 5.21  Blunt dissection with gauze

Fig. 5.22  Placing gauze underneath the mesentery

Fig. 5.23  Dissection downwards along the Toldt’s fascia Fig. 5.20  Exposure and protection of ureters and gonadal vessels

3.2.4 D  issection 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. 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 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. 5.24  Dissection of the right rectal wall

Fig. 5.25  Dissection of the posterior rectal wall

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Fig. 5.27  The peritoneal reflection is incised from right side to left side

Fig. 5.28  The peritoneum on the left of mesocolon is opened

Fig. 5.26  Dissection of the posterior rectal wall

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

3.2.5 D  issection of the Sigmoid Colon, the Left and the Anterior Rectal Wall The lateral attachments of the sigmoid colon are dissected free, and 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 upwards and downwards sufficiently (Figs. 5.29 and 5.30). Dissect the left side of the rectum downwards 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. 5.30  The left side of the mesocolon is dissected downward

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Fig. 5.33  The dissection of the anterior rectal wall

Fig. 5.34  Isolation of the bowel wall below the tumor Fig. 5.31  The left side of the peritoneal reflection is opened

Fig. 5.35  A gauze is placed underneath the sigmoid mesocolon

Fig. 5.32  The anterior rectal wall is dissected downward

3.2.6 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. 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. 5.36  Dividing the sigmoid mesocolon

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Fig. 5.39  Transection of the sigmoid colon

Fig. 5.37  Ligation of vessels within the sigmoid mesocolon Fig. 5.40  Disinfection of the rectal lumen with iodoform gauze

Fig. 5.38  Isolation of bowel wall of sigmoid colon

3.3  S  pecimen Resection and Digestive Tract Reconstruction

Fig. 5.41  Incision of the rectal wall above the dentate line

3.3.1 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 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

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Fig. 5.44  Full-thickness suture of reserved sutures to anal stump Fig. 5.42  The distal resection margin could be clearly exposed under direct vision

Fig. 5.43  Transanal extraction of rectal specimen

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

resection margin can be determined under direct vision to ensure the 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).

3.3.2 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

Fig. 5.46  Stitch by stitch reinforcement and suture of anastomosis

sutures, respectively, and perform full-thickness suture of 2–3 stitches between the two sutures for 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 single-layer sigmoid-anal end-to-end anastomosis (Fig. 5.47).

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Fig. 5.47  Inspection of anastomotic integrity

Fig. 5.48  Display of abdominal wall after operation

3.4  Postoperative Abdominal Wall and Specimen Pictures (Figs. 5.48 and 5.49) (Xishan Wang, Ma Chenxi, Xu Guan)

4  K  ey Points, Difficulties, and Hotspots Related to Surgery 4.1  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, etc. Parks proposed transabdominal resection of rectal cancer with transanal coloanal anastomosis. The main steps of this

Fig. 5.49  Display of specimen

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 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. 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

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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 short-term problem for patients’ status after the Parks procedure. 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 sphincter preserving 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. (Wang Xishan, Tianyu Qiao, Xu Guan)

4.2  F  our-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,

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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. (Xishan Wang, Ming Yang, Xu Guan)

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

X. Wang (*) · Z. Jiang Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China

1  Indications and Contraindications of NOSES 1.1  Indications (Figs. 6.1, 6.2 and 6.3)

Middle Rectum

5 cm

Upper Rectum

5 cm

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-well differentiated adenocarcinoma.

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 the key to the accurate completion of the procedure. The operating characteristics of NOSES ID are Intersphincteric transection 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 ultra-low 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.

Fig. 6.1  Tumor location suitable for NOSES I

M. Wang Department of Colorectal Cancer Surgery, Cancer Hospital of the University of Chinese Academy of Sciences, Hangzhou, China © People’s Medical Publishing House, PR of China 2021 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-15-7925-7_6

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2  A  nesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position 2.1  Anesthesia Method General anesthesia or general epidural anesthesia.

2.2  Patient Positioning 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).

2.3  Trocar Placement Fig. 6.2  Colonoscopy: Tumors of protuberant type, 2–4 cm from the dentate line, maximum diameter of 2 cm

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

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

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 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, in the meantime, facilitate 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).

2.4  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. 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).

2.5  Special Surgical Instruments Ultrasonic scalpel, Electric scalpel with needle electrode, anal retractor.

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Fig. 6.4  The Patient’s position

3.1  Exploration and Surgical Planning

Surgeon’s Auxiliary Trocar (5 mm)

Camera Trocar (10 mm)

Surgeon’s Main Trocar (12 mm)

Based on a detailed preoperative examination and surgical plan discussion, the exploration mainly includes three steps: Assistant’s Main Trocar (5 mm) Assistant’s Auxiliary Trocar (5 mm)

Fig. 6.5  Trocar sites (Five-ports method)

3  S  urgical 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).

3.1.1 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). 3.1.2 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).

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a

b

Monitor

Camera Holder

Assistant

Surgeon

Assistant

Scrub Nurse Monitor

Scrub Nurse

Assistant

Surgeon

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

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Fig. 6.8  Exploration of the liver

Fig. 6.10  Exploration of the tumor

Fig. 6.9  Exploration of the pelvic cavity

Fig. 6.11  Exploration of the sigmoid mesocolon

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3.1.3 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.

3.2  Dissection and Separation 3.2.1 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 towards 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 start dissection with an ultrasonic scalpel. Along the course

Fig. 6.12  Adequate exposure of the root of the mesentery

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).

3.2.2 I solation 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 mesentery, the surgeon may apply the scalpel to hold the gauze to

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Fig. 6.13  The first cutting point of the incision

Fig. 6.16  Exposure and protection of the inferior hypogastric nerve

Fig. 6.14  Entering the Toldt’s space

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

Fig. 6.15  Dissection downward along the Toldt’s fascia

Fig. 6.18  Ligation of the inferior mesenteric artery

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).

3.2.3 Dissection of the Mesorectum The surgeon further separates the sigmoid mesocolon downwards 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 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

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Fig. 6.19  Ligation of the inferior mesenteric vein

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

Fig. 6.23  Dissection along the presacral space

Fig. 6.20  Exposure and protection of ureters

Fig. 6.21  Placing a gauze underneath the mesentery

excision. Dissect downwards 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).

Fig. 6.24  Exposure of the inferior hypogastric nerves

3.2.4 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

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Fig. 6.25  Dissection downwards to the level of the coccyx

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

Fig. 6.26  Display of levator ani muscles of both sides

3.2.5 D  issection 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 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 upwards and downwards sufficiently (Fig.  6.30) When dissecting upwards, most cases do not require to mobilize splenic flexure, then dissect the left side of the rectum downwards to the peritoneal reflection and join with the right side (Fig. 6.31). 3.2.6 Isolation of the Mesorectum Separate downwards 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.

Fig. 6.27  Dissection of the right rectal wall

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).

3.2.7 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

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

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Fig. 6.33  Isolation of the right rectum wall

Fig. 6.30  The peritoneum on the left of mesocolon is opened Fig. 6.34  A gauze is placed underneath the sigmoid mesocolon

Fig. 6.31  The left side of the mesocolon is dissected downward Fig. 6.35  Ligation of vessels of sigmoid mesocolon

Fig. 6.32  Dissection of the anterior rectal wall

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 EndoGIA stapler (Fig. 6.37).

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Fig. 6.36  Isolation of the wall of sigmoid mesocolon

Fig. 6.38  Opening the rectal wall

Fig. 6.37  Transection of the proximal sigmoid colon

Fig. 6.39  Opening the lateral rectal wall

3.3  I ntersphincteric Specimen Resection and Digestive Tract Reconstruction 3.3.1 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 rectal wall is incised circumferentially (Fig.  6.38). Afterward, dissection is performed upwards 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. 3.3.2 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

Fig. 6.40  Opening the anterior rectal wall

there is no bleeding and perform local disinfection (Fig. 6.44). Place two drainage tubes in the pelvic cavity and close the trocar incisions.

3.4  Postoperative Abdominal Wall and Specimen Pictures (Figs. 6.45 and 6.46) (Xishan Wang, Xiaolong Ma, Qingchao Tang)

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Fig. 6.41  Transanal specimen extraction

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Fig. 6.44  Inspection of anastomosis

Fig. 6.42  Opening of the sigmoid colon stump

Fig. 6.45  Display of abdominal wall after operation

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

4  K  ey Points, Difficulties, and Hotspots Related to Surgery 4.1  Precautions for NOSES ID

Fig. 6.46  Display of specimen

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 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 promon-

tory, 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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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. 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 over isolated. 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 intra-corporeally and extra-corporeally. 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 downwards 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.

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 for the pathological examination should be performed if necessary. 2. 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. 3. 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. 4. 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.

(Xishan Wang, Hanqing Hu, Qingchao Tang)

4.2  P  roblems in Conventional Laparoscopic Surgery 1. Limitations of exploration. Conventional laparoscopic exploration of occult sites in the abdominal and pelvic

Fig. 6.47  Separated resection of lymph nodes

6  Laparoscopic Ultralow Rectal Cancer Resection with Transanal Specimen Extraction: Intersphincteric Resection Method…

5. 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

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Fig. 6.48  Gauze is put in the protective sleeve and removed along with specimen

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.

7

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

B. Jiang (*) · Y. Feng Anal and Colorectal Surgery, Shanxi Cancer Hospital, Affiliated Cancer Hospital of Shanxi Medical University, Taiyuan, China

1  Indications and Contraindications of NOSES 1.1  Indications (Figs. 7.1, 7.2 and 7.3)

Middle Rectum

5 cm

Upper Rectum

5 cm

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.

Lower Rectum

5 cm

NOSES IE is mainly applicable to patients with lower rectal cancer who have a large circumference of invasion. As with conventional laparoscopic radical resection of rectal cancer, this method should also strictly follow the principles of total mesorectal excision (TME). There is no difference in extent of resection and lymph node dissection between the two methods. The main differences between conventional laparoscopic surgery and NOSES IE are digestive tract reconstruction and specimen extraction. The operation characteristics of NOSES IE are to prolapse the rectum from the anus, remove the rectum specimen extracorporeally, suture and fix the excess rectum to the perianal, remove the redundant rectum and finally complete anoplasty after the perianal is healed at 2–3 weeks. 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 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; 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 non-touch 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.

Fig. 7.1  Tumor location suitable for NOSES I

© People’s Medical Publishing House, PR of China 2021 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-15-7925-7_7

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Fig. 7.4  The patient’s position

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

2  A  nesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position 2.1  Anesthesia Method General anesthesia with or without epidural anesthesia.

2.2  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).

2.3  Trocar Placement

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

1.2  Contraindications 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). 5. Local inflammation is serious in patients with rectovaginal fistula.

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).

2.4  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

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

3.1  Exploration and Surgical Planning

2.5  Special Surgical Instruments

3.1.1 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).

Ultrasonic scalpel, Electric scalpel with needle electrode, anal tractor.

3  S  urgical 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).

Surgeon's Auxiliary Trocar (5 mm)

Camera Trocar (10 mm)

Surgeon's Main Trocar (12 mm)

3.1.2 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). 3.1.3 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).

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

3.2  Dissection and Separation 3.2.1 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

Fig. 7.5  Trocar sites (Five-ports method)

a

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

b

Camera Holder

Monitor

Assistant

Surgeon

Assistant

Scrub Nurse Monitor

Scrub Nurse

Assistant

Surgeon

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

roots of the inferior mesenteric vessels. The assistant needs to lift the anterior rectal wall towards 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).

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Toldt’s Fascia

Gerota’s Fascia

Fig. 7.10  Location of inferior mesenteric vessels and iliac vessels

Fig. 7.11  Assessment of mesenteric length

Fig. 7.13  Entry of the space above Toldt’s fascia

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

3.2.2 I solation 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 mes-

enteric vessels at the root of the intended resection line with an ultrasonic scalpel (Figs. 7.14, 7.15, 7.16 and 7.17).

3.2.3 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

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Gonadal vessels Ureter

Fig. 7.16  Ligation of the inferior mesenteric artery

Fig. 7.19  Exposure and protection of ureter and gonadal vessels

Fig. 7.17  Ligation of the inferior mesenteric vein

Fig. 7.20  Protection of left inferior hypogastric plexus

Fig. 7.18  Opening the avascular area of sigmoid mesocolon

Fig. 7.21  Display of bilateral inferior hypogastric nerves

identified and protected (Fig.  7.19). The surgeon should ­continue dissecting downwards 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 (Fig. 7.20, Fig. 7.21). The presacral space needs to be further expanded in combination with the dissection in the left and right sides of the rectum.

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

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Fig. 7.22  Dissection of the right rectal wall

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

Fig. 7.25  The peritoneum on the left of mesocolon is opened Fig. 7.23  The peritoneal reflection is incised from right side to left side

3.2.5 D  issection 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 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 upwards (Fig. 7.26). Dissect the left side of the rectum downward to the peritoneal reflection and join with the right side (Fig. 7.27). 3.2.6 Dissection of the Posterior Wall of the Rectum The surgeon should dissect downwards 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

Fig. 7.26  Separation of mesocolon upward

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. 7.27  Separation of mesocolon downward

Fig. 7.28  Cutting off the sacrorectal ligament

B. Jiang and Y. Feng

Fig. 7.30  Cutting off the sacrococcygeal ligament

Fig. 7.31  Dissection of the anterior rectal wall (male)

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). Fig. 7.29  Dissection of presacral space

3.2.7 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

3.2.8 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 line is measured visually. After the extent of division is determined, the mesentery is continuously dissected till to

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

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

Right neurovascular bundle

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

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.

Left neurovascular bundle

Fig. 7.34  Cutting off the left neurovascular bundle

3.2.9 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, dissect upward

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Fig. 7.40  Pursing string suture Fig. 7.37  Dividing the sigmoid mesocolon

Fig. 7.41  Cut off the rectal wall

Fig. 7.38  the anus is clearly explored

Fig. 7.39  Disinfection with iodoform cotton ball

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 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. 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).

3.2.10 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

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

a

b

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

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Fig. 7.48  Anus after the anoplasty is completed Fig. 7.46  Full exposure of perineum

Fig. 7.47  Extracorporeal excision of the rectum

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 be excessive eversion so as to avoid mucosa necrosis or mucosa prolapse (Fig. 7.48).

3.3  Postoperative Abdominal Wall and Specimen Display (Figs. 7.49 and 7.50)

4  K  ey Points, Difficulties, and Hotspots Related to Surgery

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

4.1  Indications of NOSES IE

4.2  L  aparoscopic Exposure to the Lowest Realignment Plane of the Pelvic Cavity and the Use of Surgical Instruments and Materials

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 diam-

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

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Fig. 7.49  Display of postoperative specimen

are exposed, the assistant should clamp the esophageal band with duck-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, avoid 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.

Fig. 7.50  Display of postoperative abdominal wall

4.3  T  ransanal and Pelvic Free Plane Meeting Operation and Aseptic and Tumor-Free Operation

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 towards 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

1. Firstly, the dentate line can be exposed by radial everting suture of the anal canal with a 0–0 mersilk suture. Generally, 4 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 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 intesti-

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nal 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.

4.4  Prediction and Management of Postoperative Complications 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 maybe two reasons for this complication.

B. Jiang and Y. Feng

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.

4.5  T  he 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

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 (NOSES Ia, Ib, Ic, Id, Ie). 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 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. This modification of NOSES I procedure decreases the chance of abdominal contamination caused by intra-abdominal bowel division. 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 (Fig. 8.1) 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 cavity. With no intra-abdominal bowel division, the risk of abdominal cavity contamination is minimized.

S. Efetov Colorectal Surgery Department, Sechenov First Moscow State Medical University, Moscow, Russia

a

b

Fig. 8.1 (a) The outline of mobilization of the rectum, the fixation of spe- cial instrument. (b) pulling out the rectum through the anus with eversion

1  Indications and Contraindications 1.1  Indications (Fig. 8.2) 1 . Tumor is located in the middle or lower rectum; 2. Localized tumor, prolapsing into the lumen; 3. Tumor diameter less than 3 cm; 4. The distance from the lower tumor margin to the dentate 3–5 cm.

I. Tulina · P. V. Tsarkov (*) Clinic of Colorectal and Minimally Invasive Surgery, Sechenov First Moscow State Medical University, Moscow, Russia © People’s Medical Publishing House, PR of China 2021 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-15-7925-7_8

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Upper Rectum

5 cm

Middle Rectum

5 cm

1.2  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)

Lower Rectum

5 cm

2  A  nesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position 2.1  Anesthesia Method General anesthesia with or without epidural component

2.2  Patient Positioning Fig. 8.2  Tumor location suitable for NOSES IF

Fig. 8.3  Patient’s position

Modified lithotomy position with right thigh a little flat (Fig. 8.3).

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Camera Holder

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)

Assistant

Surgeon

Scrub Nurse

Fig. 8.4  Trocar placement (five-port method) Monitor

2.3  Trocar Placement (Fig. 8.4) 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.

2.4  Surgical Team Position The operating surgeon stands on the right side of the patient, the assistant surgeon stands on the left side of the patient, and the camera holder stands on the same side of surgeon, to his left (Fig. 8.5).

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

Fig. 8.5  Surgical team position

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

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

3.1.1 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. 3.1.2 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 determination of the tumor location, size, and the depth of tumor invasion (Fig. 8.7).

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

3.1.3 A  djusted 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.

3.2  Dissection and Separation

Fig. 8.7  Intraoperative examination of tumor size and localization

3.2.1 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

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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

used to retract and protect the small bowel and to ensure access to the inferior mesenteric artery (Fig. 8.8). 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 (Fig. 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

3.2.2 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

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Gerota’s fascia. Skeletonization of the inferior mesenteric 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.

3.2.3 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.

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

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Proceeding the dissection distally, total mesorectal excision is started. It is recommended to start separating 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.

3.2.4 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. 3.2.5 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

Experience sharing: To attain a more accurate pathology report on the status of apical lymph nodes, the connective tissue from the zone around the inferior mesenteric artery root can be removed and studied separately from the main 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

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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.

3.2.6 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. 3.2.7 P  roximal 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.

3.3  R  ectal Resection and Digestive Tract Reconstruction 3.3.1 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

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

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

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 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).

3.3.2 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.

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

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

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

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 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-to-end 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

Fig. 8.20  Closing the rectal stump

abdomen. The purse-string suture is performed at the rectal 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 purse-­ string suture is closed around it (Fig. 8.20).

3.3.3 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 anasto-

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

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

3.4  Final View of Abdomen (Fig. 8.25)

Fig. 8.23 Colorectal anastomosis is performed using a circular stapler

4  Robotic NOSES Operation

mosis is formed (Fig. 8.23). It is important to prevent fatty tissues or other structures from getting caught in the anastomotic site. 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.

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. In our practice, we widely use these two advanced technologies. Both the advantages and disadvantages of robotic technologies in colorectal surgery are well known. Robotics allows to use the instruments with higher number of freedom degrees, to eliminate tremor, and to

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Trocar D (12 mm)

Trocar E (8 mm) Assistant

Robotic cart

Trocar C (8 mm)

Scrub Nurse

Fig. 8.26  Trocars positioning for robotic rectal resection

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, 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.

4.1  T  rocar 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

Fig. 8.27  The patient console positioning

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

2. Trocar B for a third robotic hand (8 mm): 4 cm lower and 2 cm to the right of the xiphoid process 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.

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

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

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

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Laparoscopic Middle Rectal Cancer Resection with Transanal Specimen Extraction (CRC-NOSES II)

1  Indications and Contraindications of NOSES 1.1  Indications (Figs. 9.1, 9.2, and 9.3) 1 . Middle rectal tumor or benign tumor. 2. The circumferential diameter of tumor is better less than 3 cm. 3. The tumor should not invade beyond the serosa.

X. Wang (*) · Z. Zhao Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Z. Yuan Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China

Middle Rectum

Lower Rectum

5 cm

Upper Rectum

5 cm

NOSES II is mainly applicable to patients with small tumors located in the middle rectum. As with conventional laparoscopic radical resection of rectal cancer, NOSES II should strictly follow the principles of total mesorectal excision (TME). Anatomy and dissection should be performed in the correct plane, which is a prerequisite for the rapid and safe operation. The main operating procedures of NOSES II include transanal rectal extraction, removal of rectal specimen extracorporeally, and totally laparoscopic end-to-end anastomosis between the sigmoid colon and rectum. The operating characteristics of NOSES II include (1) opening bowel lumen intracorporeally and (2) rectal tumor specimen extraction through the rectum and anus. This procedure requires closer cooperation between the surgeon and assistant during the operation. In addition, the aseptic and tumor-­ free techniques must be strictly practiced. NOSES II not only ensures the effect of radical cancer resection but also reduces the damage to organs and tissues. Therefore, this is an ideal procedure that is fully satisfying the requirements of functional surgery.

5 cm

Xishan Wang, Ziming Yuan, and Zhixun Zhao

Fig. 9.1  Tumor location suitable for NOSES II

1.2  Contraindications 1 . The tumor is too large to be pulled out through the anus. 2. The sigmoid colon and mesentery are too short to be pulled out through the anus. 3. The mesorectum is too thick to be pulled out through the anus. 4. Severely obese patients (BMI > 35 kg/m2).

2  A  nesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position 2.1  Anesthesia Method General anesthesia or general epidural anesthesia.

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Fig. 9.2  Colonoscopy: tumor of protuberant type, the tumor is located 8 cm from the dentate line, the maximum diameter is 4.5 cm before radiotherapy, and the lesion obviously shrinks into scar tissue after radiotherapy

Fig. 9.3  Rectal MRI: T2, 9.2 cm from the dentate line, maximum diameter of 2.3 cm

2.2  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. 9.4).

2.3  Trocar Placement 1. Camera trocar (10  mm trocar) is located just above the umbilicus.

2. The surgeon’s main trocar (12 mm trocar) is better located at the McBurney’s point. 3. The surgeon’s auxiliary trocar (5 mm trocar) is located at 5 cm above the intersection of the umbilicus level and the right midline. 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 at the umbilicus level at the lateral edge of the left rectus abdominis (Fig. 9.5).

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Fig. 9.4  The patient’s position

Camera Holder Surgeon’s Auxiliary Trocar (5 mm)

Camera Trocar (10 mm)

Surgeon’s Main Trocar (12 mm)

Assistant’s Main Trocar (5 mm)

Assistant

Surgeon

Assistant’s Auxiliary Trocar (5 mm)

Fig. 9.5  Trocar placement (five-port method)

2.4  Surgical Team Position The positions of the surgeon, assistant, and camera holder should be on the right side, the left side, and the same side of the surgeon, respectively (Fig. 9.6).

Scrub Nurse Monitor

Fig. 9.6  Surgical team position

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

3  S  urgical Procedures, Techniques, and Key Points The schematic view of main surgical procedures of specimen extraction and digestive reconstruction in NOSES II (Fig. 9.7).

3.1  Exploration and Surgical Planning 3.1.1 General Exploration On the basis of detailed preoperative examination, the liver, gallbladder, stomach, spleen, colon, small intestine, greater omentum, and pelvic cavity are examined for the presence of tumor seeding or ascites (Figs. 9.8 and 9.9).

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3.1.2 Tumor Exploration The middle rectal cancer is often located around the peritoneal reflection (Fig. 9.10). 3.1.3 Evaluation of Anatomical Structures It is necessary for the surgeon to check the length of the sigmoid colon, the length of mesenteric vessels, as well as the thickness of the middle mesorectum, so as to evaluate the feasibility of transanal specimen extraction (Fig. 9.11).

3.2  Dissection and Separation 3.2.1 The First Point of the Incision The patient is placed in the head down position (Trendelenburg position), and the small intestine is moved to the upper abdomen in order to expose the entire pelvic cavity and the roots of the inferior mesenteric vessels. The surgeon performs the first incision at the thin area 3–5 cm below the sacral promontory (Fig. 9.12).

CRC-NOSES II

Fig. 9.7  The main surgical procedures of specimen extraction and digestive reconstruction in NOSES II

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3.2.2 I solation and Ligation of the Root of the Inferior Mesenteric Artery and Vein The mesorectum is lifted for the dissection of the root of inferior mesenteric vessels and the left side of the mesentery. Meanwhile, the surgeon expands the space up and down along the Toldt’s fascia (Fig. 9.14). The course and peristalsis of the left ureter can be observed during the dissection, and care should be taken to protect the ureter. A small gauze is placed underneath the lateral side of the inferior mesenteric artery

Fig. 9.8  Exploration of the small intestine

Fig. 9.9  Exploration of the pelvic cavity

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(Fig. 9.15), which is the avascular area of sigmoid mesocolon. Dissect and isolate the root of the inferior mesenteric artery and vein by the ultrasonic scalpel at the intended resection line layer by layer. After being fully isolated, ligate and transect the inferior mesenteric artery and vein (Figs. 9.17 and 9.18).

3.2.3 Dissection of the Mesorectum When the inferior mesenteric artery and vein are transected, the avascular area of the sigmoid mesocolon can be partially opened (Fig. 9.19). The left ureter and the left gonadal vessel should be identified and protected (Fig.  9.20). The surgeon dissects downward, in a medial to lateral fashion, to the bifurcation of the left common iliac artery. Separation is performed downward along the presacral space to identify the course of the inferior hypogastric nerves. Afterward, the dissection is continued downward on the nerve surface at a uniform speed (Figs. 9.21 and 9.22). The dissection further proceeds in conjunction with the dissection of the left and right sides of the rectum, until 5 cm below the distal margin of the tumor. 3.2.4 D  issection of the Right Side of the Rectum Dissection of the right side of the rectum should be in conjunction with the presacral dissection (Fig.  9.23). The surgeon should dissect the right side of the rectum down to the peritoneal reflection and then incise the peritoneal reflection from the right side to the left side (Fig. 9.24). The dissection of the mesorectum proceeds distally to 5 cm below the distal margin of the tumor, and the extent of dissection should not beyond the necessity. 3.2.5 D  issection of the Sigmoid Colon and the Left Side of the Rectum The sigmoid adhesion is detached (Fig. 9.25), and then the dissection is performed in a lateral to medial pattern along the Toldt’s fascia to open the mesocolon (Fig.  9.26). The surgeon then continues to dissect the left side of the rectum

Experience sharing: For tumors above the peritoneal reflection, the surgeon can explore the location and size of the tumor with atraumatic forceps combined with digital rectal examination when necessary.

Fig. 9.10  Exploration of the tumor

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Experience sharing: This procedure requires the patient to have a long sigmoid colon; at the same time, the surgeon should adequately dissect the bowel to ensure that the bowel can be smoothly

Fig. 9.11  Adequate exposure of the bowel

Operating skills: (1) The ultrasonic scalpel generates heat and dissects the mesenteric space. The surgeon can dissect along the presacral fascia. The white cellular tissue is visible by moving the scalpel tip up and down. Dissect along this space so that the mesentery can be lifted to a certain extent (Fig. 9.13); (2) The assistant lifts the anterior wall of the upper rectum and the root of the inferior mesenteric artery, so that the complete view of the pelvic cavity and thecourse of the inferior mesenteric vessels will be under full visualization.

Fig. 9.12  The first point of the incision

3.2.6 Isolation of the Bowel Below the Tumor The tumor location is confirmed again, and approximately 3 cm of bowel wall is isolated below the distal edge of the tumor. At the peritoneal reflection, the dissection is continued downward along the Denonvilliers’ fascia. The seminal vesicles (male patient) (Fig. 9.28a) or posterior vaginal wall (female patient) (Fig.  9.28b) can then be clearly exposed. Subsequently, the right rectal wall is isolated (Fig. 9.29), and the posterior mesentery is transected. Then the dissection proceeds to isolate the left rectal wall (Fig. 9.30) and finally join with the right side. Fig. 9.13  Entering the space anterior to Toldt’s fascia

downward to the peritoneal reflection and join with the right side (Fig. 9.27). In most cases, mobilization of the splenic flexure is not necessary, unless the anastomosis is hard to be performed due to the short length of the descending colon.

3.2.7 Dividing the Sigmoid Mesocolon The sigmoid colon is pulled to the left to expose the gauze underneath the sigmoid mesocolon. The extent of division is checked to determine the intended resection line (Fig. 9.32). By lifting the mesocolon, the course of the inferior mesenteric artery and vein is identified. Division is performed

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Operating skills: Blunt dissection could be performed with the help of a small gauze. The correctdissection plane should be Inferior Mesenteric Vein

smooth, flat and clean.

Inferior Mesenteric Artery

Fig. 9.14  Dissection of the root of the inferior mesenteric artery

Left Ureter

Fig. 9.15  Placing the gauze on the lateral side of the inferior mesenteric artery

Smart usage of the small gauze: The gauze can be used to protect the ureter underneath. Rotate the camera to see the Marking Gauze

gauze marking underneath the inferior mesenteric vessels (Fig. 9.16).

Fig. 9.16  Gauze is visible beneath the mesocolon

along their course, and several sigmoid colon vessels should be ligated and transected (Fig.  9.33). Ultrasonic scalpel is applied to isolate approximately 2  cm of the bowel wall (Fig. 9.34). Pay attention to ensure enough length of the dissected sigmoid colon for the subsequent transanal specimen extraction.

3.3  S  pecimen Resection and Digestive Tract Reconstruction 3.3.1 Specimen Resection After anal dilation, iodoform gauze is introduced through the anus below the tumor (Fig. 9.35). The assistant holds

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Experience sharing: (1) En bloc resection technique should be

Inferior Mesenteric Vein

mastered in the dissection of lymph nodes at the root of mesentery; (2) The isolated length of blood vessel should not be longer enough for ligation. When the inferior mesenteric artery and vein are adjacent to each other, the artery and vein can be ligated at the same time. Otherwise, they can be ligated separately. Inferior Mesenteric Artery

Fig. 9.17  Ligation and transection of the inferior mesenteric artery

Fig. 9.18  Ligation and transection of the inferior mesenteric vein

Experience sharing: The sigmoid mesocolon should not be over-dissected. Otherwise, the mobility of increased, and there by operation.

Fig. 9.19  Opening of the avascular area of the sigmoid mesocolon

the suction in the right hand at 2  cm below the tumor to avoid the intestinal content entering into the abdominal cavity when the bowel is incised transversely. The surgeon applies the ultrasonic scalpel to open the rectal wall transversely 2 cm below the tumor under the guidance of

the gauze in the lumen (Fig.  9.36). The assistant inserts the oval forceps through the anus to remove the iodoform gauze. Then, a protective sleeve is placed in the abdominal cavity through the trocar (Fig.  9.37). The assistant pulls one end of the protective sleeve out through the anus and

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Left Gonadal Vessel Left Ureter

Fig. 9.20  Exposure and protection of ureters and gonadal vessels

Fig. 9.23  Dissection of the right rectal wall

Inferior Hypogastric Nerve

Fig. 9.21  Dissection to the left in the presacral space Fig. 9.24  Opening the right side of the peritoneal reflection

Inferior Hypogastric Nerve

Fig. 9.22  Dissection to the right in the presacral space

Fig. 9.25  Detachment of physiological adhesion of the sigmoid colon

places the proximal rectal stump into the protective sleeve (Fig. 9.38). The assistant clamps the proximal rectal stump with the oval forceps and slowly pulls the rectum out of the anus. The purse string forceps is applied extracorporeally at the intended resection line above the tumor. Finally, the bowel is transected to remove the specimen (Fig. 9.39).

3.3.2 Digestive Tract Reconstruction The anvil is introduced into the sigmoid colon stump and closed with a purse string suture, and then the sigmoid colon is reintroduced into the abdominal cavity with the oval forceps after being rinsed and disinfected (Fig. 9.40). 1000  mL of dilute iodine solution is injected into the

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Smart usage of the small gauze: During opening of the sigmoid mesocolon, the small gauze underneath can be used for marking and protecting to prevent accidental damage.

Gauze Underneath the

Fig. 9.26  Sigmoid mesocolon is dissected in a lateral to medial fashion

Fig. 9.27  Dissecting the left rectal wall downward

a

b Posterior Vaginal Wall

Semin

Fig. 9.28 (a) Dissection of the anterior rectal wall (male), (b) dissection of the anterior rectal wall (female)

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Experience sharing: If the tumor is small, it can be marked with a titanium clip.

Fig. 9.29  Isolation of the right rectum wall

Experience sharing: (1) After the transection of posterior mesorectum, a small gauze can be placed underneath the rectum for marking to ensure that both sides are dissected at the same level (Fig. 9.31); (2) The extent of isolation of this segment of rectum should be as large as possible, and the transection should be performed twice: The first transection is at about 2 cm below the distal edge of the tumor; The second transection is 1-2 cm below the first one.

Fig. 9.30  Isolation of the left rectum wall

abdominal cavity for irrigation. The rectal stump is closed by a linear Endo-­GIA stapler (Fig. 9.41), whereafter a circular stapler is inserted transanally to complete the end-toend anastomosis (Figs.  9.42 and 9.43). Air leak test is performed to confirm the integrity of the anastomosis (Fig.  9.44). Two drainage tubes are placed in the pelvic cavity (Fig. 9.45).

Fig. 9.31  Placing small gauze underneath the rectum for marking

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Experience sharing: The length of the dissected sigmoid mesocolon should be long enough, i.e., the length of the proximal bowel stump is about 5-7 cm, to facilitate the specimen extraction from the anus.

Gauze

Fig. 9.32  Dividing the sigmoid mesocolon

Fig. 9.33 Ligation and transection of vessels of the sigmoid mesocolon

Iodoform Gauze in the Bowel Lumen

Fig. 9.34  Isolation of the wall of the sigmoid colon

Operating skills: Using iodoform gauze can facilitate disinfection, lubrication and indication. In addition, it can dilate the bowel to facilitate its incision.

Fig. 9.35  Transanal introduction of iodoform gauze

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Operating key points: Intracorporeal incision of the bowel is a special step in this procedure. Improper operation may cause bowel content to enter into the abdominal cavity. Therefore, the surgeon and assistant should cooperate closely during the operation and strictly follow the principle of aseptic

Fig. 9.36  Transverse opening of the rectum

Operating skills: (1) The clamping of rectal stump with the oval forceps should be definite. Pay attention not to clamp other tissues, which may result in secondary damage; (2) During the operation, avoid anal air leakage and maintain pneumoperitoneum; (3) The extraction of bowel out of anus should be performed gently and slowly; (4) The insertion of sterile plastic sleeve can facilitate lubrication, support and isolation, and it is a key point of aseptic and tumor-free operation.

Fig. 9.37  Insertion of sterile plastic sleeve through the trocar

Fig. 9.38  Transanal extraction of the rectal specimen

Fig. 9.39  Transection of the bowel at the intended resection line proximal to the tumor

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Fig. 9.41  Closing of the rectal stump

Fig. 9.40  The anvil is introduced into the proximal sigmoid

Operating key points: (1) Close the rectal stump by using the linear Endo-GIA stapler with 60 mm staple cartridge as far as Right Corner of Rectal Stump

possible. If the closure is performed with two 45 mm staple cartridges, pay attention to the intersection of the two staple line; (2) If the closure can be completed with one linear Endo-GIA stapler, the trocar of the circular stapler should be protruded through one corner the stump to reduce a “dog ear” (Fig 9.42). If the closure is completed with two staplers, the Trocar of the stapler can be protruded from the intersection of the two staple lines.

Fig. 9.42  The trocar of stapler is protruded from a corner of the rectal stump

Fig. 9.43  Sigmoid colorectal end-to-end anastomosis

Fig. 9.44  Air leak test

3.4  Postoperative Abdominal Wall and Specimen Display (Figs. 9.46 and 9.47)

4.1  T  he Concept of “Dog Ear” and “Danger Triangle of the Anastomosis”

4  K  ey Points, Difficulties, and Hotspots Related to Surgery

Double-stapling technique is inevitably associated with bilateral intersecting margins at the distal rectal stump, which is called “dog ear.” The “dog ear” has been considered

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Experience sharing: Air or water leak test is essential in this procedure. If anastomotic leakage aoccurs, laparoscopic "8-figure" suture can be performed.

Fig. 9.45  Placing drainage tubes in the pelvic cavity

Dogear

Danger triangle

Fig. 9.46  Specimen display

Fig. 9.48  “Dog ear” and “danger triangle of the anastomosis” (laparoscopic view)

Dogear Danger triangle

Fig. 9.49  “Dog ear” and “danger triangle of the anastomosis” (transanal intraluminal view)

Fig. 9.47  Postoperative abdominal wall display

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Fig. 9.50  Location of Denonvilliers’ fascia (male)

Peritoneum

Bladder

Seminal vesicle

Nerve vessel bundles Prostate

Rectum Denonvilliers fascia The fascia propria of rectum

to associate with potential anastomotic leaks. In addition to “dog ears,” the “danger triangle of the anastomosis” in rectal cancer surgery also increases the potential leakage, which refers to the angle of intersection between the straight and curved staple lines formed by the transection of the bowel with linear or curved stapler and the circular staple line formed by the anastomosis of the other end with circular stapler. Instead of a complete circular anastomosis, the “danger triangle of the anastomosis” of intersection appears at one side or both sides of the anastomosis, resulting from the overlap of staples, which is prone to cause incomplete anastomosis and anastomotic leakage (Figs.  9.48 and 9.49). In the anus preserving surgery for lower and ultralow rectal cancer, we usually perform an 8-figure suture on the “danger triangle of the anastomosis” to reduce the risk of postoperative anastomotic leakage.

4.2  M  anagement of Denonvilliers’ Fascia in the Dissection of the Anterior Rectal Wall Proper anatomy of Denonvilliers’ fascia is one of the difficulties and key points of laparoscopic rectal TME surgery. The inappropriate operation during surgery is prone to cause damage to the visceral fascia of the anterior rectal wall, which causes positive circumferential resection margin or damage to the vascular nerve bundle that is associated with postoperative sexual dysfunction. Therefore, it is necessary to master the important anatomical structure of Denonvilliers’ fascia in the laparoscopic rectal TME surgery (Fig.  9.50).

This fascia is a thin and tough connective tissue diaphragm in histology, namely, rectovesical diaphragm in male and rectovaginal diaphragm in female. For male, the fascia is located between the bladder, prostate, seminal vesicle, and rectum. For female, the fascia is located between the posterior vaginal wall and rectum. This fascia is up to the peritoneal reflection, down to the central tendon of the perineum, and fused with the mesorectum on both sides. There are neurovascular bundles that dominate the genitourinary apparatus on both sides of the fascia, and intraoperative injury of this tissue is prone to cause sexual dysfunction. Therefore, during the laparoscopic rectal TME surgery, the dissection should be performed underneath the Denonvilliers’ fascia if the tumor does not invade this fascia. This approach can protect the pelvic autonomic nerve from being damaged. If the tumor invades the Denonvilliers’ fascia, it is recommended to dissect anterior to Denonvilliers’ fascia and resect this fascia. However, due to the close connection between the Denonvilliers’ fascia and the prostate capsule, dissection here is prone to cause bleeding.

4.3  A  pplication of 3D Laparoscopic Technique in Colorectal Surgery At present, laparoscopic technique has been extensively applied in colorectal surgery. The safety and the short-term and long-term efficacy of this technique have been confirmed. In conventional laparoscopic surgery, the surgeon can only determine the anatomical structure and location of tissues by “motion parallax,” “occlusion effect,” “perspec-

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Fig. 9.51  Performing NOSES with 3D laparoscopy

tive projection,” and other skills. The beginners, especially the inexperienced young surgeons without enough understanding of 3D anatomical structures, should be particularly cautious to avoid operational errors and secondary damage to tissues. The advent of 3D laparoscope overcomes the shortcomings of conventional 2D laparoscopic surgery, so that the surgeon can feel the depth of surgical field of vision, restore the real surgical field of vision, and improve the accuracy of surgical operation. At present, our team has applied the 3D laparoscopic technique to NOSES, and the advantages of this technique have been appreciated (Fig. 9.51). Its advantages include the following: (1) The real sense of space helps the surgeon to carry out the operation of suturing, knotting, and other operations more accurately and quickly. NOSES has many special operating procedures, e.g., taking the anvil shaft out of the bowel lumen, disinfection of the bowel lumen with iodoform gauze, etc. All of these require the surgeons to have very professional skills. 3D laparoscopy can assist the surgeons to better perform these operations. (2) Clear exposure of the tissue space, such as the exposure of Toldt’s fascia

and anterior sacral space, can better protect the vessels and nerves in lateral resection and reduce secondary damage. (3) Shortening of the learning curve: several studies have confirmed that 3D laparoscopy can reduce the difficulty of operation and shorten the operation time. (4) Robotic arm has better stability, which can reduce the tremor of surgical field of vision and other shortcomings caused by human factor. In addition, the number of assistants can be reduced with the application of this technique. The shortcomings of 3D laparoscopic technique are as follows: (1) According to the principle of binocular imaging, the 30° dual camera cannot be rotated to change the angle of view. Therefore, during the rectal and pelvic operation, it is difficult to expose the complete surgical field. In addition, the early 3D laparoscopy is prone to cause visual fatigue due to design defects, but the new 3D laparoscopy has overcome this shortcoming. From the perspective of surgical technique, the minimal trauma and the maximal benefit to patients are the goals of minimally invasive surgery. The combination of 3D laparoscopic technique with NOSES will perfectly exhibit the unique charm of minimally invasive surgery.

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1  Indications and Contraindications of NOSES

Middle Rectum

Lower Rectum

5cm

Upper Rectum

5cm

NOSES III is mainly applicable to female patients with slightly larger rectal tumors. The main operating procedures of NOSES III include transvaginal rectal extraction, extra-­ corporeal specimen removal, and totally laparoscopic end-­ to-­ end anastomosis between sigmoid colon and rectum. Compared with NOSES II, the main features of NOSES III are as follows: (1) there is no need to open the bowel intracorporeally, which better meets the requirements of aseptic principle; (2) more stringent vaginal preparation is needed before operation; (3) because of the strong vaginal extensibility, the indications of NOSES III are wider, but this procedure is limited to female patients. Although there is difference between NOSES III and conventional laparoscopic rectal resection, this technology is entirely reasonable, safe, and feasible as long as surgeons have clear anatomic understanding and solid operating skills.

5cm

Xishan Wang, Qian Zhang, and Haipeng Chen

Fig. 10.1  Tumor location suitable for NOSES III

1.1  Indications (Figs. 10.1, 10.2, and 10.3) 1 . Female patients with middle rectal tumor or benign tumor. 2. The circumferential diameter of tumor is 3–5 cm. 3. The tumor should not invade beyond the serosa. 4. The sigmoid colon and mesentery are long enough to be pulled out.

1.2  Contraindications

2. The sigmoid colon and mesentery is too short to be pulled out through the vagina. 3. Severely obese patients (BMI > 35 kg/m2).

2  Anesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position 2.1  Anesthesia Method

1. The tumor is too large to be pulled out. General anesthesia or general epidural anesthesia. X. Wang (*) · H. Chen Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Q. Zhang Department of Colorectal Cancer Surgery, Cancer Hospital of the University of Chinese Academy of Sciences, Hangzhou, China © People’s Medical Publishing House, PR of China 2021 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-15-7925-7_10

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2.2  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. 10.4).

2.3  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 at the McBurney’s point.

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3. The surgeon’s auxiliary trocar (5 mm trocar) is located at the umbilical level at 10  cm from the right side of the umbilicus. 4. The assistant’s main trocar (5 mm trocar) is located at the left side of upper umbilical level at the lateral edge of the rectus abdominis. 5. The assistant’s auxiliary trocar (5 mm trocar) is located opposite the McBurney’s point, which is mainly used for lifting and retracting tissues. In the meantime, the trocar should be placed more laterally in order to facilitate the placement of the drainage tube (Fig. 10.5).

2.4  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. 10.6).

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

3  Surgical Procedure, Techniques, and Key Points

Fig. 10.2  Colonoscopy: Tumor of ulcerated type, 8 cm from the dentate line, maximum diameter of 3.5 cm

The schematic view of main surgical procedures of specimen extraction and digestive reconstruction in NOSES III (Fig. 10.7).

Fig. 10.3  Rectal MRI: T2, 5.0 cm from the dentate line, maximum diameter of 3.5 cm

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Fig. 10.4  The patient’s position

Camera Holder Surgeon’s Auxiliary Trocar (5 mm)

Camera Trocar (10 mm)

Surgeon’s Main Trocar (12 mm)

Assistant’s Main Trocar (5 mm)

Assistant

Surgeon

Assistant’s Auxiliary Trocar (5 mm)

Fig. 10.5  Trocar placement (Five-ports method) Scrub Nurse

Fig. 10.6  Surgical team position

Monitor

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

ness of middle mesorectum, so as to evaluate the feasibility of transvaginal specimen extraction (Figs. 10.10, 10.11, and 10.12).

3.1.1 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. 10.8). 3.1.2 Tumor Exploration The location and size of the tumor should be checked (Fig. 10.9). 3.1.3 Evaluation of Anatomical Structures It is necessary for the surgeon to check the length of sigmoid colon, the length of mesenteric vessels as well as the thick-

Fig. 10.8  Exploration of the liver and greater omentum

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Fig. 10.7  The main surgical procedures of specimen extraction and digestive reconstruction in NOSES III

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Experience sharing: This procedure is suitable for female patients with middle rectal cancer, and in most cases the tumor is located above the peritoneal reflection.

Fig. 10.9  Exploration of tumor location

Fig. 10.10  Evaluating the status of sigmoid colon and mesorectum

3.2  Dissection and Separation 3.2.1 The First Point of the Incision The surgeon performs the initial incision at the thin mesenteric region below the sacral promontory with an ultrasonic scalpel. The scalpel tip generates heat and spreads along the mesorectal presacral space (Figs. 10.13, 10.14, and 10.15). The white presacral fascia is visible by moving the scalpel tip up and down, which proves that the correct space has been entered. The course of the inferior hypogastric nerves is sometimes visible by extending the space up and down with an ultrasonic scalpel (Fig. 10.16). 3.2.2 I solation and Ligation of the Root of Inferior Mesenteric Artery and Vein The surgeon lifts the mesentery along the course of superior rectal artery and the inferior mesenteric artery with the forceps in the left hand. With the ultrasonic scalpel in the right hand, dissection is performed along the Toldt’s fascia to the mesenteric root and the lateral side (Fig.  10.17). A small

gauze can be used for blunt dissection (Fig. 10.18), and the right dissection plane is smooth, flat, and clean. The course and peristalsis of the left ureter can be identified (Fig. 10.19). Another gauze is placed underneath the lateral side of the inferior mesenteric artery and vein, so as to expose the avascular area of sigmoid mesocolon. The root of the inferior mesenteric vessels and the gauze underneath can be seen clearly by adjusting the direction of camera. The gauze can facilitate indication and protection of the ureter and gonadal vessels (Fig. 10.20). The ultrasonic scalpel is applied to dissect toward the root of vessels (Fig. 10.21); however the isolated length of the blood vessel should not be longer than enough for ligation (Figs.  10.22 and 10.23). The inferior mesenteric artery and vein are double ligated with vascular clips (Figs. 10.24 and 10.25).

3.2.3 Dissection of the Mesorectum When the inferior mesenteric artery and vein 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 turns the stump of the inferior mesenteric vessels with the forceps in the right hand. The surgeon further dissects the sigmoid mesocolon space downward, in a medial to lateral fashion, to the bifurcation of the left common iliac artery (Fig. 10.26). Attention should be paid to protect the ureters and gonadal vessels (Fig. 10.27), and a gauze is placed in this area (Fig. 10.28). Dissection is then continued downward to join with the dissection of the right side of the rectum (Fig. 10.29). 3.2.4 D  issection of the Right Side of the Rectum The dissection line of the right side of rectum is clearly visible (Fig. 10.30). Dissection of the right rectal wall should be in conjunction with the dissection of the posterior rectal wall. The extent of dissection is determined based on the location

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Experience sharing: The feasibility of transvaginal specimen extraction is evaluated by the length of sigmoid colon and mesorectum, and the thickness of mesorectum. Perform digital vaginal examination to determine whether the status of posterior vaginal fornix is suitable for incision and specimen extraction (Fig. 10.11).

Fig. 10.11  Performing digital vaginal examination to check the status of posterior vaginal fornix

Fig. 10.12  Exploration of posterior vaginal fornix

Cooperating skills: The assistant lifts the uterus extracorporeally with a uterine manipulator to fully expose the pelvic cavity. The other assistant lifts the bowel wall above the rectal tumor with forceps in the left hand, and lifts the root of mesentery with forceps in the right hand to fully expose the surgical field (Fig. 10.13).

Fig. 10.13  Exposure of the root of mesentery

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Experience sharing: The surgeon can block the small intestine to the upper abdomen with 1/2 gauze, so as to expose the entire pelvic cavity and the roots of the inferior mesenteric vessels (Fig. 10.14).

Fig. 10.14  The first point of the incision

Fig. 10.15  Entering the space anterior to Toldt’s fascia

Fig. 10.17  Dissection to the root of the inferior mesenteric artery

Fig. 10.16  Exposure of the inferior hypogastric nerves

Fig. 10.18  Blunt dissection with gauze

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of tumor, usually 3–5 cm below the distal edge of tumor. It is noted that the extent of dissection should be limited, since the function preservation of rectum is an important consideration.

3.2.5 D  issection of the Sigmoid Colon and the Left Side of the Rectum The sigmoid adhesion is detached (Fig. 10.32). Dissection is performed in a lateral to medial pattern along the Toldt’s fascia, and the gauze can be observed underneath the mesocolon (Fig.  10.33). The surgeon then opens the mesentery to dissect upward and downward adequately (Figs. 10.34 and 10.35). 3.2.6 Isolation of the Bowel Below the Tumor Depending on the size and pathological features of the tumor, the mesorectum can be transected at 3–5 cm below

the distal edge of tumor. It is enough to isolate the bowel wall for approximately 2 cm (Fig. 10.37).

3.2.7 Dividing the Sigmoid Mesocolon The sigmoid colon is turned to the left, and a gauze is inserted underneath the sigmoid mesocolon. The surgeon checks the extent of dissection and determines the intended resection line of the sigmoid mesocolon. What calls for special attention is that the divided mesocolon should be long enough to allow the specimen to be easily extracted through the vagina (Fig. 10.38). By lifting the mesentery, the course of the inferior mesenteric vessels and the superior rectal vessels can be seen. The division of sigmoid mesocolon is performed along with the ligation of 2–3 sigmoid colon vessels (Fig. 10.39), until reaching the intended resection line of bowel. The length of the isolated sigmoid colon should also be appropriately 2 cm, and there is no need to over-isolate.

Ureter

Fig. 10.19  Adequate exposure of the ureter

Fig. 10.21  Dissection of lymph nodes at the root of mesentery

Operating skills: The blade of the ultrasonic scalpel should be face-up while cutting the tissue. After the incision, the blade can be turned down to dissect the lymphatic and adipose tissue with its afterheat. The advantages of this method include: (1) safety; (2) sufficient hemostasis ensures clean surgical field; (3) fully isolation of vessels helps achieve en bloc resection.

Fig. 10.20  Placing gauzes underneath the mesentery

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Operating skills: The inferior mesenteric artery and vein should be ligated separately. Occasionally, mesenteric artery and vein may be ligated and transected together if the artery is closely accompanied by the vein.

Inferior Mesenteric Artery

Fig. 10.22  Isolation of the inferior mesenteric artery

Fig. 10.23  Ligation and transection of the inferior mesenteric artery

Inferior Mesenteric Vein

Fig. 10.24  Isolation of the inferior mesenteric vein

Fig. 10.25  Ligation and transection of the inferior mesenteric vein

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Experience sharing: While cutting the sigmoid mesocolon, attention should be paid to protect the marginal vessels. Accidental injury of marginal vessels may affect the blood supply, leading to bowel ischemia and anastomotic leakage.

Fig. 10.26  Dissection of the sigmoid mesocolon downward from medial to lateral

Gonadal Vessels

Ureter

Fig. 10.27  Exposure and protection of ureters and gonadal vessels

Fig. 10.28  Placing small gauze underneath the mesentery

Fig. 10.29  Dissection downward along the Toldt’s fascia

Fig. 10.30  Dissection of the right rectal wall

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Experience sharing: If the tumor is located above the peritoneal reflection, the necessity of incising the peritoneal reflection depends on the distance between the tumor and peritoneal reflection. The incision is required in most cases (Fig. 10.31).

Fig. 10.31  Opening the right side of the peritoneal reflection

Fig. 10.32  Separation of physiological adhesion of the sigmoid colon

Fig. 10.34  Dissecting upward in the lateral of sigmoid colon

Gauze Underneath the Mesentery

Fig. 10.33  Opening the peritoneum to the left of the sigmoid colon

3.3  Specimen Resection and Digestive Tract Reconstruction 3.3.1 Specimen Resection The surgeon transects the bowel with a linear EndoGIA stapler at 4–5 cm from the distal edge of the tumor

Fig. 10.35  Dissecting the left rectal wall downward

(Fig.  10.40). After the vaginal irrigation, the assistant introduces the bladder retractor through the vagina to indicate the posterior vaginal fornix (Fig.  10.41). The surgeon applies 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.  10.42), and inserts the protective sleeve into the

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Operating skills: Most cases do not require to mobilize splenic flexure. Dissect the left side of rectum downwards to the peritoneal reflection or the mark, and join with the right side (Fig. 10.36).

Fig. 10.36  Opening the left side of the peritoneal reflection

Fig. 10.37  Isolation of the bowel below the tumor

Fig. 10.39 Ligation and transection of vessels of the sigmoid mesocolon

Linear Endo-GIA Stapler

Isolated Rectal Wall

Fig. 10.38  Dividing the sigmoid mesocolon Fig. 10.40  Transection of rectum below the tumor

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p­ elvic cavity through the trocar (Fig.  10.43). The assistant inserts the oval forceps through the vagina to pull the distal end of the protective sleeve out of the body. The surgeon places the specimen in the protective sleeve as the assistant clamps the rectal stump with the oval forceps through the vagina and pulls the stump out of the body (Fig.  10.44). The purse-string forceps is applied extra-­ corporeally at the intended resection line of the sigmoid colon (Fig.  10.45), and then the bowel is transected for specimen removal.

Fig. 10.41  Transvaginal placement of bladder retractor for indication

Experience sharing: The surgeon applies the ultrasonic scalpel to open the posterior vaginal fornix for approximately 3 cm, and extend the incision to 5-6 cm by longitudinal stretch. During the operation, the pneumoperitoneum should be maintained.

Fig. 10.42  Opening the posterior vaginal fornix

Fig. 10.43  Placement of protective sleeve Fig. 10.44  Transvaginal extraction of rectal specimen

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Operating skills: The assistant should carefully and slowly pull the rectum out of the vagina. Rough operation may lead to mesenteric laceration or damage to marginal vessels, which may lead to potential surgery failure.

Fig. 10.45  Transection of the bowel at the intended resection line proximal to the tumor

Fig. 10.46  The anvil is introduced into the sigmoid colon stump

3.3.2 Digestive Tract Reconstruction The stapler anvil is introduced into the sigmoid colon stump (Fig.  10.46) and secured with a purse-string suture (Fig. 10.47). After being rinsed and disinfected, the sigmoid colon is returned into the abdominal cavity with the oval forceps. A circular stapler is inserted transanally, and then the anvil is connected to the trocar of stapler to create the sigmoid rectal end-to-end anastomosis (Figs. 10.48, 10.49, and 10.50). The integrity of the anastomosis is checked, and then perform an 8-figure suture on the “danger triangle of the anastomosis” with absorbable suture for reinforcement. Air leak test is performed to confirm the integrity of the anastomosis. 3.3.3 C  losure of Trocar and Suture of Vaginal Incision Intraperitoneal gas is expelled. The vaginal incision can be sutured under laparoscopy (Fig. 10.51). Then the pelvic cavity is irrigated with normal saline or distilled water, and drainage tubes are indwelled (Figs. 10.52 and 10.53). Close the trocar, and count the gauze and all instruments before the completion of surgery.

3.4  Postoperative Abdominal Wall and Specimen Pictures (Figs. 10.54 and 10.55) Fig. 10.47  The purse-string suture

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4  Key Points, Difficulties, and Hotspots Related to Surgery 4.1  The Distribution of Nerves Around the Rectum

Fig. 10.48  Inserting a circular stapler through the anus and extend trocar to pierce the stump

Preserving the pelvic autonomic nerve is one of the essentials in the radical resection of rectal cancer. Under the premise of ensuring radical resection, it reduces the possibility of postoperative sexual dysfunction and urination disorder to the minimum, so as to improve the patients’ quality of life after operation. Therefore, it is necessary to master the composition and course of the pelvic autonomic nerve in total mesorectal excision.

Operating skills: The Trocar of the stapler should be protruded from one corner of the stump to reduce a ‘danger triangle of the anastomosis’.After the anvil is connected to the trocar of stapler, pay attention to the direction of the sigmoid mesocolon.

Fig. 10.49  Sigmoid colorectal end-to-end anastomosis

Experience sharing: There is no need to open the bowel wall intraabdominally during the whole operation, so the principle of aseptic operation is met and the possibility of intraabdominal contamination is small.

Fig. 10.50  Complete the anastomosis

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Fig. 10.51  Suturing of vaginal incision under laparoscopy

Fig. 10.52  One drainage tube is placed on the left side of the pelvic cavity

Experience sharing: Place two drainage tubes in the pelvic cavity through the trocar sites on the left and right lower abdomen, or place one drainage tube on the right side of the rectum through the vagina.

Fig. 10.53  One drainage tube is placed on the right side of the pelvic cavity

The celiac plexus, composed of the sympathetic nerve from the thoracic cord T11–T12 and the high lumbar spinal cord, encircles the abdominal aorta and extends downward to the superior hypogastric plexus (Fig. 10.56). Superior hypogastric plexus from the abdominal aorta bifurcation extends to the level of sacral promontory, close to the course underneath the inferior mesenteric vessels. Inferior mesenteric vessels can be identified as a marker to find the superior

hypogastric plexus. During the ligation of inferior mesenteric vessels, particular attention should be paid to avoid damage to the posterior superior hypogastric plexus. Superior hypogastric plexus in the iliac vascular bifurcates into the left and right hypogastric nerves. The hypogastric nerve is on the medial side of the internal iliac vessels, runs downward along the pelvic wall, and joins the sacral 2–4 pelvic splanchnic nerves originating from the sacral foramina to form pel-

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Pelvic Plexus

Right Common Iliac Artery

Rectum Pelvic Splanchnic Nerve Vesical Plexus

Rectal Plexus

Fig. 10.54  Picture of abdominal wall after operation

Prostatic Plexus

Fig. 10.57  Pelvic plexus

Right Hypogastric Nerve

Fig. 10.55  Specimen display Fig. 10.58  Pelvic plexus (right hypogastric nerve)

Superior Hypogastric Plexus

Fig. 10.56  Superior hypogastric plexus

vic plexus (Fig. 10.57) and the inferior hypogastric plexus, which are difficult to distinguish. Pelvic plexus is a retroperitoneal structure. On the dorsal bilateral sides of the rectum, seminal vesicle, prostate, and bladder (in the lateral ligament) of male, the pelvic plexus forms the secondary plexuses, i.e., the rectal plexus, vesical plexus, and prostatic plexus. Those secondary plex-

uses are accompanied by the branches of the internal iliac artery and distributed in corresponding organs. The sympathetic composition of the plexus (Figs.  10.58 and 10.59) comes from the hypogastric nerve and the sacral sympathetic trunk, and the parasympathetic component comes from the pelvic splanchnic nerve from the sacral 2–4 spinal cord segments. The pelvic plexus is adjacent to the lower third of the rectum, with partial nerve fibers involved in the composition of lateral rectal ligament. The inferior hypogastric plexus is divided into four branches to dominate different organs: the rectal branch is the main component of the lateral rectal ligament; the ureteral branch is the branch of the hypogastric nerve which surrounds the ureter; the vesical and the prostatic branches are on the posterolateral distribution of the posterior rectal space; and the erectile nerve is the most distal branch of the inferior hypogastric plexus, which is involved in the formation of neurovascular bundles within the course of the anterior lobe of the Denonvilliers’ fascia.

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Hypogastric nerve is relatively thick with a more fixed location, which is easier to identify in operation. Pelvic splanchnic nerve is relatively small, which is composed by plexus fibers around the lateral rectal wall. The parasympathetic nerves control the erection of penis. During the operation, the traction and transection of rectum and lateral ligament are prone to damage the pelvic plexus and pelvic splanchnic nerve, which may cause erectile dysfunction. Abdominal aorta and iliac vascular lymph node dissection is prone to damage the hypogastric nerve, which may cause ejaculation disorder. Additionally, abdominoperineal resection can damage the pudendal nerve and its branches, which may cause damage to the afferent fibers. The abovementioned damages can lead to the occurrence of postoperative sexual dysfunction. Compared with laparotomy, laparoscopic surgery allows improved visualization of the surgical field as well as more clear exposure of nerves and their courses. These can greatly improve the accuracy of surgeons’ operation and avoid damage to nerves.

Left Hypogastric Nerve

Fig. 10.59  Pelvic plexus (left hypogastric nerve)

Fig. 10.60 “Neorectum” formed after bowel anastomosis

Ultra-low Anastomosis

4.2  The Concept of “Neorectum” and Low Anterior Resection Syndrome The so-called neorectum refers to the formation of a new anatomical structure of anastomosis after the resection of partial or all of the rectum. Although in the same location of the rectum, the anatomy and function can be significantly different. This is called the “neorectum” (Fig.  10.60). The “neorectum” is different from the original rectum in terms of blood supply, nerve reflex and conduction, as well as defecation and bowel control. It is particularly worth noting that after the relapse or recurrence of tumor in the “neorectum,” the selection of surgical procedure can no longer be evaluated according to the location of the original rectum. The mesenteric blood supply and surrounding anatomical changes of the “neorectum” should be adequately considered for the selection of a reasonable surgical procedure. For most patients who undergo rectal resection, the “neorectum” losses the original function of storing feces to a certain extent. Meanwhile, because of the changes of bowel diameter and scar formation at the anastomosis after operation, the bowel capacity of the “neorectum” is decreased significantly. In addition, compared with the original rectum, the “neorectum” has a certain degree of difference in the innervation, peristalsis, and tension, leading to changes in the compliance of the “neorectum.” Therefore, some patients are presented with low anterior resection syndrome after the formation of “neorectum.” For such patients, the pelvic autonomic nerve should be protected during operation to reduce the damage to autonomic nerves of the pelvis. Gentle operation during the surgery can reduce the damage to the function of anal sphincter. Furthermore, patients should be advised to conduct postoperative pelvic floor exercises or physical therapy, which can minimize the symptoms of low anterior resection syndrome.

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

1

Indications and Contraindications of NOSES

1.1

Indications (Figs. 11.1, 11.2, and 11.3)

Middle Rectum

Lower Rectum

Lower Rectum

5cm

Middle Rectum

5cm

5cm

Upper Rectum

5cm

Upper Rectum

5cm

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

5cm

NOSES IV is mainly applicable to patients with small tumor in the upper rectum and distal sigmoid colon. The main operating procedures of NOSES IV include complete dissection and transection of specimen in abdominal cavity, transanal rectal extraction, and totally laparoscopic end-to-end anastomosis between sigmoid colon and rectum. Compared with conventional laparoscopic surgery, NOSES IV can not only ensure radical resection of tumor but also minimize the trauma caused by abdominal incision. Therefore, NOSES IV is a procedure that can ensure radical resection and rectal function preservation. Surely, this procedure also puts forward high requirements for the surgeons, including solid anatomical understanding, proficient laparoscopic operation, and clear surgical thinking. The technological difficulties of this procedure include introducing the anvil into the abdominal cavity transanally and inserting the anvil into the proximal bowel lumen above the tumor, while following the principles of aseptic and tumor-free operation.

Fig. 11.1  Tumor location suitable for NOSES IV

1. Tumor is located in the upper rectum, rectosigmoid colon, and distal sigmoid colon.

X. Wang (*) Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China S. Wang Department of Colorectal Cancer Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China

Fig. 11.2  Colonoscopy: Tumors of ulcerated and protuberant type, 12 cm from the dentate line, maximum diameter of 2.5 cm

P. Sun Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Shenzhen Center, Shenzhen, China © People’s Medical Publishing House, PR of China 2021 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-15-7925-7_11

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Fig. 11.3  Rectal MRI: T3, 12 cm from the dentate line, maximum diameter of 2.9 cm

1.2

Contraindications

1. The tumor is too large to be pulled out through the rectum and anus. 2. The sigmoid mesocolon is too thick to be pulled out through the anus. 3. Severely obese patients (BMI > 36 kg/m2).

2

 nesthesia, Patient Positioning, A Trocar Placement, and Surgical Team Position

2.1

Anesthesia Method

Fig. 11.4  The patient’s position

General anesthesia or general epidural anesthesia.

The patient is placed in functional lithotomy position, with the right thigh slightly flattened, which facilitates to perform the operation for the surgeon (Fig. 11.4).

3. The surgeon’s auxiliary trocar (5 mm trocar) is located at the umbilical level beside the right rectus abdominis. 4. The assistant’s main trocar (5 mm trocar) is located at the umbilical level beside the left rectus abdominis. 5. The assistant’s auxiliary trocar (5  mm trocar) is located opposite the McBurney’s point, which facilitate to place the drainage tube (Fig. 11.5).

2.3

2.4

2.2

Patient Positioning

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.

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. 11.6).

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greater omentum, and pelvic cavity are routinely examined for the presence of tumor seeding or ascites (Figs. 11.8 and 11.9). 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. 11.5  Trocar placement (Five-port method)

3.1.3 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.

3.2

Camera Holder

Assistant

Surgeon

Scrub Nurse

3.1.2 Tumor Exploration The location and size of the tumor and the feasibility of specimen extraction should be evaluated (Fig. 11.10).

Monitor

Dissection and Separation

3.2.1 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.  11.11). 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. 11.12 and 11.13).

Fig. 11.6  Surgical team position

2.5

Special Surgical Instruments

Ultrasonic scalpel, 60 mm linear Endo GIA stapler, 30 mm circular stapler, sterile protective sleeve.

3

Surgical Procedure, Techniques, and Key Points

The schematic view of main surgical procedures of specimen extraction and digestive reconstruction in NOSES IV (Fig. 11.7).

3.1

Exploration and Surgical Planning

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

3.2.2 I solation 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. 11.14). Attention should be paid to protect the inferior mesenteric plexus (Fig.  11.15). The course and peristalsis of the left ureter can be observed during the dissection (Fig. 11.16). 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.  11.17). 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. 11.18). 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 (Fig. 11.19).

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Fig. 11.7  The main surgical procedures of specimen extraction and digestive reconstruction in NOSES IV

Fig. 11.8  Exploration of the left lobe of the liver

Fig. 11.9  Exploration of the small intestine

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Fig. 11.10  Exploration of the tumor

Fig. 11.11  Application of gauze to block the small intestine and expose the surgical field

Fig. 11.12  The first point of the incision

Fig. 11.13  Entering the space anterior to Toldt’s fascia

Experience sharing: The inferior mesenteric artery and vein may be ligated and transected together if the artery is closely accompanied by the vein. Otherwise, they can be ligated separately.

Fig. 11.14  Dissection to the root of the inferior mesenteric artery

Operating skills: Perform separation up and down along the space to the root of the inferior mesenteric artery and vein (Fig. 11.15). Meanwhile, expand the space up and down along the Toldt’s fascia to the left side. Inferior Mesenteric Plexus

Fig. 11.15  Exposure and protection of nerves

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Left Ureter

Fig. 11.19  Isolation of the inferior mesenteric vein Fig. 11.16  Dissection to the left lateral side to expose the course of the left ureter

Gauze

Inferior Mesenteric Vein

Fig. 11.20  Ligation and transection of the inferior mesenteric vein Fig. 11.17  Gauze is visible beneath the mesocolon

paying attention to the extent of dissection, as well as the protection of the inferior hypogastric nerves (Fig. 11.21) and presacral vessels (Fig. 11.22).

Fig. 11.18  Ligation and transection of the inferior mesenteric artery

Once the inferior mesenteric vein is exposed, it is ligated and transected (Fig.  11.20), and the avascular area of sigmoid mesocolon can be partially opened.

3.2.3 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

3.2.4 D  issection 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.  11.23), 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 lateral to medial pattern, a gauze can be seen, which can be used as a landmark (Fig. 11.24) 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. 11.25). 3.2.5 I solation 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

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Operating skills: Separate along the posterior rectal space, the inferior hypogastric nerves will be visible; separate to the left and right at the bifurcation; perform separation with an ultrasonic scalpel on the nerve surface at a uniform speed.

Inferior Hypogastric Nerve

Fig. 11.21  Dissection downward along the posterior rectal space

Gauze Underneath the Mesocolon

Presacral Vessels

Fig. 11.22  Presacral vessels

Fig. 11.24  Sigmoid mesocolon is dissected in a lateral to medial fashion

Left Inferior Hypogastric Nerve

Fig. 11.23  Detachment of physiological adhesion of the sigmoid colon

Fig. 11.25  Dissection of the left rectal wall

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Fig. 11.26  Isolation of the anterior rectal wall Fig. 11.29  Transection of the distal rectum

Fig. 11.27  Isolation of the right rectum wall Fig. 11.30  Dissection of the sigmoid mesocolon

3.3

Fig. 11.28  Isolation of the left rectum wall

vascular clip. The extent of isolation below the tumor is 3–5 cm (Figs. 11.26, 11.27, and 11.28). Lastly, the isolated bowel is transected with a linear Endo GIA stapler (Fig. 11.29).

3.2.6 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. 11.30 and 11.31). 2 cm of bowel wall should be isolated around the proximal intended resection line (Fig. 11.32).

 pecimen Resection and Digestive S Tract Reconstruction

3.3.1 Specimen Resection The protective sleeve is inserted into the abdominal cavity through the main trocar (Fig.  11.33). Next, a window is opened at the top of the rectal stump by the ultrasonic scalpel, insert the oval forceps through the anus to pull the protective sleeve out of the anus (Fig. 11.34), then apply oval forceps to hold the anvil, and slide it into the abdominal cavity through the protective sleeve (Fig. 11.35). 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. 11.36). Iodoform gauze is inserted into the sigmoid colon lumen through the longitudinal incision to disinfect the bowel lumen (Fig.  11.37). The anvil is introduced into the sigmoid colon lumen through the longitudinal incision (Fig. 11.38). The isolated bowel is transected with a linear Endo GIA stapler above the longitudinal incision (Fig. 11.39), and the sigmoid colon stump is disinfected with iodoform gauze (Fig. 11.40). At this point, the specimen is completely resected (Fig. 11.41). The used gauze in the protective sleeve is accompanied by the resected specimen (Fig. 11.42). Afterward, the surgeon tightens the drawstring

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Operating skills: Ligate at the retained side with the vascular clip, and transect the other side with the ultrasonic scalpel. This approach can reduce the damage to vessels and rectal mucosa caused by the vascular clip when pulling out the specimen.

Fig. 11.31  Ligation and transection of vessels of the sigmoid mesocolon

Fig. 11.32  Isolation of wall of the sigmoid colon Fig. 11.34  Transanal extraction of protective sleeve

Fig. 11.33  Insertion of protective sleeve through the main trocar

Fig. 11.35  Inserting the anvil with the protective sleeve

on the protective sleeve to prevent the leakage and slowly pulls the protective sleeve out through the rectum and anus (Fig. 11.43).

self-made finger cot (resected from a rubber glove), and removed through the 12 mm trocar (Fig. 11.45). The surgeon grabs the anvil from the outside of the bowel and takes the anvil shaft out of the sigmoid colon stump through one corner of it (Figs. 11.46 and 11.47). The assistant inserts a circular stapler transanally and extends the trocar to pierce the rectal stump through its corner (Fig. 11.48). The anvil shaft is connected, and the direction of mesocolon should be adjusted before complete the sigmoid colorectal end-to-end

3.3.2 Digestive Tract Reconstruction The rectal stump is re-stapled with a linear Endo-GIA stapler (Fig. 11.44). 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

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Fig. 11.39  Transection of the sigmoid colon Fig. 11.36  Placing the distal bowel in the protective sleeve and making a small longitudinal incision on the bowel wall above the tumor

Fig. 11.37  Disinfection in the sigmoid colon lumen

Fig. 11.38  Inserting the anvil into the proximal sigmoid colon

Fig. 11.40  Disinfection of the sigmoid colon stump

Fig. 11.41  Resected specimen is placed into the protective sleeve

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Experience sharing: If the gauze is removed through the trocar directly, the fluid in the gauze may flow back to the abdominal cavity through the trocar. In order to meet the aseptic and tumor-free principles, the gauze should be removed along with the specimen in the protective sleeve.

Fig. 11.42  Placing the small gauze and specimen in the protective sleeve

Fig. 11.43  Transanal extraction of rectal specimen

Fig. 11.45  Removal of the resected rectal stump with the retrieval bag

anastomosis (Fig.  11.49). 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.  11.50 and 11.51). Air leak test is performed to confirm the integrity of the anastomosis (Figs. 11.52 and 11.53). After irrigating the abdominal cavity, two drainage tubes are placed in the left and right lower abdomen, respectively (Figs. 11.54 and 11.55). The pneumoperitoneum is released, and trocar sites are closed. Local anesthetic drugs, e.g., procaine, can be used to reduce postoperative pain. Fig. 11.44  Closing of the rectal stump

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Experience sharing: The anvil shaft is protruded from one corner of the sigmoid colon stump, and the surrounding tissue should be smooth.

Fig. 11.46  Grab the anvil from the outside of the bowel

Fig. 11.47  Taking out the anvil shaft

Fig. 11.48  Extend trocar to pierce the rectal stump

Fig. 11.49  Sigmoid colorectal end-to-end anastomosis

Fig. 11.50  “Danger triangle of the anastomosis”

Fig. 11.51 Suture to reinforce the “danger triangle of the anastomosis”

Fig. 11.52  Air leak test

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3.4

Postoperative Abdominal Wall and Specimen Display (Figs. 11.56 and 11.57)

Fig. 11.53  Air leak test to confirm the integrity of the anastomosis

Fig. 11.56  Abdominal wall after surgery Fig. 11.54  Drainage tube is placed on the left side of the pelvic cavity

Fig. 11.55  Drainage tube is placed on the right side of the pelvic cavity

Fig. 11.57  Specimen display

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4

 ey Points, Difficulties, and Hotspots K Related to Surgery

4.1

 urgical Plane and Operating S Procedure of TME

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. 11.58). 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, ade- Fig. 11.58  Presacral plane (after TME resection) quately 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.

4.2

 natomy of Lateral Ligaments A 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.  11.59). 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 fiber bundle structures on both sides of rec-

Fig. 11.59  Lateral ligaments of the rectum

tum can be identified in 71% of patients, middle rectal artery and vein can only be found in the “lateral ligaments” of 57% of patients. The significance of this structure for the radical resection of rectal cancer is far less than that of the mesorectum. Long-term 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.

Laparoscopic Upper Rectal Cancer Resection with Transvaginal Specimen Extraction (CRC-NOSES V)

12

1

Indications and Contraindications of NOSES

1.1

Indications (Figs. 12.1, 12.2, 12.3, and 12.4)

Middle Rectum

Lower Rectum

Lower Rectum

5cm

Middle Rectum

5cm

5cm

Upper Rectum

5cm

Upper Rectum

5cm

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. 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 meet the principle of aseptic operation. 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.

5cm

Xishan Wang and Zhixun Zhao

Fig. 12.1  Tumor location suitable for NOSES V

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.

1.2

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.

Fig. 12.2  Colonoscopy: Tumor of protuberant type, 13  cm from the dentate line, maximum diameter of 4 cm

X. Wang (*) · Z. Zhao Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China © People’s Medical Publishing House, PR of China 2021 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-15-7925-7_12

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Fig. 12.5  The patient’s position

3. The tumor invades beyond serosa, which increases the risk of neoplasm seeding by transvaginal extraction. 4. Severely obese patients (BMI > 35 kg/m2).

Fig. 12.3  Rectal MRI: T2, 11  cm from the dentate line, maximum diameter of 3.5 cm

2

 nesthesia, Patient Positioning, A Trocar Placement, and Surgical Team Position

2.1

Anesthesia Method

General anesthesia or general epidural anesthesia.

2.2

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. 12.5).

2.3

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. 5. The assistant’s auxiliary trocar (5 mm trocar) is located opposite the McBurney’s point, which facilitate to place the drainage tube (Fig. 12.6). Fig. 12.4  CT virtual endoscopy: The tumor is located at the upper rectum, involving 1/3 of the rectal circumference

12  Laparoscopic Upper Rectal Cancer Resection with Transvaginal Specimen Extraction (CRC-NOSES V)

3

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)

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Surgical Procedure, Techniques, and Key Points

The schematic view of main surgical procedures of specimen extraction and digestive reconstruction in NOSES V (Fig. 12.8).

3.1

Exploration and Surgical Planning

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

Fig. 12.6  Trocar placement (Five-port method)

3.1.1 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. 12.9 and 12.10).

Camera Holder

Assistant

Surgeon

3.1.2 Tumor Exploration The location and size of the tumor is explored to assess the feasibility of transvaginal specimen extraction (Fig. 12.11). 3.1.3 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.

Scrub Nurse

3.2

Fig. 12.7  Surgical team position

2.4

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. 12.7).

2.5

Dissection and Separation

Monitor

Special Surgical Instruments

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

3.2.1 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. 12.13). The surgeon may open the mesentery at or below the sacral promontory as appropriate (Fig. 12.14). 3.2.2 D  issection 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. The course and peristalsis of the left ureter can be observed during the dissection (Fig. 12.16). A

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Fig. 12.8  The main surgical procedures of specimen extraction and digestive reconstruction in NOSES V

Fig. 12.9  Exploration of the left lobe of liver and stomach

Fig. 12.10  Exploration of the greater omentum

12  Laparoscopic Upper Rectal Cancer Resection with Transvaginal Specimen Extraction (CRC-NOSES V)

gauze is placed underneath the root of the inferior mesenteric artery and vein for protection and indication (Fig.  12.17). The gauze underneath the avascular area of sigmoid mesocolon can be observed by changing the direction of the camera (Fig. 12.18). 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. 12.19). Continue dissecting to the left lateral side. The mesentery is flipped for the i­ dentification 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. 12.20 and 12.21), and the avascular area of sigmoid mesocolon can be partially opened (Fig. 12.22).

below the distal edge of tumor, and the extent of dissection should not be too large.

3.2.4 D  issection 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. 12.25).

3.2.3 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.  12.23 and 12.24). The dissection of mesorectum proceeds distally to 5  cm Fig. 12.13  Exposure of the root of mesentery

Tumor

Fig. 12.11  Exploration of the tumor location

Fig. 12.14  The first point of the incision

Experience sharing: Perform digital vaginal examination to determine whether the status of posterior vaginal fornix is Posterior Vaginal Fornix

Fig. 12.12  Posterior vaginal fornix

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suitable for incision and specimen extraction (Fig. 12.12).

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Experience sharing: The scalpel tip generates heat and spreads along the presacral space. The white cellular tissue of Toldt’s fascia is visible by moving the scalpel tip up and down, indicating the correct space for dissection (Fig. 12.15).

Inferior Hypogastric Nerve

Fig. 12.15  Entering the space anterior to Toldt’s fascia

Ureter

Experience sharing: Blunt dissection of Toldt’s fascia may be performed with a small gauze. The dissection plane should be smooth, flat and clean.

Fig. 12.16  Ureter exposing

Avascular Area of Sigmoid Mesocolon

Fig. 12.17  Placing gauze underneath the mesentery

Fig. 12.18  Exposure of the avascular area of sigmoid mesocolon

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Experience sharing: When the inferior mesenteric artery is Inferior Mesenteric Artery

double ligated, over isolation of vessels is not necessary, especially in elderly patients with arteriosclerosis. Even if a small amount of connective tissue is caught in the clip, the risk of clip falling off is low. On the other hand, over isolation of vessels may increase the risk of vascular injury and bleeding. Abdominal Aorta

Fig. 12.19  Ligation and transection of the inferior mesenteric artery

Fig. 12.20  Exposure of the inferior mesenteric vein Inferior Mesenteric Vein

Inferior Mesenteric Artery

Experience sharing: Whether to transect the inferior mesenteric vein is determined by the course of marginal vessels in the mesentery.

Fig. 12.21  Ligation and transection of the inferior mesenteric vein

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Fig. 12.22  Opening of the avascular area of sigmoid mesocolon

Experience sharing: During the dissection, the downward course from the bifurcation of the inferior hypogastric nerves can be seen. In order to avoid unnecessary damage, the pelvic plexus should not be dissected.

Inferior Hypogastric Nerve

Fig. 12.23  Dissection downward along the Toldt’s fascia

Fig. 12.24  Dissection downward along the right side of the rectum

3.2.5 Dissection of the Sigmoid Colon and the Left Side of the Rectum A gauze is placed underneath the sigmoid colon and mesorectum (Fig. 12.26), and the sigmoid colon is pulled to the right. The lateral sigmoid adhesion is detached (Fig. 12.27), and dissection is continued upward along the Toldt’s fascia in a lateral to medial pattern (Fig. 12.28). Most cases do not require to mobilize splenic flexure. The left side of the

Fig. 12.25  Dissection of the right rectal wall

r­ectum is also dissected downward to the same level as the right side (Fig. 12.29).

3.2.6 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. 12.30), the stump can be ligated with the vascular clip. The length of the isolated bowel below the tumor should be appropriately 2 cm (Fig. 12.31).

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Physiological Adhesion

Ureter

Fig. 12.26  Placing small gauze underneath the mesentery

Fig. 12.27  Detachment of physiological adhesion of the sigmoid colon

Smart usage of the small gauze: During the dissection in a lateral to medial pattern along the Toldt's fascia, the gauze can Marking Gauze

be observed underneath the mesocolon, which can indicate and protect the tissue in the rear from being damaged (Fig. 12.28).

Fig. 12.28  Opening the peritoneum to the left of the sigmoid colon

Superior Rectal Artery and Vein

Fig. 12.29  Dissecting the left rectal wall downward

Fig. 12.30  Ligation of the superior rectal artery

3.2.7 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. 12.32 and 12.33), and approximately 2 cm of the sigmoid colon is isolated (Fig. 12.34).

3.3

 pecimen Resection and Digestive S Tract Reconstruction

3.3.1 Specimen Resection The surgeon inserts the protective sleeve into the pelvic cavity through the main trocar (Fig. 12.35). After the vaginal irrigation, the assistant introduces the bladder retractor through the

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~ 2 cm

Operating skills: (1) The extent of dissection of the mesorectum should be appropriate. After each incision, the afterheat of the blade can be applied for detachment; (2) The bowel should not be transected immediately after the isolation of bowel wall, which

Isolated Bowel Wall

reduces the range of motion of the bowel wall. Since a small incision will be made on the bowel wall above the tumor, the above- mentioned approach facilitates aseptic operation and reduces the risk of intraperitoneal infection.

Fig. 12.31  Isolation of the bowel below the tumor

Operating skills: During the dissection to the predetermined bowel, attention should be paid to the status of the marginal vessels. Do not transect in parallel manner. Instead, the division should be performed by an inverse parabolic curve.

Fig. 12.32  Dividing the sigmoid mesocolon

Fig. 12.33 Ligation and transection of vessels of the sigmoid mesocolon

Fig. 12.34  Isolation of wall of the sigmoid colon

vagina to indicate the posterior vaginal fornix (Fig.  12.36), 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. 12.37). The assistant inserts the oval forceps through the vagina to pull the distal end of the protective sleeve out of the body (Fig. 12.38). Subsequently, the anvil is introduced into the abdominal cavity through the protective sleeve (Fig. 12.39). A small longitudinal incision is made in the bowel wall between the tumor and the proximal intended resection line (Fig. 12.40). 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.  12.41 and 12.42). The anvil is introduced into the proximal sigmoid colon lumen (Fig.  12.43) and the proximal bowel is transected with the linear Endo-GIA stapler (Fig. 12.44). Following this, the isolated bowel below the tumor is transected with a linear EndoGIA stapler (Fig. 12.45). At this point, the rectal tumor and the bowel segment are completely resected. The surgeon and

12  Laparoscopic Upper Rectal Cancer Resection with Transvaginal Specimen Extraction (CRC-NOSES V) Fig. 12.35  Insertion of protective sleeve through the main trocar

The Tip of Bladder Retractor

Fig. 12.36  Indication of bladder retractor Fig. 12.39  Inserting the anvil through the protective sleeve

Fig. 12.37  Opening the posterior vaginal fornix Fig. 12.40  A small incision on the bowel wall above the tumor

Fig. 12.38  Transvaginal extraction and spreading of the protective sleeve Fig. 12.41  Timely suction of intestinal contents

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Smart usage of the small gauze: Inserting iodoform gauze into the sigmoid colon lumen can facilitate the disinfection and lubrication in the lumen (Fig. 12.42).

Fig. 12.42  Disinfection in the sigmoid colon lumen

Experience sharing: Specimen resection and digestive tract reconstruction are special steps in this procedure, which requires close cooperation between the surgeon and assistant, as well as the skilled application of suction device, iodoform gauze, etc. These operations can minimize the incidence of intra-abdominal infection.

Fig. 12.43  Inserting the anvil into the proximal sigmoid colon

Fig. 12.44  Transection of the bowel of the sigmoid colon

an 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. 12.46).

3.3.2 Digestive Tract Reconstruction The anvil shaft is protruded from one corner of the proximal colon stump (Fig. 12.47). The assistant inserts a circular sta-

Fig. 12.45  Transection of the rectal bowel below the tumor

pler transanally and extends the trocar to pierce the rectal stump from one side of the staple line (Fig. 12.48). The anvil is connected to the trocar of stapler (Fig. 12.49) to complete the sigmoid colorectal end-to-end anastomosis (Fig.  12.50). 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” (Fig.  12.51). Lastly, air leak test is performed to confirm the integrity of the anastomosis (Fig. 12.52). After irrigating the abdominal cavity, transabdominal or transvaginal drainage tubes are placed.

12  Laparoscopic Upper Rectal Cancer Resection with Transvaginal Specimen Extraction (CRC-NOSES V)

Fig. 12.47  Taking out the anvil shaft Fig. 12.46  Transvaginal extraction of rectal specimen and gauze

Operating skills: (1) During the digestive tract reconstruction, placement of iodoform gauze in the vagina facilitates the maintenance of pneumoperitoneum; (2) The clamping of rectal stump with the oval forceps should be completed under direct vision to avoid clamping other tissues, which may result in secondary damage; (3) Pay attention to check the direction of the sigmoid mesocolon before firing the stapler to create the anastomosis.

Fig. 12.48  Extend trocar to pierce the rectal stump

Fig. 12.49  Connecting the anvil and trocar

Fig. 12.50  Sigmoid colorectal end-to-end anastomosis

3.3.3 C  losure 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 incision with two Allis forceps, and interrupted suture is performed with absorbable sutures to close the incision (Fig. 12.53).

3.4

Postoperative Abdominal Wall and Specimen Display (Figs. 12.54 and 12.55)

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Fig. 12.52  Air leak test

Fig. 12.51  Suture to reinforce the “danger triangle of the anastomosis”

Experience sharing: (1) The vaginal incision can be sutured by continuou barbed suture under laparoscopy or interrupted suture under direct vision. (2) Transvaginal placement of drainage tube is suitable for anastomosis above the posterior vaginal fornix to facilitate drainage.

Fig. 12.53  Transvaginal placement of drainage tube

Fig. 12.54  Postoperative abdominal wall display

4

 ey Points, Difficulties, and Hotspots K Related to Surgery

4.1

 kills in the Use of Stapler in Anus S 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 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. The stapler primarily applied in the NOSES is the linear Endo GIA stapler. The length of cartridge mainly includes 30, 45, and 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:

12  Laparoscopic Upper Rectal Cancer Resection with Transvaginal Specimen Extraction (CRC-NOSES V)

Fig. 12.55  Specimen display

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Fig. 12.56  “Z”-shaped transection line formed by three linear Endo GIA staplers

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. 12.56). 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. 12.57, 12.58, 12.59, and 12.60). 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 25, 28, 29, 31, 33  mm, and several other sizes. The selection of stapler should be made according to the diameter of the bowel. 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, 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. 2. 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 associ-

Stapler Trocar

Fig. 12.57  Remnant bowel after the first closure

Stapler Trocar

Fig. 12.58  Extend trocar to pierce the rectal stump

ated 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. 3. 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.

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Fig. 12.61  Transanal injection of dilute iodine solution to observe anastomotic leakage Fig. 12.59  Transection of the remnant rectum

Fig. 12.60  One corner of the rectal stump is pierced by the stapler trocar

4. 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. 5. 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. 6. 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 check immediately. If necessary, air leak test should be performed to check the integrity of the anastomosis.

4.2

Application of Air Leak Test

Anastomotic leakage is the main complication of anus preserving surgery for lower and ultra-low rectal cancer. Accurate anastomosis during operation is the main method to reduce the incidence of anastomotic leakage. Air leak test after anastomosis is one of the main methods to check the integrity of anasto-

Fig. 12.62 Suture the “danger triangle of the anastomosis” for reinforcement

Fig. 12.63  Suture around the anastomosis for reinforcement

mosis. 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. 12.61). 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.  12.62 and 12.63). During this process, the assistant 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.

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

13

Xishan Wang and Zheng Jiang

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 anastomosis between transverse colon and rectum. 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, totally laparoscopic digestive tract reconstruction, and application of aseptic and tumor-free operation. These are the challenges the surgeons need to face and overcome.

1

Indications and Contraindications of NOSES

1.1

Indications (Figs. 13.1, 13.2, and 13.3)

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.

1.2

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).

2

 nesthesia, Patient Positioning, A Trocar Placement, and Surgical Team Position

2.1

Anesthesia Method

General anesthesia or general epidural anesthesia.

2.2

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. 13.4).

2.3

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.

X. 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 2021 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-15-7925-7_13

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Fig. 13.1  Extent of surgical resection

specimen extraction, the assistant returns to the left side of patient. The camera holder stands on the same side of surgeon (Fig. 13.6).

2.5

Special Surgical Instruments

Ultrasonic scalpel, 60 mm linear Endo GIA stapler, 29 mm circular stapler, sterile protective sleeve

3

Surgical Procedure, Techniques, and Key Points

The schematic view of main surgical procedures of specimen extraction and digestive reconstruction in NOSES VIA (Fig. 13.7). Fig. 13.2  Colonoscopy: Tumor of protuberant type, 29  cm from the dentate line, maximum diameter of 2.5 cm

3.1 5. The assistant’s auxiliary trocar (5 mm trocar) is located opposite the McBurney’s point, which facilitate to place the drainage tube (Fig. 13.5).

2.4

Surgical Team Position

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

Exploration and Surgical Planning

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

3.1.1 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. 13.8 and 13.9).

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Fig. 13.3  CT virtual endoscopy: The tumor is located at the descending colon

Surgeon’s Auxiliary Trocar (5 mm)

Camera Trocar (10 mm)

Surgeon’s Main Trocar (12 mm)

Fig. 13.4  The patient’s position

Fig. 13.5  Trocar placement (Five-port method)

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

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a

b

Camera Holder

Monitor

Surgeon Surgeon Camera Holder

Assistant

Monitor Assistant Scrub Nurse

c

Scrub Nurse

Camera Holder

Assistant

Surgeon

Scrub Nurse

Monitor

Fig. 13.6 (a) Surgical team position (before the mobilization of splenic flexure), (b) surgical team position (mobilization of splenic flexure), (c) surgical team position (specimen extraction and digestive tract reconstruction)

3.1.2 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. 13.10). 3.1.3 Evaluation of Anatomical Structures Firstly, 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; secondly, the surgeon should determine whether the thickness of mesentery and the circumferential diameter of tumor facilitate the transrectal specimen extraction.

3.2

Dissection and Separation

3.2.1 M  anagement 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.  13.11 and 13.12) 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.  13.13), 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

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

Fig. 13.7  The main surgical procedures of specimen extraction and digestive reconstruction in NOSES VIA

Fig. 13.8  Exploration of liver and stomach Fig. 13.9  Exploration of the pelvic cavity

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transected (Figs.  13.14 and 13.15). 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 transect the inferior mesenteric vein at the inferior boarder of pancreas (Figs. 13.16 and 13.17).

3.2.2 D  issection 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 lateral fashion (Fig.  13.18). 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. 13.19 and 13.20).

3.2.3 M  anagement 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.  13.21). Subsequently, the surgeon divides the mesorectum to the bowel wall, and the distal superior rectal vessels are better ligated with vascular clips (Figs.  13.22 and 13.23). Approximately 3–4 cm of bowel wall is isolated at the junction between the rectum and sigmoid colon (Fig. 13.24). 3.2.4 M  anagement 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 mid-

Fig. 13.10  Exploration of the tumor location

Cooperating skills: The assistant lifts the inferior mesenteric Treitz Ligament

Inferior Mesenteric Vein

artery with the forceps in the left hand, and move the small intestine to the right abdominal cavity with gauze in the forceps in the right hand to expose the root of the inferior mesenteric artery. The abdominal aortic pulsation and the course of the Treitz ligament and its lateral inferior mesenteric vein can be seen (Fig. 13.11).

Fig. 13.11  Exposure of the Treitz ligament and inferior mesenteric vein

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Fig. 13.12  The first point of the incision Fig. 13.15  Ligation and transection of the inferior mesenteric artery

Fig. 13.13  Entering the space anterior to Toldt’s fascia Fig. 13.16  Dissection of the inferior mesenteric vein

Inferior Mesenteric Artery

Fig. 13.14  Isolation of the inferior mesenteric artery

Fig. 13.17  Ligation of the inferior mesenteric vein

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Pancreas

Left

Left Ureter

Adipose

Capsule of Kidney

Fig. 13.18  Dissection of mesentery along the Toldt’s fascia from medial to lateral

Fig. 13.19  Dissection of mesentery upward along the Toldt’s fascia

Smart usage of the small gauze: Place a gauze underneath the dissected sigmoid mesocolon for protection and indication (Fig. 13.20).

Pancreas

Left

Adipose

Capsule of Kidney

Fig. 13.20  Placing small gauze underneath the mesentery

The Level of Sacral Promontory

Fig. 13.21  Dissection downward along the right side of the bowel to open the mesentery

Fig. 13.22  Dividing the upper mesorectum

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Superior Rectal Artery

Fig. 13.23  Ligation of the superior rectal artery

Fig. 13.24  Isolation of wall of the sigmoid colon

Cooperating skills: The surgeon lifts the greater omentum with the forceps in the left hand. The assistant lifts the greater omentum near the splenic flexure with the forceps in the right hand, and pulls the colon wall with the forceps in the left hand to expose the surgical field adequately.

Fig. 13.25  Separating of the transverse colon from the greater omentum

dle transverse colon to the left and transects the attachment of the greater omentum (Fig. 13.25) 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. 13.26). After that, the greater omentum is flipped upward, the adhesions between the stomach and the transverse mesocolon is detached, and dissection is continued to the left to the lower pole of spleen (Fig. 13.27). Following this, 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. Then the dissection proceeds to the left to lower pole of spleen along the inferior boarder of the pancreas (Figs. 13.28 and 13.29).

3.2.5 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. 13.30). The left paracolic sulcus is incised upward to the lower pole of spleen as indicated by the gauze (Fig. 13.31). At this time, the dissection of the left colon is completed. 3.2.6 D  ividing 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. 13.32). Dissection is continued to the bowel wall, and 2  cm of the bowel is isolated (Fig. 13.33).

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Experience sharing: Preservation of the greater omentum is a feature of this procedure. The function of the greater omentum is to maintain immunity and lubrication, anti-adhesion, prevent the onset of intestinal obstruction, andreduce the difficulties of transanal specimen extraction.

Fig. 13.26  Dissection to the left to detach the adhesion of the greater omentum to the transverse colon

Spleen Inferior Boarder of Pancreas

Fig. 13.27  Dissection to the lower pole of spleen

Fig. 13.28  Dissection upward to the inferior boarder of the pancreas

Smart usage of the small gauze: Place a gauze at the inferior boarder of pancreas and the lower pole of spleen for protection and indication (Fig. 13.29).

Pancreas Gauze at the Inferior Boarder of Pancreas

Fig. 13.29  Gauze visible at the inferior boarder of pancreas

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Fig. 13.30  Opening the left paracolic sulcus

Fig. 13.32  Ligation of the marginal vessels

The Lower Pole of Spleen

Fig. 13.31  Dissection to the lower pole of spleen along the left paracolic sulcus

3.3

Fig. 13.33  Isolation of the transverse colon

 pecimen Resection and Digestive S Tract Reconstruction

3.3.1 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. 13.34 and 13.35). 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 into the abdominal cavity through the protective sleeve (Fig.  13.36). A small longitudinal incision is made in the bowel wall proximal to the tumor (Fig.  13.36). After the

Fig. 13.34  Opening the sigmoid colon below the tumor

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Cooperating skills: (1) During the incision of bowel, the assistant should suction the intestinal contents at an appropriate speed. Pneumoperitoneum will be deflated if the suction is too fast (Fig. 13.35); (2) Apply the iodoform gauze for disinfection and protect the surrounding area with gauze.

Fig. 13.35  Timely suction of intestinal contents

Fig. 13.36  Inserting the anvil into the abdominal cavity through the anus and rectum

Fig. 13.37  Opening the transverse colon wall above the tumor

Cooperating skills: (1) During the incision of bowel, the assistant should suction the intestinal contents; (2) Meanwhile, the bowel lumen should be disinfected with iodoform gauze (Figs. 13.38 and 13.39).

Fig. 13.38  Timely suction of bowel contents

opened bowel lumen is disinfected, the anvil is introduced into the proximal colon (Figs. 13.37, 13.38, 13.39, and 13.40). The colon is transected with a linear stapler (Fig. 13.41). At this point, the anvil is left in the proximal bowel, and the bowel stump should be disinfected again with iodoform gauze

(Fig. 13.42). 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

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Fig. 13.39  Disinfection of the bowel lumen with iodoform gauze

Fig. 13.42  Disinfection of bowel stump with iodoform gauze

Fig. 13.40  Inserting the anvil into the proximal transverse colon

Fig. 13.43  Transanal extraction of the left colon specimen

Fig. 13.41  Transection of the transverse colon

bowel extra-corporeally and slowly pulls the specimen out of the rectum and anus (Fig. 13.43). While most of the specimen is extracted, the inner opening of protective sleeve is tightened to facilitate the extraction (Fig. 13.44).

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3.3.2 Digestive Tract Reconstruction The opened rectal stump is closed with a linear Endo GIA stapler (Fig. 13.45), 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 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.  13.46). The assistant inserts a circular stapler transanally and extends the trocar to pierce the left lateral corner of rectal stump (Fig. 13.47). The anvil is connected to the trocar of stapler, and the direction of mesocolon is adjusted (Fig.  13.48), then the stapler is fired to complete the anastomosis (Fig. 13.49). 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.  13.50). Air leak test is performed to ­confirm the integrity of the anastomosis (Fig.  13.51). After irrigating the abdominal cavity, two drainage tubes

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Experience sharing: Placing the protective sleeve from the pelvis cavity not only complies with the principle of aseptic and tumor-free operation, but also facilitates the specimen extraction.

Fig. 13.44  Tighten the drawstring on the protective sleeve

Fig. 13.45  Closing the rectal stump

Fig. 13.46  Taking out the anvil shaft

Experience sharing: The trocar of the stapler can be protruded from one corner of the rectal stump to reduce a ‘danger triangle of the anastomosis’, and thereby reduce a technical factor for anastomotic leakage.

A Corner of Rectal Stump

Fig. 13.47  One corner of the rectal stump is pierced by the trocar of stapler

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Fig. 13.48  Connection of the anvil to the trocar

Fig. 13.51  Air leak test

Fig. 13.49  Transverse colorectal end-to-end anastomosis

Fig. 13.52  One drainage tube is placed on the right side of the pelvic cavity

Fig. 13.53  One drainage tube is placed on the left side of the pelvic cavity Fig. 13.50  “Danger triangle of the anastomosis”

are placed close to the anastomosis (Figs.  13.52 and 13.53). Finally, pneumoperitoneum is released, and the trocar sites are closed.

3.4

Postoperative Abdominal Wall and Specimen Display (Figs. 13.54 and 13.55)

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Fig. 13.56  Dissection of the inferior boarder of pancreatic body and tail

Fig. 13.54  Postoperative abdominal wall display

Fig. 13.57  Preservation of the inferior mesenteric vein

Fig. 13.55  Specimen display

4

 ey Points, Difficulties, and Hotspots K Related to Surgery

4.1

 election of Surgical Approach S 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 identifi-

cation of the correct operation plane and space and facilitates the surgeon to distinguish the anatomical planes of ureters. 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. 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 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. 13.56) while preserving the inferior mesenteric vein (Fig. 13.57).

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4.2

 ommon Approaches for Preoperative C Tumor Localization

With the development and popularization of laparoscopic technique, the preoperative localization of colon cancer has gradually attracted wide attention. Accurate tumor 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. 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 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

Fig. 13.58  CT Virtual endoscopy shows the tumor location

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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. CT virtual endoscopy has gradually replaced double-contrast barium radiography (Fig. 13.58). 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

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Fig. 13.59  Tumor localization using carbon nanotube injection

Fig. 13.60  Lymph nodes labeled with carbon nanotubes

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.  13.59). In addition, the carbon nanotube is also a good indicator for lymph node detection (Fig. 13.60).

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

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Haipeng Chen, Zhaoxu Zheng, and Xishan Wang

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

1

Indications and Contraindications of NOSES

1.1

Indications

Fig. 14.1  Extent of surgical resection

1. Tumor is located at the splenic flexure and transverse colon near the splenic flexure (Figs. 14.1, 14.2, and 14.3). 2. The circumferential diameter of the tumor is preferably less than 3 cm. 3. The tumor should not invade beyond the serosa.

H. Chen · Z. Zheng · X. Wang (*) Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China Fig. 14.2 Colonoscopy © People’s Medical Publishing House, PR of China 2021 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-15-7925-7_14

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Fig. 14.3  CT virtual endoscopy: the tumor is located at the splenic flexure

1.2

Contraindications

2.2

Patient Positioning

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

The patient is placed in functional lithotomy position, with the right thigh slightly flattened, which facilitates to perform the operation for the surgeon (Fig. 14.4).

2

2.3

2.1

 nesthesia, Patient Positioning, A Trocar Placement and Surgical Team Position Anesthesia Method

General anesthesia or general epidural anesthesia.

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.

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Assistant

Surgeon Scrub Nurse

Monitor Camera Holder

Fig. 14.4  The patient’s position

Fig. 14.6  Surgical team position (left hemicolectomy)

Surgeon’s Auxiliary Trocar (5 mm)

Camera Trocar (10 mm)

Surgeon’s Main Trocar (12 mm)

Camera Holder

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

Assistant

Surgeon

Fig. 14.5  Trocar placement (Five-ports method)

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. 14.5).

2.4

Surgical Team Position

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. 14.6 and 14.7).

2.5

Special Surgical Instruments

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

Scrub Nurse Monitor

Fig. 14.7  Surgical team position (specimen extraction and digestive tract reconstruction)

3

Surgical Procedure, Techniques, and Key Points

The schematic view of the main surgical procedures of specimen extraction and digestive reconstruction in NOSES VIB (Fig. 14.8).

3.1

Exploration and Surgical Planning

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

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Fig. 14.8  The main surgical procedures of specimen extraction and digestive reconstruction in NOSES VIB

Fig. 14.9  Exploration of the liver and stomach

Fig. 14.10  Exploration of the pelvic cavity

3.1.1 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. 14.9 and 14.10).

3.1.2 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. 14.11).

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Fig. 14.11  Exploration of the tumor location

Fig. 14.12  Exposure of the Treitz ligament and inferior mesenteric vein

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Fig. 14.13  The first point of the incision

Fig. 14.14  Entering the space anterior to Toldt’s fascia

3.1.3 Evaluation of Anatomical Structures Firstly, evaluate the anatomic structure of colon and mesocolon, i.e., whether the length of the dissected bowel and the course of the marginal vessels facilitate the anastomosis; Secondly, evaluate whether the thickness of mesentery and the circumferential diameter of the tumor facilitate the transrectal specimen extraction.

3.2

Dissection and Separation

3.2.1 M  anagement of the Root of the Inferior Mesenteric Vessels The Treitz ligament and inferior mesenteric vein are exposed (Fig.  14.12). The surgeon applies the ultrasonic scalpel to open the retroperitoneum at the root of the inferior mesenteric artery (Fig. 14.13 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.  14.14). then space above, below, and to the left of the root of the inferior mesenteric artery is extended. Subsequently, the root of the infe-

Fig. 14.15  Isolation of the left colic artery, preservation of the sigmoid artery and superior rectal artery, and dissection of station 253 lymph nodes

rior 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. 14.15), then the left colic artery is double ligated and

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Fig. 14.16  Double ligation and transection of the left colic artery

Fig. 14.17  Isolation of the inferior mesenteric vein to the inferior border of the pancreas, and dissection of the surrounding lymphatic tissue

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Fig. 14.18  Isolation of the left colic vein, and ligation and transection of the left colic vein

Fig. 14.19  Surgical field after dissection of lymph nodes with preservation of the superior mesenteric vein

transected (Fig. 14.16). Attention should be paid to protect the nerves. After that, dissection is continued upwards 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.  14.17). Following this, the left colic vein is isolated, ligated, and transected (Fig. 14.18). The surgical field after dissection of lymph nodes with preservation of the superior mesenteric vein is shown as follows (Fig. 14.19).

3.2.2 D  issection 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 downwards and upwards in a medial to lateral fashion (Fig.  14.20). The course and peristalsis of the left ureter can be observed. For the medial side, the surface of the left adipose capsule of the kidney is adequately dissected (Fig. 14.21). Dissection is continued along the surface of the pancreas while paying attention to protect the pancreas to avoid postoperative pancreatic leak. Subsequently, dissec-

Fig. 14.20  Dissection of mesentery along the Toldt’s fascia from medial to lateral

tion proceeds along with the space upwards to the left to the tail of the pancreas (Figs. 14.22 and 14.23). A small gauze is placed lateral to the mesentery after adequate dissection (Fig. 14.24).

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Fig. 14.21  Dissection of mesentery upwards along the Toldt’s fascia

Fig. 14.22  Dissection along the surface of the pancreas

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Fig. 14.24  Placing small gauze lateral to the mesentery

Fig. 14.25 Detachment of transverse colon from the greater omentum

Fig. 14.26  Entering the omental bursa Fig. 14.23  Dissection along the space upwards to the left to the tail of the pancreas

3.2.3 M  anagement 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 transect the attachment of the greater omentum (Fig. 14.25) until the lower pole of the spleen and the peritoneum lateral to the splenic flexure are exposed. At this point, the omental bursa is entered (Fig.  14.26). After that, the greater omentum is

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Fig. 14.27  Dissection toward the spleen

Fig. 14.29  Dissection to the left to the lower pole of spleen along the inferior boarder of the pancreas

Fig. 14.28  Transection of the transverse mesocolon from the inferior mesenteric vein stump which lies lateral to the Treitz ligament

Fig. 14.30  Open the left paracolic sulcus

flipped upwards, 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. 14.27). The 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. 14.28). Then the dissection proceeds to the left to the lower pole of the spleen along the inferior border of the pancreas (Fig. 14.29).

3.2.4 Dissection of the Left Paracolic Sulcus The sigmoid colon is pulled to the right while the left side of the rectum is dissected upwards along the Toldt’s fascia (Fig. 14.30). The left paracolic sulcus is incised upwards to the lower pole of the spleen as indicated by the gauze (Fig. 14.31). At this time, the dissection of the left colon is completed.

Fig. 14.31  Dissection to the lower pole of spleen along the left paracolic sulcus

3.2.5 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 meso-

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Fig. 14.32  Ligation and transection of marginal vessels of the sigmoid colon

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Fig. 14.34  Ligation of marginal vessels of the transverse colon

Fig. 14.35  Isolation of transverse colon Fig. 14.33  Isolation of wall of the sigmoid colon

colon and divides along the intended resection line to the marginal arteries, then ligates and transects the marginal vessels (Fig. 14.32). Dissection is continued to the bowel wall, and 2 cm of the bowel is isolated (Fig. 14.33).

3.2.6 D  ividing the Mesocolon Above the Tumor and Isolating the Bowel The splenic flexure is pulled downwards for the evaluation of the intended resection line. The transverse mesocolon is divided, and the marginal vessels are ligated and transected (Fig. 14.34). Dissection is continued to the bowel wall, and 2 cm of the bowel is isolated (Fig. 14.35). Fig. 14.36  Transection of the transverse colon

3.3

 pecimen Resection and Digestive S Tract Reconstruction

3.3.1 Specimen Resection The surgeon transects the bowel at the intended resection line of the transverse colon with a linear Endo-GIA stapler

(Fig.  14.36). 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 Endo-­

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Fig. 14.37  Transection of the sigmoid colon Fig. 14.39  Suture of the transverse colon stump with the bowel 8 cm from the sigmoid colon stump

Fig. 14.38  Overlapping of the sigmoid colon with transverse colon

GIA stapler (Fig.  14.37). At this point, the left hemicolectomy is completed, and the specimen is placed in the left upper abdomen.

3.3.2 Digestive Tract Reconstruction (Isoperistaltic Side-To-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.  14.38). Perform suture of the transverse colon stump with the bowel 8  cm from the sigmoid colon stump (Fig.  14.39). 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. 14.40 and 14.41), and both bowel lumens are disinfected with iodoform gauze. The linear Endo-GIA stapler is introduced through the surgeon’s main trocar, where after 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. 14.42, 14.3 and 14.44).

Fig. 14.40  Making an incision of 1  cm long on the sigmoid colon stump

Fig. 14.41  Making an incision of 1  cm long on the corresponding antimesenteric side of the transverse colon

The bowel lumen is disinfected with iodoform gauze, and the integrity of the anastomosis is confirmed. After exclud-

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Fig. 14.42  Insertion of linear Endo-GIA stapler into the sigmoid colon

Fig. 14.43  Insertion of linear Endo-GIA stapler into the two sides of the bowel

Fig. 14.44  Completion of side-to-side anastomosis between the sigmoid colon and transverse colon

ing anastomotic leakage, traction sutures are fixed in both ends and the middle of the enterotomies, respectively (Fig. 14.45). The surgeon and assistant grasp the tail of traction sutures of the two sides to keep the bowel wall straight

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Fig. 14.45  Suture each end of the common opening of bowel stump with one stitch

Fig. 14.46  Closing the common opening of the two sides of the bowel

Fig. 14.47  Digestive tract reconstruction with an isoperistaltic side-to-­ side anastomosis

and close the enterotomies with linear Endo-GIA stapler. Digestive tract reconstruction with isoperistaltic side-to-side anastomosis is completed (Figs.  14.46 and 14.47). Eight-­

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Fig. 14.48  8-Figure suture for the reinforcement of anastomosis

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Fig. 14.50  Insertion of the protective sleeve through the trocar

Fig. 14.49  Longitudinal incision on the upper rectum

figure suture is performed for the reinforcement of anastomosis (Fig. 14.48).

3.3.3 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. 14.49). The protective sleeve is inserted through the 12 mm trocar (Fig. 14.50), 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. 14.51 and 14.52). All the used gauzes in the abdominal cavity are 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. 14.53 and 14.54) 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. 14.55).

Fig. 14.51  Placement of oval forceps into the abdominal cavity through the incision on the rectum

Fig. 14.52  Pulling the end of the protective sleeve out through the rectum and anus

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. 14.53  Insertion of oval forceps with the protective sleeve Fig. 14.56  Full-thickness continuous suture of incision on the rectum

Fig. 14.54  Clamping one end of the bowel with oval forceps

Fig. 14.57  Continuous seromuscular layer embedding of incision on the rectum

Fig. 14.55  Specimen extraction

incision on the rectum under laparoscopy (Fig. 14.56), followed by seromuscular layer embedding (Fig.  14.57). The rectal incision was checked again by colonoscopy (Fig. 14.58). The abdominal cavity is irrigated with distilled water (Fig. 14.59), and the drainage tube is indwelled in the abdominal cavity (Fig.  14.60). Pneumoperitoneum is released, and the trocar sites are closed. Fig. 14.58  Rectal incision in colonoscopy

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Fig. 14.59  Irrigation of abdominal cavity

Fig. 14.61  Specimen display

Fig. 14.60  Placing a drainage tube in the abdominal cavity

3.4

 ostoperative Recovery and Specimen P Display (Figs. 14.61, 14.62, and 14.63)

4

 ey Points, Difficulties, and Hotspots K Related to Surgery

4.1

 issection and Anatomy of the Splenic D Flexure

The low morbidity of left colon cancer resulting in less cases of left hemicolectomy, 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 is 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

Fig. 14.62  Picture of the abdominal wall after operation

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 upwards to the splenic flexure; (3) alternately perform the dissection in the above two ways from the peripheral to the center of the splenic flexure; (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

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Fig. 14.63  Rectal incision in colonoscopy, 3 months after surgery. (Hu Xiyue, Haipeng Chen, Zhaoxu Zheng, Xishan Wang)

during surgical manipulation. Therefore, the spleen should be adequately exposed during operation to avoid excessive traction and bleeding.

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 he Concept of Complete Mesocolic T 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, 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.

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

15

Xishan Wang, Zheng Liu, and Zhao Lu

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 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, and the strict maintenance of aseptic and tumor-free operation, etc.

1.2

1

Indications and Contraindications of NOSES

1.1

Indications (Figs. 15.1, 15.2, 15.3)

The patient is placed in functional lithotomy position, with the right thigh slightly flattened, which facilitates to perform the operation for the surgeon (Fig. 15.4).

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.

X. Wang (*) · Z. Liu · Z. Lu Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China

Contraindications

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

2

 nesthesia, Patient Positioning, A Trocar Placement, and Surgical Team Position

2.1

Anesthesia Method

General anesthesia or general epidural anesthesia.

2.2

2.3

Patient Positioning

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 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.

© People’s Medical Publishing House, PR of China 2021 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-15-7925-7_15

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Fig. 15.1  Extent of surgical resection

to the left side of the patient. The camera holder stands on the same side of the surgeon (Figs. 15.6, 15.7, 15.8).

2.5

Special Surgical Instruments

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

3

Surgical Procedure, Techniques, and Key Points

The schematic view of the main surgical procedures of specimen extraction and digestive reconstruction in NOSES VII (Fig. 15.9). Fig. 15.2  Colonoscopy: Tumor of ulcerated type, 33 cm from the dentate line, the maximum diameter of 5 cm

3.1 5. The assistant’s auxiliary trocar (5 mm trocar) is located opposite the McBurney’s point (Fig. 15.5).

2.4

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

Exploration and Surgical Planning

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

3.1.1 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.  15.10, 15.11).

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Fig. 15.3  a-c CT virtual endoscopy: The tumor is located at the junction between the descending colon and sigmoid colon, involving 1/2 of the rectal circumference

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Monitor

Surgeon

Camera Holder

Fig. 15.4  The patient’s position

Assistant Scrub Nurse

Fig. 15.7  Surgical team position (mobilization of splenic flexure) Surgeon’s Auxiliary Trocar (5 mm)

Assistant’s Main Trocar (5 mm)

Camera Trocar (10 mm)

Assistant’s Auxiliary Trocar (5 mm)

Surgeon’s Main Trocar (12 mm)

Camera Holder

Surgeon

Assistant

Fig. 15.5  Trocar placement (Five-ports method)

Camera Holder

Surgeon

Scrub Nurse Assistant

Monitor

Monitor

Scrub Nurse

Fig. 15.6  Surgical team position (before the mobilization of splenic flexure)

3.1.2 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. 15.12).

Fig. 15.8  Surgical team position (specimen extraction and digestive tract reconstruction)

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

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Fig. 15.9  The main surgical procedures of specimen extraction and digestive reconstruction in NOSES VII.

Fig. 15.10  Exploration of the spleen

Fig. 15.11  Exploration of the greater omentum

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Experience sharing: For the small lesion which is hard to be detected laparoscopically, submucosal injection of methylthioninium chloride or carbon nanotube can be performed under colonoscopy before operation (Fig 15.12).

Fig. 15.12  Exploration of the tumor location (marked with methylthioninium chloride preoperatively)

Smart usage of the small gauze: Move the small intestine to the right side of abdominal cavity with a small gauze to expose the root of the inferior mesenteric vessels (Fig 15.13), and the course and pulsation of the abdominal aorta can be seen.

Fig. 15.13  Exposure of the inferior mesenteric vein

Fig. 15.14  The first point of the incision

3.2

Dissection and Separation

3.2.1 M  anagement 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, dissect along the lateral side of the abdominal aorta upwards to open the pos-

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

terior peritoneum (Fig. 15.13). Ultrasonic scalpel is applied to dissect along the Toldt’s fascia (Figs. 15.14, 15.15), and expand the space above, below, and to the left of the inferior mesenteric artery (Fig.  15.16). Double ligation and ­transection of the inferior mesenteric artery are performed (Fig. 15.17). 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 upwards to the Treitz ligament, then the inferior

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mesenteric vein is transected and ligated at the inferior border of the pancreas (Figs. 15.18, 15.19).

Fig. 15.16  Isolation of the inferior mesenteric artery

3.2.2 D  issection of Left Mesocolon with Medial Approach The inferior mesenteric vessel stumps are lifted, and dissection is performed along the Toldt’s fascia downwards and upwards in a medial to lateral fashion (Figs.  15.20 and 15.21). The course and peristalsis of the left ureter as well 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

Operating skills: Transection of blood vessels should be performed with laparoscopic scissors to prevent damage to the vascular clip caused by excessive heat generated by the ultrasonic scalpel.

Fig. 15.17  Ligation and transection of the inferior mesenteric artery

Fig. 15.18  Exposure of the inferior border of pancreas and the inferior mesenteric vein

Fig. 15.19  Ligation of the inferior mesenteric vein

Operating skills: Blunt and sharp dissection should be combined in the management of this mesentery. During the dissection, care should be taken to protect the ureters and gonadal vessels.

Fig. 15.20  Dissection of mesentery along the Toldt’s fascia from medial to lateral

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medial to lateral, and the dissection plane should be smooth, flat, and clean.

3.2.3 M  anagement 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 downwards to the sacral

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promontory along the course of the inferior mesenteric artery, then the sigmoid mesocolon or mesorectum is transected (Fig. 15.22). The distal superior rectal vessels are better ligated with vascular clips (Fig. 15.23). 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. 15.24, 15.25), and iodoform gauze is used to disinfect the stump of the sigmoid colon (Fig. 15.26).

Smart usage of the small gauze: A gauze is placed underneath the mesentery for indication and protection (Fig 15.21).

Fig. 15.21  Placing small gauze underneath the mesentery

Fig. 15.22  Dividing the sigmoid mesocolon

Fig. 15.24  Isolation of wall of the sigmoid colon

Fig. 15.23  Ligation of the superior rectal artery

Fig. 15.25  Transection of the bowel of the sigmoid colon

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3.2.4 M  anagement 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. 15.27). Dissection is performed from the attachment of the greater omentum to the splenic flexure (Fig. 15.28). 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. 15.29). 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. 15.30, 15.31, 15.32). With the indication and protection

Fig. 15.26  Disinfection of stump with iodoform gauze

Fig. 15.29  Indication and protection of the gauze

Experience sharing: For the resection of transverse colon, the greater omentum can be preserved or partially resected. The greater omentum may be reserved if the tumor does not invade beyond the serosa.

Fig. 15.27  Separation of the transverse colon from the greater omentum

Cooperating skills: The surgeon lifts the greater omentum with the forceps in the left hand. The assistant clamps the colon wall with the forceps in the left hand and clamps the greater omentum in the right hand to expose the surgical field adequately.

Fig. 15.28  Dissection to the left to the lower pole of the spleen

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Operating skills: The splenic flexure should be dissected appropriately to avoid potential surgical failure due to splenic rupture (Fig 15.30).

Fig. 15.30  Dissection upwards to the inferior border of the pancreas

Fig. 15.31  Dividing the transverse mesocolon

Fig. 15.33  Open the left paracolic sulcus

Fig. 15.32  Ligation of marginal vessels

Fig. 15.34  Dissection along the left paracolic sulcus

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

3.2.5 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. 15.33), and finally toward the lower pole of the spleen and the tail of the pancreas (Figs. 15.34, 15.35). At this point, the dissection of the left colon is completed. Fig. 15.35  Dissection to the lower pole of the spleen

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3.2.6 D  ividing 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 2cm (Fig. 15.36).

3.3

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protective sleeve (Fig. 15.40). 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. 15.41, 15.42), and the assistant applies the suction to push the iodoform gauze into the distal bowel lumen of the incision. Then,

 pecimen Resection and Digestive S Tract Reconstruction

3.3.1 Specimen Resection The surgeon inserts the protective sleeve into the pelvic cavity through the main trocar (Fig. 15.37). After the vaginal irrigation, the assistant introduces the bladder retractor through the vagina to indicate the posterior vaginal fornix (Fig. 15.38). 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.  15.39). 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

Fig. 15.38  Transvaginal placement of bladder retractor for the indication of the posterior vaginal fornix

Fig. 15.39  Opening the posterior vaginal fornix transversely Fig. 15.36  Isolation of bowel of the transverse colon

Fig. 15.37  Insertion of the protective sleeve through the main trocar

Fig. 15.40  Pulling the protective sleeve through the vagina and introducing the anvil into the pelvic cavity through the protective sleeve

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Operating skills: Make a small incision on the bowel above the tumor and insert the anvil. Aseptic operation is the key of this step. Proper use of the suction device and iodoform gauze is required (Fig 15.41-44).

Fig. 15.41  Timely suction of bowel contents

Fig. 15.42  Disinfection of the bowel lumen with iodoform gauze Fig. 15.44  Transection of the bowel of the transverse colon

Fig. 15.43  Inserting the anvil into the proximal transverse colon

the anvil is placed in the proximal bowel lumen through the incision (Fig. 15.43), and the proximal bowel is transected with the linear Endo-GIA stapler (Fig. 15.44). At this point, the left colon is completely resected, and the anvil is left in the proximal bowel stump. assistant applies

Fig. 15.45 Transvaginal extraction of gauze and the left colon specimen

the oval forceps to clamp one end of the specimen to slowly pull out the specimen through the vagina (Fig. 15.45).

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3.3.2 Digestive Tract Reconstruction The anvil shaft is protruded from one corner of the proximal colon stump (Fig. 15.46). 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. 15.47) to complete the end-to-end anastomosis between colon and rectum (Fig. 15.48). The integrity of the anastomotic ring is checked before the 8-Figure suture is performed on the “danger triangle of the anastomosis” (Fig. 15.49). Air leak test is performed to confirm the integrity of the anastomosis (Fig. 15.50). After irrigating the abdominal cavity, two drainage tubes are placed through the trocars on the abdominal wall (Fig. 15.51).

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Fig. 15.48  Connecting the stapler

Fig. 15.46  The anvil shaft is protruded from the proximal bowel stump

Fig. 15.49  “danger triangle of the anastomosis”

Fig. 15.47  Extend trocar to pierce the rectal stump

Fig. 15.50  Air leak test

Experience sharing: Transvaginal placement of drainage tube is not applicable because of the location of the anastomosis.

Fig. 15.51  Placing drainage tubes in the pelvic cavity

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Fig. 15.52  Extracorporeal interrupted suture of the vaginal incision

3.3.3 C  losure 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: 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. 15.52).

3.4

Postoperative Abdominal Wall and Specimen Display (Figs. 15.53 and 15.54)

4

 ey Points, Difficulties, and Hotspots K Related to Surgery

4.1

 election and Suture of the Incision S 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. However, the majority of colorectal surgeons lacks 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. 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

Fig. 15.53  Postoperative abdominal wall display

Fig. 15.54  Specimen display

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. 15.55). Physiological Characteristics: The response to sexual stimulation is different in different parts of the vagina. The outer 1/3 of the vagina is originated from the ectoderm, which is rich in nerve fibers and more sensitive to tactile stimulation. The inner 2/3 of the vagina is originated from the mesoderm, where there is no nerve ending distribution. Therefore, the outer 1/3 has more sexual sensation than the inner 2/3. Since the posterior vaginal fornix is deep without

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Fig. 15.57  The length of the vaginal incision

Fig. 15.55  Posterior vaginal fornix

Fig. 15.58  Dilation of the incision up and down

Fig. 15.56  Introduction of bladder retractor with its tip withstanding the posterior vaginal fornix

nerve innervation, it does not respond to sexual stimulation. Therefore, damage to the posterior vaginal fornix will not affect sex activity. Rectouterine pouch is the lowest point in the abdominal cavity in the female. Peritoneal fluid is most likely to accumulate in this site and 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.  15.56). 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. 15.57). As the vagina has a strong ductility, the incision can be expanded to 5  cm to meet the requirements of specimen extraction (Fig. 15.58). 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 (Figs. 15.59 and 15.60): 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.  15.61): This approach is more difficult and puts forward higher requirements for the surgeon’s operating skills.

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Fig. 15.61  Laparoscopic suturing of vaginal incision

Fig. 15.59  Extracorporeal interrupted suture of the vaginal incision

Fig. 15.60  Vaginal incision after extracorporeal interrupted suture

The dedicated vaginal barbed suture is needed for the laparoscopic vaginal suture (no longer than 15 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 hours after the operation.

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

16

Xishan Wang, Xu Guan, and Haiyang Huang

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 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-to-end 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, and 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.

1

Indications and Contraindications of NOSES

1.1

Indications (Figs. 16.1, 16.2, 16.3)

1. Female patients with right colon tumor. X. Wang (*) · X. Guan · H. Huang Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China

2. The circumferential diameter of the tumor is better less than 5 cm. 3. The tumor should not invade beyond the serosa.

1.2

Contraindications

1 . The circumferential diameter of tumor is more than 5 cm. 2. Tumor invades adjacent tissues and organs. 3. Severely obese patients (BMI>35 kg/m2). 4. Male patients with right colon cancer.

2

 nesthesia, Patient Positioning, A Trocar Placement, and Surgical Team Position

2.1

Anesthesia Method

General anesthesia or general epidural anesthesia.

2.2

Patient Positioning

Supine position or functional lithotomy (Fig. 16.4).

2.3

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,

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Fig. 16.1  Extent of surgical resection

2.4

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 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. 16.6 and 16.7).

2.5

Fig. 16.2  Colonoscopy: Tumor of protuberant type, located at the ascending colon (90 cm from the anal verge), the maximum diameter of 4 cm

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. 16.5).

Special Surgical Instruments

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

3

Surgical Procedure, Techniques, and Key Points

The schematic view of the main surgical procedures of specimen extraction and digestive reconstruction in NOSES VIIIA (Fig. 16.8).

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Fig. 16.3  CT virtual endoscopy: The tumor is located at the ascending colon

3.1

Exploration and Surgical Planning

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

3.1.1 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. 16.9 and 16.10).

3.1.2 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. 16.11).

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Camera Holder

Surgeon Assistant

Monitor

Scrub Nurse Fig. 16.4  The patient’s position

Assistant’s Auxiliary Trocar (5 mm)

Fig. 16.7  Surgical team position (specimen extraction)

Surgeon’s Main Trocar (12 mm)

Camera Trocar (10 mm)

Assistant’s Main Trocar (5 mm)

Surgeon’s Auxiliary Trocar (5 mm)

Fig. 16.5  Trocar placement (Five-ports method)

3.1.3 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-to-side 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.

Monitor

3.2 Surgeon

Assistant

Monitor Scrub Nurse Camera Holder

Fig. 16.6  Surgical team position (right hemicolectomy)

Dissection and Separation

3.2.1 A  natomy 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. 16.12 and 16.13). The ultrasonic scalpel is applied to open the mesentery (Fig. 16.14), and the vessels are dissected and isolated gently. Along the Toldt’s fascia, dissection is performed upwards from medial to lateral in a cavernous manner. While dissecting upwards, the identification of the duodenum proves that the correct space has been entered (Figs. 16.15 and 16.16). The sheath of the superior mesenteric vein is opened as far as possible at the root of the ileocolic artery and vein, then dissection

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Fig. 16.8  The main surgical procedures of specimen extraction and digestive reconstruction in NOSES VIIIA

Fig. 16.9  Exploration of the stomach and visceral surface of the left lobe of liver

Fig. 16.10  Exploration of the pelvic cavity

is continued upwards 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. 16.17 and 16.18).

3.2.2 M  anagement of the Root of Right Colic Artery and Vein The surgeon dissects the surface of the duodenum along the Toldt’s fascia (Fig.  16.19), then the right colic vein, the right gastroepiploic vein, and Henle’s trunk, which con-

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Experience sharing: This procedure is not suitable for multiple organ resection.

Fig. 16.11  Exploration of the tumor location

Experience sharing: (1) The medial approach should be taken, and the search for ileocolic artery and vein is essential. This approach is not difficult for thin patients. However, it is difficult for obese patients. (2) This requires a surgeon to have a spatial thinking in anatomy. The marks for evaluation include: 1) There is a ridge in the course of superior mesenteric vein. 2) The horizontal part of duodenum is often visible. 3) There is a ridge on the ileocolic artery and vein.

Fig. 16.12  The angle between the superior mesenteric vein and ileocolic vessels

Depressed and Thin Area

Cooperating skills: The assistant moves the transverse colon to the upper abdomen with the gauze in the forceps in the left hand, expose the root of the transverse mesocolon, and lift the mesentery on the surface of the ileocolic artery and vein with the forceps in the right hand.

Fig. 16.13  Depressed area at the angle between the ileocolic artery and vein and superior mesenteric vein

Fig. 16.14  The first point of the incision

Fig. 16.15  Entering the space anterior to Toldt’s fascia

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Operating skills: Blunt and sharp dissection may be combined in the dissection of the mesentery.

Fig. 16.16  Dissection along the Toldt’s fascia from medial to lateral

Experience sharing: This area has many blood vessels and the operation must be performed carefully. The surgeon may place a small gauze beside the surgical field, so that compression hemostasis can be performed quickly if bleeding occurs.

Fig. 16.17  Isolation of the root of the ileocolic vessels

3.2.3 M  anagement of the Root of the Middle Colic Artery and Vein After the isolation of the right colic vessels, dissection is performed upwards 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 upwards along the superior mesenteric vein. The middle colic artery and vein are double ligated and transected at the inferior border of the pancreas (Figs. 16.23 and 16.24). At this point, all vessels supplying the right colon have been transected. Fig. 16.18  Ligation and transection of ileocolic vessels

verge into the superior mesenteric vein, are identified (Fig. 16.20). The right colic vein is ligated and transected (Fig.  16.21), where after the dissection is continued upwards along the superior mesenteric vein to expose the right colic artery (Fig. 16.22). Double ligation and transection are performed at the root of it.

3.2.4 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.  16.25 and 16.26). 3.2.5 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

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Operating skills: The course of the right colic vein can be seen in the ascending mesocolon (Fig 16.19). Take this as the landmark and dissect towards the head of pancreas to separate the right colic vein, the right gastroepiploic vein, and Henle's trunk.

Fig. 16.19  Dissection of the surface of the duodenum

Fig. 16.20  Exposure of Henle’s trunk

Fig. 16.21  Ligation of the right colic vein

to extend the degree of dissection of the ileum, so as to facilitate the laparoscopic anastomosis of the bowel (Fig. 16.27). 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. 16.28).

Fig. 16.22  Isolation of the right colic artery

3.2.6 M  anagement 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. 16.29). The ultrasonic scalpel is used to free the right greater omentum is 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 hand, and the course of the right gastroepiploic artery and vein can be seen. Dissection of the gastrocolic ligament starts at the transverse colon, with subsequent entry into the omental cavity (Fig.  16.30). The dissection can be continued to the right along the right gastroepiploic artery and vein (Figs.  16.31 and 16.32). 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 3.2.7 Management of the Transverse Mesocolon After the mesentery is transected in the antrum area, the mesentery is further divided transversely to the avascular

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Experience sharing: In the radical resection of right colon cancer, the ligation site of the middle colic artery should be determined based on the location of the tumor and the extent of resection. If the extent of resection is an extended right hemicolectomy, the ligation can be performed at the root of the middle colic artery. If the extent of resection is small, the ligation and transection of the right branch of the middle colic artery can be performed with the left branch preserved.

Fig. 16.23  Isolation of the middle colic artery and vein

Fig. 16.25  Dissection along the Toldt’s fascia from medial to lateral Fig. 16.24  Ligation and transection of the middle colic artery and vein

Smart usage of the small gauze: Place a gauze parallelly underneath the dissected mesentery for indication and protection (Fig 16.26).

Fig. 16.26  Placing small gauze underneath the mesentery

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Experience sharing: (1) The blood supply of the small intestine is abundant and the segmental blood supply is very obvious. The blood supply line of bowel can be clearly seen after the wall of the small intestine is isolated. (2) In the dissection of the terminal mesoileum, the extent of dissection should reach the upper abdomen to facilitate the anastomosis.

Fig. 16.27  Opening the peritoneum posterior to the cecum

Fig. 16.28  Isolation of wall of the ileum

Fig. 16.30  Dissection and transection of the gastrocolic ligament

Fig. 16.29  Dissection of the greater omentum

Fig. 16.31  Dissection to the right along the right gastroepiploic artery and vein

area of the transverse mesocolon (Fig. 16.33). Subsequently, the surgeon ligates and transects the marginal vessels, then dissects to the intended resection line of the transverse colon. The bowel wall is isolated for 1cm (Fig. 16.34).

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, as indicated and protected by the gauze until the dissection plane is connected with the dissection plane below (Fig. 16.36). In the isolated area of ileum, the blood supply line is clearly visible (Fig. 16.37). Following this, the surgeon transects the ileum medial to the blood supply line with a linear Endo-GIA staple (Fig. 16.38). At this point, the right hemicolectomy is completed and the specimen is placed in the pelvic cavity.

3.3

 pecimen Resection and Digestive Tract S Reconstruction

3.3.1 Specimen Resection The mobilized transverse colon is isolated using a linear Endo-GIA stapler at the intended resection line (Fig. 16.35).

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Experience sharing: In this process, an unnamed vessel is derived from the right gastroepiploic vein to the hepatic flexure of the colon. With a large diameter, the vessel should be ligated with the vascular clip.

Fig. 16.32  Dissection of lymph nodes along the right gastroepiploic vein

Fig. 16.33  Dividing the transverse mesocolon

Fig. 16.34  Isolation of the bowel wall of the transverse colon

3.3.2 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. 16.39). The surgeon makes an incision of 5 mm in one corner of the resection line of the ileum with ultrasonic scalpel (Fig. 16.40). 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. 16.41). Similarly, another incision of 10 mm is made in one corner of the transverse colon stump (Fig. 16.42). Then, the assistant and the surgeon lift the colon and place the cartridge jaw into the colon lumen (Fig.  16.43). The stapler is

Fig. 16.35  Transection of the transverse colon

fired to complete the functional end-to-end anastomosis between the ileum and transverse colon (Fig. 16.44). The presence of anastomotic bleeding in the bowel lumen is checked (Fig.  16.45). After confirming that there is no active bleeding, the bowel stump is lifted, the linear Endo-­ GIA stapler is inserted through the 12 mm trocar to close the stump transversely, then the functional end-to-end anastomosis is completed (Fig. 16.46). 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.  16.47). The digestive tract reconstruction after right hemicolectomy is completed.

3.3.3 Specimen Extraction The sterile plastic protective sleeve is inserted through the 12  mm trocar in the left upper quadrant (Fig.  16.48). The opening of the protective sleeve is expended, the gauze and specimen in the abdominal cavity are placed into the protective sleeve (Fig.  16.49), then the opening of the protective sleeve is closed with the ligating clip (Fig.  16.50). 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

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Experience sharing: The blood supply of the small intestine is abundant and the segmental blood supply is very obvious. Therefore, it is recommended to perform transection and anastomosis after the demarcation line appears, so that the operation can be safer and more reliable.

Fig. 16.36  Dissection downwards along the right paracolic sulcus

Fig. 16.37  Blood supply line of the terminal ileum

Fig. 16.39  The transverse colon is parallelly placed to the ileum

Fig. 16.38  Transection of ileum

Fig. 16.40  Making an incision on the terminal ileum

manipulator to fully expose the posterior vaginal fornix (Fig.  16.51). The surgeon applies the ultrasonic scalpel to open the vagina transversely for approximately 3  cm (Fig. 16.52), 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, then slowly pulls the specimen and the protective sleeve out of the body (Figs. 16.53 and 16.54).

3.3.4 S  uture 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. 16.55 and 16.56). Two drainage tubes are placed in the right upper quadrant through the two trocars on the right side (Fig. 16.57).

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Fig. 16.41  Placing the side of the anvil into the ileum

Fig. 16.44  Functional end-to-end anastomosis between ileum and transverse colon

Fig. 16.42  Making an incision on the transverse colon

Fig. 16.45  Inspection of anastomotic bleeding

Fig. 16.43  Placing the side of cartridge into the transverse colon

3.4

Postoperative Abdominal Wall and Specimen Display (Figs. 16.58 and 16.59)

4

 ey Points, Difficulties, and Hotspots K Related to Surgery

4.1

 natomy and Exposure of Surgical A 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 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 3.8  cm. 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

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Experience sharing: (1) Before the anastomosis between ileum and transverse colon, the apposition between ileum and transverse colon should be examined to avoid entrapment of mesentery and fatty appendices; (2) Close cooperation of the surgeon and assistant is required for the anastomosis between ileum and transverse colon.

Fig. 16.46  Closing the stump transversely

Fig. 16.47  Suture for the reinforcement of anastomosis

Fig. 16.49  Placing the gauze and specimen into the protective sleeve

Fig. 16.48  Insertion of the protective sleeve through the trocar

Fig. 16.50  Opening of the protective sleeve clipped with the vascular clip

mesenteric artery on the left side, 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 branches of the vessels should be ligated and transected at the root (Fig. 16.60). (Xishan Wang, Ming Yang, Xiaolong Ma)

4.2

 he Anatomical Variation of the Right T 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). 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

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Fig. 16.51  Exposure of the posterior vaginal fornix

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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, it originates from the superior mesenteric artery in 40% of patients, from the middle colic artery in 30% of patients, and from the ileocolic artery in 12% of patients. The remaining 18% of patients have no right colic artery, and their blood supply of right colon originates from the ileocolic artery and the middle colic artery. Because of the large variation in the right colic artery, the surgeons should be more careful during the management of vessels and take various possible variations into consideration. (Xishan Wang, Xu Guan, Haiyang Huang)

Cooperating skills: When making the incision of the vagina, the assistant inserts a bladder retractor into the vagina with its tip to withstand the posterior vaginal fornix, which facilitates the surgeon to select the point of incision of the posterior vaginal fornix.

Fig. 16.52  Opening the posterior vaginal fornix

Experience sharing: Transvaginal specimen extraction is the key to successful operation: (1) The size and location of the tumor should be accurately evaluated; (2) The size of the vaginal incision should be appropriate; (3) Since both ends of the specimen are closed, air sacs are formed during specimen extraction due to pneumatosis in the bowel lumen, which is not conducive to specimen removal. Therefore, during the specimen extraction, the bowel can be opened from outside the vagina, and the gas in the bowel lumen can be suctioned by decompression, so that the specimen can be easily extracted

Fig. 16.53  Transvaginal placement of oval forceps to clamp the protective sleeve

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Fig. 16.54  Transvaginal extraction of specimen

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Fig. 16.57  Placing drainage tubes in the abdominal cavity

Fig. 16.55  Adequate exposure and closure of the vaginal incision

Fig. 16.58  Specimen display

Experience sharing: After the suture of vagina, an iodoform gauze can be indwelled in the vagina to compress the posterior vaginal fornix, and the gauze should be extracted 48 hours after operation.

Fig. 16.56  Inspection of the suturing of the vaginal incision

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Fig. 16.59  Postoperative abdominal wall display

Fig. 16.60  Surgical trunk of superior mesenteric vein

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Xiyue Hu and Haitao Zhou

Previously, the possibility to use NOSES to treat right colon cancer is described only for women, in whom the transvaginal way for specimen extraction is used (CRC-NOSES VIIIA). 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 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 operating difficulties of this procedure mainly involve three aspects. 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 delta-shaped 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, this procedure requires surgeons and assistants to be more experienced. In the process of transrectal specimen extraction, the application of aseptic and tumor-free techniques and the accurate understanding of indications of this procedure is crucial. Compared with NOSES-VIIIA, this proce-

dure requires more accurate understanding of indications, clear surgical thinking and proficient skills.

1

Indications and Contraindications of NOSES

1.1

Indications (Figs. 17.1, 17.2, 17.3)

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.

1.2

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).

2

 nesthesia, Patient Positioning, A Trocar Placement, and Surgical Team Position

2.1

Anesthesia Method

General anesthesia or general epidural anesthesia.

2.2 X. Hu · H. Zhou (*) Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China e-mail: [email protected]

Contraindications

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. 17.4).

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Fig. 17.1  Extent of surgical resection

Fig. 17.3  Abdominal CT: The tumor is located at the ascending colon Fig. 17.2  Colonoscopy: Tumor of superficial protuberant type, with partial mucosal depressions and erosions.

2.3

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. 17.5).

2.4

Surgical Team Position

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,

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Monitor

Assistant

Fig. 17.4  The patient's position

Surgeon

Monitor Scrub Nurse Camera Holder

Fig. 17.6  Surgical team position (right hemicolectomy) Surgeon’s Auxiliary Trocar (5 mm)

Camera Trocar (10 mm)

Surgeon’s Main Trocar (12 mm)

Assistant’s Main Trocar (5 mm) Camera Holder

Assistant’s Auxiliary Trocar (5 mm)

Surgeon

Fig. 17.5  Trocar sites (Five-ports method)

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. 17.6 and 17.7).

2.5

Special Surgical Instruments

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

3

Surgical Procedure, Techniques, and Key Points

The schematic view of main surgical procedures of specimen extraction and digestive reconstruction in NOSES VIIIB (Fig. 17.8).

Assistant

Monitor

Scrub Nurse

Fig. 17.7  Surgical team position (specimen extraction)

3.1

Exploration and Surgical Planning

Based on the thorough preoperative examination and surgical planning, the exploration mainly includes three steps:

3.1.1 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. 17.9 and 17.10).

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CRC-NOSES VIIIB

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

Fig. 17.9  Exploration of the stomach and visceral surface of the left lobe of the liver

Fig. 17.10  Exploration of the pelvic cavity

3.1.2 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. 17.11).

3.1.3 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. In

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Fig. 17.11  Exploration of the tumor location

Fig. 17.13  Entering the space anterior to Gerota’s fascia

Fig. 17.12  The first point of the incision

Fig. 17.14  Dissection along the Toldt’s fascia from medial to lateral

particular, the middle colic artery and 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.

3.2

Dissection and Separation

3.2.1 A  natomy 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.  17.12), 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. 17.13 and 17.14). The dissection of the superior mesenteric pedicle should start in the root of ileocolic vessels, dissect upwards and give

Fig. 17.15  Isolation of the root of the ileocolic vessels

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. 17.15 and 17.16).

3.2.2 M  anagement of the Root of Right Colic Artery The right colic artery is then separated with the dissection upwards along the superior mesenteric vein (Fig.  17.17), then the right colic artery is isolated and clipped (Fig. 17.18). The dissection continued in the surface of the duodenum and head of the pancreas along the Toldt's fascia, reaching the

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Fig. 17.16  Ligation and transection of ileocolic vessels

Fig. 17.19  Isolation of the root of the accessory right colic vein

Fig. 17.17  Isolation of the root of the right colic artery

Fig. 17.20  Ligation and transection of the accessory right colic vein

Fig. 17.18  Ligation and transection of the right colic artery

Fig. 17.21  Isolation of the right branch of the middle colic artery and vein

right colic vein, the right gastroepiploic vein, and anterior superior pancreaticoduodenal vein which formed Henle's trunk, then drain into the superior mesenteric vein. The right colic vein is isolated and clipped (Figs. 17.19 and 17.20).

3.2.3 M  anagement of the Right Branch of the Middle Colic Artery and Vein The dissection is continued upwards 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 artery and vein are divided and clipped (Figs.  17.21 and

17.22). At this point, all the vessels supplying the right colon have been transected.

3.2.4 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 mesoileum, ascending mesocolon, and the right transverse mesocolon is completed by medial-to-lateral dissection. (Fig. 17.23).

17  Laparoscopic Right Hemicolectomy with Transrectal Specimen Extraction (CRC-NOSES VIIIB)

Fig. 17.22  Ligation and transection of the right branch of the middle colic artery and vein

Fig. 17.25  Isolation of wall of the ileum

Fig. 17.23  Dissection along the Toldt’s fascia from medial to lateral

Fig. 17.26  Dissection of the greater omentum

Fig. 17.24  Opening the peritoneum posterior to the cecum

3.2.5 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. 17.24). 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. 17.25).

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3.2.6 M  anagement 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. 17.26). The ultrasonic scalpel is used to free the right greater omentum is 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 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. 17.27). 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. 3.2.7 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. 17.28). Subsequently, the ­surgeon ligates and transects the marginal vessels, then

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Fig. 17.27  Dissection and transection of the gastrocolic ligament and entry into the omental cavity

Fig 17.30  Transection of the transverse colon

Fig. 17.28  Dividing the transverse mesocolon

Fig 17.31  Blood supply line of the terminal ileum

Fig. 17.29  Isolation of the bowel wall of the transverse colon

Fig 17.32  Transection of the ileum

dissects to the intended resection line of the transverse colon. The bowel wall is isolated for 1cm (Fig. 17.29).

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. 17.31). Following this, the surgeon transects the ileum medial to the blood supply line with a linear Endo-GIA stapler (Fig.  17.32). At this point, the right hemicolectomy is completed.

3.3

 pecimen Resection and Digestive S Tract Reconstruction

3.3.1 Specimen Resection The mobilized transverse colon is isolated using a linear Endo-GIA stapler at the intended resection line (Fig. 17.30).

17  Laparoscopic Right Hemicolectomy with Transrectal Specimen Extraction (CRC-NOSES VIIIB)

Fig. 17.33  Overlapping of the terminal ileum with transverse colon

Fig. 17.34  Suture of the transverse colon stump with the bowel wall 8 cm from the terminal ileum stump

3.3.2 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. 17.33). Suture for fixation is performed between the transverse colon stump and the bowel wall at 8 cm from the terminal ileum stump (Fig. 17.34). 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 lines on the antimesenteric border (Figs.  17.35 and 17.36), then both bowel lumens are disinfected with iodoform gauze. The linear Endo-GIA stapler is introduced through the surgeon's main trocar, where after 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. 17.37, 17.38, 17.39). 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 and the middle of the enterotomies, respectively (Fig. 17.40). The surgeon and assistant grasp the tail of traction sutures to keep the bowel wall straight and close the

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Fig. 17.35  Making an incision of 1  cm long on the terminal ileum stump

Fig. 17.36  Making an incision of 1  cm long on the corresponding antimesenteric side of the transverse colon

Fig. 17.37  Insertion of linear Endo-GIA stapler into the terminal ileum

enterotomies with a linear Endo-GIA stapler. The overlapped delta-shaped anastomosis between ileum and transverse colon is completed (Figs. 17.41 and 17.42).

3.3.3 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

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Fig. 17.38  Insertion of linear Endo-GIA stapler into both sides of the bowel

Fig. 17.39  Side-to-side anastomosis between ileum and transverse colon

X. Hu and H. Zhou

Fig. 17.41  Closing the enterotomies of the bowel stump

Fig. 17.42  Overlapped delta-shaped anastomosis

Fig. 17.43  Transverse incision on the upper rectum Fig. 17.40  Fixing traction sutures in both ends and the middle of the enterotomies

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. 17.43). The protective sleeve is inserted through the 12 mm trocar (Fig. 17.44), 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. 17.45 and 17.46). One end of the specimen is smoothly placed into the protective sleeve with

Fig. 17.44  Insertion of the protective sleeve through the trocar

17  Laparoscopic Right Hemicolectomy with Transrectal Specimen Extraction (CRC-NOSES VIIIB)

Fig. 17.45  Placement of oval forceps through the incision in the upper rectum through the anus

Fig. 17.46  Pulling the end of the protective sleeve out through the anus

Fig. 17.47  Placement of oval forceps into the abdominal cavity through the protective sleeve

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. 17.47 and 17.48) and slowly pulls the specimen along with the protective sleeve out of the rectum and anus (Fig. 17.49). The assistant wipes the bowel lumen with iodoform gauze as the surgeon confirms that there is no active bleeding. Traction sutures are fixed in both ends of the rectal incision,

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Fig. 17.48  Clamping one end of the bowel with oval forceps

Fig. 17.49  Specimen extraction

Fig. 17.50  Traction sutures are fixed in both ends of the rectal incision

respectively (Fig. 17.50). The surgeon and assistant grasp the tail of the suture of the two sides to keep the incision away from the opposite bowel wall and close the incision with a linear Endo-GIA stapler (Figs.  17.51 and 17.52). Laparoscopic seromuscular layer embedding of the anastomosis is performed (Fig.  17.53). 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. 17.51  Closing the rectal incision with the linear Endo-GIA stapler

Fig. 17.54  Specimen display

Fig. 17.52  Closing the rectal incision

Fig. 17.55  Display of postoperative abdominal wall recovery

Fig. 17.53  Seromuscular layer embedding of anastomosis

3.4

 ostoperative Recovery and Specimen P Display (Figs. 17.54 and 17.55)

(Hu Xiyue, Haitao Zhou)

4

 ey Points, Difficulties, and Hotspots K Related to Surgery

4.1

 he Advantages and Feasibility T 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 over-

17  Laparoscopic Right Hemicolectomy with Transrectal Specimen Extraction (CRC-NOSES VIIIB)

lapped delta-shaped anastomosis between the ileum and transverse colon. 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 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. (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. At the

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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 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. 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. (Xiyue Hu, Haitao Zhou)

Laparoscopic Right Hemicolectomy with Transcolonic Specimen Extraction (CRC-NOSES VIIIC)

18

Jian Peng

Natural Orifice Specimen Extraction Surgery (NOSES) is a new technique that combines traditional laparoscopy with specimen extraction through a natural orifice. Currently, specimens of laparoscopic radical right colon cancer resection are mainly extracted transvaginal for female patients (NOSES VIII A) or transrectally for male patients (NOSES VIII B). For some well-selected patients, transcolonic NOSES (NOSES VIII C) for laparoscopic radical right hemicolectomy for right colon cancer is feasible and safe. The main procedures of NOSES VIII C include total laparoscopic right hemicolectomy, specimen extraction from the left half of the transverse colon, splenic flexure, descending colon, sigmoid colon, rectum and anus, and side-to-side anastomosis between the transverse colon and ileum under laparoscopy.

1  Indications and Contraindications of NOSES 1.1  Indications (Figs. 18.1, 18.2, 18.3) 1 . Patients with right colon cancer. 2. The circumferential diameter of the tumor should be less than 5 cm. 3. The tumor should not invade beyond the serosa.

1.2  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).

2  A  nesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position 2.1  Anesthesia Method General anesthesia or general epidural anesthesia.

2.2  Patient Positioning Supine position or functional lithotomy (Fig. 18.4).

2.3  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. 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. 18.5).

2.4  Surgical Team Position The dissection of the right colon: The surgeon should stand on the left side of the patient, and the assistant should stand on the right side of the patient. The camera holder should stand between two legs of the patient.

J. Peng (*) Hepatobiliary and Enteric Surgery Research Center, Xiangya Hospital, Central South University, Changsha, Hunan, China © People’s Medical Publishing House, PR of China 2021 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-15-7925-7_18

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Fig. 18.1  Extent of resection

2.5  Special Surgical Instruments Dissecting device (ultrasonic scalpel), 60 mm linear Endo-­ GIA stapler, sterile plastic protective sleeve, colonoscopy, endoscopic forceps.

3  S  urgical Procedure, Techniques, and Key Points The schematic view of main surgical procedures of specimen extraction and digestive reconstruction in NOSES VIIIC (Fig. 18.8).

3.1  Exploration and Surgical Planning

Fig. 18.2  Colonoscopy: The tumor is located at the ascending colon (arrow), 1.5 × 2.0 cm.

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

Specimen extraction and digestive tract reconstruction: The surgeon should stand on the right side of the patient; the assistant should stand on the left side of the patient. The camera holder should stand on the same side of the surgeon. The endoscopist and assistant should stand between two legs of the patient. (Figs. 18.6 and 18.7).

3.1.1 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. 18.9 and 18.10).

18  Laparoscopic Right Hemicolectomy with Transcolonic Specimen Extraction (CRC-NOSES VIIIC)

a

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b

Fig. 18.3  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

Monitor

Surgeon

Assistant

Monitor

Fig. 18.4  The patient’s position

Scrub Nurse

Camera Holder

Fig. 18.6  Surgical team position (Right hemicolectomy)

Assistant’s Auxiliary Trocar (5 mm)

Camera Trocar (10 mm)

Assistant’s Main Trocar (5 mm)

Surgeon’s Main Trocar (12 mm)

Camera Holder

Surgeon’s Auxiliary Trocar (5 mm)

Assistant

Surgeon

Scrub Nurse

Fig. 18.5  Trocar placement (Five-ports method)

3.1.2 Exploration of Tumor The tumor is located at the ascending colon. The surgeon should examine the tumor location, tumor size, as well as the depth of tumor invasion (Fig. 18.11).

Monitor Endoscopist

Fig. 18.7  Surgical team position (Specimen extraction and digestive tract reconstruction)

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CRC-NOSES VIIIC

Fig. 18.8  The main surgical procedures of specimen extraction and digestive reconstruction in NOSES VIIIC.

Fig. 18.9  Right liver, gallbladder, and greater omentum

Fig. 18.10  Left lateral liver, stomach, and spleen

18  Laparoscopic Right Hemicolectomy with Transcolonic Specimen Extraction (CRC-NOSES VIIIC)

Fig. 18.11  Exploration of the tumor

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Fig. 18.12  The root of ileocolic pedicle and the duodenum

3.1.3 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.

3.2  Dissection and Separation 3.2.1 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. 18.12). 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.  18.13). The fat and lymph nodes surrounding the ileocolic vessels are cleared, then the ileocolic artery and vein are identified, ligated, and divided (Fig. 18.14). With adequate traction of the mesocolon toward the right upper quadrant, the ileocolic vessels are easily mobilized, and the peritoneal window is expanded from medial to lateral. 3.2.2 D  issection 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. 18.15). Henle's trunk is fused of the right gastroepiploic vein with the right colic vein. The right colic vein is ligated and divided (Figs. 18.16

Fig. 18.13  The initial incision starts from the root of the ileocolic pedicle

Fig. 18.14  The ileocolic artery and vein are ligated

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Fig. 18.15  The right branch of the middle colic artery is identified and ligated

Fig. 18.16  The right colic vein is identified and ligated

J. Peng

Fig. 18.17  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. 18.18  The surrounding fat of the right transverse colon is cleared

and 18.17). 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.

middle transverse colon. The exposed length of the bowel wall should be appropriately 2–3 cm (Fig. 18.18).

3.2.3 D  issection 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

3.2.4 D  issection 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. 18.19). The dissection can be continued from the middle to right along the outer margin of the right gastroepiploic vein. This plane connects the previous dissec-

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Fig. 18.19  The greater omentum is incised from the middle point of the transverse colon

Fig. 18.21  Dissection of ileocecal mesentery to the bowel wall of terminal ileum at about 12 cm from ileocecum

Fig. 18.20  The hepatocolic ligament is dissected

Fig. 18.22  Dissection of the lateral peritoneum around ileocecum

tion 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. 18.20).

3.2.5 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.  18.21). 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. 18.22).

3.2.6 D  ivision 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. 18.23), where the division is performed by applying the 60 mm linear Endo-GIA stapler through the left upper quadrant trocar (Fig.  18.24). The stumps of the terminal ileum are disinfected with povidone gauze (Fig. 18.25). Then, the povidone gauze is put into a sterilized plastic bag (Fig.  18.26). The same operational procedure is repeated with the transverse colon after colonoscopic reverification of the tumor lesion in the ascending colon. (Figs. 18.27 and 18.28). The transverse colon stump is also disinfected with povidone gauze. The right colon specimen including the tumor-bearing segment is mobilized.

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Fig. 18.23  The blood supply line of the terminal ileum

Fig. 18.24  The division of the terminal ileum is performed with linear Endo-GIA stapler

3.3  S  pecimen Extraction and Digestive Tract Reconstruction 3.3.1 Specimen Extraction The right colon specimen is packed into a sterile protective sleeve (Fig. 18.29). Under the guidance of laparoscopy, colonoscopy reaches the closed transverse colon through the anus (Fig. 18.30). 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. 18.31). The protective sleeve containing the specimen is clamped by endoscopic foreign body retrieval (Fig. 18.32),

J. Peng

Fig. 18.25  The division ends of the terminal ileum are disinfected with povidone gauze

Fig. 18.26  After disinfection, the povidone gauze is placed into a sterilized plastic bag

inserted into the colonic lumen, pulled out through the colon, and finally removed through the anus (Figs.  18.33, 18.34, 18.35, 18.36 and 18.37).

3.3.2 Digestive Tract Reconstruction The opened stump of the transverse colon is closed with a 60  mm linear Endo-GIA stapler (Fig.  18.38). 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.  18.39). Similarly, a small incision is made on the antimesenteric

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Fig. 18.27  The division of the middle transverse colon is performed with 60 mm linear Endo-GIA stapler

Fig. 18.29  The right colon specimen is put into a sterile plastic protective sleeve and the opening is fastened

Fig. 18.28  The stumps of the transverse colon are disinfected with povidone gauze

Fig. 18.30  Colonoscopy is inserted into transverse colon lumen from anus

bowel wall of the transverse colon about 6 cm from the stump (Fig.  18.40). Povidone gauze is also put into the opened bowel lumen for disinfection (Fig.  18.41). 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. 18.42). After careful check of the anastomotic integrity in the bowel lumen and disinfection with povidone gauze (Fig. 18.43), the common opening of the anastomosis is closed with an absorbable suture (Fig. 18.44). The anastomotic seromuscular layer is sutured to reinforce and reduce anastomotic tension. Ileocolic mesentery is sutured to avoid internal abdominal hernia (Fig. 18.45). Two drainage tubes are placed in the abdominal cavity.

3.4  Postoperative Abdominal Wall and Specimen Display] (Figs. 18.46 and 18.47)

4  K  ey Points, Difficulties, and Hotspots Related to Surgery In the process of transcolonic specimen extraction, there are two narrow points 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

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J. Peng

Fig. 18.31  Cut open the bowel stump to expose the colonoscopy and disinfect it with povidone gauze

Fig. 18.33  The protective sleeve with the specimen is moved into the left transverse colon

Fig. 18.32  After being disinfected with the povidone gauze, the protective sleeve is clamped with the endoscopic foreign body retrieval

Fig. 18.34  The protective sleeve with the specimen is moved into the splenic flexure of the colon

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 the key to the success of NOSES VIII C. Here are a few tips:

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 side-­ to-­side anastomosis. D. The sterile protective sleeve should be long (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

A. Transcolonic NOSES is highly dependent on the patient’s clinical condition. The specimen should be less than 5cm in circumferential diameter to be extracted through the colon, and the patient’s body mass index (BMI) should be less than 25 kg/m2.

18  Laparoscopic Right Hemicolectomy with Transcolonic Specimen Extraction (CRC-NOSES VIIIC)

Fig. 18.35  The protective sleeve with the specimen is moved into the descending colon

Fig. 18.36  The protective sleeve with the specimen is moved into the sigmoid colon

Fig. 18.37  The protective sleeve with the specimen is moved out of the anus

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Fig. 18.38  The opened transverse colon stump is closed with 60 mm linear Endo-GIA stapler

Fig. 18.39  The bowel lumen of the terminal ileum is disinfected with povidone gauze

Fig. 18.40  A small incision is made on the antimesenteric bowel wall of the transverse colon

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Fig. 18.41  Povidone gauze is inserted into the bowel lumen for disinfection

J. Peng

Fig. 18.43  Povidone gauze is inserted into the common opening of the anastomosis for disinfection

Fig. 18.42  The functional side-to-side anastomosis between the termi- Fig. 18.44  The common opening of the anastomosis is closed with nal ileum and the transverse colon is made with 60 mm linear Endo-­ absorbable suture GIA stapler

cooperation between the laparoscopic physician and 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 wellselected patients. 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 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.

18  Laparoscopic Right Hemicolectomy with Transcolonic Specimen Extraction (CRC-NOSES VIIIC)

Fig. 18.45  Ileocolic mesentery is sutured to avoid an internal abdominal hernia

Fig. 18.47  The display of specimen

Fig. 18.46  The display of abdominal wall

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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 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 reduce the difficulty of transanal specimen extraction. This technique is entirely feasible as long as surgeons have clear anatomic understanding and solid operating skills.

1

Indications and Contraindications of NOSES

1.1

Indications

1 . Familial adenomatous polyposis. (Figs. 19.1 and 19.2) 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.

Fig. 19.1  Extent of surgical resection

4. Ulcerative colitis which is not sensitive to medical treatment. 5. Patients with constipation or other benign diseases that need total colectomy.

1.2

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.

X. 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 2021 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-15-7925-7_19

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Cancer 2

Fig. 19.3  The patient’s position

Cancer 1

Auxiliary Trocar 2 (5mm)

Camera Trocar (10mm)

Surgeon’s Main Trocar 2 (12mm)

Fig. 19.2  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

2

 nesthesia, Patient Positioning, A Trocar Placement, and Surgical Team Position

2.1

Anesthesia Method

General anesthesia or general epidural anesthesia.

2.2

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. 19.3).

2.3

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.

Surgeon’s Main Trocar 1 (12mm) Auxiliary Trocar 1 (5mm)

Fig. 19.4  Trocar placement (Five-ports method)

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 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. 19.4).

2.4

Surgical Team Position

The right hemicolectomy: The surgeon stands on the left side of the patient, 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, the camera holder stands on the same side of the surgeon or between two legs of the patient (Figs. 19.5 and 19.6).

19  Laparoscopic Total Colectomy with Transanal Specimen Extraction (CRC-NOSES IX)

3.1 Monitor

Exploration and Surgical Planning

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

Surgeon

Assistant

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3.1.1 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. 19.8). Monitor Scrub Nurse Camera Holder

3.1.2 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. 19.9).

Fig. 19.5  Surgical Team Position (Right hemicolectomy)

Monitor

Camera Holder

Surgeon

3.2 Assistant

Monitor

Scrub Nurse

Fig. 19.6  Surgical Team Position (Left hemicolectomy, rectal resection)

2.5

Special Surgical Instruments

Ultrasonic scalpel, 60 mm linear Endo-GIA stapler, 25 mm circular stapler, sterile protective sleeve.

3

3.1.3 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 mesenteric thickness should be excluded, and the feasibility of this procedure should be evaluated again.

Surgical Procedure, Techniques, and Key Points

The schematic view of main surgical procedures of specimen extrac­ tion and digestive reconstruction in NOSES IX (Fig. 19.7).

Dissection and Separation

3.2.1 M  anagement 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. 19.10). 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.  19.11 and 19.12). 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.  19.13), the ileocolic vessels are ligated and transected at the root (Figs. 19.14 and 19.15). 3.2.2 M  anagement 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. After that, dissection is continued along the right colic vein to the head of the pancreas and the superior mes-

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Fig. 19.7  The main surgical procedures of specimen extraction and digestive reconstruction in NOSES IX

3.2.3 M  anagement 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.  19.20). Dissection in this area should be performed extremely carefully before double ligate and transect the middle colic vessels (Fig. 19.21). Then, the dissection is continued along the pancreatic neck to the left, to dissect the transverse mesocolon toward the Treitz ligament. Fig. 19.8  Exploration of the transverse colon and its mesocolon

enteric vein. Ligation and transection can be performed at the root of the right colic vein (Fig. 19.18). 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. 19.19).

3.2.4 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. 19.22). Approximately 2–3 cm of the wall of the ileum is isolated (Fig.  19.23). The blood supply line should be

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Experience sharing: (1) If the tumor is small, submucosal injection of methylthioninium chloride can be performed under colonoscopy preoperatively to facilitate intraoperative localization; (2) NOSES IX should not be performed in patients with tumor invading beyond the serosa.

Fig. 19.9  Exploration of the tumor location (marked with methylthioninium chloride preoperatively)

Experience sharing: The triangle formed between the ileocolic vessels and the superior mesenteric vein is an important landmark for the identification of the root of ileocolic vessels.

Fig. 19.10  The angle between the superior mesenteric vein and ileocolic vessels

checked carefully to ensure the blood supply of the anastomosis.

Fig. 19.11  Entering the space anterior to Toldt’s fascia

3.2.5 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. 19.24). 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

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Smart usage of the small gauze: (1) Blunt and sharp dissection may be combined in the dissection of Toldt's fascia; (2) During the dissection to the horizontal part of duodenum, a gauze can be placed underneath the mesentery for identification and protection.

Fig. 19.12  Dissection along the Toldt’s fascia from medial to lateral

Fig. 19.13  Isolation of the ileocolic artery and vein

Fig. 19.15  Transection of the ileocolic vein

pletely. 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. 19.25).

Fig. 19.14  Ligation of the ileocolic artery

3.2.6 D  issection 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. 19.26 and 19.27) until reaching the cecum. At this point, the right colon is completely mobilized.

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 com-

3.2.7 M  anagement 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

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Experience sharing: The right colic vein in the course of the mesentery can be seen during the dissection (Fig 19.16), this landmark is very important for the identification of the root of the right colic vein. Right Colic Vein

Fig. 19.16  Right colic vein within the mesentery

Operating skills: (1) The right colic artery and vein have many variations. In most cases, the right colic artery is not accompanied by the vein and they need to be managed separately; (2) In most cases, the right gastroepiploic vein and right colic vein form the Henle's trunk and enter the superior mesenteric vein (Fig 19.17).

Fig. 19.17  Exposure of Henle’s trunk

Right Colic Vein

Fig. 19.18  Ligation of the Right Colic Vein

Fig. 19.19  Ligation of the right colic artery

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Fig. 19.20  Ligation of the middle colic artery

Middle Colic Vein

Fig. 19.21  Isolation of the middle colic vein

Fig. 19.22  Dissection of the mesoileum

sacral promontory to enter the presacral space and dissects upwards to the left (Figs.  19.28 and 19.29) to identify the inferior hypogastric nerves. The dissection is continued upwards to the root of the inferior mesenteric artery (Fig.  19.30). Approximately 1  cm of the vessel is isolated before double ligation and transection is performed at its origin (Figs. 19.31 and 19.32).

3.2.8 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 the inferior mesenteric vein can be identified (Fig. 19.33). On the left side of the Treitz ligament, the inferior mesenteric vein is ligated and transected at the inferior border of the pancreas (Fig. 19.34). After the dissection of the mesentery, the surgeon places a gauze underneath the dissected mesentery for protection and indication (Fig.  19.35). At this point, all vessels supplying the left colon have been transected. 3.2.9 M  anagement 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. 19.36), as well as the left gonadal vessels and left adipose capsule of the kidney (Fig. 19.37). 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. 19.38). Afterward, the dissection proceeds downwards along the left paracolic sulcus to the sigmoid colon (Fig. 19.39). 3.2.10 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. 19.40 and 19.41). Detailed operation is the same as before. Subsequently, the adhesion between the sigmoid colon and the left abdominal wall is detached (Fig. 19.42), the peritoneum on the left of the rectum is separated to the intended resection line. 3.2.11 I solation 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 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. 19.43). The peritoneal reflection is incised to perform dissection around the anterior rectal wall (Fig. 19.44).

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Experience sharing: In most cases, transanal ileum extraction is difficult. Since this procedure adopts side-to-end anastomosis between the ileum and rectum, the dissection of terminal ileum can be performed appropriately.

Fig. 19.23  Isolation of wall of the ileum

Experience sharing: Radical resection with preservation of the greater omentum is a feature of this procedure. The greater omentum has the function of maintaining immunity and lubrication, anti-adhesion, preventing the onset of intestinal obstruction, and reducing the difficulties of specimen extraction through the rectum and anus.

Fig. 19.24  Opening the greater omentum

Fig. 19.25  Dissect to the left for the dissection of the greater omentum to the lower pole of the spleen

Fig. 19.26  Dissection of hepatic flexure of the colon

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Fig. 19.27  Opening the right paracolic sulcus from the hepatic flexure of colon downwards

Fig. 19.28  Dissection along the Toldt’s fascia to the left

Fig. 19.29  Dissection downwards along the Toldt’s fascia

3.3

 pecimen Resection, Extraction, S and Digestive Tract Reconstruction

3.3.1 Specimen Resection The ileum is transected with a linear Endo-GIA stapler at the isolated area of the ileum (Fig. 19.45) and a window is made on the rectal wall above the intended resection line of the rectum (Fig. 19.46). The distal rectum is transected after suf-

Fig. 19.30  Dissection upwards along the Toldt’s fascia

Fig. 19.31  Isolation of the inferior mesenteric artery

Fig. 19.32  Double ligation of the inferior mesenteric artery

ficient safe distal resection margin is double-checked. At this point, the dissection and resection of the total colon are completed.

3.3.2 Specimen Extraction 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

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Experience sharing: In the inferior mesenteric vein, variation in the artery and vein supplying the left colon is occasionally seen. In these cases, they can be ligated and transected at the same time. Occasionally, they are derived from the tail of pancreas and supplied by artery and vein branches, which can be managed based on detailed circumstances.

Fig. 19.33  Isolation of the inferior mesenteric vein

Fig. 19.36  Exposure of the left ureter Fig. 19.34  Ligation of the inferior mesenteric vein

Fig. 19.35  Placing small gauze underneath the mesentery

distal rectal stump (Fig.  19.48). The assistant and surgeon place the proximal rectal stump into the protective sleeve (Fig.  19.49), 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. 19.50 and 19.51).

3.3.3 Digestive Tract Reconstruction The pelvic cavity is then irrigated by sufficient dilute iodine solution and inspected for bleeding before digestive tract reconstruction (Fig.  19.52). The assistant inserts the anvil into the abdominal cavity through the protective sleeve inside the rectal stump (Fig. 19.53). 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.  19.54) and places the anvil into the intended anastomosis site in the ileal cavity (Fig.  19.55). The ileum stump is closed with a linear Endo-GIA stapler (Fig. 19.56), then a small incision is made in the intended anastomosis site of the ileum to take out the anvil shaft (Fig. 19.57). The rectal stump is closed with a linear Endo-GIA stapler (Fig. 19.58), and the resected stump tissue is extracted with a specimen retrieval bag through the 12  mm trocar (Fig. 19.59). The assistant inserts the circular stapler through the anus and extends the trocar to pierce one corner of the

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Experience sharing: At this point, do not detach the sigmoid colon from the left side of the abdominal wall. Instead, the physiological adhesion can fix the sigmoid colon to avoid excessive mobility of it, which may interfere with the dissection of rectum.

Fig. 19.37  Exposure of adipose capsule of the kidney

Fig. 19.40  Dissection of the posterior rectal wall Fig. 19.38  Dissection of the mesentery to the lower pole of the spleen

Fig. 19.41  Dissection of the right rectal wall Fig. 19.39  Dissection of mesentery along the left paracolic sulcus to the splenic flexure

19  Laparoscopic Total Colectomy with Transanal Specimen Extraction (CRC-NOSES IX)

Fig. 19.42  Detach the adhesion between the sigmoid colon and the lateral abdominal wall

Fig. 19.43  Isolation of the right rectum wall

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Fig. 19.44  Cutting open the peritoneal reflection

Fig. 19.45  Transection of ileum

Experience sharing: When it is difficult to evaluate the distal resection margin of the bowel, the distal edge of tumor can be marked with titanium clip, methylthioninium chloride, or carbon nanotube under colonoscopy before operation.

Titanium Clip

Fig. 19.46  Making an incision on the rectal wall above the intended resection line of the rectum

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Operating skills: When opening the rectal wall, the assistant can suction the intestinal contents timely to prevent the abdominal cavity from being contaminated by the intestinal contents. Iodoform gauze should be used promptly to disinfect the bowel stump (Fig 19.47.

Fig. 19.47  Disinfection of bowel stump with iodoform gauze

Fig. 19.48  Placement of protective sleeve Fig. 19.50  Transanal extraction of the specimen (intraperitoneal view)

Experience sharing: Since the specimen is long, the surgeon and assistant should place the specimen into the protective sleeve step by step. The protective sleeve not only ensures aseptic and tumor-free operation, but also prevents damage and provides support.

Fig. 19.49  Placing the specimen into the protective sleeve

19  Laparoscopic Total Colectomy with Transanal Specimen Extraction (CRC-NOSES IX)

Fig. 19.55  Inserting the anvil into the ileum Fig. 19.51  Transanal extraction of the specimen (extracorporeal view)

Fig. 19.52  Irrigation with dilute iodine solution

Fig. 19.56  Transection of the ileum

Fig. 19.53  Inserting the anvil through the anus

Fig. 19.57  Taking out the anvil shaft

Fig. 19.54  Cutting open the ileum stump

Fig. 19.58  Transection of the rectal stump

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Fig. 19.59  Taking out the rectal stump from the main trocar

Fig. 19.60  Extend the trocar of the stapler to pierce the rectal stump

Fig. 19.61  Connecting the anvil with trocar of the stapler

X. Wang and Z. Jiang

Fig. 19.63  Air leak test

Fig. 19.64  Drainage tube is placed on the left side of the abdominal cavity

rectal stump (Fig. 19.60). The anvil is connected to the stapler (Fig. 19.61), and the stapler is fired to complete the side-­ to-­ end anastomosis between the ileum and the rectum (Fig. 19.62). Check the integrity of the anastomotic ring carefully. An Air leak test is also performed to confirm the integrity of the anastomosis (Fig.  19.63). 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 lower quadrant (Fig.  19.64–19.65). Finally, the pneumoperitoneum is released and the trocar sites are closed to complete the surgery.

3.4

Postoperative Abdominal Wall and Specimen Display (Figs. 19.66 and 19.67)

(Xishan Wang, Zheng Jiang, Jichuan Quan)

Fig. 19.62  Side-to-end anastomosis between the ileum and rectum

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Fig. 19.65  Drainage tube is placed on the right side of the abdominal cavity

Fig. 19.67  Specimen display

Fig. 19.68  Exposure of the middle colic vein and its left and right branches Fig. 19.66  Postoperative abdominal wall display

4

 ey Points, Difficulties, and Hotspots K Related to Surgery

4.1

 he Anatomical Characteristics T 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. 19.68). 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

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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. (Xishan Wang, Zheng Jiang, Meng Zhuang)

4.2

 he Importance of Preserving T the Greater Omentum in Total Colectomy

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. (Xishan Wang, Zheng Jiang, Hengchang Liu)

4.3

Fig. 19.69  Intraperitoneal dissection of rectum to the intersphincteric sulcus

Fig. 19.70  Complete transanal transection of the rectum

 ther Anastomosis Methods for Total O 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 be dissected intraperitoneally to the intersphincteric sulcus (Fig. 19.69), the rectum is completely transected extracorpore-

Fig. 19.71  Transanal placement of incision protector

ally through the anus (Fig. 19.70), and the proximal end of the rectal stump is sutured with fixation sutures for traction. A 60 mm incision protector is inserted (Fig. 19.71). The speci-

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Fig. 19.72  Transanal extraction of specimen

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Fig. 19.74  Ileum stump after the completion of anastomosis

men is extracted out of the anus (Fig. 19.72), 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.  19.73). After the completion of the anastomosis (Fig. 19.74), the second anoplasty is performed electively. (Xishan Wang, Zheng Jiang)

Fig. 19.73  Suture of terminal ileum to distal rectal stump

Laparoscopic Total Colectomy with Transvaginal Specimen Extraction (CRC-NOSES X)

20

Xishan Wang, Zheng Jiang, and Runkun Yang

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 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.

1

Indications and Contraindications of NOSES

1.1

Indications

1. Multiple colorectal cancer, and the circumferential diameter of tumor, is better at 3–5 cm (Fig. 20.1). 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.

X. Wang (*) · Z. Jiang Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China

Fig. 20.1  Extent of surgical resection

1.2

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.

2

 nesthesia, Patient Positioning, A Trocar Placement, and Surgical Team Position

2.1

Anesthesia Method

General anesthesia or general epidural anesthesia.

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 2021 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-15-7925-7_20

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Patient Positioning

2.4

The patient is placed in functional lithotomy position with both thighs slightly elevated, which facilitates to perform the operation for the surgeon (Fig. 20.2).

2.3

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 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. 20.3).

Surgical Team Position

2.4.1 The Right Hemicolectomy The surgeon stands on the left side of the patient; the assistant stands on the right side of the patient. 2.4.2 T  he 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. 20.4 and 20.5).

Monitor

Surgeon

Assistant

Monitor Scrub Nurse Camera Holder

Fig. 20.4  Surgical team position (right hemicolectomy)

Monitor

Camera Holder

Fig. 20.2  The patient’s position

Surgeon

Auxiliary Trocar 2 (5mm)

Camera Trocar (10mm)

Surgeon’s Main Trocar 2 (12mm)

Assistant

Surgeon’s Main Trocar 1 (12mm) Auxiliary Trocar 1 (5mm)

Monitor Scrub Nurse

Fig. 20.5 Surgical team position (left hemicolectomy, rectal resection) Fig. 20.3  Trocar placement (Five-port method)

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2.5

Special Surgical Instruments

Ultrasonic scalpel, 60 mm linear Endo GIA stapler, 25 mm circular stapler, vaginal suture line, uterine manipulator, sterile protective sleeve.

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3.1.1 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. 20.7 and 20.8).

Surgical Procedure, Techniques, and Key Points

The schematic view of main surgical procedures of specimen extraction and digestive reconstruction in NOSES X (Fig. 20.6).

3.1

Exploration and Surgical Planning

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

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Fig. 20.7  Exploration of the liver’s surface

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Fig. 20.6  The main surgical procedures of specimen extraction and digestive reconstruction in NOSES X.

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Fig. 20.8  Exploration of gallbladder and liver (visceral surface) Fig. 20.10  The junction between superior mesenteric vein and ileocolic vessels

Fig. 20.9  Exploration of the tumor location (marked with methylthioninium chloride preoperatively)

3.1.2 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. 20.9).

Fig. 20.11  Opening the mesentery at the root of the ileocolic vessels

3.1.3 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.

3.2

Dissection and Separation

3.2.1 M  anagement 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. 20.10) and on the surface

Fig. 20.12  Dissection of mesentery along the Toldt’s fascia from medial to lateral

of the superior mesenteric vein (Figs.  20.11 and 20.12). 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

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Fig. 20.13  Ligation of ileocolic vessels

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Fig. 20.14  Transection of ileocolic vessels

Experience sharing: The surface of the horizontal part of the duodenum can be seen during the dissection upwards from medial to lateral, which is an important anatomical landmark (Fig 20.15).

Fig. 20.15  Dissection of the mesentery on the surface of duodenum

Experience sharing: The management of vessels should be gentle and patient. In the event of bleeding, the blood should be suctioned timely. Do not blindly clamp the vessels.

Fig. 20.16  Isolation of the right colic artery and vein

mesenteric vein. After adequate isolation, the ileocolic vessels are ligated and transected at the root (Figs. 20.13 and 20.14).

3.2.2 M  anagement 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 firstly. 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. 20.15, 20.16, and 20.17). 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

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Fig. 20.17  Ligation of the right colic artery and vein

Fig. 20.18  Transection of the right colic artery and vein

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Fig. 20.19  Exposure of the pancreatic capsule

Fig. 20.20  Dissection of the Toldt’s fascia on the surface of the pancreatic capsule

Experience sharing: Most middle colic arteries are accompanied by their veins at the inferior border of pancreas, with the initial part of jejunum on the left side. The operation in this area should be carefully performed to avoid damage to the pancreas.

Fig. 20.21  Isolation of the middle colic artery and vein

dissected on the surface of the pancreas (Figs. 20.18, 20.19, and 20.20). 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.

3.2.3 M  anagement 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. 20.21). At this point, all vessels supplying the right colon have been managed.

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3.2.4 Dissection of the Right Mesocolon Firstly, 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. 20.22).

Fig. 20.22  Complete dissection of Toldt’s fascia

Fig. 20.23  Dissection of the mesoileum

Fig. 20.24  Opening the gastrocolic ligament

3.2.5 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 p­ erformed. 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. 20.23). 3.2.6 D  issection 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. 20.24, 20.25, and 20.26), 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. 20.27 and 20.28), whereafter the dissection is continued to the right to Henle’s trunk (Fig. 20.29). Subsequently, the posterior gastric wall and the right transverse mesocolon are dissected, and the dissection planes are connected. After the hepatocolic ligament is transected (Fig. 20.30), the surgeon incises downward along the right paracolic sulcus to the attachment of cecum (Fig. 20.31) and gives direct access to the dissected mesentery of the terminal ileum. At this point, the dissection of the right colon has been completed.

Operating skills: Gauze placed underneath the mesentery is visible after entering the omental bursa. The gauze can provide protection and indication (Fig 20.25).

Fig. 20.25  Gauze underneath the mesentery

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3.2.7 M  anagement 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 are visible (Fig.  20.32). The posterior peritoneum is incised at the angle between the abdominal aorta and the

3.2.8 M  anagement 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

Fig. 20.26  Management of the transverse mesocolon

Fig. 20.29  Exposure of Henle’s trunk

Fig. 20.27  Dissection and transection of the gastrocolic ligament

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. 20.33 and 20.34).

Fig. 20.30  Transection of the hepatocolic ligament

Experience sharing: During the dissection of the gastrocolic ligament, a blood vessel is derived from the right gastroepiploic vein to the course of the hepatic flexure (Fig 20.28). With a large diameter, the vessel should be ligated with the vascular clip to prevent bleeding.

Fig. 20.28  Exposure of the branch of right gastroepiploic vein

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Treitz ligament in a medial to lateral fashion. The left mesocolon is lifted (Fig. 20.35) to transect the inferior mesenteric vein at the inferior border of the pancreas lateral to the Treitz ligament (Fig. 20.36).

3.2.9 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.

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The correct dissection plane should be smooth, flat, and clean (Fig. 20.37). The course and peristalsis of the left ureter 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. 20.38).

Fig. 20.31  Dissection of the right paracolic sulcus

3.2.10 M  anagement 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. 20.39). Gradually, dissection is continued to the gastrocolic ligament, then to the lower pole of spleen (Fig. 20.40). 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. 20.41, 20.42, and 20.43). When

Fig. 20.32  Dissection along the Toldt’s fascia from medial to lateral

Fig. 20.34  Double ligation of the inferior mesenteric artery

Fig. 20.33  Isolation of the inferior mesenteric artery

Fig. 20.35  Dissection along the Toldt’s fascia from medial to lateral

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Experience sharing: Dissect the lymph nodes at the root of the inferior mesenteric artery. The isolated length of the root of blood vessel should not be longer than enough for ligation.

Fig. 20.36  Ligation of the inferior mesenteric vein

Fig. 20.37  Surface of the left mesocolon Fig. 20.39  Dissection to the left along the gastroepiploic vessels

Fig. 20.38  Placing a gauze beneath the mesocolon Fig. 20.40  Dissection to the left to the lower pole of spleen

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the dissection reaches the gauze underneath the left mesocolon, the left colon is mobilized completely (Fig. 20.44).

3.2.11 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 according to the principle of TME (Fig. 20.45), the surgeon detaches the physiological sigmoid adhesions and dissects the peritoneum on the left of the rectum to the intended resection line (Fig. 20.46). 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 vascular clips to

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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.

3.3

 pecimen Resection, Extraction, S and Digestive Tract Reconstruction

3.3.1 Specimen Resection With linear Endo GIA stapler, the rectum is transected at the intended resection line on the isolated area of rectum (Fig. 20.47), as well as the ileum (Fig. 20.48). 3.3.2 Specimen Extraction 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 the ultrasonic scalpel to open the posterior vaginal fornix transversely for

Experience sharing: After the change of surgeon's position, the monitor should be moved to the upper left of the patient. The operation should be performed carefully to avoid splenic injury, which is prone to cause conversion to laparotomy. The surgeon and assistant expand the left greater omentum and determine the intended resection line to avoid repetition work.

Fig. 20.41  Dissection of the splenocolic ligament

Fig. 20.42  Dissection of the left paracolic sulcus

Fig. 20.43  Dissection upward along the left paracolic sulcus to the splenic flexure

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approximately 3 cm and extends the incision to 5–6 cm by longitudinal stretch (Fig.  20.49). 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. 20.50). At the same time, the surgeon and the assistant place the whole colon into the protective sleeve step by step (Fig. 20.51), and the assistant gently pulls the specimen out of the body through the protective sleeve inside the vagina (Fig. 20.52).

Fig. 20.44  The inferior border of pancreas and the splenic flexure after dissection

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3.3.3 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. 20.53), through which the anvil is placed in the ileal cavity (Fig.  20.54). After the adjustment of position, the ileum stump is transected with the linear Endo GIA stapler (Fig. 20.55), 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. 20.56). The assistant inserts the circular stapler through the anus and extends trocar to pierce one corner of the rectal stump (Fig. 20.57). The anvil is connected to the trocar of stapler (Fig. 20.58) to complete the side-to-end anastomosis between the ileum and the rectum, then the anastomosis is sutured to be reinforced (Fig. 20.59). Check the integrity of the anastomotic ring carefully. Air leak test is performed to confirm the integrity of the anastomosis (Fig. 20.60), and active bleeding should be excluded. Two drainage tubes are placed in the pelvic cavity through the trocars on the left and right lower quadrant (Figs. 20.61 and 20.62). Finally, the pneumoperitoneum is released and trocar sites are closed.

Fig. 20.45  Dissection downward along the Toldt’s fascia Fig. 20.46  Opening the left sigmoid mesocolon

Operating skills: During the transection of rectum, try to make the resection line at a right angle to the bowel.

Fig. 20.47  Transection of the rectum

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Fig. 20.48  Transection of the small intestine

Fig. 20.49  Opening the posterior vaginal fornix

Fig. 20.50  Placement of protective sleeve

Fig. 20.51  Placing the specimen into the protective sleeve

Experience sharing: The specimen extraction should be gently performed. If resistance is encountered, the cause should be carefully sought.

Fig. 20.52  Transvaginal extraction of specimen

3.3.4 Suturing of the Vaginal Incision Fully expose the vaginal incision, clamp the anterior and posterior wall of the vaginal incision with two Allis forceps, and perform interrupted suture with absorbable sutures (Fig.  20.63). 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 hours after operation.

3.4

Postoperative Abdominal Wall and Specimen Display (Figs. 20.64 and 20.65)

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 ey Points, Difficulties, and Hotspots K Related to Surgery

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Fig. 20.53  Cutting open the ileum stump

Fig. 20.55  Closing the ileum

Fig. 20.54  Inserting the anvil into the ileum

Fig. 20.56  Taking out the anvil shaft

4.1

verse 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 overall situation. In order to overcome this difficulty, we must have a solid anatomical understanding and a spatial thinking in anatomy.

 he Dissection Sequence T 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 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 trans-

4.2

 otal Colectomy with Rectal Ampulla T Preserved

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

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Fig. 20.57  Inserting the stapler through the anus

Fig. 20.58  Side-to-end anastomosis between the ileum and rectum

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Fig. 20.61  Drainage tube is placed on the left side of the abdominal cavity

Fig. 20.62  Drainage tube is placed on the right side of the abdominal cavity

Fig. 20.59  Reinforcement and suture of anastomosis

Fig. 20.63  Interrupted suture of vaginal incision

Fig. 20.60  Air leak test

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

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Fig. 20.64  Specimen display

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 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.

4.4

Fig. 20.65  Postoperative abdominal wall display

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.

4.3

 iagnosis and Treatment of Familial D 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

Diagnostic Criteria for Lynch Syndrome

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 firstly proposed in 1991, i.e., the famous Amsterdam Criteria: (1) having at least 3 relatives with histologically confirmed colorectal cancer, 1 of whom is a first degree relative of the other 2, familial adenomatous polyposis should be excluded; (2) at least 2 successive generations are involved; and (3) at least 1 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.

Transanal Total Mesorectal Excision (taTME)

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The taTME for rectal cancer is an integrated combination of transanal endoscopic microsurgery (TEM), transanal microinvasive surgery, transabdominal-transanal (TATA) operations, TME, etc. This procedure epitomized the concept of NOTES. In China, specimens are often extracted through the anus after taTME. In this regard, taTME belongs to the definition of NOSES. At present, relevant clinical studies have shown that taTME can preserve organs and protect neural function to the greatest extent on the basis of radical resection of tumors. It can achieve maximum anus preservation for lower rectal cancer and improve the quality of life of patients after surgery. According to the difference in implementation strategy and the definition of taTME, taTME can be divided into pure taTME and laparoscopic-assisted taTME (hybrid taTME). There are some differences between rectal taTME and conventional rectal surgery. First and foremost, its surgical approach is in the reverse direction of the conventional transabdominal procedure. Therefore, taTME has unique technical characteristics, and its learning curve is longer than that of the conventional surgery.

4. History of abdominal surgery with intra-abdominal adhesions.

1.2

Contraindications

1 . History of anal stenosis or damage. 2. Physical condition and organ function cannot tolerate surgery and anesthesia. 3. Extensive distant metastases unable to be completely resected, with no need of emergency treatment of complications.

2

 nesthesia, Patient Positioning, A Trocar Placement, and Surgical Team Position

2.1

Anesthesia Method

General anesthesia or general epidural anesthesia.

1

Indications and Contraindications of taTME

1.1

Indications

1. Middle and lower rectal cancer, especially lower rectal cancer less than 5 cm from the dentate line. 2. Upper rectal cancer, with close adhesion to the bladder, uterus, or seminal vesicles, and the distal edge of tumor cannot be determined by the transabdominal approach. 3. Diffuse cavernous hemangioma of the rectum (DCHR) and other benign diseases invading the lower rectum and anal canal.

L. Kang (*) Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China

2.2

Patient Positioning

The patient is placed in the Trendelenburg position, with both legs lifted and abducted. The patient’s coccyx should be placed on the edge of the table, leaving part of the buttocks on the outside of the table to facilitate full exposure of the anus and ensure sufficient operating space on the side of the anus. Prepare another instrument table for the placement of instruments (Fig. 21.1).

2.3

Trocar Placement

Trocar sites of transabdominal laparoscopic operation are consistent with those of conventional rectal TME.

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2.4

Surgical Team Position

Surgeons’ positions in the transabdominal surgery are the same as those in conventional laparoscopic-assisted TME.  During the transanal operation, the surgeon sits between the patient’s legs (Fig. 21.2).

2.5

Special Surgical Instruments

Transanal open surgery operation platform, constant pressure insufflator, anal retractor (Figs. 21.3, 21.4, 21.5, and 21.6).

Fig. 21.1  The patient’s position Monitor

a

Camera Holder Assistant

Surgeon Scrub Nurse

Scrub Nurse

b

Monitor

Assistant

Surgeon

c

Fig. 21.2 (a) Surgical team position, (b) surgical team position in hybrid transanal procedure, (c) surgical team position in pure transanal procedure

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Fig. 21.3  Commonly used transanal open surgery operation platform

Fig. 21.4  Constant pressure insufflator

Fig. 21.6  Anal retractor Fig. 21.5  Anal retractor

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Surgical Procedures, Techniques, and Key Points

3.1

Laparoscopic-Assisted taTME

3.1.1 Transabdominal Operation The operating procedures of transabdominal laparoscopic operation are generally consistent with those of the conventional laparoscopic rectal TME. According to the TME principles, the mesorectum is dissected to the pelvic floor under laparoscopy. Recommended insertion for transabdominal surgery is as follows. The surgeon opens the peritoneal reflection anterior to the rectum and dissects the posterior mesorectum to the sacrorectal ligament (S3 level). A window is opened for approximately 2 cm on the lateral peritoneum on either side. After reaching the transabdominal insertion, it is recommended to place a gauze in the presacral space to absorb the exudate. This gauze can also be a marker to identify the presacral plane in the subsequent transanal operation. Sometimes, the splenic flexure must be mobilized to ensure transanal specimen extraction and tension-free anastomosis. 3.1.2 Transanal Operation 1. After disinfection of the perineal area, the rectum is irrigated with a diluted iodine solution. The dentate line can be seen on slight retraction of the anal retractor (Fig. 21.7). 2. For rectal cancer patients with distal edge of tumor less than 5 cm from the dentate line, the tumor is exposed with a semicircular anoscope under direct vision (Fig.  21.8), and a purse-string suture is performed 1–2 cm below the distal edge of tumor. The bowel lumen is closed, the tumor is isolated, and adequate irrigation is performed (Fig.  21.9). Following purse-string occlusion of the

r­ectum, the rectal mucosa is incised by full-thickness ­circumferential incision of the rectal wall (Fig.  21.10). Resect partial or all of the internal sphincter if necessary, and enter the space between the rectum and the adjacent organs (Fig. 21.11). For diseases invading the anal canal, the purse-string suture can only be performed after the bowel wall is cut open. 3. Transanal surgery operation platform and surgical instruments can be inserted after dissection for more than 4 cm under direct vision. Establish pneumoperitoneum with the

Fig. 21.8  Exposure of tumor with a semicircular anoscope

Fig. 21.9  Purse-string suture and rectal irrigation

Fig. 21.7  Exposure of dentate line with the anal retractor

Fig. 21.10  Cutting open the bowel wall under direct vision

21  Transanal Total Mesorectal Excision (taTME)

Fig. 21.11  Dissection under direct vision

Fig. 21.12  Dissection completely under laparoscopy

constant pressure insufflator, maintain the pressure at 12–15 mmHg, and dissect upward along the plane. 4. For patients with distal edge of tumor more than 5  cm from the anal margin, the abovementioned procedures can be performed completely under laparoscopy after the operation platform is inserted first (Fig. 21.12). 5. The rectal mucosa is scored circumferentially with monopolar cautery. In the lateral side, full-thickness rectal and mesorectal mobilization is carried out, and the superior fascia of pelvic diaphragm can be seen after opening the conjoined longitudinal muscle (Fig. 21.13). At this point, the dissection plane has been entered. Anteriorly and posteriorly, dissection is carried out from distal to proximal sides. The dissection of contralateral side is completed in the same manner. Ultimately, anterior dissection is carried out until the Denonvilliers’ fascia is reached (Fig. 21.14). Posterior entry can usually be extended toward S1–S2 levels (Fig. 21.15). In the dissection in male patients with lower rectal cancer, attention should be paid to the anterior rectourethral muscle and the posterior hiatal ligament (Fig.  21.16). Mesorectal dissection must be carried out along the “holy plane” between the visceral layer and

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Fig. 21.13  Conjoined longitudinal muscle

Fig. 21.14  Denonvilliers’ fascia anterior to the rectum and bilateral lateral ligaments

Fig. 21.15  Posterior rectal space

parietal layer of pelvic fascia until connected with the abdominal operation plane (Figs. 21.17, 21.18, 21.19, and 21.20). At this point, the dissection of total mesorectum is completed.

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Fig. 21.16  Hiatal ligament

L. Kang

Fig. 21.19  Up and down rendezvous on the left side

Fig. 21.20  Up and down rendezvous on the right side Fig. 21.17  Opening the peritoneal reflection

Fig. 21.18  Posterior rendezvous

3.1.3 S  pecimen Resection and Digestive Tract Reconstruction 1. After removing the operation platform, an incision protector is inserted through the anus to facilitate transanal specimen extraction (Fig. 21.21). If the specimen is too large, an additional abdominal incision should be made to remove

Fig. 21.21  Transanal specimen resection

the specimen (Fig. 21.22). It should be noted that that the division of the mesentery should follow the principles of radical resection, and the bowel is transected at more than 10 cm above the proximal end of the tumor. Irrigation of the abdominal cavity is performed (Fig. 21.23). The post-

21  Transanal Total Mesorectal Excision (taTME)

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Fig. 21.24  Anterior postoperative field

Fig. 21.22  Transabdominal specimen resection

Fig. 21.23  Irrigation of pelvic cavity

operative field should be double-checked (Figs.  21.24, 21.25, 21.26, and 21.27). 2. If the resection margin is more than 2 cm from the dentate line, the digestive tract reconstruction can be performed with circular stapler. The anvil is inserted into the proximal bowel, followed by the return of proximal bowel into the pelvic cavity. After the full-thickness purse-string suturing of the distal stump is completed, the purse-string line is tightened to the anvil shaft. After confirming that no bowel volvulus has been observed, the anvil is con-

Fig. 21.25  Right postoperative field

Fig. 21.26  Left postoperative field

nected to the trocar of stapler to complete the end-to-end anastomosis (Fig. 21.28). 3. If the anastomosis is within 2 cm from the dentate line, continuous full-thickness suture with 3/0 or 2/0 barbed suture can be used to perform the end-to-end anastomosis under direct vision (Fig. 21.29).

3.1.4 Drainage Tube and Protective Stoma Place a drainage tube in the pelvic cavity through the trocar. For patients with lower rectal cancer who underwent neoadjuvant radiotherapy and/or dissatisfied with anastomosis,

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diverting ileostomy can be performed. Place the transanal drainage tube (Fig. 21.30).

3.2

Pure taTME

3.2.1 Transanal Dissection 1. After disinfection of the perineal area, the rectum is irrigated with a diluted iodine solution. The dentate line can be seen on slight retraction of the anal retractor. 2. For patients with distal edge of tumor less than 5 cm from the dentate line, the tumor is exposed with a semicircular anoscope. A purse-string suture is performed 1–2  cm below the distal edge of tumor, the bowel lumen is closed, and the tumor is isolated (Fig. 21.31). The distal lumen is irrigated, then the rectal mucosa is incised circumferentially, just distal to the purse string. With full-thickness dissection of the rectal wall, the space between the rectum and the adjacent organs is entered. For diseases invading the anal canal, the purse-string suture can only be performed after making an incision on the bowel wall and

Fig. 21.27  Posterior postoperative field

a

Fig. 21.28 (a) Stapled anastomosis, (b) stapled anastomosis

resecting partial or all of the internal sphincter if necessary. 3. Transanal surgery operation platform and surgical instruments can be inserted after dissection for approximately 4  cm under direct vision. Establish pneumoperitoneum with the constant pressure insufflator, maintain the pressure at 12–15 mmHg, and dissect upward along the dissection plane. 4. For patients with distal edge of tumor more than 5  cm from the anal margin, the purse-string suture can be performed under laparoscopy after the insertion of operation platform and the establishment of pneumoperitoneum (Fig. 21.32).

Fig. 21.29  Continuous anastomosis with barbed suture

b

21  Transanal Total Mesorectal Excision (taTME)

Fig. 21.30  Pelvic drainage tube and transanal drainage tube

Fig. 21.31  Purse-string suture and scored mucosa below the distal edge of tumor

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5. The rectal mucosa is scored circumferentially with monopolar cautery. In the lateral side, full-thickness rectal and mesorectal mobilization is carried out, (Fig. 21.33), and the superior fascia of pelvic diaphragm can be seen after opening the conjoined longitudinal muscle (Fig. 21.34). At this point, the dissection plane has been entered. Anteriorly and posteriorly, dissection is carried out from distal to proximal sides. The dissection of contralateral side is completed in the same manner. Ultimately, anterior dissection is carried out until the Denonvilliers’ fascia is reached. Posterior entry can usually be extended toward S1–S2 levels. In the dissection in male patients with lower rectal cancer, attention should be paid to the anterior rectourethral muscle and the posterior hiatal ligament (Fig. 21.35). 6. Continue to dissect the mesorectum upward along the “holy plane” between the visceral layer and parietal layer of the pelvic fascia. Opening the posterior rectosacral fascia (Waldeyer’s fascia) (Fig.  21.36), continue to dissect along the retrorectal space proximally to the plane of sacral promontory. On the lateral sides, dissect the medial side of bilateral lateral ligaments proximally along the plane. 7. In the anterior side, continue to dissect along the Denonvilliers’ space proximally, open the peritoneal reflection, and enter the abdominal cavity (Fig. 21.37). 8. Flip the dissected distal rectum into the abdominal cavity along the incision of the peritoneal reflection (Fig. 21.38), and continue to dissect proximally along the fascia propria of the rectum to approximately 2 cm above the intersection of the left and right common iliac arteries, where the root of the inferior mesenteric artery can be seen (Fig. 21.39). 9. Perform ligation and transection of the inferior mesenteric vessels (Fig. 21.40). 10. Adequately dissect the sigmoid mesocolon (Fig. 21.41). Divide the mesorectum (Fig. 21.42).

3.2.2 S  pecimen Resection and Digestive Tract Reconstruction Resect and remove the specimen transanally (Fig.  21.43). Circular stapler can be applied to perform anastomosis 2 cm above the dentate line (Fig. 21.44). Otherwise, manual anastomosis should be performed, and continuous suture with 3.0 barbed suture is recommended (Fig. 21.45). 3.2.3 Drainage Tube and Protective Stoma Pelvic drainage tube is placed through the perineum if there is much exudate. Whether to perform the diverting ileostomy should be determined based on the intraoperative situation. Place the transanal drainage tube (Fig. 21.46). Display postoperative specimens (Fig. 21.47).

Fig. 21.32  Circumferentially scored rectal mucosa

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Fig. 21.33 (a) Cutting open all layers of bowel wall from the lateral side, (b) cutting open all layers of bowel wall in the lateral side

Fig. 21.34  Cutting open the anterior conjoined longitudinal muscle to enter the dissection plane Fig. 21.36  Rectosacral fascia (Waldeyer’s fascia)

Fig. 21.35  Cutting open the posterior hiatal ligament Fig. 21.37  Open the peritoneal reflection

21  Transanal Total Mesorectal Excision (taTME)

Fig. 21.38  Flip the dissected bowel into the abdominal cavity

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Fig. 21.41  Dissection of the sigmoid mesocolon

Fig. 21.42  Dividing the mesorectum Fig. 21.39  Transanal dissection to the root of the inferior mesenteric vessels

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Fig. 21.40 (a) Transanal ligation of the root of the inferior mesenteric vessels, (b) transanal transection of the root of the inferior mesenteric vessels

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Fig. 21.43  Transanal specimen removal

a

 ey Points, Difficulties, and Hotspots K Related to Surgery

According to the preliminary clinical study results of rectal taTME from Chinese and international colleagues, rectal taTME can achieve the equal effects of TME. As a safe and feasible procedure, it has advantages in the treatment of patients with obesity or “difficult pelvis” and the preserving of pelvic nerves. In conventional gastrointestinal surgery, regardless of whether through transabdominal approach or posterior sacral-perineal approach, the fused attachment between gastrointestinal tract and posterior peritoneum should be detached

b

Fig. 21.44 (a) Stapled anastomosis, (b) stapled anastomosis

Fig. 21.45 Continuous suture with barbed suture to create the anastomosis

Fig. 21.46  After pure taTME

21  Transanal Total Mesorectal Excision (taTME)

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c

Fig. 21.47 (a–c) Postoperative specimens

first, and the blood vessels supplying the bowel should be ligated before the transection of bowel. However, the idea of transanal surgery is quite different. In the transanal surgery, the dissection begins at the bowel mucosa, followed by the dissection of bowel wall layer by layer to the serosa. Therefore, the bowel is transected first, followed by the detachment of the gastrointestinal tract from the posterior peritoneum, the mobilization of the bowel, and the dissection of lymph nodes. In the pure taTME, the transection vessels and the exploration of abdominal cavity should be performed lastly. As previously mentioned, the taTME procedure can be divided into the following three approaches: simultaneous approach, sequential approach, and pure taTME approach. (1) Simultaneous approach: With this approach, the surgery is performed by abdominal and transanal teams simultaneously. The advantage of this approach is that the advantages of both abdominal and transanal approaches can be given full play, and the two teams can guide each other in the direction to facilitate operation. This approach also facilitates the accumulation of early experience for the transanal team. At the same time, with the simultaneous operation of “up and down,” the operation time can be greatly shortened, and the incidence of related complications can be reduced. However, since this approach requires two teams and two sets of laparoscopic equipment, it is more costly. (2) Sequential approach: This approach is similar to the simultaneous approach, but only one operative team is required to perform the abdominal operation first, then dissect upward transa-

nally, and finally open the peritoneal reflection to join with the abdominal operation. Conversely, transanal operation may be followed by abdominal operation. (3) Pure taTME approach: After returning the dissected rectum into the abdominal cavity, complete transanal dissection of lateral and posterior sides of the rectum to the inferior mesenteric vessels is required, as well as dissection of the left mesocolon and ligation of inferior mesenteric vessels. After transanal opening of the peritoneal reflection anterior to the rectum, air entering the abdominal cavity will reduce the lateral rectal space, which makes the operation more difficult. At present, since the equipment and instruments cannot fully meet the requirements of the existing surgery, routine application of pure taTME is not recommended yet. It is recommended that the hybrid taTME, either simultaneous or sequential approach, should be used in the early experience with adoption of TaTME operation. This approach can not only reduce the difficulty of operation by bidirectional guidance of the dissection plane but also facilitate to the accumulation of transanal surgery experience and lay the foundation for the development of other approaches. The distal lumen is irrigated, then the rectal mucosa is incised circumferentially, just distal to the purse string. With full-thickness dissection of the rectal wall, the space between the rectum and the adjacent organs is entered. It is important to emphasize that the taTME can only be performed routinely after sufficient experience has been accumulated.

Part III NOSES for Gastrointestinal Cancer

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

22

Su Yan

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 caused by additional auxiliary incisions. The surgeons should have clear understanding of the indications and contraindications of this procedure.

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.

1

2.2

1.1

Indications and Contraindications of NOSES Indications

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

1.2

Contraindications

1. The tumor is too large to be pulled out through the rectum.

S. Yan (*) Department of Gastrointestinal Surgery, Affiliated Hospital of Qinghai University, Qinghai University, Xining, China

2

 nesthesia, Patient Positioning, A Trocar Placement, and Surgical Team Position

2.1

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 (Fig. 22.1a,b). During the transanal specimen extraction, the patient is placed in the Trendelenburg position (Fig. 22.2a,b).

2.3

Trocar Placement

In principle, the trocar sites are no different from those of laparoscopic distal gastrectomy, and the five-port method is routinely adopted (Fig. 22.3), 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.

© People’s Medical Publishing House, PR of China 2021 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-15-7925-7_22

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Fig. 22.1 (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. 22.2 (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

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.

22  Laparoscopic Distal Gastrectomy (Billroth I) with Transrectal Specimen Extraction (GC-NOSES I)

2.4

Surgical Team Position

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. 22.3). The camera holder stands between

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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. 22.2a,b).

2.5

Special Surgical Instruments

Ultrasonic scalpel, 60 mm linear Endo GIA stapler, 3-0 barbed suture, 4-0 absorbable suture, sterile protective sleeve, etc.

Fig. 22.3  Trocar sites (Five-port method)

3

Surgical Procedure, Techniques, and Key Points

3.1

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. 22.4a,b), then observe the right abdominal cavity

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Fig. 22.4 (a) Exploration of the left lobe of the liver, (b) exploration of the right lobe of the liver, (c) exploration of the pelvic cavity, (d) exploration for the presence of peritoneal nodules

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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.  22.4c). 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 the 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, 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 (Fig. 22.4d).

S. Yan

3.2

Perigastric Lymph Node Dissection

3.2.1 D  issection of the Greater Omentum and Dissection of Lymph Nodes of the Subpyloric Region First, lift the greater omentum cranial 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 the spleen and the splenic flexure (Fig.  22.5a). Then, move the greater omentum cranial, lift the right gastroepiploic mesentery cranial ventrally, dissect along the fusion fascia space between the transverse mesocolon and the right gastroepiploic mesentery from the right of

a

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e

Fig. 22.5 (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

nodes, (d) transection of the duodenum, (e) under the premise of ensuring the safety of resection margin, preserving duodenum long enough for Billroth I gastroduodenal anastomosis

22  Laparoscopic Distal Gastrectomy (Billroth I) with Transrectal Specimen Extraction (GC-NOSES I)

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. 22.5b). 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.  22.5c). After the duodenum is lifted ventrally, a window is created in the triangle formed by the superior border of the duodenum with the right gastric vessels and anterior pyloric vessels, then the duodenum is transected with a 60 mm linear Endo GIA stapler with white cartridge (Fig. 22.5d–e).

3.2.2 D  issection 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.  22.6a). Dissect along the superior border of the 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. 22.6b). 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. 22.6c–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.  22.6f,g). Dissect the coronary vein right anterior to the left gastric artery, and perform ligation and transection (Fig. 22.6h). Then dissect the station 9 lymph nodes at the root of the celiac artery, and pull the left gastric artery cephalad ventrally (Fig. 22.6i), ligate and transect the left gastric artery at the root, and dissect station 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.  22.6j), and finally complete the dissection of lymph nodes in the superior pancreatic region (Fig. 22.6k). 3.2.3 D  issection 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. 22.6l), thoroughly resect the adipose tissues anterior to the abdominal esophagus on the right side of the esophageal hiatus, and gradually isolate

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the lesser curvature caudally (Fig. 22.6m). Complete the dissection of station 1 and 3 lymph nodes (Fig. 22.6n).

3.2.4 D  issection 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 the spleen and the tail of the pancreas cephalad to the splenic hilar region; expose the left gastroepiploic vessels originating from the vessels of the lower pole of spleen. Ligate and transect the left gastroepiploic vessels at the root to complete the dissection of station 4sb lymph nodes (Fig. 22.7a), continue to dissect cranially to transect a short gastric vessel (Fig. 22.7b), and then isolate the greater curvature from left to right (Fig. 22.7c).

3.3

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. 22.8a). Place the specimen in the specimen bag to complete the D2 lymph node dissection for distal gastric cancer (Fig. 22.8b).

3.4

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 chief surgeon lifts the bowel wall at the rectal incision and gently pulls it cephalad with the left hand. Meanwhile, the assistant slowly pulls the specimen bag out of the anus to complete the transrectal specimen extraction (Fig.  22.9a–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.

3.5

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

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a

b

c

d

e

f

g

h

Fig. 22.6 (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 the 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 the hepatic hilum; (f) dissection of the station 11p lymph nodes along the surface of the splenic artery; (g) surgical 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 station 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 station 1 and 3 lymph nodes; (m) after the isolation of the lesser curvature; (n) surgical field after the dissection of station 1 and 3 lymph nodes

22  Laparoscopic Distal Gastrectomy (Billroth I) with Transrectal Specimen Extraction (GC-NOSES I)

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n

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Fig. 22.6 (continued)

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. 22.10a). After firing the stapler, remove the stapler and see if there is active bleeding (Fig. 22.10b), and suture the common opening with 3-0 V-Loc barbed suture in a continuous manner (Fig. 22.10c). Lift the remnant stomach ventrally, check for the presence of anastomotic tension, and complete the Billroth I gastroduodenal anastomosis (Fig. 22.10d).

4

 ey Points and Difficulties Related K 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

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b

c

Fig. 22.7 (a) Left gastroepiploic vessels originating from the artery of the lower pole of spleen, (b) transection of a short gastric vessel, (c) isolation of the greater curvature

a

b

Fig. 22.8 (a) Transection of the gastric body at 8 cm from the upper pole of the primary tumor, (b) surgical field after specimen extraction

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 rec-

tum 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. The rectum should be irrigated routinely before the specimen extraction. During the specimen extraction, rectal damage caused by excessive

22  Laparoscopic Distal Gastrectomy (Billroth I) with Transrectal Specimen Extraction (GC-NOSES I)

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Fig. 22.9 (a) Transanal specimen extraction, (b) transanal specimen extraction, the specimen can be slowly pulled out of specimen bag, (c) specimen display

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c

d

Fig. 22.10 (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

3-0 V-Loc barbed suture in a continuous manner, (d) completion of Billroth I gastroduodenal anastomosis

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stretching of specimen bag is contraindicated. After specimen extraction, the rectal incision should be sutured, and the pelvic cavity should be irrigated again until clean. In addition, the rectal incision should be closed by m ­ ucosa-to-­mucosa and serosa-to-serosa suturing. If necessary, interrupted suture is required for reinforcement to ensure that the rectal incision

S. Yan

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 degrees; during the transanal specimen extraction, the patient should be placed in the Trendelenburg position, where the head is lowered by approximately 30 degrees.

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

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Su Yan

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 is 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.

1.2

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.

2

 nesthesia, Patient Positioning, A Trocar Placement, and Surgical Team Position

2.1

Anesthesia Method

General anesthesia or general epidural anesthesia.

1

Indications and Contraindications of NOSES

1.1

Indications

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

S. Yan (*) Department of Gastrointestinal Surgery, Affiliated Hospital of Qinghai University, Qinghai University, Xining, China

2.2

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. 23.1a,b). During the transanal specimen extraction, the patient is placed in the Trendelenburg position (Fig. 23.2a,b).

2.3

Trocar Placement

In principle, the trocar sites are no different from those of laparoscopic distal gastrectomy, and the five-port method is routinely adopted (Fig. 23.3), and the trocar sites should be adjusted appropriately according to the patient’s BMI and shape of abdomen.

© People’s Medical Publishing House, PR of China 2021 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-15-7925-7_23

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a

S. Yan

b

Fig. 23.1 (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

a

b

Fig. 23.2 (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

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.

23  Laparoscopic Distal Gastrectomy (Billroth I) with Transvaginal Specimen Extraction (GC-NOSES II)

Fig. 23.3  Trocar sites (five-port method)

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.

2.4

Surgical Team Position

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. 23.3). 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 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. 23.2a,b).

2.5

Special Surgical Instruments

Ultrasonic scalpel, 60  mm linear Endo GIA stapler, 3-0 barbed suture, 4-0 absorbable suture, sterile protective sleeve, etc.

3

Surgical Procedure, Techniques, and Key Points

3.1

Exploration of the Abdominal and Pelvic Cavity

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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. 23.4a,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. 23.4c). 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 (Fig.  23.4d). 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.

3.2

Perigastric Lymph Node Dissection

3.2.1 D  issection 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 the transverse mesocolon, and dissect to the right to the hepatic flexure and to the left to the lower pole of the spleen and the splenic flexure (Fig. 23.5a). The vessels of the lower pole of spleen are found along the lower pole of the spleen and the tail of the pancreas; 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. 23.5b). 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. 23.5c,d).

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a

b

c

d

Fig. 23.4 (a) Exploration of the left lobe of the liver, (b) exploration of the right lobe of the liver, (c) exploration of the pelvic cavity, (d) exploration of primary lesion

Exposure of the root of superior mesenteric vein and dissection of the station 14v lymph nodes (Fig. 23.5e). 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. 23.5d). 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. 23.5f); dissect and expose the right gastric vascular pedicle (Fig. 23.5g). After the duodenum is lifted ventrally, a window is created in the triangle formed by the superior border of the duodenum with the right gastric vessels and anterior pyloric vessels (Fig. 23.5h), then the duodenum is transected with a 60 mm linear Endo GIA stapler with white cartridge (Fig. 23.5i).

3.2.2 D  issection 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.  23.6a). Dissect along the superior border of the 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. 23.6b,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. 23.6d,e). Expose the coronary vein superior and posterior to the common hepatic artery and perform transection (Fig.  23.6f), 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.  23.6g), expose the root of the left gastric artery, dissect the station 7 lymph nodes (Fig. 23.6h), and dissect along the right diaphragmatic crus cephalad (Fig.  23.6i). 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. 23.6j).

3.2.3 D  issection 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

23  Laparoscopic Distal Gastrectomy (Billroth I) with Transvaginal Specimen Extraction (GC-NOSES II)

a

b

c

d

e

f

g

h

Fig. 23.5 (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

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superior 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 the duodenum

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S. Yan

patient is placed in the reverse Trendelenburg position again for the following digestive tract reconstruction.

i

3.5

Fig. 23.5 (continued)

curvature caudally (Fig. 23.7a). Complete the dissection of station 1 and 3 lymph nodes (Fig. 23.7b).

3.3

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. 23.8a). Place the specimen in the specimen bag to complete the D2 lymph node dissection for distal gastric cancer (Fig. 23.8b).

3.4

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.  23.9a), and the protective sleeve is taken out of the abdominal cavity through the incision (Fig. 23.9b). 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. 23.9c,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. 23.9e,f). After the suture, the pelvic cavity is irrigated again, and the

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 curvature of the remnant stomach and the anterior wall of the duodenum (Fig.  23.10a). After firing the stapler, remove the linear Endo GIA stapler and see if there is active bleeding (Fig.  23.10b), and suture the common opening with 3-0 V-Loc barbed suture in a continuous manner (Fig. 23.10c). Lift the remnant stomach ventrally, check for the presence of anastomotic tension, and complete the Billroth I gastroduodenal anastomosis (Fig. 23.10d).

4

 nalysis of Key Points and Difficulties A 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; 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. 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

23  Laparoscopic Distal Gastrectomy (Billroth I) with Transvaginal Specimen Extraction (GC-NOSES II)

a

b

c

d

e

f

g

h

Fig. 23.6 (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 the dissection of lymph nodes in the hepa-

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toduodenal 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 station 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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i

S. Yan

j

Fig. 23.6 (continued)

a

b

Fig. 23.7 (a) Adopting the posterior approach for the dissection of station 1 and 3 lymph nodes, (b) after the isolation of the lesser curvature

a

b

Fig. 23.8 (a) Transection of the gastric body at 8 cm from the upper pole of the primary tumor, (b) surgical field after specimen extraction

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 anti-Trendelenburg position, where the head is elevated by approximately 30 degrees; during the transvaginal specimen extraction, the patient should be placed in the Trendelenburg position, where the head is lowered by approximately 30 degrees.

23  Laparoscopic Distal Gastrectomy (Billroth I) with Transvaginal Specimen Extraction (GC-NOSES II)

a

b

c

d

e

f

Fig. 23.9 (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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S. Yan

a

b

c

d

Fig. 23.10 (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

3-0 V-Loc barbed suture in a continuous manner, (d) completion of Billroth I gastroduodenal anastomosis

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

24

Gang Yu

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 and 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.

1

Indications and Contraindications of NOSES

1.1

Indications

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.

G. Yu (*) Department of General Surgery, Qilu Hospital of Shandong University (Qingdao), Qingdao, China

1.2

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.

2

 nesthesia, Patient Positioning, A Trocar Placement, and Surgical Team Position

2.1

Anesthesia Method

General anesthesia or general epidural anesthesia.

2.2

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. 24.1), which will be changed to the functional lithotomy position (Fig.  24.2) when removing the specimen through rectal incision.

2.3

Trocar Placement

Trocar sites of the operation should meet the needs of both radical gastrectomy for gastric cancer and transrectal specimen collection. 1. Camera trocar (10  mm trocar) is 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.

© People’s Medical Publishing House, PR of China 2021 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-15-7925-7_24

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Laparoscope Holder

Assistant

Surgeon

Scrub Nurse

Fig. 24.1  The patient’s position during gastric cancer resection

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. 24.3).

2.4

Surgical Team Position

2.4.1 A  bdominal 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. 24.4). 2.4.2 Digestive Tract Reconstruction The surgeon and assistant can exchange positions. The monitor should be located on the side of the patient’s head. 2.4.3 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. 24.5). The monitor should be placed on the side of the patient’s foot.

2.5

Surgical Instruments

Ultrasonic knife, 60  mm linear cutting closure, 3-0 barbed suture, 4-0 absorbable suture, sterile protector. Fig. 24.2  Functional lithotomy position during specimen extraction

Fig. 24.3  Trocar placement (five-port method)

24  Laparoscopic Distal Gastrectomy (Billroth II) with Transrectal Specimen Extraction (GC-NOSES III)

3

Surgical Procedure, Techniques, and Key Points

3.1

Surgical Exploration

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3.1.1 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. 24.6). 3.1.2 Tumor Exploration The tumor is located in the gastric antrum and did not infiltrate the serosal layer (Fig. 24.7).

Fig. 24.4  Surgical team position during gastric cancer resection

Fig. 24.5  Surgical team position during specimen removal

Fig. 24.6  Comprehensive exploration of the abdominal cavity

Experience sharing: Preoperative gastroscopy evaluation is very important. If the location and the upper and lower tangent of the tumor cannot be determined under laparoscopy, gastroscopy will be used for precise localization during the operation.

Fig. 24.7  Not infiltrating the serosa by tumor exploration

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3.2

G. Yu

Dissection and Separation

3.2.1 D  issection 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 the mesocolon. Next, the anterior lobe of the mesocolon is resected (Fig. 24.8). 3.2.2 Dissection of Group 6 Lymph Nodes The gastrocolic trunk (Henle’s trunk) is exposed, and the right gastroepiploic vein is transected at the root, and then the dissection is continued along the surface of the pancre-

atic 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. 24.9).

3.2.3 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. 24.10). 3.2.4 D  issection 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

Cooperating skills: The assistant needs to lift the omentum with two atraumatic forceps, with the left hand in front and the right hand behind, forming a triangle stretch to maintain a certain tension, so as to facilitate the judgement of dissociating range and direction.

Fig. 24.8  The assistant’s cooperation on tensioning omentum by triangular stretch

Experience sharing: With the marker of middle colic artery, enter into the fusion fascia space between the gastroduodenum and transverse mesocolon.

Right Gastroepiploic Vein Middle Colic Artery

Right Colic Artery

Fig. 24.9  Treatment of the right gastroepiploic vein

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Experience sharing: When mobilizing the splenic flexure, be careful to separate the adhesion between the greater omentum and inferior spleen to avoid spleen rupture; use the tail of the pancreas as a marker to easily locate and track the left gastroepiploic vein.

Fig. 24.10  Root of the left gastroepiploic vein

3.3

 pecimen Resection and Digestive S Tract Reconstruction

3.3.1 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. 24.16); the resected specimen is placed in a specimen bag (Fig. 24.17).

Fig. 24.11  Dissection of group 11p lymph nodes along the splenic artery

(Fig. 24.11). 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. 24.12).

3.2.5 D  issection 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. 24.13). Then group 5 lymph nodes are dissected, and group 12a lymph nodes are further dissected along the proper hepatic artery (Fig. 24.14). 3.2.6 D  issection 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 the cardia (group 1 and 3 lymph nodes) (Fig. 24.15).

3.3.2 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 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 the stomach and jejunum is ligated with a 4-0 silk suture in an interrupted pattern (Figs. 24.18, 24.19, 24.20, 24.21, and 24.22). 3.3.3 R  oux-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 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. The blocking position of afferent loop is about 3 cm from the gastric jejunum anastomosis (Figs. 24.23, 24.24, and 24.25). 3.3.4 Transrectal Specimen Extraction After radical resection of 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

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Experience sharing: The initial segment of the splenic artery is relatively fixed, few anatomical variations existed, which is regarded as an entry point. The assistant should grasp and hold the plica gastropancreatica,then turn the stomach upwards to facilitate exposure.

Fig. 24.12  Isolation of the left gastric artery and common hepatic arteries, dissection of group 7, 8, and 9 lymph nodes

Fig. 24.13  Transection of duodenum with an Endo GIA stapler at 2 cm to the distal of pylorus

Experience Sharing: Transect the duodenum first to easily exposurethe right gastric artery and hepatoduodenal ligament, making lymphatic dissection easier.

Fig. 24.14  Transection of the right gastric artery at the root, dissection of group 5 and 12a lymph nodes

24  Laparoscopic Distal Gastrectomy (Billroth II) with Transrectal Specimen Extraction (GC-NOSES III)

Fig. 24.15  Dissection of group 1 and 3 lymph nodes

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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 length in the anterior wall of the upper rectum (Fig.  24.26). The protective sleeve is inserted into the rectum after disinfecting with dilute iodine solution (Figs. 24.27 and 24.28), and the specimen is removed from the anus through the protective sleeve (Figs.  24.29 and 24.30). Finally, the bowel wall is sutured in continuous or intermittent pattern (Figs. 24.31 and 24.32), and the pelvic cavity is irrigated repeatedly.

Experience sharing: Press the stapler for 15 seconds when closing it to shape the stomach wall better and reduce bleeding.

Fig. 24.16  Amputation of the stomach at 5 cm from the proximal end of tumor

Experience Sharing: Place the specimen in the specimen bag to ensure asepticand tumor-free operation.

Fig. 24.17  Placing the specimen in the specimen bag

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Experience sharing: 1. The opening length of gastric stump should be appropriate. Being too small will bring trouble inserting the Endo-GIA stapler, while being too large will increasethe difficulty of closing up. 2. Make sure to cut open the mucosal layer when opening the windowin gastric stump and avoid entering into the interlayer of gastric wall.

Fig. 24.18  Opening a window at the point of gastric stump and greater curvature

Operating skills: Flatten the antimesentericintestinal wall of the jejunum, cut the whole layer of the intestinal wall open with acautery hookand avoid injuring themesenteric intestinal wall.

Fig. 24.19  Measuring a 20 cm length of proximal jejunum from the Treitz ligament, a window opening in the antimesenteric intestinal wall

Experience sharing: Billroth II anastomosis is easy to operate, performing side-to-side anastomosis between the greater curvature and jejunum in an antecolic fashion.

Fig. 24.20  Antecolic side-to-side gastric jejunal anastomosis

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Experience sharing: When closing up the common opening, suture 3 stitches first to stretch the common opening and ensure the complete closing.

Fig. 24.21  Closing up the common opening of the stomach and jejunum with a linear Endo GIA stapler

Experience sharing: Check the quality of the anastomosis and reinforce the suture if necessary, there by reduce the risk of leakage of the anastomosis as much as possible, while avoiding anastomotic stenosis.

Fig. 24.22  Quality check of sutures

Operating skills: Before anastomosis, note that directions of the intestineand mesentery should not be twisted, and the cutting position should be located in the antimesenteric side, without any other tissue insertion. Proximal and distal jejunal openings should be aligned as much as possible, and the common opening should be minimized to facilitate closing up.

Fig. 24.23  Side-to-side anastomosis of proximal and distal jejunum

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Fig. 24.24 Intermittent sutures with 4-0 absorbable thread to close the common jejunal opening

Operating skills: The strength of knotting is appropriate when seeing the intestinal wall at the ligation site in white colour. It may be reopened if the knotting is too loose.

Fig. 24.25  Blocking the afferent loop at about 3 cm from the gastric jejunum anastomosis position of the gastric jejunum

Operation points: 1. Select the upper rectum for incision, as to be easily exposed and sutured. 2. Incision should be performed along the anterior wall of the rectum to avoid incision deflection and reduce the mucosal eversion after incision. 3. Fully cut open 5-6 cm along the long axis and avoid bowel wall tearing during removal.

Fig. 24.26  Cutting open the anterior wall of the upper rectum after repetitive disinfection of the bowel cavity

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Operation points: 1. Ensure the full intestinal preparation by preoperative fluid diet, oral cathartic agent, etc. During the operation, the perineum, rectal lumenand pelvic cavity should be disinfected with iodophor gauze and dilute iodophor solution multiple times, which conforms to the principle of aseptic operation. 2. After the specimen resection, put it in a sterile specimen bag, place a sterile protective sleeve through the natural cavity when removing the specimen, and fully ensure the sterile and tumorfree principle of the operation. 3. The protective sleeve should be long enough; the contact with the bowelwall and anus should be avoided for the specimen.

Fig. 24.27  Irrigation of pelvic cavity with dilute iodophor solution and normal saline

Operation points: Apply the dilute iodophor solution before putting into the protector as to fully lubricate and reduce the resistance when removing the specimen.

Fig. 24.28  Insertion of a protective sleeve

Operation points: Tension the protective sleeveand avoid the rectal wall tearing, which may cause difficulty in suture.

Fig. 24.29  Removing the specimen from the protective sleeve

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Operation points: During the process of specimen removal, keep the force uniform to prevent tearing the specimen.

Fig. 24.30  Anal appearance during specimen removal

Operation points: The stitch length and edge distance should both be 5 mm; apply two barbed threads to reinforce the sutures; reduce the risk of leakage of the anastomosis as much as possible.

Fig. 24.31  3-0 continuous sutures with barbed suture for rectum incision

Operation points: Ensure that sutures are tight byperforming air leak test or intraoperative colonoscopy. After the suture, repetitively irrigate the pelvic cavity to ensure asterileand tumor-free operation.

Fig. 24.32  Quality check of sutures, repetitive irrigation of the pelvic cavity

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3.4

Postoperative Specimens and Abdominal Wall Pictures (Figs. 24.33 and 24.34)

4

 ey Points, Difficulties, and Hotspots K Related to Surgery

4.1

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. Because it shortens the surgical incision and has a good prognostic effect and significant advantages, it has gained wide recognition and comprehensive promotion. The corresponding lapa-

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roscopic 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 combines laparoscopic technology with the NOTES concept. NOSES eliminates the auxiliary incision of the abdominal wall, which makes the advantages of laparoscopy more perfect. 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 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 equipments.

Fig. 24.33  Specimen picture

4.2

Fig. 24.34  Appearance of abdominal wall after operation

 alues and Disputes of Transrectal V Specimen Removal

1. Values ①The 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 occurs, the consequences are quite serious.

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

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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 fornix and the specimen extraction are performed in the lower abdomen. The patient’s position, 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 as follows: (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.

G. Yu (*) Department of General Surgery, Qilu Hospital of Shandong University (Qingdao), Qingdao, China e-mail: [email protected]

1

Indications and Contraindications of NOSES

1.1

Indications

1. Female patients. 2. Gastric cancer, stage cT1–3N0–1M0, with lesions in the distal part of the stomach. 3. The circumferential diameter of tumor is better ≤4 cm.

1.2

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.

2

 nesthesia, Patient Positioning, A Trocar Placement, and Surgical Team Position

2.1

Anesthesia Method

General anesthesia or general epidural anesthesia.

2.2

Patient Positioning

The patient should be placed in the horizontal supine position with leg abduction (Fig. 25.1), which will be changed to the functional lithotomy position (Fig. 25.2) when removing the specimen through the posterior vaginal fornix.

© People’s Medical Publishing House, PR of China 2021 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-15-7925-7_25

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2.3

Fig. 25.1  Horizontal supine position with leg abduction

Trocar Placement (Fig. 25.3)

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.

2.4

Surgical Team Position

2.4.1 A  bdominal 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. 25.4). 2.4.2 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. 25.5).

Fig. 25.2  Functional lithotomy position

Fig. 25.3  Trocar placement (five-port method)

Assitant’s Auxiliary Trocar 5 mm

Surgeon’s Main Trocar 12 mm

Assitant’s Main Trocar 12 mm

Surgeon’s Auxiliary Trocar 5 mm Camera Trocar10 mm

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Camera Holder Monitor Surgeon Assistant Scrub nurse Assistant Surgeon

Monitor Scrub Nurse

Fig. 25.6  Surgical team position

Camera Holder

Fig. 25.4  Surgical team position

3

Surgical Procedure, Techniques, and Key Points

3.1

Surgical Exploration

Monitor

Scrub Nurse Assistant

Surgeon

Assistant for Specimen Extraction

3.1.1 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. 25.8). 3.1.2 Tumor Exploration The tumor is located in the anterior wall of gastric antrum and does not invade beyond the serosal layer (Fig. 25.9).

Camera Holder

Fig. 25.5  Surgical team position

3.2

2.4.3 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.  25.6). In this step, the monitor should be placed on the side of the patient’s foot. The trocar function should be changed accordingly (Fig. 25.7).

3.2.1 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 the 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. 25.10).

2.5

Surgical Instruments

Ultrasonic scalpel, 60  mm linear Endo GIA stapler, 3-0 barbed suture, 4-0 absorbable suture, sterile protective sleeve.

Dissection and Separation

3.2.2 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

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Fig. 25.7  Changes in trocar function during specimen extraction

Assistant’s Auxiliary Trocar 5mm

Assistant’s Main Trocar 12mm

Camera Trocar 10mm

Surgeon’s Main Trocar 12mm Surgeon’s Auxiliary Trocar 5mm

Fig. 25.8  Exploration of the abdominal and pelvic cavity

Tumor

Fig. 25.9  Exploration of the tumor

Experience sharing: For patients with small tumor or early local stage, preoperative gastroscopic injection of carbon nanotubes or intraoperative gastroscopy can be performed to assist in localization.

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protection of the pancreatic tail. The left gastroepiploic artery and vein are exposed and transected at the root after they derived into the branch of the lower pole of spleen, and then station 4sb lymph nodes are dissected (Figs.  25.11, 25.12, and 25.13).

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3.2.3 Dissection of Station 6 Lymph Nodes With the guidance of the middle colic vessel, the fusion fascia space between the gastroduodenum and transverse mesocolon is entered, and the right gastroepiploic vein is transected (Figs.  25.14, 25.15, and 25.16). The dissection is continued

Operating skills:The assistant needs to lift the greater omentum with two atraumatic forceps, with two atraumatic forceps, with the left hand in front and the right behind, forming a triangle stretch to maintain a certain tension, so as to facilitate the judgement of dissecting extent and direction.

Fig. 25.10  Transection of the greater omentum and entry into the lesser omental sac

Operating skills: Pay attention to protect the branch ofleft gastroepiploic artery which suppliesthe lower pole of spleen, so as to prevent splenic ischemia.

Fig. 25.11  Dissection and isolation of the left gastroepiploic artery

Operating skills:The assistant holds the gastrosplenic ligament upwards with theforceps in the left hand, and holds the posterior gastric wall on the side of the greater curvature upwards to the right with the forceps in the right hand to expand the splenogastric ligament, so as to facilitate the transection. The operation should be gentle to avoid laceration of the splenic capsule.

Fig. 25.12  Transection of the left gastroepiploic artery at the root

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Operating skills: The dissection should beperformed from distal to proximal to the confluence at the left gastroepiploic artery. Attention should be paid to protect the short gastric vessels to prevent ischemia of the remnant stomach.

Fig. 25.13  Isolation of the greater curvature

Right Gastroepiploic Vein

Experience sharing:The fusion fascia space between the greater omentum and transverse mesocolon, which is an avascular space, is located anterior to the middle colic vein. The superior mesenteric vein and the Henle's trunk are exposed during the dissection along the surface of the vessel to the root of the transverse mesocolon and the inferior border of pancreas.

Fig. 25.14  Dissection along the fusion fascia space

Operating skills: Attention should be paid to the protection of the anterior superior pancreaticoduodenal vein and the perforating vessels that enter the head of pancreas to avoid bleeding.

Right Gastroepiploic Vein

Fig. 25.15  Isolation of the right gastroepiploic vein

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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. 25.17).

Right Gastroepiploic Vein

Fig. 25.16  Transection of the right gastroepiploic vein at the root

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3.2.4 Transection of the Duodenum (Fig. 25.18) 3.2.5 D  issection of Station 8a and 12a Lymph Nodes The surgeon then dissects along the superior border of the pancreas to expose the common hepatic artery. The pancreas is gently pushed to the lower left, and the station 8a lymph node is dissected along the anterior and superior border of the common hepatic artery (Fig. 25.19). 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 the 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

Experience sharing: Adequate dissection of the left and right sides of the subpyloric region along the fusion fascia space between the gastroduodenum and transverse mesocolon

Right Gastroepiploic Artery

facilitates the vascular management and lymphatic dissection.

Fig. 25.17  Isolation of the right gastroepiploic artery for the dissection of station 6 lymph nodes

Operating skills: The dissected length of duodenum should be sufficient to ensure the safety of the distal resection margin. Keep the linear Endo-GIA stapler perpendicular to the duodenum, and the assistant performs lifting and retracting at moderate tension to avoid tissue retraction after closure due to excessive tension, which increases the risk of stump leakage.

Fig. 25.18  Transection of duodenum

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vein has a large diameter (Figs. 25.20 and 25.21). The duodenum should be transected first to facilitate the exposure of the right gastric artery and hepatoduodenal ligament; therefore the lymph node can be dissected easier (Figs. 25.22 and 25.23). The assistant pulls the common hepatic artery downward 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. 25.24). The root of the right gastric vascular is ligated and transected.

3.2.6 D  issection of Station 11p, 7, and 9 Lymph Nodes The pancreatic capsule is opened to perform dissection along the superior border of the 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 station 7 and 9 lymph nodes are dissected (Figs. 25.25, 25.26, and 25.27). 3.2.7 D  issection 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. 25.28), and dissect the lymph nodes in lesser curvature and the right side of the cardia (station 1 and 3 lymph nodes) (Figs. 25.29, 25.30, and 25.31).

3.3

Common Hepatic Artery

Fig. 25.19  Dissection of station 8a lymph nodes

 pecimen Resection and Digestive S Tract Reconstruction

3.3.1 Specimen Resection (Figs. 25.32 and 25.33) 3.3.2 Billroth II Anastomosis Windows are opened in the antimesenteric side of the jejunum 15–20 cm from the ligament of Treitz (Fig. 25.34) and

Right Gastric Artery

Right Gastric Vein

Gastroduodenal Artery

Common Hepatic Artery

Fig. 25.20  Isolation of the right gastric vein Fig. 25.22  Isolation of the right gastric artery

Fig. 25.21  Transection of the right gastric vein at the root

Fig. 25.23  Transection of the right gastric artery at the root

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Proper Hepatic Artery

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Experience sharing: The significance of separating the space anterior to portal vein lymph nodes dissection along the proper hepatic artery, which facilitates to improve the safety of operation.

Portal Vein

Fig. 25.24  Dissection of station 12a lymph nodes

Operating skills: The assistant should pull the plica gastropancreatica with the left hand and make precise adjustment for better exposure with the right hand. The surgeon dissects the pancreatic capsule along the pre-pancreatic space, search for the left gastric vein and perform the ligation and transection.

Fig. 25.25  Isolation of the left gastric vein

Experience sharing: The initial segment of the splenic artery is relatively fixed, few anatomical variations exist, which is regarded as an entry point. The assistant should grasp and hold the plica gastropancreatica, then turn the stomach upwards to facilitate exposure.

Fig. 25.26  Isolation of the left gastric artery for the dissection of station 7 lymph nodes

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Operating skills: Continue to expand cephalad in the pre-pancreatic space, expose the celiac trunk and left gastric artery, ligate and transect the root of the left gastric artery to complete the dissection of stations 7 and 9 lymph nodes.

Fig. 25.27  Dissection of station 9 and 11p lymph nodes

Fig. 25.30  After dissection of the superior border of the pancreas Fig 25.28  Open the lesser curvature hierarchically with the ultrasonic scalpel

Portal Vein

Inferior Vena Cava

Fig. 25.29  Dissection of station 1 and 3 lymph nodes in the lesser curvature

Fig. 25.31  After dissection of the hepatoduodenal ligament

at the point of gastric stump and greater curvature (Fig. 25.35). 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.  25.36). 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. 25.37).

3.3.3 R  oux-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

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Operating skills: Stomach is transected at 5 cm from the proximal end of the tumor. Press the stapler for 15 seconds when closing it to shape the stomach wall better and reduce bleeding.

Fig. 25.32  Transection of the stomach at 5 cm from the proximal end of tumor

Operating skills: The tumor-free principle should be strictly followed. After placing the specimen in the self-made specimen bag, the opening of the bag is closed and temporarily placed in the left lower abdomen.

Fig. 25.33  Placing the resected specimen in the specimen bag

Operating skills: Flatten the antimesenteric intestinal wall of the jejunum, cut the whole layer of the intestinal wall open with a cautery hook.

Fig. 25.34  Opening a window in the antimesenteric side of the jejunum

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Experience sharing: The opening length of gastric stump should be appropriate. Being too small will bring trouble inserting the Endo- GIA stapler, while being too large will increase the difficulty of closing up.

Fig. 25.35  Opening the window at the point of gastric stump and greater curvature

Experience sharing: Billroth II anastomosis is easy to operate, performing the side-to-side anastomosis between the greater curvature and jejunum in an antecolic fashion.

Fig. 25.36  Side-to-side gastric jejunal anastomosis

Operating skills: The common opening is sutured with full-thickness suture in an intermittent pattern, the stitch length is 3 mm and the edge distance is 5 mm. Care should be taken not to miss stitch at both ends of the common opening.

Fig. 25.37  Closure of the common opening with intermittent suture

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from the ligament of Treitz and 40–45 cm from the gastric jejunal anastomosis (Figs.  25.38 and 25.39). The blocking position of afferent loop is about 3 cm from the anastomosis position of gastric jejunum (Fig. 25.40).

3.3.4 Transvaginal Specimen Extraction The vagina is disinfected repeatedly. After the uterus is suspended (Fig.  25.41), the posterior vaginal fornix is withstood with an abdominal spatula (Fig.  25.42) 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. 25.43). A protective sleeve is introduced through the main trocar and inserted into the vagina through the incision (Fig. 25.44). The specimen is held by the oval forceps and extracted along the long axis of stomach (Figs.  25.45, 25.46, and 25.47). The abdominal cavity is irrigated repeatedly with distilled water, dilute iodine solution, and saline solution (Fig. 25.48). The incision of the posterior vaginal fornix is closed by continuous suture with 3-0 barbed suture (Fig. 25.49).

3.4

 ostoperative Abdominal P Wall and Specimen Display (Figs. 25.50, 25.51, 25.52)

4

 ey Points, Difficulties, and Hotspots K Related to Surgery

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. The key techniques and difficulties involve four aspects:

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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 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 needs to be changed and the operation time needs 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. Transvaginal NOSES has the common advantage of NOSES, which elimi-

Fig. 25.39  4-0 intermittent suture with 4-0 absorbable suture to close the common opening of jejunum

Operating skills:Before anastomosis,note that directions of the intestine and mesentery should not be twisted, and the cutting position should be located in the antimesenteric side, without any other tissue insertion.

Fig. 25.38  Side-to-side anastomosis of proximal and distal jejunum

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Operating skills: The strength of knotting is appropriate when seeing the intestinal wall at the ligation site in white color. It may be reopened if the knotting is too loose.

Fig. 25.40  Ligation for blocking the afferent loop at about 3 cm from the anastomosis position of gastric jejunum

Fig. 25.41  Suspension of the uterus

Fig. 25.42  Posterior vaginal fornix is withstood with the abdominal spatula after repeated disinfection of the vagina

Fig. 25.43  Opening the posterior vaginal fornix with the incision not exceeding the bilateral sacral ligaments

nates 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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Experience sharing: Apply the dilute iodine solution in the protective sleeve to fully lubricate and reduce the resistance when removing the specimen. The length should be sufficient to prevent the specimen from touching the vaginal incision or vulva.

Fig. 25.44  Placement of protective sleeve

Experience sharing: Tightening the protective sleeve, holding the gastric wall distal to the tumor, and pulling the specimen along the long axis of stomach facilitate the removal of the specimen.

Fig. 25.45  The gastric stump is held by the oval forceps and extracted along the long axis of the stomach

Experience sharing: If it is difficult to take out the specimen, the method of anal dilation can be adopted to dilate the incisionmoderately. The operation of specimen extraction should be performed gently to avoid the specimen rupture caused by rough operation.

Fig. 25.46  Transvaginal extraction of specimen

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Experience sharing: Strict aseptic and tumor-free principles should be followed during operation. The specimen bag should be extracted through the protective sleeve.

Fig. 25.47  Extraction of specimen bag

Operating skills: Irrigation should be repeatedly performed with distilled water, dilute iodine solution, and saline solution. Strict aseptic and tumor-free principles should be followed.

Fig. 25.48  Repeated irrigation with distilled water, dilute iodine solution, and saline solution

Fig. 25.49  Incision of the posterior vaginal fornix closed by continuous suture with 3-0 barbed suture

Fig. 25.50  Specimen resection

25  Laparoscopic Distal Gastrectomy (Billroth II) with Transvaginal Specimen Extraction (GC-NOSES IV)

Fig. 25.51  Open the gastric wall for specimen observation

Fig. 25.52  Postoperative abdominal wall recovery

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Laparoscopic Proximal Gastrectomy with Transrectal Specimen Extraction (GC-NOSES V)

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Proximal gastrectomy is a standard procedure for early gastric cancer or benign lesions in the upper stomach. Proximal gastrectomy with transrectal 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 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.

1

Indications and Contraindications of NOSES

1.1

Indications

1 . Upper gastric cancer, stage cT1–2N0M0. 2. The circumferential diameter of tumor is better ≤4 cm.

G. Yu (*) Department of General Surgery, Qilu Hospital of Shandong University (Qingdao), Qingdao, China e-mail: [email protected]

1.2

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.

2

 nesthesia, Patient Positioning, A Trocar Placement, and Surgical Team Position

2.1

Anesthesia Method

General anesthesia or general epidural anesthesia.

2.2

Patient Positioning

The patient should be placed in the horizontal supine position with leg abduction (Fig. 26.1), which will be changed to the functional lithotomy position (Fig. 26.2) when removing the specimen by opening the rectum.

2.3

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. 4. The assistant’s auxiliary trocar (5 mm trocar) is located under the costal margin of the right anterior axillary line.

© People’s Medical Publishing House, PR of China 2021 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-15-7925-7_26

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5. The assistant’s main trocar (12 mm trocar) is located at the umbilical level of the right midclavicular line (Fig. 26.3).

2.4

Surgical Team Position

2.4.1 A  bdominal 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. 26.4).

Fig. 26.1  Horizontal supine position with leg abduction Monitor

Scrub nurse Assistant Surgeon

Camera Holder

Fig. 26.4  Surgical team position

Fig. 26.2  Functional lithotomy position

Fig. 26.3  Trocar placement (five-port method)

Assistant’s Auxiliary Trocar 5 mm

Surgeon’s MainTrocar 12 mm

Assistant’s Main Trocar 12 mm

Surgeon’s Auxiliary Trocar 5 mm Camera Trocar 10 mm

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2.4.2 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. 26.5).

3

Surgical Procedure, Techniques, and Key Points

3.1

Exploration and Surgical Planning

2.4.3 Transrectal 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.  26.6). In this step, the monitor should be placed on the side of the patient’s foot.

3.1.1 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. 26.7).

2.5

3.2

Surgical Instruments

Ultrasonic scalpel, 60  mm linear Endo GIA stapler, 3-0 barbed suture, 4-0 absorbable suture, sterile protective sleeve.

Dissection and Separation

3.2.1 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

Monitor Camera Holder

Surgeon Assistant

Scrub Nurse Assistant

Surgeon

Monitor Scrub Nurse

Assistant for Specimen Extraction

Camera Holder

Fig. 26.6  Surgical team position Fig. 26.5  Surgical team position

Operating skills: Observe carefully to avoid missed identification of lesions.

Fig. 26.7  Exploration of the abdominal and pelvic cavity

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entered, and the incision is extended to the hepatic flexure of the 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. 26.8 and 26.9).

3.2.2 Dissection of the Gastrosplenic Ligament The greater omentum is transected from the middle of the colon to the splenic flexure. The left gastroepiploic artery

G. Yu

and vein are transected at the root, and station 4sb lymph nodes are dissected. The patient is placed in the right-leaning anti-Trendelenburg 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.  26.10, 26.11, 26.12, 26.13, 26.14, 26.15, and 26.16).

Operating skills: The assistant cooperates with the surgeon to form a triangle stretch to maintain enough tension to facilitate tissue dissection. Damage to the colon and mesentery should be avoided.

Fig. 26.8  Entering the lesser omental bursa

Operating skills: Accurately identify the space to avoid damage to the blood supply of the transverse colon.

Fig. 26.9  Dissect to the right for the dissection of the greater omentum to the hepatic flexure

Operating skills: Taking the tail of the pancreas as a marker to locate the left gastroepiploic vessel.

Fig. 26.10  Isolation of the left gastroepiploic vein

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Operating skills: Dissect the left gastroepiploic vessel branch to the lower pole of spleen.

Fig. 26.11  Transection of the left gastroepiploic vein Fig. 26.12  Ligation of the left gastroepiploic artery

Operation points: The suture can be performed with two barbed sutures in a continuous pattern to double reinforce the rectal incision to ensure tight suture.

Fig. 26.13  Transection of the left gastroepiploic artery Fig. 26.14  Ligation of the short gastric artery

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Operating skills: Place the dissected greater omentum in the right abdomen and pull the splenogastric ligament to the right with atraumatic forceps. Be careful not to damage the spleen.

Fig. 26.15  Transection of the short gastric artery

3.2.4 D  issection of Station 7, 8a, 9, and 11p Lymph Nodes The left gastric vein and artery are identified, isolated, and transected at the origin (Figs. 26.18 and 26.19). Station 7, 9, and 11p lymph nodes are dissected (Fig. 26.20). Afterward, the surgeon then performs dissection along the splenic artery to remove station 11d lymph nodes (Fig. 26.21) and then performs dissection along the common hepatic artery and the proper hepatic artery to remove station 8 and 12a lymph nodes (Fig. 26.22).

Fig. 26.16  Dissection of station 4sa lymph nodes

3.2.5 D  issection of Station 1 and 2 Lymph Nodes and Isolation of Esophagus Dissection is continued to the left side of the cardia. After the anterior and posterior vagal trunk are transected, the lower esophagus is isolated from surrounding tissues. Traction stitch is sutured in the esophagus proximal to the tumor to pull the esophagus downward. The surgeon then continues to dissect the esophagus upward adequately, until the length of isolated esophagus is enough to obtain enough resection margin and to meet the need of anastomosis (Figs. 26.23 and 26.24).

3.3

Fig. 26.17  Protection of the right gastroepiploic vessel

3.2.3 C  are 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. 26.17).

 pecimen Resection and Digestive S Tract Reconstruction

3.3.1 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. 26.25, 26.26, and 26.27). 3.3.2 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

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Operating skills: Since the left gastric vein has many variations, care should be taken to avoid bleeding.

Fig. 26.18  Isolation and dissection of the left gastric vein and transection at the root

Fig. 26.19  Isolation and dissection of the left gastric artery

Operating skills: The sheath of left gastric artery is circumferentially opened, and station 7 lymph nodes are thoroughly dissected.

Fig. 26.20  Transection of the left gastric artery at the root and dissection of station 7, 9, and 11p lymph nodes

applied to open the middle of the esophageal stump. 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. 26.28, 26.29, 26.30, and 26.31).

3.3.3 Transrectal Specimen Extraction After radical resection of the gastric cancer and the digestive tract reconstruction, the patient is placed in the functional

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Operating skills: The proximal end of the splenic artery trunk can be easily identified by dissecting along the superior border of pancreas.

Fig. 26.21  Dissection of station 11d lymph nodes along the splenic artery

Operating skills: Exposing the anterior wall of portal vein clearly facilitates to reduce the damage and bleeding.

Fig. 26.22  Dissection of station 8 and 12a lymph nodes along the common hepatic artery and the proper hepatic artery

Operating skills: Most of the accessory left hepatic artery originate from the left gastric artery. Transection of the accessory left hepatic artery has little effect on the blood supply of the liver.

Fig. 26.23  Transection of the accessory left hepatic artery and dissection of station 3 lymph nodes

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Operating skills: Adequate dissection of esophagus facilitates gastroesophageal anastomosis and ensures the safety of proximal resection margin.

Fig. 26.24  Proximally dissection of the esophagus

Operating skills: Select a 45 mm cartridge and keep the direction of transection perpendicular to the longitudinal axis of the esophagus.

Fig. 26.25  Transection of esophagus at 2 cm above the esophagogastric junction

Operating skills: Adjust the direction of transection of the gastric wall according to the tumor location to ensure the safety of the distal resection margin.

Fig. 26.26  Transection of the stomach at 5 cm from the distal end of tumor

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Operating skills: The specimen is placed in the specimen bag with the stump of the stomach close to the opening of the bag. The specimen is placed in the left lower abdomen, which facilitates the operation of specimen extraction and shortens the operation time.

Fig. 26.27  Placing the specimen in the specimen bag

Experience sharing: Traction stitches are sutured in both sides of the esophageal stump, so as to facilitate the closing of the common opening.

Fig. 26.28  Suture of the gastric wall with the esophageal wall

Experience sharing: The use of 45 mm cartridge facilitates the alignment of the esophageal and the remnant gastric openings, reduces the common opening and facilitates closure.

Fig. 26.29  Anastomosis between the posterior wall of the esophagus and the anterior wall of the remnant stomach (overlap method)

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Experience sharing: The gastric tube can be used as indication to prevent the insertion of the linear Endo-GIA stapler into the interlayer of esophageal wall.

Fig. 26.30  Placement of gastric tube

Experience sharing: Barbed suture can play a role in the traction and fixation of esophageal stump. It can also ensure the quality of suture and shorten the operation time. Double barbed suture is used for the reinforcement of suture.

Fig. 26.31  Common opening of gastroesophageal anastomosis closed by continuous suture with 3-0 barbed suture

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 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. 26.32). The protective sleeve is inserted into the rectum after disinfecting with dilute iodine solution (Figs. 26.33 and Fig  26.34), whereafter the specimen is removed from the anus through the protective sleeve (Figs. 26.35 and 26.36). Finally, the bowel wall is sutured in continuous or intermittent pattern, and the pelvic cavity is irrigated repeatedly (Figs. 26.37 and 26.38).

3.4

Postoperative Abdominal Wall and Specimen Pictures (Figs. 26.39 and 26.40)

4

 ey Points, Difficulties, and Hotspots K 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. 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

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Operation points: 1. Make the incision in the upper rectum, so as to be easily exposed and sutured. 2. Incision should be made along the anterior wall of the rectum to avoid incision deflection and reduce the mucosal eversion after incision. 3. Adequately open 5-6 cm along the long axis. The length of incision should be appropriate, too short of incision may cause bowel wall laceration during the extraction, while too long of incision will increase the difficulty in suture and operation time. 4. At this time, the assistant's main operation is keeping the rectum straight by maintaining tension, and providing appropriate exposure of the surgical field.

Fig. 26.32  Cutting open the anterior wall of the upper rectum after disinfection of the bowel cavity

Operation points: Repeatedly irrigate the pelvic cavity with dilute iodine solution and normal saline to ensure an aseptic and tumor-free operation.

Fig. 26.33  Repeated irrigation of pelvic cavity with dilute iodine solution and normal saline

Operation points: The protective sleeve can also be inserted through the 12 mm trocar and extracted from the abdominal cavity through the anus.

Fig. 26.34  Insertion of sterile protective sleeve

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increased risk of intraperitoneal infection, tumor implantation, and spreading. Moreover, the possibility of serious complications such as intestinal leakage, rectal stenosis, and abnormal bowel function, etc. also exists. We believe that adequate preoperative bowel preparation, adequate anal dilation, gentle specimen extraction, precise suturing of the incision on bowel wall, and ensuring of aseptic and tumor-free operation are effective measures to prevent complications of transrectal NOSES.  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. Fig. 26.35  Transrectal specimen extraction (intraperitoneal picture)

Operation points: The transrectalanal specimen extraction should be performed gently to avoid laceration of the specimen.

Fig. 26.36  Transrectal specimen extraction (extracorporeal picture)

Operation points: The suture can be performed with two barbed sutures in a continuous pattern to double reinforce the rectal incision to ensure tight suture.

Fig 26.37  Continuous suture of rectal incision with barbed suture

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Fig. 26.38  Inspection of the quality of the rectal suture and repeated irrigation

Fig. 26.39  Appearance of abdominal wall after operation

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Fig. 26.40  Specimen picture

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

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Gang Yu

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 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.

1

Indications and Contraindications of NOSES

1.1

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.

1.2

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.

2

 nesthesia, Patient Positioning, A Trocar Placement, and Surgical Team Position

2.1

Anesthesia Method

General anesthesia or general epidural anesthesia.

2.2

G. Yu (*) Department of General Surgery, Qilu Hospital of Shandong University (Qingdao), Qingdao, China e-mail: [email protected]

Patient Positioning

The patient should be placed in the horizontal supine position with leg 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.

© People’s Medical Publishing House, PR of China 2021 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-15-7925-7_27

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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 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. 27.3).

2.4

Surgical Team Position

2.4.1 A  bdominal 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).

Fig. 27.1  Horizontal supine position with leg abduction

2.4.2 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). 2.4.3 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).

2.5

Surgical Instruments

Ultrasonic scalpel, 60 mm linear Endo GIA stapler, 3-0 barbed suture, 4-0 absorbable suture, sterile protective sleeve.

Fig. 27.2  Functional lithotomy position Fig. 27.3  Trocar sites (five-port method)

Assistant’s Auxiliary Trocar 5 mm

Surgeon’s Main Trocar 12 mm

Assistant’s Main Trocar 12 mm

Surgeon’s Auxiliary Trocar 5 mm Camera Trocar 10 mm

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Camera Holder Monitor Surgeon Assistant Scrub nurse Assistant Surgeon

Monitor Scrub Nurse

Assistant for Specimen Extraction

Fig. 27.6  Surgical team position Camera Holder

Fig. 27.4  Surgical team position Surgeon’s Auxiliary Trocar 5mm

Monitor

Surgeon’s Main Trocar 12mm

Camera Trocar 12mm Assistant’s Main Trocar 12mm

Scrub Nurse Assistant

Surgeon

Fig. 27.7  Changes in trocar function during specimen extraction

Camera Holder

Fig. 27.5  Surgical team position

3

Surgical Procedure, Techniques, and Key Points

3.1

 eneral Exploration and Surgical G 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. 27.8 and 27.9).

Fig. 27.8  Routine exploration

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Dissection and Separation

3.2.1 S  uspension of Liver, 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. 27.10 and 27.11).

Fig. 27.9  Routine exploration

3.2.2 D  issection 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 the colon on the right side. Dissection is performed along the posterior region of the anterior lobe of the transverse mesocolon. Afterward, the anterior lobe of the transverse mesocolon is resected, and attention should be paid to the preservation of the right gastroepiploic vessel (Fig. 27.12). 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 the 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 spleen, and station 4sa lymph nodes are dissected (Figs. 27.13, 27.14, and 27.15). 3.2.3 D  issection of Station 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 (Fig. 27.16). The celiac trunk is exposed, and the left gastric artery and vein are dissected and transected after being ligated at the root. Station 7 and 9 lymph nodes are dissected, whereafter the

Experience sharing: Suspension of the left lobe of liver facilitates the exposure of surgical field and frees the left hand of the assistant. Coating the purse-string suture with the silicone tube can avoid cutting the liver.

Fig. 27.10  Suspension of the liver

Experience sharing: Dissecting the space between the right side of the cardia and the right diaphragmatic crus can increase the mobilization of the cardia, which facilitates the dissection of lymph nodes at the superior border of pancreas.

Fig. 27.11  Dissecting the space between the right side of the cardia and the right diaphragmatic crus

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Experience sharing: The right gastroepiploic vessel is the only blood supply to the remnant stomach. It should be carefully dissected to avoid accidental damage.

Fig. 27.12  Preservation of the right gastroepiploic vessel

Left Gastroepiploic Vessel

Fig. 27.13  Tracking the origin of the left gastroepiploic vessel along the pancreatic tail

Fig. 27.14  Dissection of station 4sb lymph nodes

Operating skills: Expose the short gastric vessels and ligate them at the root.

Fig. 27.15  Dissection of station 4sa lymph nodes

dissection is continued along the common hepatic artery for the excision of station 8a lymph nodes (Figs. 27.17, 27.18, and 27.19). Station 11d lymph nodes are further dissected along the splenic artery. Whether to dissect station 10 lymph nodes depends on the tumor location and the sizes of the lymph nodes (Fig. 27.20).

3.2.4 D  issection of Station 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

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Operating skills: The splenic artery is exposed along the superior border of pancreas, and stations 11p and 11d 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.

Fig. 27.16  Exposure of the proximal splenic artery along the superior border of pancreas

Experience sharing: Since the left gastric vein has many variations, it is necessary to distinguish the relationship between the left gastric vein and common hepatic artery and splenic artery during operation.

Fig. 27.17  Dissection of the left gastric vein

Experience sharing: Open the sheath of artery during the dissection of the left gastric artery to facilitate the identification of the course of the blood vessels.

Fig. 27.18  Dissection of station 7 and 9 lymph nodes

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 downward as much as possible. The esophagus should be adequately dissected upward in the posterior mediastinum to ensure that there is enough resection margin (Figs. 27.21 and 27.22).

3.3

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. After esophageal dissection is completed,

27  Laparoscopic Proximal Gastrectomy with Transvaginal Specimen Extraction (GC-NOSES VI)

Fig. 27.19  Effects of lymph node dissection at the superior border of pancreas

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Fig. 27.20  Splenic hilar dissection

Operating skills: Adequate dissection of esophagus facilitates gastroesophageal anastomosis.

Fig. 27.21  Dissection of the left side of esophagus

Operating skills: The diaphragm can be opened for 4-5 cm from the fornix of the esophageal diaphragmatic hiatus anteriorly when the tumor invades the esophagus. The esophagus is adequately dissected upwards in the posterior mediastinum to ensure that there is enough resection margin.

Fig. 27.22  Transection of the anterior and posterior gastric vagal nerves

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the esophagus is transected with a linear Endo GIA stapler (Fig. 27.23). The resected specimen is placed in a specimen bag (Figs. 27.24 and 27.25).

the stapler is fired to complete the side-to-side esophagojejunal anastomosis (Figs.  27.26, 27.27, and 27.28). The remaining opening is sutured with 3-0 barbed suture (Fig. 27.29).

3.4

3.4.2 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. 27.30). 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. 27.31).

Digestive Tract Reconstruction

3.4.1 D  igestive 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

Experience sharing: Intraoperative gastroscopy can be performed for locating the proximal end of tumor, which can be marked with titanium clip to ensure that there is enough proximal resection margin.

Fig. 27.23  Transection of the esophagus at 3 cm from the proximal end of tumor

Operating skills: Stomach is transected at 5 cm from the distal end of the tumor. Press the stapler for 15 seconds when closing it to shape the stomach wall better and reduce bleeding.

Fig. 27.24  Transection of the stomach at 5 cm from the distal end of tumor

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Operating skills: The tumor-free principle should be strictly followed. After placing the specimen in the self-made specimen bag, the opening of the bag is closed and temporarily placed in the left lower abdomen to facilitate the operation during specimen extraction.

Fig. 27.25  Placing the specimen in the specimen bag and temporarily placing it in the left lower abdomen

Experience sharing: Pull the esophageal stump downwards with the traction stitch to avoid stump retraction and ensure the quality of anastomosis.

Fig. 27.26  Opening of the esophageal stump

Experience sharing: Adequate dissection of the esophagus is the key to reduce the tension of anastomosis.

Fig. 27.27  Anastomosis between the posterior wall of the esophagus and the anterior wall of the remnant stomach

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Experience sharing: Suturing under the support of the gastric tube can avoid accidental suture of the posterior wall, ensure the quality of suture, and reduce anastomotic stenosis.

Fig. 27.28  Placement of gastric tube

Experience sharing: Barbed suture can ensure the quality of suture and shorten the operation time. Double barbed suture is used for the reinforcement of suture.

Fig. 27.29  Remaining opening sutured in a continuous pattern with 3-0 barbed suture

Experience sharing: The posterior wall of the esophagus and the anterior wall of the remnant stomach are sutured with 3 stitches, and the esophagus is sutured before being transected. Note that the distance between the insertion point and the intended resection point should be no less than 5 mm to leave room for anastomosis.

Fig. 27.30  The posterior wall of the esophagus and the anterior wall of the remnant stomach are sutured with three stitches

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3.5

Transvaginal Specimen Extraction

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 placing the patient in the right-leaning Trendelenburg position, the surgeon should suspend the uterus to expose the posterior vaginal

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fornix (Fig.  27.32). 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. 27.33, 27.34, and 27.35) to remove the specimen from it (Figs. 27.36, 27.37, and 27.38). Finally, the posterior vaginal fornix is continuously sutured, and irrigation of the pelvic cavity is performed repeatedly (Figs. 27.39, 27.40, 27.41, and 27.42).

Experience sharing: Reinforcement suture is generally adopted to ensure a tight suture.

Fig. 27.31  Remaining opening sutured in an intermittent pattern with 3-0 absorbable suture

Experience sharing: Purse-string suture is applied for the suturing of uterine corpus or adnexa.

Fig. 27.32  Suspension of uterus

Experience sharing: Strict aseptic and tumor-free principles should be followed. Perineal skin preparation and vaginal lavage should be performed preoperatively. Repeated disinfection with dilute iodine solution should be performed during operation.

Fig. 27.33  Posterior vaginal fornix is withstood with the abdominal spatula after repeated disinfection of vagina

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Experience sharing: The power of electrocoagulation should be moderate to avoid damage to bilateral ligaments.

Fig. 27.34  Open the posterior vaginal fornix with monopolar electrocoagulation

Experience sharing: The length of the protective sleeve should be sufficient to prevent the specimen from touching the posterior vaginal fornix incision or vulva.

Fig. 27.35  Insertion of protective sleeve through the main trocar

Fig. 27.36  Extraction of specimen and specimen bag

Experience sharing: The operation of specimen extraction should be performed gently to avoid the specimen rupture caused by rough operation.

Fig. 27.37  Transvaginal extraction of specimen

27  Laparoscopic Proximal Gastrectomy with Transvaginal Specimen Extraction (GC-NOSES VI)

Experience sharing: Strict aseptic and tumor-free principles should be followed during operation. The specimen bag should be extracted through the protective sleeve.

Fig. 27.38  Extraction of specimen bag Fig. 27.39  Repeated irrigation with dilute iodine solution

Operating skills: Irrigation should be repeatedly performed with distilled water, dilute iodine solution, and saline solution. Strict aseptic and tumor-free principles should be followed.

Fig. 27.40  Repeated irrigation with normal saline

Fig. 27.41  Incision of the posterior vaginal fornix closed by continuous suture with 3-0 barbed suture

Fig. 27.42  Quality check of sutures

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Fig. 27.43  Specimen display

Fig. 27.44  Appearance of abdominal wall after operation

3.6

Postoperative Abdominal Wall and Specimen Display (Figs. 27.43 and 27.44)

 ey Points, Difficulties, and Hotspots K Related to Surgery

1. 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. Station 1, 2, 3, 4sa, 4sb, 7, 8a, 9, and 11p lymph nodes should be routinely dissected in D1 + 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. 2. 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. 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. 3. 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. The patient’s position, the placement of laparoscope, and the monitor should be changed during the operation. Operating in the lower abdomen through the trocars placed for upper abdominal operation without placing extra trocars increases the difficulty of operation. The surgeon should closely cooperate with the assistant to overcome the difficulty. 4. 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 for gynecological operation and specimen extraction. 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.

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

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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 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, and preserving the structure and function of the abdominal wall, thereby reducing the influence on patients’ quality of life.

1  Indications and Contraindications of NOSES 1.1  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.

G. Yu (*) Department of General Surgery, Qilu Hospital of Shandong University (Qingdao), Qingdao, China e-mail: [email protected]

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.

1.2  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.

2  A  nesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position 2.1  Anesthesia Method General anesthesia or general epidural anesthesia.

2.2  Patient Positioning The patient should be placed in the horizontal supine position with leg abduction for gastric cancer resection and digestive tract reconstruction operation (Fig.  28.1), which will be changed to the functional lithotomy position (Fig. 28.2) when removing the specimen through the anus.

2.3  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.

© People’s Medical Publishing House, PR of China 2021 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-15-7925-7_28

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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. 28.3).

2.4  Surgical Team Position 2.4.1 A  bdominal 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). Fig. 28.1  The patient’s position during gastric cancer resection and digestive tract reconstruction

2.4.2 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). 2.4.3 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). The monitor should be placed on the side of the patient’s foot. At the same time, the function of trocars is changed (Fig. 28.7).

2.5  Surgical Instruments

Fig. 28.2  The patient’s position during specimen extraction

Ultrasonic scalpel, 60  mm linear Endo GIA stapler, sterile protective sleeve.

Fig. 28.3  Trocar placement (five-port method)

Assistant’s Auxiliary Trocar 5 mm

Surgeon’s Main Trocar 12 mm

Assistant’s Main Trocar 12 mm

Surgeon’s Auxiliary Trocar 5 mm Camera Trocar 10 mm

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Camera Holder Monitor Surgeon Assistant Scrub Nurse Assistant Surgeon

Monitor Scrub Nurse

Assistant for Specimen Extraction

Fig. 28.6  Surgical team position during specimen extraction Camera Holder

Fig. 28.4  Surgical team position

Surgeon’s Auxiliary Trocar 5 mm

Monitor

Surgeon’s Main Trocar 12 mm

Camera Trocar 12 mm Assistant’s Main Trocar 12 mm

Scrub Nurse Assistant

Surgeon

Fig. 28.7  Function of trocars during specimen extraction

Camera Holder

Fig. 28.5  Surgical team position

3  S  urgical Procedure, Techniques, and Key Points 3.1  S  urgical Exploration and Surgical Planning 3.1.1 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. 28.8 and 28.9). Pay attention to explore the surface of liver for metastatic lesions (Fig. 28.10), and assess the condition of the primary

Fig. 28.8  Exploration of the diaphragm

tumor and the enlargement of the surrounding lymph nodes. If necessary, the position may be adjusted for thorough exploration.

3.1.2 Tumor Exploration Gastric body tumors should not invade beyond the serosa (Fig. 28.11).

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Experience sharing: A thorough and careful exploration facilitates the precise staging of tumor and the development of an appropriate surgical plan.

Fig. 28.9  Exploration of the pelvic cavity and bowel

3.2  Dissection and Separation

Fig. 28.10  Exploration of the liver

3.2.1 D  issection 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 the 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. 28.12).

Experience sharing: If the location of the tumor can not be determined from the serosal side, intraoperative gastroscopy can be applied for precise localization of the tumor as well as the proximal and distal resection margin. It is important for surgeons to master the technique of gastroscopy.

Fig. 28.11  Exploration of the tumor

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Experience sharing: The assistant grasps the greater omentum to maintain some tension, which facilitates the dissection of the greater omentum and avoids damage to colic vessels.

Fig. 28.12  The assistant’s cooperation on tensioning omentum by triangular stretch

Experience sharing: Dissection along the fusion fascia facilitates complete resection of mesogastrium, complete lymph node dissection, and less bleeding. The anterior superior pancreaticoduodenal vein is exposed, and the right gastroepiploic vein is transected above the junction between the anterior superior pancreaticoduodenal vein and the right gastroepiploic vein.

Fig. 28.13  Dissection along the fusion fascia space

3.2.2 Perigastric Lymphadenectomy (1) Dissection of the station 6 lymph nodes: The gastric antrum is lifted upward. The gastrocolic trunk (Henle’s trunk) is exposed, and the right gastroepiploic vein is transected at the root (Figs. 28.13 and 28.14). 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. 28.15).

(2) Dissection of station 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 the spleen is detached (Fig. 28.16). The pancreatic tail is protected, and the root is exposed. The left gastroepiploic artery and vein are transected (Fig. 28.17), station 4sb lymph nodes are dissected, and splenic hilar lymph nodes are further dissected (Fig. 28.18).

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Fig. 28.14  Dissection, ligation, and transection of the right gastroepiploic vein

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Fig. 28.15  Dissection, ligation, and transection of the right gastroepiploic artery

Experience sharing: When mobilizing the splenic flexure, the adhesion between the greater omentum and the lower pole of spleen should be carefully dissected to avoid spleen rupture.

Fig. 28.16  Dissecting the greater omentum to the splenic flexure, taking the tail of the pancreas as a marker to locate the left gastroepiploic vessel

Experience sharing: Taking the tail of the pancreas as a marker to easily locate and track the left gastroepiploic vessel.

Fig. 28.17  Transection of the left gastroepiploic vessel at the root

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Fig. 28.18  Further dissection of splenic hilar lymph nodes

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(3) Dissection of station 4sa lymph nodes: After pulling the stomach and the greater omentum to the left, the dissection is continued upward. The short gastric vessels are transected for the dissection of station 4sa lymph nodes (Fig. 28.19). (4) Dissection of station 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 upward, and the station 12a lymph nodes are dissected (Fig. 28.20). The right gastric artery and vein are transected after being

Experience sharing: The greater omentum is placed below the liver, and the assistant pulls the stomach to the right for adequate exposure. The operation should be gentle to avoid damage to the spleen and massive bleeding.

Fig. 28.19  Transection of short gastric vessels and dissection of station 4sa lymph nodes

Experience sharing: In the anterior pancreatic region, the gastroduodenal artery is a major marker of dissection.

Fig. 28.20  Exposure of the gastroduodenal artery, common hepatic artery, proper hepatic artery, and right gastric artery

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Fig. 28.21  Transection of the right gastric artery

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Fig. 28.22  Status after the dissection of the subpyloric region

Experience sharing: Transection of the duodenum facilitates the exposure and dissection of the superior pancreatic region.

Fig. 28.23  Transection of the duodenum at the distal end of the pylorus

Experience sharing: The assistant pulls the proper hepatic artery and portal vein to the right for adequate exposure. The operation of the surgeon should be gentle to avoid damage to the portal vein.

Fig. 28.24  Exposure of the portal vein and dissection of station 12a lymph nodes

ligated at the root (Fig.  28.21), and the station 5 lymph nodes are dissected. The duodenum is transected with a linear Endo GIA stapler at the distal end of the pylorus, and the station 5 lymph nodes are dissected (Figs. 28.22 and 28.23). 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 the pancreas to expose the portal vein. The common 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 upward along the medial side of the portal vein to the hepatic hilum. Afterward, the common hepatic artery is pulled downward to the right, and the lymphatic and adipose tissues are dissected along the medial side of the proper hepatic artery and the portal vein

28  Laparoscopic Total Gastrectomy with Transrectal Specimen Extraction (GC-NOSES VII)

(Fig. 28.24). Station 8, 12, and 5 lymph nodes are dissected (Fig. 28.25). (5) Dissection of station 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 upward. The anterior pancreatic capsule is dissected. The dissection is performed closely along the superior border of the pancreas to expose the proximal end of the 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 station 7 and 9 lymph nodes are dissected (Figs. 28.26 and 28.27). Dissection along the splenic artery to the distal end to transect the posterior gastric vessels is performed (Fig. 28.28), 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. 28.29). (7) Dissection of the lower esophagus and dissection of lymph nodes in the right and left sides of the 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 the cardia (station 1 and 2 lymph nodes) are dissected (Figs. 28.30, 28.31, and 28.32).

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Fig. 28.27  Dissection and transection of the left gastric artery and further dissection of station 7, 9, and 11p lymph nodes

Fig. 28.28  Transection of the posterior gastric vessels

Fig. 28.25  Status after the dissection of station 8, 12, and 5 lymph nodes

Fig. 28.29  Opening the lesser omentum

Experience sharing: The initial segment of the splenic artery is relatively fixed, few anatomical variations exist, which is regarded as an entry point. The assistant should grasp and hold the plica gastropancreatica, then turn the stomach upwards to facilitate exposure.

Fig. 28.26  Dissection and transection of the left gastric vein

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3.3  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. 28.33, 28.34, and 28.35).

Fig. 28.30  Dissection of the left side of the esophagus

G. Yu

3.4  D  igestive Tract Reconstruction (Laparoscopic Roux-en-Y Esophagojejunal Anastomosis, 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. 28.31  Dissection of the right side and the posterior region of the esophagus and transection of the posterior vagal trunk

Experience sharing: The dissected length of the lower esophagus should be appropriate to ensure the safety of the proximal resection margin and the quality of the anastomosis.

Fig. 28.32  Dissection of the lower esophagus to an appropriate length

Experience sharing: If necessary, intraoperative gastroscopy can be performed to locate the proximal edge of tumor, and the safety of the proximal resection margin can be ensured by intraoperative fast-frozen pathology.

Fig. 28.33  Intraoperative gastroscopy for the localization of the proximal edge of tumor, and transection of the esophagus

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Experience sharing: Place the specimen in the specimen bag to ensure aseptic and tumor-free operation. Temporarily place it in the left lower abdomen to facilitate specimen extraction.

Fig. 28.34  Placing the specimen in the specimen bag and temporarily placing it in the left lower abdomen

(Fig.  28.36), and then the jejunum is transected at 20  cm from Treitz’s ligament (Figs. 28.37 and 28.38), so as to facilitate the creation of the overlap anastomosis between the distal jejunum and esophagus (Fig.  28.39). The remaining opening is closed with barbed suture in a continuous pattern (Figs.  28.40, 28.41, and 28.42). After the esophagojejunal anastomosis is created, 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 remaining opening of jejunum is closed with a 3.0 absorbable suture in an intermittent pattern (Figs. 28.43 Fig. 28.35  Status after the dissection of station 10 and 11 lymph nodes and 28.44).

Experience sharing: Double barbed sutures can be used to pull the lower esophagus for better exposure and facilitate the suturing of the common opening to ensure the quality of the anastomosis.

Fig. 28.36  Open the middle of the esophageal stump

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Experience sharing: Transect the mesojejunum and pay attention to protect the jejunal mesenteric vessels, and ensure the blood supply of anastomosis.

Fig. 28.37  Transection of the proximal mesojejunum

3.5  Transanal Specimen Extraction

Fig. 28.38  Transection of the jejunum

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 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. 28.45). The protective sleeve is inserted into the rectum through the trocar after further disinfecting with dilute iodine solution

Experience sharing: The gastric tube can be used as indication to prevent the insertion into the interlayer of esophagus. During the anastomosis, the force of linear Endo-GIA stapler upwards should be moderate to prevent laceration of mesojejunum and perforation of the bowel wall.

Fig. 28.39  Overlap anastomosis of the esophagus and jejunum

Experience sharing: Full-thickness suture is performed with a stitch length of 3 mm and an edge distance of 5 mm. The gastric tube can be used to prevent the insertion into the interlayer of esophagus.

Fig. 28.40  Opening is closed by double suture in a continuous pattern with barbed suture

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Fig. 28.41  Status after esophagojejunal anastomosis

Experience sharing: Check the quality of the anastomosis, and intraoperative gastroscopy can be performed if necessary.

Fig. 28.42  Intraoperative gastroscopy to check the quality of anastomosis

Fig. 28.43  Side-to-side jejunal anastomosis

Fig. 28.44  Opening closed in an intermittent pattern with absorbable suture

(Figs. 28.46 and 28.47), whereafter the specimen is removed from the anus through the protective sleeve (Figs. 28.48 and 28.49). Finally, the bowel wall is sutured in continuous or intermittent pattern (Figs. 28.50, 28.51, and 28.52).

3.6  P  ostoperative Specimen and Abdominal Wall Pictures (Figs. 28.53 and 28.54)

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Operating skills: 1. Select the upper rectum for incision, so as to be easily exposed and sutured. 2. Incision should be made along the anterior wall of the rectum to avoid incision deflection and reduce the mucosal eversion after incision. 3. Adequately open 5-6 cm along the long axis. The length of incision should be appropriate, too short of incision may cause bowel wall laceration during the extraction, while too long of incision will increase the difficulty in suture and operation time. 4. The assistant's main operation is keeping the rectum straight by maintaining tension, and providing appropriate exposure of the surgical field.

Fig. 28.45  Cutting open the anterior wall of the upper rectum after repeated disinfection of the bowel cavity

Operating skills: 1. Repeatedly disinfect the bowel lumen with iodoform gauze. 2. The protective sleeve should be long enough. Any contact between the specimen and the bowel wall and anus should be avoided.

Fig. 28.46  Repeated disinfection of the bowel lumen with iodoform gauze

Fig. 28.47  Insertion of protective sleeve

4  K  ey 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

have been improved continuously, and its application has received more and more attention. At the same time, with the surgeons’ constant exploration, NOSES become an advancement that combines laparoscopic technology with the NOTES concept. 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 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 over-tension of the anastomosis. It has obvious advantages in terms of the safety of the operation, but there are still many difficulties and controversies.

4.1  Difficulties in Surgery 1. In the totally laparoscopic radical gastrectomy, esophagojejunal anastomosis is a difficulty. This procedure requires

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Operating skills: Tighten the protective sleeve and avoid the rectal wall tearing, which may cause difficulty in suture.

Fig. 28.48  Specimen extraction from the protective sleeve

Fig. 28.49  The specimen is extracted

Fig. 28.50  Repeated irrigation of the pelvic cavity with dilute iodine solution and normal saline

Operating skills: The stitch length and edge distance of suture should both be 5 mm. Apply two barbed sutures to reinforce, thereby reduce the risk of anastomosis leakage to the minimum

Fig. 28.51  Continuous double sutures with 3.0 barbed suture for rectum incision

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 equipments.

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Operating skills: 1. Ensure the tightness of suture by performing air leak test or intraoperative colonoscopy; 2. After the suture, repetitively irrigate the pelvic cavity to ensure a sterile and tumor-free operation;

Fig. 28.52  Irrigation of the pelvic cavity with dilute iodine solution and normal saline again and rectal air leak test

Fig. 28.53  Specimen picture Fig. 28.54  Appearance of the abdominal wall after operation

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.

4.2  C  ontroversy 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, 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 long-­ term efficacy of NOSES. Therefore, doctors should strictly follow the indications to ensure the safety of patients, so as to maximize the benefits for patients.

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

29

Gang Yu

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, and 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 the abdominal wall to the maximum, and reduces postoperative pain, which facilitates early ambulation and shortens recovery time, so as to minimize the physical and psychological effects of surgery.

1  Indications and Contraindications of NOSES 1.1  Indications 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.

1.2  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.

2  A  nesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position 2.1  Anesthesia Method General anesthesia or general epidural anesthesia.

2.2  Patient Positioning G. Yu (*) Department of General Surgery, Qilu Hospital of Shandong University (Qingdao), Qingdao, China e-mail: [email protected]

The patient should be placed in the horizontal supine position with leg abduction for gastric cancer resection and

© People’s Medical Publishing House, PR of China 2021 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-15-7925-7_29

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digestive tract reconstruction operation (Fig.  29.1), which will be changed to the functional lithotomy position (Fig. 29.2) when removing the specimen through the vagina.

2.3  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 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).

Fig. 29.1  The patient’s position during resection and reconstruction

2.4  Surgical Team Position 2.4.1 A  bdominal 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). 2.4.2 Digestive Tract Reconstruction The surgeon switches positions with the assistant. 2.4.3 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.  29.5). In this step, the monitor should be placed on the side of the patient’s foot.

Fig. 29.2  The patient’s position during specimen extraction

Fig. 29.3  Trocar placement (five-port method)

Assistant’s Auxiliary Trocar 5 mm

Surgeon’s Main Trocar 12 mm

Assistant’s Main Trocar 12 mm

Surgeon’s Auxiliary Trocar 5 mm Camera Trocar 10 mm

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2.5  Surgical Instruments

3.2  Dissection and Separation

Ultrasonic scalpel, 60  mm linear Endo GIA stapler, 3-0 barbed suture, 4-0 absorbable suture, sterile protective sleeve.

3.2.1 D  issection 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

3  S  urgical Procedure, Techniques, and Key Points 3.1  S  urgical Exploration and Surgical Planning

Camera Holder

3.1.1 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.  29.6 and 29.7). 3.1.2 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. 29.8).

Surgeon Assistant

Monitor Scrub Nurse

Assistant for Specimen Extraction

Fig. 29.5  Surgical team position during specimen extraction

Monitor

Fig. 29.6  Comprehensive exploration of the abdominal cavity Scrub Nurse Assistant Surgeon

Camera Holder

Fig. 29.4  Surgical team position during gastric cancer resection

Fig. 29.7  Comprehensive exploration of the abdominal cavity

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Fig. 29.8  Exploration of the tumor

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Fig. 29.9  The assistant’s cooperation on the tensioning omentum by triangular stretch

Experience sharing: With the marker of middle colic vessel, enter into the fusion fascia space between the gastroduodenum and transverse mesocolon.

Fig. 29.10  Dissection along the fusion fascia space

Experience sharing: 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.

Fig. 29.11  Transection of the right gastroepiploic vein

sac is entered, and the incision is extended to the hepatic flexure of the 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. 29.9).

3.2.2 Perigastric Lymphadenectomy (1) Dissection of station 6 lymph nodes: With the marker of the middle colic vessel, the surgeon firstly enters into the fusion fascia space between the gastroduodenum and trans-

verse mesocolon. The anterior superior pancreaticoduodenal vein is exposed, and the right gastroepiploic vein is transected above the junction between the anterior superior pancreaticoduodenal veins 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. 29.10, 29.11, and 29.12).

29  Laparoscopic Total Gastrectomy with Transvaginal Specimen Extraction (GC-NOSES VIII)

(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 vein distally until the branch vessels of splenic hilum are exposed, and station 4sb lymph nodes are dissected (Figs.  29.13, 29.14, and 29.15). (3) Dissection of station 11p, 11d, 7, and 9 lymph nodes: The dissection is performed closely along the supe-

Fig. 29.12  Transection of the right gastroepiploic artery

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rior border of the pancreas to expose the proximal end of the 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 station 7 and 9 lymph nodes are dissected (Figs. 29.16, 29.17, 29.18, 29.19, and 29.20). (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 the pylorus (Fig. 29.21). 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 the right gastric vessel is ligated and transected (Fig. 29.22). The assistant pulls the common hepatic artery downward 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. 29.23 and 29.24). (5) Isolation of the 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 the esophagus to dissect the station 110

Experience sharing: When mobilizing the splenic flexure, the adhesion between the greater omentum and the middle and lower pole of spleen should be carefully dissected to avoid spleen rupture;

Fig. 29.13  Root of the left gastroepiploic vessel

Experience sharing: Taking the tail of the pancreas as a marker to easily locate and track the left gastroepiploic vessel.

Fig. 29.14  Exposure of the left gastroepiploic vessel and dissection of station 4sb lymph nodes

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Fig. 29.15  Dissection of station 4sa lymph nodes at the splenic hilum

Experience sharing: The initial segment of the splenic artery is relatively fixed, few anatomical variations exist, which is regarded as an entry point. The assistant should grasp and hold the plica gastropancreatica, then turn the stomach upwards to facilitate exposure.

Fig. 29.16  Dissection of station 11p lymph nodes proximal to the splenic artery

Fig. 29.17  Dissection of station 7 lymph nodes around the left gastric artery

Fig. 29.18  Dissection of station 9 lymph nodes around the celiac trunk

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lymph nodes (Fig.  29.25). 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 downward to dissect the esophagus adequately to ensure the safety of the proximal resection margin (Fig. 29.26).

Fig. 29.19  Dissection of station 11d lymph nodes along the splenic artery

Experience sharing: Dissect along the splenic artery and vein distally until the branch vessels of splenic hilum are exposed, and stations 10 and 11d lymph nodes are dissected.

Fig. 29.20  After the dissection of station 10 and 11d lymph nodes

Fig. 29.21  Transection of the duodenum

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Experience sharing: Transect the duodenum first to facilitate the exposure of the right gastric artery and hepatoduodenal ligament, making lymphatic dissection easier.

Fig. 29.22  Transection of the right gastric artery at the root

Fig. 29.23  Exposure of portal vein and dissection of station 12a lymph nodes

Fig. 29.24  Dissection of station 8a and 12a lymph nodes

Fig. 29.25  Dissection of station 110 lymph nodes

Fig. 29.26  Adequate dissection of the lower esophagus

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Fig. 29.27  Transection of the esophagus at 3  cm from the proximal end of tumor

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Fig. 29.28 Transection of the jejunum at 25  cm from Treitz’s ligament

3.3  Digestive Tract Reconstruction (Total Laparoscopic Roux-en-Y Esophagojejunal Anastomosis) 3.3.1 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. 29.27). The jejunum is transected at 25  cm from Treitz’s ligament (Fig. 29.28). Two windows are opened in the posterior wall of the 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 stapler to complete the side-to-side esophagojejunal anastomosis (Figs. 29.29, 29.30, and 29.31). The remained opening is closed with a 3-0 barbed suture (Fig. 29.32). 3.3.2 Digestive Tract Reconstruction with Hand-Sewn Suture The esophagojejunal anastomosis is completed by performing anastomosis first and followed by transection, i.e., lift the bowel at 25 cm from Treitz’s Ligament to esophageal hiatus to be sutured with the posterior wall of the esophagus for three stitches, and open the lateral wall of the jejunum and the posterior wall of the esophagus for hand-sewn anastomosis (Figs. 29.33 and 29.34). The anastomosis of the posterior

Fig. 29.29  The esophageal stump is sutured with two traction stitches

wall is full thickness sutured in an intermittent pattern with absorbable suture (Fig. 29.35). The anterior wall is sutured in a continuous pattern with barbed suture (Fig. 29.36). 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. 29.37, 29.38, and 29.39).

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Experience sharing: Pull the esophageal stump downwards with the traction stitch to avoid stump retraction and ensure the quality of anastomosis.

Fig. 29.30  Opening of the esophageal stump between the two traction stitches

Experience sharing: Place and fire the linear Endo-GIA stapler under the support of the gastric tube can avoid accidental suture of the gastric tube and provide better exposure of the posterior wall of esophagus.

Fig. 29.31  Anastomosis between the posterior wall of the esophagus and bowel wall

Experience sharing: Barbed suture can ensure the quality of suture and shorten the operation time. Double barbed suture is used for the reinforcement of suture.

Fig. 29.32  Remaining opening is closed in a continuous pattern with 3-0 barbed suture

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3.4  Transvaginal Specimen Extraction

Fig. 29.33  The posterior wall of the esophagus and the lateral wall of the jejunum are sutured

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 place 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. 29.40). The protective sleeve is inserted through the main trocar after disinfected with dilute iodine solution (Fig.  29.41). The specimen is removed from the vagina through the protective sleeve (Figs.  29.42 and 29.43). Next, the pelvic cavity is irrigated repeatedly with dilute

Experience sharing: The posterior wall of the esophagus and the anterior wall of the jejunum are sutured with 3 stitches. Note that the distance between the anastomosis and the fixing suture should be more than 5 mm to leave room for full-thickness suture.

Fig. 29.34  Opening the anterior wall of the jejunum and the posterior wall of the esophagus for hand-sewn anastomosis

Experience sharing: The full-thickness suture has a stitch length of 3 mm and an edge margin of 5 mm.

Fig. 29.35  Posterior wall of the anastomosis is sutured in an intermittent full-thickness pattern with absorbable suture

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Experience sharing: After the posterior wall of anastomosis is sutured, the gastric tube can be placed to provide support to facilitate exposure and prevent accidental suture of the posterior wall.

Fig. 29.36  Continuous suture of anterior wall with 3-0 barbed suture

Experience sharing: The esophagojejunal anastomosis is completed by performing anastomosis first and followed by transection of bowel. Laparoscopic operation can effectively avoid mistakes while operating with small auxiliary incision, such as bowel torsion and over-tension of the anastomosis.

Fig. 29.37  Esophagojejunal anastomosis followed by transection of the proximal jejunum

Experience sharing: Ensure that both sides of bowel openings are aligned to reduce the common opening. The antimesenteric side of bowel wall is anastomosed with no insertion of other tissues.

Fig. 29.38  Side-to-side jejunal anastomosis

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Fig. 29.39  Closure of the common opening

Fig. 29.40  Suspension of the uterus

Fig. 29.41  Opening the posterior vaginal fornix with a cautery hook

Experience sharing: Tighten the protective sleeve to reduce the resistance to specimen extraction.

Fig. 29.42  Specimen extraction through the protective sleeve

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Experience sharing: The operation of specimen extraction should be performed gently to avoid the specimen rupture caused by rough operation.

Fig. 29.43  Transvaginal extraction of specimen

Experience sharing: Strict aseptic and tumor-free principles should be followed during operation.

Fig. 29.44  Repeated irrigation with dilute iodine solution

4  K  ey Points, Difficulties, and Hotspots Related to Surgery

Fig. 29.45  Repeated irrigation with normal saline

iodine solution and normal saline (Figs. 29.44 and 29.45). Lastly, the posterior vaginal fornix is closed with continuous suture (Fig.  29.46). The postoperative appearance of specimen and abdominal wall is displayed (Figs. 29.47 and 29.48).

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. The patient should be placed in the functional lithotomy position during specimen extraction, 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

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Operating skills: The Trendelenburg position facilitates the exposure and suturing.

Fig. 29.46  Incision of the posterior vaginal fornix closed by continuous suture with 3-0 barbed suture

Fig. 29.47  Specimen display

monitor should be adjusted, and the operation time will be prolonged accordingly. Vaginal irrigation should be performed before transvaginal specimen extraction. Strict tumorfree and aseptic principles should be followed during the operation. 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 the esophagus and jejunum should be ensured, and the mesenteric vessels should be transected if necessary; (3) the blood 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 includes stapled anastomosis and hand-sewn anastomo-

Fig. 29.48  Appearance of the postoperative abdominal wall

sis. Hand-sewn anastomosis can save the cost of stapler, save the length of the esophagus, and reduce the tension of the anastomosis. However, hand-sewn 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 endto-end (FETE) and side-to-side (overlap) anastomosis. (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 Treitz’s ligament. Two windows are opened on the left side of the 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

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closed with a linear Endo GIA stapler. This technique is only applicable to patients with gastric body 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-

G. Yu

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.

Robotic Gastric Tumor Resection with Transoral Specimen Extraction (GC-NOSES IX)

30

Zhiwei Jiang

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 (Figs.  30.1–30.2), 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.

1

Indications and Contraindications of NOSES

1.1

Indications (Figs. 30.1–30.2)

1 . Gastric tumor that can be resected locally. 2. The largest diameter of the lesion is less than 2.5 cm. Z. Jiang (*) Department of General Surgery, Jiangsu Province Hospital of Traditional Chinese Medicine, Nanjing, China

1.2

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.

2  A  nesthesia, Patient Positioning, Trocar Placement, and Surgical Team Position 2.1

Anesthesia Method

General anesthesia or general epidural anesthesia.

2.2

Patient Positioning

The patient is placed in the anti-Trendelenburg supine position (Fig. 30.3).

2.3

Trocar Placement

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. 30.4).

© People’s Medical Publishing House, PR of China 2021 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-15-7925-7_30

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Fig. 30.1  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

Fig. 30.3  The patient’s position

Fig. 30.2 Contrast-enhanced CT of the upper abdomen: Space-­ occupying lesion in the anterior wall of the lesser curvature of the gastric body, with intact capsule, approximately 2 cm × 2 cm in size

2.4

Surgical Team Position

Instrument Trocar

Instrument Trocar

Instrument Trocar

Auxiliary Trocar CameraTrocar

The surgeon stands in front of the da Vinci robotic platform, and the assistant stands on the left side of the patient (Fig. 30.5–30.6). Fig. 30.4  Trocar placement (five-port method)

2.5

Surgical Instruments

da Vinci robot, gastroscope.

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Fig. 30.7  Suspension of the liver

Fig. 30.5  Layout of operating room

Fig. 30.8  Tumor located in the anterior wall of the lesser curvature of the gastric body

Fig. 30.6  The assistant stands on the left side of the patient

3

Surgical Procedure, Techniques, and Key Points

3.1

Exploration and Surgical Planning

The surgical exploration and operation are initiated after the assembly of da Vinci robotic surgical system.

3.1.1 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. 3.1.2 Tumor Exploration The liver is suspended by extracorporeal purse-string knot to expose the field of surgery (Fig. 30.7). 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. 30.8). No other abnormalities are noted in the abdomen.

Fig. 30.9  Isolation of gastric wall around the tumor

3.2

Tumor Resection

The surgeon applies the ultrasonic scalpel to isolate the gastric wall of the lesser curvature around the tumor (Fig. 30.9), ligates the great vessels with titanium clip (Fig. 30.10), and isolates the gastric wall of the lesser curvature adequately (Fig. 30.11). The intended resection gastric wall is lifted with the third arm of the robot (Fig. 30.12). Afterward, the surgeon applies the ultrasonic scalpel to open all layers of gastric wall at the intended resection line (Fig.  30.13) and perform complete circular resection of the tumor under direct vision (Figs. 30.14–30.15).

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Fig. 30.10  Large vessels are ligated with titanium clip

Fig. 30.13  Open all layers of gastric wall

Fig. 30.11  Isolated gastric wall of the lesser curvature

Fig. 30.14  Complete circular resection of the tumor

Fig. 30.12  Lifting the gastric wall around the tumor

Fig. 30.15  Complete resection of gastric tumor

3.3

3.3.2 Closing the Incision in the Gastric Wall Full-thickness suture of the incision in the gastric wall is performed upward with 3-0 single-stitch self-retaining knotless suture (Fig. 30.19), followed by continuous seromuscular layer embedding of the incision downward with the same suture (Fig.  30.20). The tail of the suture is ligated with titanium clip to prevent falling off (Fig. 30.21). After the closure of the gastric incision, the surgeon should inspect the suture of incision under laparoscopy carefully (Fig. 30.22).

Digestive Tract Reconstruction and Specimen Extraction

3.3.1 P  lacement of Specimen in the Gastric Cavity The resected tumor is placed in the specimen bag (Fig. 30.16), and the opening of the bag is ligated with 0 suture (Fig. 30.17). The surgeon places the closed specimen bag into the gastric cavity through the incision in the gastric wall under laparoscopy (Fig. 30.18).

30  Robotic Gastric Tumor Resection with Transoral Specimen Extraction (GC-NOSES IX)

Fig. 30.16  Placing the tumor in the specimen bag

Fig. 30.17  Ligation of the opening of specimen bag with 0 suture

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Fig. 30.19  Full-thickness suture of incision in the gastric wall

Fig. 30.20  Seromuscular layer embedding of incision in the gastric wall

Fig. 30.18  Placing the specimen bag in the gastric cavity Fig. 30.21  Ligation of the tail of the suture with titanium clip to prevent falling off

3.3.3 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. 30.23). Foreign-body forceps is applied to grasp the ligature at the opening of the

specimen bag and pullback to extract the specimen gently (Fig. 30.24). Inspection of specimen: The specimen is 2.5 cm × 3.0 cm in size with safe resection margin. The specimen is sent for analysis, the instruments are counted, incisions for trocars are sutured, and the operation is completed.

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Fig. 30.22 Inspection of the incision in the gastric wall under laparoscopy Fig. 30.25  The abdominal wall after operation

Fig. 30.26  Specimen display Fig. 30.23  Gastroscopic inspection of gastric wall incision

3.4

Postoperative Abdominal Wall and Specimen Pictures (Figs. 30.25 and 30.26)

(Zhiwei Jiang, Liu Jiang)

4  K  ey Points, Difficulties, and Hotspots Related to Surgery 4.1

Fig. 30.24  Specimen extraction with foreign-body forceps

 recautions for Transoral Specimen P 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 are the main routes of specimen extraction. Colorectal speci-

30  Robotic Gastric Tumor Resection with Transoral Specimen Extraction (GC-NOSES IX)

mens 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, 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 the 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

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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. Transoral NOSES also shows promising minimally invasive results, and this technique is a supplement and improvement of the NOSES system. 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. (Zhiwei Jiang)

Laparoscopic Small Intestinal Tumor Resection with Transrectal Specimen Extraction

31

Haitao Zhou

Small bowel tumor refers to tumor of the small bowel from the duodenum to the ileocecal valve. The incidence of small bowel tumors is very low and accounts for approximately 5% of digestive tract tumors, and small bowel malignant tumors are even less common. The clinical manifestations of small bowel tumors are atypical, which are related to the type, location, size, and nature of the tumor and whether there are obstruction, hemorrhage, and metastasis. Its diagnosis is difficult, and delayed diagnosis and treatment are common. Common benign tumors include stromal tumors, adenomas, leiomyomas, lipomas, hemangiomas, etc., and some of them can become malignant. At present, surgical operation is the main therapeutic method. With the improvement of the minimally invasive concept of NOSES and the technique of laparoscopic digestive tract reconstruction, NOSES can be used in the treatment of small bowel tumors. The approach for specimen extraction can be through the rectum or vagina, which avoids 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, accelerates postoperative rehabilitation, and reduces the psychological trauma of patients, so that they can return to the everyday life better. For surgeons, NOSES has good safety and operability, and the difficulty of operation is not significantly increased. In this chapter, the laparoscopic resection of stromal tumors of the small bowel with transrectal specimen extraction is introduced.

priate according to the actual conditions of the patient, including the thickness of mesentery, the anatomical characteristics of the natural orifice, etc. 3. The tumor should not invade beyond the serosa. 4. The length and thickness of mesentery of the small bowel are suitable for extraction.

1

Indications and Contraindications of NOSES

1.1

Indications (Figs. 31.1, 31.2, and 31.3)

The patient is placed in supine lithotomy position, with the right thigh slightly flattened, which facilitates to perform the operation for the surgeon (Fig. 31.4). The patient is placed in the Trendelenburg position during transrectal specimen extraction, which facilitates the pelvic operation (Fig. 31.5).

1 . Tumors of jejunum and ileum. 2. The circumferential diameter of tumor is better less than 5 cm. The limit of tumor size can be broadened as approH. Zhou (*) Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China e-mail: [email protected]

1.2

Contraindications

1 . The tumor is too large to be pulled out. 2. The mesentery of the small bowel is too thick to be pulled out through the rectum or vagina. 3. Severely obese patients (BMI>35 kg/m2).

2

 nesthesia, Patient Positioning, A Trocar Placement, and Surgical Team Position

2.1

Anesthesia Method

General anesthesia or general epidural anesthesia.

2.2

2.3

Patient Positioning

Trocar Placement

Localization of tumor is difficult due to the high mobility of small bowel. The camera trocar and the main trocar can be placed first for exploration and thereby determine the posi-

© People’s Medical Publishing House, PR of China 2021 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-15-7925-7_31

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Fig. 31.1  Adenoma of small bowel, filling phase: localized stenosis of the proximal jejunum lumen, with clear demarcation and rigid bowel wall

H. Zhou

Fig. 31.4  The patient’s position during small bowel operation

Fig. 31.5  The patient’s position during pelvic operation

Fig. 31.2  Adenoma of small bowel, mucosal phase: with localized mucosal damage and polypoid defects in the mucosa

Fig. 31.3  Stromal tumor of the small bowel: a quasi-circular filling defect (arrow) is presented in the small bowel, with well-defined contour, flattening of the surface mucosa, and compression of the adjacent bowel

tion of other trocars. The pelvic operation should also be considered in the placement of trocars. 1. Camera trocar (10 mm trocar) is located just above the umbilicus. 2. The surgeon’s main trocar (12  mm trocar) is located at McBurney’s point. 3. The surgeon’s auxiliary trocar (5 mm trocar) is located at the umbilical level at 10 cm from the right side of the umbilicus. 4. The assistant’s trocar (5 mm trocar) is located at the left side of the upper umbilical level at the lateral edge of the rectus abdominis. 5. (The above are the positions of the four-trocar method. According to the tumor location, the patient’s body form, the thickness of mesentery, and the operational process, etc., the assistant’s auxiliary trocar can be placed in the following location when necessary. 6. The assistant’s auxiliary trocar (5 mm trocar) is located opposite McBurney’s point. Usually, a laparoscopic grasper is inserted through this trocar for lifting and retracting tissue. The author prefers to place this trocar more laterally, so as to facilitate the placement of drainage tube (Fig. 31.6).

31  Laparoscopic Small Intestinal Tumor Resection with Transrectal Specimen Extraction

Surgeon’s Auxiliary Trocar (5 mm)

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Assistans’t Main Trocar (5 mm)

Camera Trocar (10 mm)

Surgeon’s Main Trocar (12 mm)

Assistans’t Auxiliary Trocar (5 mm)

Fig. 31.6  Trocar placement (five-port method)

Fig. 31.8  Exploration of tumor location

Camera Holder

Surgeon Assistant

Monitor

Scrub Nurse

Fig. 31.7  Surgical team position

Fig. 31.9  Evaluate the status of small bowel and its mesentery

2.4

The positions of the surgeon, assistant, and camera holder should be on the right side, left side and the right side of the patient, separately (Fig. 31.7).

3.1.1 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.

2.5

3.1.2 Tumor Exploration The location and size of the tumor (Fig. 31.8).

Surgical Team Position

Special Surgical Instruments

According to the characteristics of small bowel tumor and the orifice of specimen extraction, special surgical instruments include ultrasonic scalpel, linear Endo GIA stapler, sterile protective sleeve, etc.

3.1.3 Evaluation of Anatomical Structures The thickness of mesentery of small bowel, the existence of any other abnormalities, and the feasibility of transrectal specimen extraction are evaluated (Fig. 31.9).

3

Surgical Procedure, Techniques, and Key Points

3.2

3.1

Exploration and Surgical Planning

Based on detailed preoperative examination and surgical planning, the exploration mainly includes three steps.

Dissection and Separation

3.2.1 D  etermination of the Extent of Resection and the Division of Mesentery of the Small Bowel The surgeon cooperates with the assistant to flatten the intestinal loop of the small bowel near the tumor location and

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H. Zhou

Fig. 31.10  Dividing the mesentery of the small bowel

Fig. 31.11  Transection of mesenteric vessels and isolation of small bowel according to tumor location and blood supply

Fig. 31.12  Isolated small bowel

Fig. 31.13  Transection of small bowel at intended resection line of small bowel with linear Endo GIA stapler

then observes the course of the mesenteric vessels and the arcade vessels to determine the extent of surgical resection. The surgeon applies the ultrasonic scalpel to divide the mesentery of the small bowel (Fig. 31.10), transect the mesenteric vessels, and isolate the small bowel at approximately 5–10 cm from the proximal and distal edge of tumor according to the nature and the blood supply of the tumor (Figs. 31.11 and 31.12).

3.2.2 Transection of the Small Bowel The surgeon transects the small bowel at the isolated segment medial to the blood supply line with linear Endo GIA staplers. Aseptic and tumor-free principles should be followed strictly during operation, and the stump of small bowel should be disinfected with iodoform gauze (Figs. 31.13 and 31.14).

3.3

Digestive Tract Reconstruction

Figure-of-eight suture is performed on the small bowel at approximately 6–8  cm from the distal and proximal stumps of the small bowel (depending on the length of the

Fig. 31.14  Transected small bowel

linear Endo GIA stapler) for fixation (Fig.  31.15). The distal and proximal small bowel stumps are opened with two small incisions (approximately 0.5–1  cm for each) close to staple lines on the antimesenteric side (Figs. 31.16 and 31.17). Attention should be paid to avoid overflow of small bowel contents. The two jaws of linear Endo GIA

31  Laparoscopic Small Intestinal Tumor Resection with Transrectal Specimen Extraction

Fig. 31.15  8-figure suture of small bowel

Fig. 31.16  Making small incision in the closed end of small bowel with the ultrasonic scalpel and exposure of the bowel lumen

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Fig. 31.18  Insertion of linear Endo GIA stapler in the bowel lumen for transection and closure of the antimesenteric side of the small bowel

Fig. 31.19  Disinfection of the bowel lumen with iodoform gauze and check for active bleeding

Fig. 31.17  Exposure of the lumen of the small bowel

Fig. 31.20 Traction suture is fixed to facilitate the closure of enterotomy

stapler are separately inserted into the proximal and distal bowel lumens, and then the stapler is fired to create the side-to-side anastomosis (Fig. 31.18). Iodoform gauze is used to disinfect the bowel lumen thoroughly. Hemostasis should be affirmed, and extra suture can be performed if necessary (Fig. 31.19). Lastly, enterotomy is closed with

a linear Endo GIA stapler. Traction sutures can be fixed to facilitate the closure of enterotomy. At this point, digestive tract reconstruction is completed, and the closed bowel stump should be disinfected with alcohol gauze (Figs. 31.20 and 31.21). The integrity of the anastomosis is checked.

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H. Zhou

Fig. 31.21  Closure of enterotomy with linear Endo GIA stapler

Fig. 31.23  Opening the anterior rectal wall and placement of sterile plastic protective sleeve

Fig. 31.22  Closing the mesentery of small bowel Fig. 31.24  Insertion of oval forceps

3.4

 losure of Mesentery of the Small C Bowel

The mesentery of small bowel should be sutured to avoid postoperative internal hernia (Fig. 31.22).

3.5

Specimen Extraction

3.5.1 O  pening of the Anterior Rectal Wall and Placement of Sterile Plastic Protective Sleeve After gentle anal dilation and irrigation of the rectum with a large amount of dilute iodine solution, ultrasonic scalpel is used to make a 3 cm longitudinal incision in the anterior rectal wall. One assistant applies the dilute iodine solution to smear the protective sleeve for lubrication, and the surgeon places the protective sleeve into the abdominal cavity through the main trocar (Fig.  31.23). Another assistant places the oval forceps through the anus and rectum to the incision of the anterior rectal wall (Fig. 31.24) and clamps one end of the sterile plastic protective sleeve. The surgeon holds both

Fig. 31.25  Pulling the sterile plastic protective sleeve out through the incision in the anterior rectal wall

sides of the rectal incision to keep the distal rectum in place, and then part of the protective sleeve is pulled out through the incision and the anus. The remained part of the protective sleeve in the pelvic cavity should not be too short to be held with forceps (Figs. 31.25 and 31.26).

31  Laparoscopic Small Intestinal Tumor Resection with Transrectal Specimen Extraction

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Fig. 31.26  Leaving part of the sterile plastic protective sleeve in the pelvic cavity

Fig. 31.28  Pulling out the sterile plastic protective sleeve

Fig. 31.27  Transrectal extraction of small bowel and mesenteric specimen

Fig. 31.29  Closure of incision in the anterior rectal wall with linear Endo GIA stapler

3.5.2 E  xtraction of the Small Bowel and Mesenteric Specimen The assistant holds the sterile protective sleeve with forceps while the surgeon is placing the small bowel and mesenteric specimen into the protective sleeve. Care should be taken to adjust the direction of the specimen to make the extraction easier. The surgeon cooperates with the assistant to gently and slowly pull the specimen out through the sterile protective sleeve (Fig.  31.27). After most of the specimen is extracted, the inner end of the sterile plastic protective sleeve is tightened, and the sleeve is pulled out along with the rest of the specimen (Fig. 31.28).

grasp the tail of sutures to keep the incision away from the opposite bowel wall and close the incision longitudinally with a linear Endo GIA stapler (Fig.  31.29). The closed end is disinfected with alcohol gauze. Seromuscular layer embedding of the incision can be performed when necessary. The patency of rectum and the integrity of the suture site is confirmed by air leak test (Fig. 31.30).

3.5.3 C  losure of the Incision in the Anterior Rectal Wall Traction sutures are fixed in both ends of the rectal incision in the anterior rectal wall. The surgeon and assistant

The pelvic cavity is irrigated with normal saline or distilled water, and drainage tubes are indwelled. Close the trocar sites and count the gauze and all instruments before the completion of surgery.

3.6

I rrigation of Abdominal Cavity and Indwelling of Drainage Tube

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H. Zhou

Fig. 31.30  Inspection of anastomosis

3.7

Postoperative Specimen and Abdominal Wall Pictures (Figs. 31.31 and 31.32)

4

 ey Points, Difficulties, and Hotspots K Related to Surgery

For small bowel tumors, such as small bowel stromal tumors, complete tumor resection is the basic principle of surgical treatment. This requires an adequate extent of surgical resection to meet the criteria of negative resection margin, i.e., R0 resection (no microscopic residual tumor). In addition, most small bowel stromal tumors are overhung on the serosal surface of the small bowel or its mesentery, especially for patients with large tumors. The improper operation during surgery can easily cause tumor rupture. Therefore, the surgical operation should be performed carefully, and attention should be paid to maintain the integrity of the tumor capsule. In principle, tumor exploration should not be performed during the operation to avoid sharp and blunt injuries caused by the instruments and surgical operations, so as to avoid extensive intraperitoneal dissemination and implantation metastases of tumor. Most scholars believe that extensive lymph node dissection is unnecessary if the tumors are completely resected. Different from cancer, gastrointestinal stromal tumors have an exocentric growth pattern rather than diffuse and infiltration. Its main metastatic route is hematogenous metastasis and intraperitoneal implantation metastasis, whereas lymphatic metastasis is rare. Therefore, systematic lymph node dissection may be counterproductive, which may increase the incidence of complications and interfere with the postoperative recovery. Other small bowel tumors

Fig. 31.31  Postoperative specimen picture

Fig. 31.32  Picture of abdominal wall after operation

should be treated individually according to their respective characteristics. In addition, adequate anal dilation and gentle specimen extraction should be performed to avoid the anal sphincter injury. The occurrence of rectal stenosis or bleeding should be strictly avoided when closing the rectal stump. If possible, intraoperative colonoscopy can be applied for confirmation, which is safer and more reliable. In addition, disinfection of the bowel stump, specimen extraction with specimen bag, and postoperative irrigation of abdominal and pelvic cavity should be performed during the operation, and the aseptic principle should be followed.

31  Laparoscopic Small Intestinal Tumor Resection with Transrectal Specimen Extraction

At present, there have been an increasing number of studies and reports about NOSES in China, and a large number of study results indicate that NOSES has a good minimally invasive effect and feasibility. However, in terms

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of studies about the application of NOSES in patients with small bowel cancer and the long-term benefits for patients, surgeons need to make further exploration with plenty of such surgeries.

Laparoscopic Small Intestinal Tumor Resection with Transvaginal Specimen Extraction

32

Xishan Wang and Haipeng Chen

The incidence of small bowel tumors is low and accounts for 5% of digestive tract tumors and 2% of malignant digestive tract tumors. Small bowel tumors are most common in middle-­aged people aged 30–59 years with a male to female ratio of 1.5–2.4:1. According to the literatures at home and abroad, most small bowel tumors are malignant. Adenocarcinomas, neuroendocrine tumors, stromal tumors, and lymphomas are the main malignant tumors. The clinical manifestations of small bowel tumors are nonspecific. At present, surgical resection is the main treatment method for small bowel tumors. The surgical methods include laparotomy, endoscopic surgery, laparoscopic surgery, combined endoscopic and laparoscopic surgery, etc. Laparoscopic small bowel tumor resection has been widely used in the clinical practice, but auxiliary incision has to be made for specimen extraction and digestive tract reconstruction. Laparoscopic small bowel tumor resection with specimen extraction through the natural orifice has been rarely reported. With the gradual popularization of the minimally invasive concept of NOSES and the improvement of surgeons’ operating skills in NOSES, the technique of NOSES can be applied for the treatment of small bowel tumors. Specimen extraction through the natural orifice can avoid auxiliary incision in the abdominal wall and only leave a few tiny trocar scars on the abdominal wall after the surgery. NOSES exhibits perfect minimally invasive effect. As a technique that’s easy to operate, replicate, and promote, NOSES exhibits great vitality. In this chapter, the laparoscopic resection of small bowel tumors with transvaginal specimen extraction is introduced.

1

Indications and Contraindications of NOSES

1.1

Indications (Figs. 32.1–32.3)

1 . Tumors of jejunum and ileum. 2. The circumferential diameter of tumor is better less than 5 cm. The limit of tumor size can be broadened as appropriate according to the actual conditions of the patient, including the thickness of mesentery, the anatomical characteristics of the natural orifice, etc. 3. The tumor should not invade beyond the serosa. 4. The length and thickness of mesentery of the small bowel are suitable for extraction.

Fig. 32.1  Quasi-circular mass in the abdominal cavity, with a maximum cross-sectional area of 5.0 cm × 3.5 cm. The margin is clear, with uneven and significant enhancement in the mass, and has a close relation to the adjacent small bowel; no definite lymph node enlargement in the abdominal and pelvic cavity, retroperitoneum, and bilateral iliac vascular and inguinal region; small bowel tumor is indicated

X. Wang (*) · H. Chen Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China © People’s Medical Publishing House, PR of China 2021 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-15-7925-7_32

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Surgeon’s Auxiliary Trocar (5 mm)

Camera Trocar (10 mm)

Surgeon’s Main Trocar (12 mm)

Fig. 32.2  The patient’s position during small bowel operation

Assistant’s Main Trocar (5 mm)

Assistant’s Auxiliary Trocar (5 mm)

Fig. 32.4  Trocar placement (five-port method)

the Trendelenburg position during transrectal specimen extraction, which facilitates the pelvic operation (Fig. 32.3).

2.3

Trocar Placement

Localization of tumor is difficult due to the high mobility of small bowel. The camera trocar and the main trocar can be placed first for exploration and thereby determine the position of other trocars. The pelvic operation should also be considered in the placement of trocars.

Fig. 32.3  The patient’s position during pelvic operation

1.2

Contraindications

1 . The tumor is too large to be pulled out. 2. The mesentery of the small bowel is too thick to be pulled out through the rectum or vagina. 3. Severely obese patients (BMI>35 kg/m2).

2

2.1

 nesthesia, Patient Positioning, A Trocar Placement, and Surgical Team Position Anesthesia Method

General anesthesia or general epidural anesthesia.

2.2

Patient Positioning

The patient is placed in supine lithotomy position, with the right thigh slightly flattened, which facilitates to perform the operation for the surgeon (Fig. 32.2). The patient is placed in

1. Camera trocar (10 mm trocar) is located just above the umbilicus. 2. The surgeon’s main trocar (12  mm trocar) is located at McBurney’s point. 3. The surgeon’s auxiliary trocar (5 mm trocar) is located at the umbilical level at 10  cm from the right side of the umbilicus. 4. The assistant’s trocar (5 mm trocar) is located at the left side of upper umbilical level at the lateral edge of the rectus abdominis. 5. The assistant’s auxiliary trocar (5  mm trocar) is located opposite McBurney’s point. Usually, a laparoscopic grasper is inserted through this trocar for lifting and retracting tissue. The author prefer to place this trocar more laterally, so as to facilitate the placement of drainage tube (Fig. 32.4).

2.4

Surgical Team Position

The positions of the surgeon, assistant, and camera holder should be on the right side, left side, and the right side of the patient, separately (Fig. 32.5).

2.5

Special Surgical Instruments

According to the characteristics of small bowel mass and the orifice of specimen extraction, special surgical instruments

32  Laparoscopic Small Intestinal Tumor Resection with Transvaginal Specimen Extraction

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Camera Holder

Surgeon Assistant

Monitor

Fig. 32.6  Exploration of tumor location Scrub Nurse

Fig. 32.5  Surgical team position

include ultrasonic scalpel, linear Endo GIA stapler, sterile protective sleeve, etc.

3

Surgical Procedure, Techniques, and Key Points

3.1

Exploration and Surgical Planning

Based on detailed preoperative examination and surgical planning, the exploration mainly includes three steps.

Fig. 32.7  Evaluate the status of small bowel and its mesentery

3.1.1 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. 3.1.2 Tumor Exploration The location and size of the tumor (Fig. 32.6). 3.1.3 Evaluation of Anatomical Structures The thickness of mesentery of small bowel, the existence of any other abnormalities, and the feasibility of transvaginal specimen extraction are evaluated (Fig. 32.7).

3.2

Dissection and Separation

3.2.1 D  etermination of the Extent of Resection and the Division of Mesentery of the Small Bowel The surgeon cooperates with the assistant to flatten the intestinal loop of the small bowel near the tumor location and then observes the distribution and course of the mesenteric vessels to determine the extent of resection. The surgeon

Fig. 32.8  Dividing the mesentery of the small bowel

applies the ultrasonic scalpel to divide the mesentery of the small bowel (Fig. 32.8), transect the mesenteric vessels (or transect the mesentery with linear Endo GIA stapler), and isolate the small bowel at approximately 5–10 cm from the proximal and distal edge of tumor according to the nature of the small bowel tumor and the blood supply of the small bowel (Figs. 32.9–32.10).

3.2.2 Resection of the Small Bowel The surgeon applies the linear Endo GIA stapler to transect the bowel at the intended resection line at the proximal end

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X. Wang and H. Chen

Fig. 32.9  Transection of mesenteric vessels and isolation of small bowel according to tumor location and blood supply

Fig. 32.10  Isolated small bowel

Fig. 32.11  Transection of the bowel at the intended resection line at the proximal end of small bowel with linear Endo GIA stapler

Fig. 32.12  Disinfect the stump of small bowel with iodoform gauze

of small bowel (Fig. 32.11). In the isolated area, the blood supply line is clearly visible. The distal small bowel is transected medial to the blood supply line with a linear Endo GIA stapler. At this point, the resection of small bowel is completed. Aseptic and tumor-free principles should be followed strictly during operation, and the stump of small bowel should be disinfected with iodoform gauze (Fig. 32.12).

3.3

Digestive Tract Reconstruction

The distal small bowel stump is placed parallel with the proximal small bowel stump (Fig.  32.13). The distal and proximal small bowel stumps are opened with two small incisions (approximately 0.5–1 cm for each) close to staple lines on the antimesenteric side (Fig. 32.14). The two jaws of linear Endo GIA stapler are separately inserted into the proximal and distal bowel lumens (Fig. 32.15), and then the stapler is fired to create the side-to-side anastomosis (Fig. 32.16). Iodoform gauze is used to disinfect the bowel lumen thoroughly before hemostasis is affirmed (Fig.  32.17). Lastly, enterotomy is closed with a linear Endo GIA stapler to complete the functional end-to-end anastomosis (Fig. 32.18) The seromuscular layer is sutured to reinforce the anastomosis

Fig. 32.13  Placing the distal small bowel parallel with the proximal small bowel

and reduce the tension (Fig.  32.19). The resected bowel stump is placed in the specimen retrieval bag and extracted from the main trocar.

3.4

 losure of Mesentery of the Small C Bowel

The mesentery of small bowel is closed with continuous suture to avoid postoperative internal hernia (Fig. 32.20).

32  Laparoscopic Small Intestinal Tumor Resection with Transvaginal Specimen Extraction

Fig. 32.14  Making an incision in one end of the staple line of the bowel stump

Fig. 32.15  Inserting the anvil jaw into the proximal small bowel lumen

Fig. 32.16  Side-to-side small bowel anastomosis with linear Endo GIA stapler

3.5

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Fig. 32.17  Disinfection of the bowel lumen with iodoform gauze and check for active bleeding

Fig. 32.18  Closure of the stump with linear Endo GIA stapler to complete the functional end-to-end anastomosis

Fig. 32.19  Reinforcement of the anastomosis

Specimen Extraction

3.5.1 Transvaginal Specimen Extraction The vagina is disinfected thoroughly. The assistant lifts the uterus extracorporeally with a uterine manipulator to fully expose the posterior vaginal fornix. The surgeon makes a 3 cm transverse incision in the posterior vaginal fornix with cautery hook and extends the incision to 5–6 cm by longitu-

dinal stretch (Fig. 32.21). The assistant inserts the oval forceps through the vaginal incision to pull the distal end of the protective sleeve out of the body (Fig. 32.22). After this, the assistant cooperates with the surgeon to adjust the direction of the specimen, and another assistant applies the oval forceps to clamp one end of the specimen to slowly pull it out through the sterile protective sleeve. When most of the speci-

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Fig. 32.20  Closing the mesentery of small bowel

Fig. 32.21  Opening the posterior vaginal fornix

X. Wang and H. Chen

Fig. 32.23  Pulling out one end of the resected specimen through the vaginal incision

Fig. 32.24  Full-thickness continuous suture of vaginal incision with absorbable suture

Fig. 32.22  Insertion of oval forceps Fig. 32.25  Inspection of anastomosis

men is extracted, all the intra-abdominal gauzes are placed in the protective sleeve, and then the inner end of the sterile plastic protective sleeve is tightened. The specimen is finally extracted along with the protective sleeve and the gauzes (Fig. 32.23).

3.5.2 Closing the Vaginal Incision Full-thickness continuous suture with absorbable suture is performed to close vaginal incision (Fig. 32.24), and then the incision is disinfected with iodoform gauze. Hemostasis should be affirmed, as well as the integrity of anastomosis and sutured vaginal incision (Fig. 32.25).

3.6

I rrigation of Abdominal Cavity and Indwelling of Drainage Tube

The pelvic cavity is irrigated with normal saline or distilled water, and drainage tubes are indwelled. Close the trocar site and count the gauze and all instruments before the completion of surgery.

3.7  P  ostoperative Specimen and Abdominal Wall Pictures (Figs. 32.26 and 32.27)

32  Laparoscopic Small Intestinal Tumor Resection with Transvaginal Specimen Extraction

Fig. 32.26  Postoperative specimen picture

Fig. 32.27  Picture of abdominal wall after operation

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Part IV Special and Extended Resection Surgery with NOSES

Laparoscopic Extended Lower Rectal Cancer Resection with En Bloc Lateral Lymph Node Dissection (Wang’s Approach)

33

Xishan Wang, Zhaoxu Zheng, and Haipeng Chen

Lateral lymph node metastasis of middle and lower rectal cancer is an objective fact and a route of lymphatic drainage of the rectum. The incidence of lateral lymph node metastasis is reported to be 9%–25%, which is related to the selection of cases in each center. Because of the inconsistency of positive rates and the high technical difficulty, lateral lymph node dissection in rectal cancer remains controversial. It is a matter of concept and technique: in terms of concept, the focus is whether it should be done; in terms of technique, the focus is whether it can be done. In both open and conventional laparoscopic procedures, specimen resection is performed before lymph node dissection. To perform NOSES, the specimen should be extracted while remaining the integrity of it, which leads us to ponder how to perform the en bloc resection. Technically, performing en bloc resection is extremely difficult, and cannot be achieved through conventional surgical approaches. In this chapter, an alternative approach is introduced. This approach has not been officially named yet, so it is hereby referred to as “Wang’s approach.” This chapter also demonstrates that extended middle and lower rectal cancer resection with en bloc lateral lymph node dissection can be achieved. In this chapter, NOSES IE combined with en bloc lateral lymph node dissection is introduced.

1 1.1

Indications and Contraindications of NOSES Indications (Figs. 33.1–33.3)

1 . Middle and lower rectal cancer. 2. MRI indicates lateral obturator lymph node metastases.

X. Wang (*) · Z. Zheng · H. Chen Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China

1.2

Contraindications

1 . Local tumor infiltration and distal metastasis 2. Unresectable distant metastatic disease 3. Patients with poor cardiopulmonary function and coagulation mechanism

2

 nesthesia, Patient Positioning, A Trocar Placement, and Surgical Team Position

2.1

Anesthesia Method

General anesthesia or general epidural anesthesia.

2.2

Patient Positioning

The patient is placed in modified lithotomy position in a Trendelenburg right-lateral tilt position, with the right thigh slightly flattened, which facilitates to perform the operation for the surgeon (Fig. 33.4).

2.3

Trocar Placement

1. Camera trocar (10 mm trocar) is located just above the umbilicus or within 2 cm above the umbilicus. 2. The surgeon’s main trocar (12  mm trocar) is located at McBurney’s point. 3. The surgeon’s auxiliary trocar (5 mm trocar) is located at 5 cm above the intersection of the umbilicus level and the right midline. 4. The assistant’s auxiliary trocar (5 mm trocar) is located opposite McBurney’s point. 5. The assistant’s main trocar (5 mm trocar) is located at the umbilicus level at the lateral edge of the left rectus abdominis (Fig. 33.5).

© People’s Medical Publishing House, PR of China 2021 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-15-7925-7_33

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MIddle Rectum

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Lower Rectum

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MIddle Rectum

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Lower Rectum

Upper Rectum

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Upper Rectum

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Fig. 33.1  Tumor location applicable for this procedure

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5cm

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Special Surgical Instruments

Ultrasonic scalpel, electric scalpel with needle electrode, anal retractor, ureteral forceps.

Fig. 33.2  Colonoscopy: Tumors of ulcerated and protuberant type, 5 cm from the dentate line

2.4

Surgical Team Position

2.4.1 Abdominal Operation The positions of the surgeon, assistant, and camera holder should be on the right side, left side, and right side of the patient, separately (Fig. 33.6a). 2.4.2 Perineal Operation The surgeon stands between the patient’s legs, and the assistants separately stands on the left and right side of the patient (Fig. 33.6b).

3

Surgical Procedure, Techniques, and Key Points

3.1

Exploration and Surgical Planning

3.1.1 General Exploration The advantage of laparoscopic exploratory is an extension of our vision, through which we can see what may be ignored in conventional laparotomy. However, lacking tactile sensation is the main disadvantage of it. Therefore, on the basis of preoperative examination, the liver, gallbladder, stomach, spleen, greater omentum, colon, small intestine and mesentery surface, and pelvic organs should be explored in detail to determine the presence of implantation metastases (Fig. 33.7). 3.1.2 Tumor Exploration Middle and lower rectal tumors are often located below the peritoneal reflection. The surgeon can perform the digital rectal examination. If the tumor is small, carbon nanotube or methylthioninium chloride may be applied preoperatively to assist laparoscopic search of the tumor (Fig. 33.8). 3.1.3 Evaluation of Anatomical Structures The locations of the iliac vessels, inferior mesenteric artery, and inferior mesenteric vein should be identified (Fig. 33.9).

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Fig. 33.3  MRI of the rectum: Male, enlarged lymph nodes are observed in the right iliac vascular area

Camera Holder

Surgeon

Assistant

Fig. 33.4  The patient’s position Scrub Nurse

Monitor

Fig. 33.6a  Surgical team position (abdominal operation)

Surgeon’s Auxiliary Trocar (5 mm)

Camera Trocar (10 mm)

Surgeon’s Main Trocar (12 mm)

Assistans’t Main Trocar (5 mm)

Monitor

Assistans’t Auxiliary Trocar (5 mm) Assistant

Assistant

Fig. 33.5  Trocar placement (five-port method)

The length of the sigmoid colon and mesenteric vessels and the thickness of the middle mesorectum should be evaluated to determine the feasibility of transanal specimen extraction (Fig. 33.10).

Scrub Nurse

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Fig. 33.6b  Surgical team position (perineal operation)

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Fig. 33.7  Exploration of the pelvic cavity

Fig. 33.10  Evaluation of the length of mesentery

Fig. 33.8  Exploration of the tumor Fig. 33.11  The first point of the incision

iliac artery and the vas deferens (male) or at the junction of the ovary and suspensory ligament (female). For obese patients whose anatomical structures are difficult to be identified, the initial incision can be performed at the external iliac artery and the inguinal peritoneal reflection (Fig. 33.11).

Fig. 33.9  Locations of inferior mesenteric vessels and iliac vessels

3.2

Dissection and Separation

3.2.1 The First Point of the Incision The patient is placed in the Trendelenburg position. The small bowel is moved to the right upper abdomen to expose the entire pelvic cavity. The surgeon applies the ultrasonic scalpel to perform the initial incision at the junction of the external

3.2.2 Determination of the Extent of Resection After the initial incision, the posterior peritoneum is incised along the lateral side of the external iliac artery, the common iliac artery, and the inferior vena cava, finally to the area anterior to the abdominal aorta (Fig. 33.12). Care should be taken to protect the right ureter. Then, dissection is continued along the course of the vas deferens downwards in a lateral to medial fashion, until the peritoneal reflection is opened (Fig. 33.13). 3.2.3 D  issection in the Area of the Right Obturator and the Right Iliac Artery The surgeon then dissects closely along the lateral side of the external iliac artery (Figs. 33.14–33.15). The idea of en bloc resection should be always kept in mind. The dissection pro-

33  Laparoscopic Extended Lower Rectal Cancer Resection with En Bloc Lateral Lymph Node Dissection (Wang’s Approach)

Fig. 33.12  Open the posterior peritoneum along the area anterior to the right common iliac artery

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Fig. 33.15  Dissection along the lateral side of the external iliac artery

Fig. 33.16  Dissection up and down along the external iliac vein Fig. 33.13  Open the peritoneum to the peritoneal reflection

Fig. 33.17  Dissection above the obturator nerve

Fig. 33.14  Dissection along the lateral side of the external iliac artery

ceeds along the surface of the external iliac vein (Fig. 33.16). After that, the dissection goes downwards to the obturator

and then continues along the obturator nerve (Figs. 33.17– 33.18). Attention should be paid to protect the nerve. The operation should be gently performed to dissect lymphatic and connective tissues in the obturator region (Fig. 33.19), and the branches of internal iliac artery are dissected. At this point, the obturator nerve, branches of the internal iliac artery, the superior and inferior vesical artery, the obturator

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Fig. 33.18  Dissection below the obturator nerve Fig. 33.21  Branches of the internal iliac artery

Fig. 33.19  The lymphatic and connective tissues are dissected in the obturator regions

Fig. 33.22  Placement of gauze in the right obturator region

Fig. 33.20  Vascular and nerve branches in the obturator region

artery, and sometimes the superior gluteal artery can be identified (Figs. 33.20–33.21). At this point, the obturator is dissected, and a small gauze can be inserted into the obturator for hemostasis and a marker to block the dissected tissues (Fig. 33.22).

3.2.4 Dissection of the Right Ureter The right ureter is separated from the right common iliac vessel and then marked and lifted with vessel loops. The ureteral forceps is applied to lift the ureter, so as to dissect downwards along its course (Figs. 33.23–33.24). This is the key for the en bloc resection of lateral lymphatic and connective tissues. Then, the obturator tissue is still connected to the rectum through the posterior peritoneum. After the ureter is completely separated, the dissection can be further continued to the mesorectal space. 3.2.5 D  issection of the Right Common Iliac Artery and Inferior Vena Cava and Dissection of the Presacral Space The right ureter is pulled laterally, and then dissection is performed upwards along the surface of the common iliac

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Fig. 33.23  Dissection downwards along the course of the ureter

Fig. 33.26  Dissection along the surface of the inferior vena cava

Fig. 33.24  Dissection of the tissue at the posterior of ureter

Fig. 33.27  Dissection to the presacral space and the retrorectal space

Fig. 33.25  Dissection along the surface of the right common iliac artery

artery in a lateral to medial fashion. Following this, dissection proceeds upwards along the surface of the inferior vena cava (Figs. 33.25–33.26), and attention should be paid to protect the horizontal part of duodenum. At the same time, further dissection of the presacral space and the posterior mesorectal space is performed to expand the operating space (Fig. 33.27).

3.2.6 D  issection of the Abdominal Aorta and Ligation of the Inferior Mesenteric Artery The surgeon dissects along the surface of the inferior vena cava from lateral to medial to the right side of the abdominal aorta and then continues along the surface of the right common iliac artery upwards from lateral to medial. The dissected lymphatic and connective tissues anterior to the inferior vena cava are swept medially for en bloc resection (Fig.  33.28). After the exposure of the root of the inferior mesenteric artery, the artery is isolated for 1cm and then ligated with hemlock clips. The extent of isolation should be no more than enough for ligation (Figs. 33.29–33.30). 3.2.7 Ligation of the Inferior Mesenteric Vein Dissection is performed along the abdominal aorta upwards to the left, from medial to lateral, and gradually return to

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Fig. 33.28  Dissection along the surface of the abdominal aorta Fig. 33.31  Exposure of the left ureter and gonadal vessels

Fig. 33.29  Isolation of the inferior mesenteric artery

Fig. 33.30  Ligation and transection of the inferior mesenteric artery

the plane of Toldt’s fascia (because of the extended dissection, the anterior abdominal aorta is not in the same plane as the Toldt’s fascia). At this point, the left ureter and left gonadal vessels can be identified (Fig. 33.31). Further dissection is continued upwards to the lateral side, and the course of the inferior mesenteric vein and the avascular

Fig. 33.32  Isolation of the inferior mesenteric vein

Fig. 33.33  Ligation and transection of the inferior mesenteric vein

area of the sigmoid mesocolon are visible. The inferior mesenteric vein is ligated and transected at the level parallel to the extent of dissection of the abdominal aorta (Figs. 33.32–33.33). Following this, division is extended to the avascular area of the sigmoid mesocolon. Do not divide too close to the marginal vessels; the ultralow anastomosis

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anus-preserving surgery cannot be completed in the event of injury for marginal vessels.

3.2.8 D  issection of the Left Common Iliac Artery, Internal Iliac Artery, and External Iliac Artery After the transection of the inferior mesenteric vein, the mesenteric stump is lifted, and dissection is performed downwards to the common iliac artery (Fig.  33.34). The left ureter is also lifted with vessel loop for protection (Fig. 33.35). Then the surgeon dissects along the surface of the abdominal aorta and the left common iliac artery. In the posterior of the left ureter, dissection proceeds to the left internal iliac artery and to the middle of left external iliac artery (Figs.  33.36–33.37). A gauze is placed underneath the mesentery.

Fig. 33.36  Dissection to the left internal iliac artery

3.2.9 F  urther Dissection of the Posterior Mesorectal Space When the left internal iliac artery is adequately dissected, dissection should be turned to the posterior mesorectal wall

Fig. 33.37  Dissection to the left external iliac artery

Fig. 33.34  Dissection above the left common iliac artery

Fig. 33.38  Further dissection to the retrorectal space

Fig. 33.35  Identifying and protecting the left ureter

(Fig. 33.38). The dissection of the posterior wall should be gently performed to enter the “holy plane,” and the “angel’s hair” will be found. Dissection should be continued to the pelvic floor as much as possible to expose the levator ani muscle plane (Fig. 33.39).

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Fig. 33.39  Dissection to the levator ani muscle plane Fig. 33.42  Dissection along the descending colon

Fig. 33.40  Separating the adhesion of the sigmoid colon

Fig. 33.43  The extent of resection of the left peritoneum

This space is further expanded to see the underneath gauze for protection and marking (Fig. 33.41). The sigmoid mesocolon is opened as dissection goes upwards to the anterior pararenal space from medial to lateral. Then the surgeon continues dissecting to the lateral of descending colon until there is no tension (Fig. 33.42).

Fig. 33.41  Giving direct access to the gauze underneath

3.2.10 Dissection of the Adhesion of the Sigmoid Colon Subsequently, the surgeon flips the sigmoid colon to the right to detach the lateral adhesion of the sigmoid colon (Fig.  33.40) and enter the space anterior to Toldt’s fascia.

3.2.11 Determination of the Landmark for the Extended En Bloc Dissection of the Peritoneum on the Left Side The left posterior peritoneum is dissected from the left common iliac artery to the left external iliac artery and towards the peritoneal reflection (Fig. 33.43). Then, the surgeon dissects from this reflection downwards along the left vas deferens to the rectal peritoneal reflection and makes the dissection plane connected with the right side (Fig. 33.44). So far, the extent of resection resembles the wings of a butterfly.

33  Laparoscopic Extended Lower Rectal Cancer Resection with En Bloc Lateral Lymph Node Dissection (Wang’s Approach)

Fig. 33.44  Connection of the left and right peritoneum of the pelvic floor

Fig. 33.45  Dissection of tissues of the obturator region along the external iliac artery and external iliac vein

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Fig. 33.46  Dissection of tissues of the obturator region along the angle between the external iliac vein and the internal iliac artery

Fig. 33.47  The lymphatic and connective tissues are dissected in the obturator region

3.2.12 Dissection of the Left Obturator Region After the extent of extended dissection is determined, dissection is performed along the external iliac vessels to the obturator region to the obturator nerve (Fig. 33.45). Dissect at the angle between the external iliac vein and the internal iliac artery (Fig. 33.46); the lymphatic and connective tissues in the obturator region are dissected as a whole to clearly expose the obturator nerve (Fig.  33.47), branches of the internal iliac artery, the obturator artery, etc. (Fig.  33.48). Place a gauze in the obturator region for the same purpose as above specified (Fig. 33.49). 3.2.13 Dissection of the Left Ureter The ureter is lifted near the left common iliac artery after the dissection of lateral lymphatic and connective tissues of the left obturator (Fig.  33.50). Dissect downwards posterior to the ureter. At the same time, the dissected bilateral tissues are

Fig. 33.48  Vascular branches and nerves of the left obturator region

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Fig. 33.51  The dissected bilateral tissues are still connected Fig. 33.49  Placement of gauze for indication

Fig. 33.52  Isolation of rectum to the level of anal canal Fig. 33.50  Dissection of the left ureter

still connected together by the posterior peritoneum (Fig. 33.51). Adequately dissect the ureter downwards to the intersection with the vas deferens. At this point, the en bloc lymph node dissection and mesorectal dissection are basically completed.

3.2.14 Isolation of the Distal Rectum In this step, the different surgical procedures, including Miles, Dixon, or NOSES I (A–E methods), can be selected according to the tumor location, tumor size, pathological type, and depth of tumor invasion. In this case, NOSES IE (Bacon) is adopted. Further isolate the anterior and posterior walls of the rectum to the level of the anal canal, and place gauzes around the bowel (Figs. 33.52–33.54).

Fig. 33.53  Placing small gauze on the right side of the rectum

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Fig. 33.54  Placing small gauze on the left side of the rectum Fig. 33.56  Transection of the sigmoid colon

Fig. 33.55  Division of the sigmoid mesocolon in reverse direction Fig. 33.57  Anal dilation

3.2.15 Division of the Sigmoid Mesocolon A small gauze is placed underneath the sigmoid mesocolon, and the sigmoid mesocolon is divided by parallel reverse direction (Fig. 33.55). During the dissection of the mesocolon, several sigmoid vessels are ligated and transected. The dissection of the mesocolon should be long enough to allow the transanal specimen extraction. After full isolation of bowel wall at the intended resection line, the sigmoid colon is divided with a linear Endo GIA stapler (Fig. 33.56).

If the tumor location is low, there is no need to suture the rectum, but the suction device should be applied for the timely suction of liquid and fractured tissues from rectum. Apply an electric scalpel with needle electrode to make a circular incision of the bowel wall at 1 cm from the suture site of rectum, and then the gauze in the pelvic cavity could be identified (Fig. 33.59). At this point, the en bloc lymph node dissection and specimen resection are completed.

3.3

3.4

Transanal Operation

After adequate anal dilation (Fig. 33.57), the distal edge of tumor is visible. The rectum should be closed by purse-string suture at 5–10 mm from the distal edge of tumor (Fig. 33.58).

Specimen Extraction

A sterile plastic protective sleeve is inserted into abdominal cavity through the main trocar. Then the transanal specimen extraction should be gently and smoothly performed to avoid damage

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Fig. 33.58  Purse-string suture for rectal closure Fig. 33.60  Close the protective sleeve tightly

Fig. 33.61  Transanal specimen extraction Fig. 33.59  Circumferential division of the rectal wall

of the lateral lymph nodes. At the same time, the gauze in the abdominal cavity should be placed into the protective sleeve and removed together with the specimen (Figs. 33.60–33.61).

3.5

Digestive Tract Reconstruction

After irrigation with distilled water and hemostasis of the pelvic cavity (Fig.  33.62), the proximal sigmoid colon is extracted through the anus, and the mesenteric volvulus

should be carefully checked (Fig. 33.63). Pull approximately 5 cm of bowel out of the anus, and perform interrupted suture for 6–8 stitches between the stump of the anal canal and the wall of the sigmoid colon. 3–4 weeks after operation, the second anoplasty is performed in the same way as described in the chapter above. Indwell drainage tube, and perform abdominal closure.

3.6

Postoperative Abdominal Wall and Specimen Pictures (Figs. 33.64–33.67)

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Fig. 33.62  Pelvic irrigation and inspection

Fig. 33.64  Postoperative specimens Fig. 33.63  Inspection for sigmoid mesocolic volvulus

4

 ey Points, Difficulties, and Hotspots K Related to Surgery

4.1

 natomical Basis of Lateral Lymph A Node Metastasis in Rectal Cancer

A large number of anatomical studies have shown that the rectal lymphatic drainage follows three different directions: upwards, lateral, and downwards. Lateral drainage is an important route of lymphatic drainage of rectum and anal canal below the peritoneal reflection. For patients with rectal cancer below the peritoneal reflection, the incidence of lat-

eral lymph node metastasis is approximately 10–25%, and the incidence of lateral lymph node metastasis is 20.1% in patients with stage T3/4 rectal cancer. Lateral lymph nodes drain in three directions: the anterolateral approach along the superior vesical artery, inferior vesical artery, and obturator artery to the medial border of the external iliac artery; the lateral approach along the middle rectal artery to the internal iliac lymph nodes and then through the common iliac lymph nodes to the para-aortic lymph nodes; and the posterior approach along the median sacral artery into the sacral lymph nodes and then upwards to enter the lymph nodes at the bifurcation of the abdominal aorta. In addition, the Japanese Society for Cancer of the Colon and Rectum (JSCCR) Guidelines for the Treatment of Colorectal Cancer divides

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Fig. 33.67  Perineal area on day 1 after operation

Fig. 33.65  Determination of distal resection margin

Fig. 33.66  Postoperative abdominal wall display

the lateral lymph node drainage into five regions: the common iliac vascular region, the external iliac vascular region, the proximal internal iliac vascular region, the distal internal iliac vascular region, and the obturator region. These five lymphatic drainage regions are the major sites of lateral lymph node metastasis, and they are the standard extent of lymph node dissection. Therefore, in order to ensure the radical resection of tumor, it is necessary to master the ­anatomical characteristics of lateral lymph node drainage and the extent of lymph node dissection, which is very important for the surgical treatment of middle and lower rectal cancer.

Laparoscopic Right Hemicolectomy and Sigmoidectomy with Transvaginal Specimen Extraction

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Xishan Wang and Haipeng Chen

At present, with the increasing incidence of colorectal cancer, the incidence and diagnosis rates of multiple primary colorectal cancer (MPCRC) are also increasing. Patients with right colon cancer complicated with sigmoid colon cancer need to receive radical resection for both right colon cancer and sigmoid colon cancer, which involves many organs. In addition, since the right colon has many adjacent organs, complicated vasculature, and high incidence of anatomical variations, this procedure is a very difficult technique in NOSES. When NOSES is performed in the right colon alone, the vagina is the preferred route of specimen extraction. When the patient is complicated with cancer in other parts of the colon, the specimen can be extracted along with the right colon specimen through the vagina. The main operating features of right colon cancer resection include complete dissection and transection of the right hemicolon in the abdominal cavity, totally laparoscopic functional end-to-end anastomosis between the terminal ileum and transverse colon, and transvaginal specimen extraction. The specimen extraction methods for sigmoid colon resection vary based on the different tumor sizes, but the principles of CME should be strictly followed. Anatomy and dissection should be performed at the correct operating plane, which is a prerequisite for the rapid and safe operation. The operating difficulties of this procedure mainly involve three aspects. Firstly, the laparoscopic technical difficulties include the correct identification of anatomical landmarks, reasonable surgical approach and complete mesentery resection, ligation of vessels at the root of the mesentery and dissection of lymph nodes, and the exposure and protection of important tissues and organs. Secondly, in NOSES for synchronous right colon cancer and sigmoid colon cancer, intracorporeal anastomosis should be performed twice, which makes this procedure particularly complicated. Thirdly, this procedure requires surgeons and assistants to have better cooperation. In the process of speci-

men extraction, the precise application of aseptic and tumorfree techniques is crucial.

1

Indications and Contraindications of NOSES

1.1

Indications (Fig. 34.1)

1 . Right colon tumor complicated with sigmoid colon tumor. 2. The largest circumferential diameter of tumor is less than 5 cm. 3. The tumor should not invade beyond the serosa.

1.2

Contraindications

1. The largest circumferential diameter of tumor is more than 5 cm. 2. Tumor invades adjacent tissues and organs. 3. Severely obese patients (BMI>35 kg/m2).

2

 nesthesia, Patient Positioning, A Trocar Placement, and Surgical Team Position

2.1

Anesthesia Method

General anesthesia or general epidural anesthesia.

2.2

Patient Positioning

The patient is placed in functional lithotomy position (Fig. 34.2).

X. Wang (*) · H. Chen Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China © People’s Medical Publishing House, PR of China 2021 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-15-7925-7_34

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Fig. 34.1  Contrast-enhanced CT of the abdomen and pelvis and colonoscopy (1A and 1C for ascending colon lesion, 1B and 1D for sigmoid colon lesion)

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 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. 34.3). Fig. 34.2  The patient’s position

2.3

Trocar Placement

1. Camera trocar (10  mm trocar) is located at any point from the umbilicus to 2 cm below the umbilicus, which takes the right colic and sigmoid colic operation into consideration.

2.4

Surgeons’ Positions

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 the same side of the surgeon or between two legs of the

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Camera Holder Assiatant’s Auxiliary Trocar (5 mm)

Surgeon’s Main Trocar (12 mm)

Camera Trocar (10 mm)

Surgeon Assistant

Assiatant’s Main Trocar (12 mm)

Surgeon’s Auxiliary Trocar (5 mm)

Fig. 34.3  Trocar placement (five-port method)

Monitor

Scrub Nurse

Fig. 34.4b  Surgical team position (dissection and resection of the sigmoid colon and specimen extraction) Monitor

Assistant

Surgeon

Monitor Scrub Nurse Camera Holder

Fig. 34.4a  Surgical team position (right hemicolectomy)

patient. Digestive tract reconstruction: 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. Specimen extraction: The surgeons’ positions are the same as those of the dissection and resection of the sigmoid colon (Fig. 34.4a). Dissection and resection of the sigmoid colon: 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. 34.4b).

2.5

Special Surgical Instruments

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

Fig. 34.5  Exploration of the stomach and liver

3

Surgical Procedure, Techniques, and Key Points

3.1

Exploration and Surgical Planning

Based on detailed preoperative examination and surgical planning, the exploration mainly includes three steps.

3.1.1 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. 34.5).

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3.1.2 Tumor Exploration Tumors are located at the ascending colon and the middle segment of the sigmoid colon, both tumors do not invade beyond the serosa, the circumferential diameter of tumor is less than 5 cm, and the specimens can be extracted through the vagina. 3.1.3 Evaluation of Anatomical Structures The right hemicolectomy is complicated since the right colon has many adjacent organs. It is necessary to evaluate the ileocolic artery and vein, the right colic artery and vein, and the middle colic artery and vein. 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 artery and vein 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. Totally laparoscopic end-to-end or end-to-side anastomosis between the ileum and transverse colon with circular stapler is not feasible due to the limitation of the current equipment and technical conditions. Do not perform this procedure if the transverse mesocolon is too short. The feasibility of transvaginal specimen extraction is evaluated by the length of sigmoid colon and mesenteric vessels and the thickness of the mesentery.

3.2

Fig. 34.6  The angle between superior mesenteric vein and ileocolic vessels

 natomy and Dissection of the Right A Colon

3.2.1 A  natomy and Transection of the Root of Ileocolic Artery and Vein The assistant pushes the small bowel and the greater omentum to the left upper abdomen, and the course of the superior mesenteric vessels can be exposed on the mesenteric surface. A depressed and thin area at the angle between the ileocolic artery and vein and superior mesenteric vein can be seen (Fig.  34.6). With the ultrasonic scalpel, the mesentery is incised, and the vessels are isolated carefully. Then dissection is performed along Toldt’s fascia upwards from medial to lateral in a cavernous manner, and the identification of duodenum proves that the correct space has been entered. The sheath of the superior mesenteric vein is opened as far as possible at the root of the ileocolic artery and vein (Fig. 34.7). Following this, dissection is performed upwards, and direct access to the posterior on the right side is obtained. The roots of the ileocolic artery and vein are isolated. After removing the lymphatic and adipose tissues, double ligation and transection are performed with vascular clips (Fig. 34.8–34.9). 3.2.2 M  anagement of the Root of Right Colic Artery and Vein The surgeon continues to dissect upwards along the superior mesenteric vein to expose the right colic vessels. Double ligation and transection are performed at the root (Fig. 34.10).

Fig. 34.7  Opening the sheath of the superior mesenteric vein

3.2.3 M  anagement of the Root of the Middle Colic Artery and Vein Subsequently, dissection is continued upwards after cutting off the right colic artery and vein and then stopped until the posterior wall of the gastric antrum is seen through the surface of pancreatic neck. A small gauze is placed here. Following this, the surgeon dissects upwards along the superior mesenteric vein and exposes and ligates the right branch of the middle colic vessels (Fig.  34.11). At this point, all vessels supplying the right colon have been transected. 3.2.4 Dissection of the Mesocolon Along Toldt’s fascia, separation is continued up and down in a medial to lateral fashion. The dissection plane should be smooth, flat, and clean (Fig. 34.12). 3.2.5 Management of the Mesoileum Once the peritoneum below the cecum is opened, the attachment of cecum is separated as much as possible to mobilize the ileum, so as to facilitate the laparoscopic anastomosis of

34  Laparoscopic Right Hemicolectomy and Sigmoidectomy with Transvaginal Specimen Extraction

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Experience sharing: This area has many blood vessels and the operation must be performed carefully. The surgeon may place a small gauze beside the surgical field, so that compression hemostasis can be performed quickly if bleeding occurs.

Fig. 34.8  Ligation and transection of the ileocolic vein

Fig. 34.9  Ligation and transection of the ileocolic artery

Fig. 34.10  Ligation and transection of right colic vessels

the bowel. 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

Fig. 34.11  Exposure of the right branch of the middle colic vessels

Fig. 34.12  Smooth and flat dissection plane

mesenteric blood supply. Division is continued to the wall of the terminal ileum, and approximately 2  cm of the bowel wall is isolated (Fig. 34.13).

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3.2.6 M  anagement of the Greater Omentum and Station 6 Lymph Nodes The surgeon should determine the intended resection line of the transverse colon before dissecting the greater omentum (Fig. 34.14). The ultrasonic scalpel is applied to divide the greater omentum to the transverse colon wall. After pulling the greater omentum to the right abdominal cavity, the assistant lifts the gastric wall with the forceps in the left hand, and the courses of the right gastroepiploic vessels are identified. Dissection of the gastrocolic ligament starts at the transverse colon, with subsequent entry into the omental cavity. The dissection can be continued to the right along the lateral marginal vessels of the right gastroepiploic artery and vein, then the branches of colic vessels are ligated, and the trunk of the right mesenteric vessels is preserved (Fig. 34.15). Following this, dissection proceeds to the head of the pancreas to expose the right gastroepiploic vein and Henle’s trunk, and this plane is connected with the previous dissection plane.

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3.2.7 Management of the Transverse Mesocolon After the dissection in the antroduodenal area, the gauze placed underneath the mesentery can be seen. The surgeon opens the mesentery transversely and dissects to the avascular area of the transverse mesocolon. The marginal vessels are ligated and transected, while the mesentery is divided towards the intended resection line of the transverse colon, and 1 cm of the bowel wall is isolated (Fig. 34.16).

3.3

 ight Colon Specimen Resection R and Digestive Tract Reconstruction

3.3.1 Specimen Resection The transverse colon is transected at the intended resection line with a linear Endo GIA stapler (Fig. 34.17). In the isolated area of the ileum, the blood supply line is clearly visi-

Experience sharing: (1) The blood supply of the small intestine is abundant and the segmental blood supply is very obvious. The blood supply line of bowel can be clearly seen after the wall of the small intestine is isolated. (2) In the dissection of the terminal mesoileum, the bowel should be adequately mobilized to allow the bowel to be lifted to the upper abdomen, so as to facilitate the anastomosis.

Fig. 34.13  Dividing the mesoileum

Fig. 34.14  Dissection of the greater omentum

Fig. 34.15  Dissection to the right along the lateral marginal vessels of the right gastroepiploic artery and vein, ligation of the branch of colic vessels and preservation of the trunk of the right mesenteric vessels

34  Laparoscopic Right Hemicolectomy and Sigmoidectomy with Transvaginal Specimen Extraction

Fig. 34.16  Division of the transverse mesocolon and isolation of the transverse colon

3.3.2 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. The surgeon makes an incision of 10  mm in the antimesenteric side of the staple line in the terminal ileum stump (Fig. 34.19). The assistant inserts the 60 mm linear Endo GIA stapler through the 12 mm trocar and places the anvil jaw into the ileum lumen (Fig. 34.20). Similarly, another incision of 10 mm is made in the antimesenteric side of the staple line in the transverse colon stump. Then, the cartridge jaw is inserted into the colon lumen. The stapler is fired to perform the side-to-side anastomosis between the ileum and transverse colon (Fig. 34.21). Anastomotic bleeding in the bowel lumen should be excluded. After confirming that there is no anastomotic leakage, the enterotomy is lifted and transversely closed with the linear stapler, and then the functional end-to-end anastomosis is completed (Fig. 34.22). Following this, seromuscular layer suturing of the anastomosis between the ileum and

Fig. 34.17  Transection of the transverse colon

Fig. 34.19  Making an incision on the terminal ileum

Fig. 34.18  Transection of the terminal ileum

ble, and then the ileum is transected above the blood supply line with another linear Endo GIA stapler (Fig.  34.18). At this point, the right hemicolectomy is completed, and the specimen is placed in the upper abdomen below the liver.

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Fig. 34.20  Placing the cartridge jaw into the ileum

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transverse colon is performed to reduce the tension of anastomosis (Fig. 34.23). At this point, the digestive tract reconstruction after right hemicolectomy is completed. The

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resected right colon, the resected stump, and the used gauzes are put into a protective sleeve (Fig. 34.24), and then the protective sleeve is placed in the right upper quadrant.

3.4

 natomy and Dissection of the Sigmoid A Colon

3.4.1 The First Point of the Incision The patient is placed in the Trendelenburg position. The small intestine is moved to the upper abdomen, and the entire pelvic cavity is exposed, and the roots of the inferior mesenteric vessels are identified. Then, the surgeon incises the mesentery above and below the sacral promontory (Figs. 34.25 and 34.26).

Fig. 34.21  Side-to-side anastomosis between the ileum and transverse colon

3.4.2 I solation and Ligation of the Root of Inferior Mesenteric Artery and Vein With the mesorectum lifted, the surgeon dissects to the root of the inferior mesenteric artery and vein and the left side of

Experience sharing: (1) Before the anastomosis between ileum and transverse colon, the apposition between ileum and transverse colon should be examined to avoid entrapment of mesentery and fatty appendices; (2) Close cooperation of the surgeon and assistant is required for the anastomosis between ileum and transverse colon.

Fig. 34.22  Closing the stump transversely

Fig. 34.23  Suture for the reinforcement of anastomosis

Fig. 34.24  Placing the resected right colon, the resected stump, and the gauze into protective sleeve

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Fig. 34.25  The first point of the incision

Fig. 34.28  Ligation of the left colic artery and the sigmoid colic artery

Fig. 34.26  Entering the space anterior to Toldt’s fascia

Fig. 34.29  Ligation of the sigmoid colic vein

ureter and gonadal vessels. The roots of the inferior mesenteric artery and vein are exposed, and then the surrounding lymphatic and adipose tissues are removed (Fig.  34.27). After adequate isolation, the left colic vessels and the sigmoid colic vessels are ligated and transected (Figs. 34.28–34.29).

3.4.3 Dissection of the Mesorectum After the ligation of the sigmoid colic vein, the assistant lifts the posterior mesorectum, and the surgeon applies the ultrasonic scalpel to dissect along Toldt’s fascia downwards to the posterior. 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. Fig. 34.27  Isolation of the trunk of the inferior mesenteric vessels and the dissection of the lymphatic and adipose tissues

the mesentery. Meanwhile, the space is expanded along Toldt’s fascia, and the course and peristalsis of the left ureter can be identified. The surgeon then places a small gauze underneath the inferior mesenteric vessels to protect the left

3.4.4 D  issection of the Sigmoid Colon and the Left Side of the Rectum A gauze is placed underneath the sigmoid colon and mesorectum. The sigmoid colon is pulled to the right to detach the lateral adhesion of the sigmoid colon (Fig.  34.30). Along Toldt’s fascia, dissection is performed in a lateral to medial pattern (Fig.  34.31) and then continued upwards after the

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mesentery is opened. In most cases, mobilization of splenic flexure is not required. Then the dissection of the left side of the rectum proceeds downwards to the same level as the right side (Fig. 34.32).

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3.4.5 Isolation of the Bowel Below the Tumor The surgeon transects the mesorectum at about 5 cm below the tumor. The length of the isolated bowel below the tumor should be appropriately 2  cm (Fig.  34.33), and the distal bowel is transected with linear Endo GIA stapler (Fig. 34.34). 3.4.6 Dividing the Sigmoid Mesocolon A gauze is placed underneath the sigmoid mesocolon. After determining the intended resection line, division of sigmoid mesocolon is performed along the course of the inferior mesenteric vein (Fig. 34.35). The sigmoid colon wall is isolated at approximately 5  cm above the proximal edge of tumor (Fig. 34.36).

3.5

Fig. 34.30  Detachment of physiological adhesion of the sigmoid colon

 pecimen Extraction and Digestive S Tract Reconstruction

3.5.1 Specimen Extraction After the vaginal irrigation, the assistant introduces the bladder retractor through the vagina to lift the posterior vaginal Smart usage of the small gauze: During the opening of sigmoid mesocolon, the small gauze placed underneath the mesentery can be used for marking and protection to prevent accidental damage.

Fig. 34.31  Sigmoid mesocolon is dissected in a lateral to medial fashion

Fig. 34.32  Dissecting the left rectal wall downwards

Fig. 34.33  Isolation of the bowel below the tumor

34  Laparoscopic Right Hemicolectomy and Sigmoidectomy with Transvaginal Specimen Extraction

fornix (Fig.  34.37), and the surgeon makes an incision of approximately 4  cm on the vagina with a cautery hook (Fig. 34.38). The protective sleeve is introduced through the

Fig. 34.34  Transection of the distal bowel

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main trocar, and then an end of it is pulled out of the vagina with oval forceps (Fig.  34.39). Subsequently, the anvil is introduced into the abdominal cavity through the protective sleeve (Fig.  34.40). The surgeon makes an incision on the bowel wall longitudinally at 1 cm below the intended resection line of the sigmoid colon above the tumor, and the assistant suctions the intestinal contents timely (Fig. 34.41). The bowel lumen is disinfected with iodoform gauze (Fig. 34.42) before the anvil is introduced into the proximal sigmoid colon lumen (Fig.  34.43), whereafter the sigmoid colon is transected with the linear Endo GIA stapler (Fig. 34.44). At this point, the bowel segment containing sigmoid colon tumor is completely resected. The surgeon and an assistant place the used gauze and specimen into the protective sleeve and tighten the inner opening of it, and another assistant extracts the sigmoid colon specimen through the vagina at a uniform speed (Fig. 34.45). After that, the previous protective sleeve containing the right colon specimen is also extracted transvaginally (Fig. 34.46).

Experience sharing: During the dissection to the intended resection line, attention should be paid to the status of the marginal vessels. Do not transect in a parallel manner. Instead, the division should be performed by an inverse parabolic curve.

Fig. 34.35  Dividing the sigmoid mesocolon

Fig. 34.36  Isolation of wall of the sigmoid colon

Fig. 34.37  Inserting the bladder retractor for indication

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Fig. 34.38  Opening the posterior vaginal fornix

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Fig. 34.41  Making an incision on the bowel wall above the tumor, then removing the intestinal contents with suction

Fig. 34.39  Extraction of the protective sleeve through the vagina with oval forceps

Fig. 34.42  Disinfection of the bowel lumen with iodoform gauze

Fig. 34.40  Inserting the anvil into the abdominal cavity through the vagina

Fig. 34.43  Inserting the anvil into the lumen of the proximal sigmoid colon

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3.5.2 Digestive Tract Reconstruction A small incision is made in one corner of the sigmoid colon stump (Fig.  34.47), and then the anvil shaft is taken out (Fig. 34.48). A circular stapler is inserted transanally, and the trocar of it is extended to pierce the rectal stump (Fig. 34.49),

and then the anvil is connected to the trocar of stapler to complete the sigmoid colorectal end-to-end anastomosis (Fig.  34.50). The integrity of the anastomosis is checked with air leak test, and the “danger triangle of the anastomosis” can be sutured for reinforcement (Fig. 34.51).

Fig. 34.44  Transection of the sigmoid colon with a linear Endo GIA stapler

Fig. 34.47  One corner of the sigmoid colon stump is cut open

Fig. 34.45  Transvaginal extraction of the sigmoid colon specimen

Fig. 34.48  Taking out the anvil shaft

Fig. 34.46  Transvaginal extraction of the right hemicolon specimen

Fig. 34.49  Extend trocar to pierce the rectal stump

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3.5.3 C  lose the Vaginal Incision and Trocar Sites The vaginal incision is closed laparoscopically (Fig. 34.52), and the abdominal cavity is adequately irrigated. After the drainage tubes are in place, intraperitoneal gas is released, and the trocar sites are closed.

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3.6

Postoperative Abdominal Wall and Specimen Display (Figs. 34.53–34.55)

Fig. 34.53  Specimen display Fig. 34.50  Sigmoid colorectal end-to-end anastomosis

Fig. 34.51 Suture to reinforce the “danger triangle of the anastomosis”

Fig. 34.54  Postoperative abdominal wall display

Fig. 34.52  Suture the incision in the posterior vaginal fornix

34  Laparoscopic Right Hemicolectomy and Sigmoidectomy with Transvaginal Specimen Extraction

Fig. 34.55  Abdominal wall display 1 month after operation

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Laparoscopic Right Hemicolectomy and Rectal Cancer Resection with Transrectal Specimen Extraction

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Guiyu Wang, Tianyi Ma, and Qian Zhang

At present, with the increasing incidence of colorectal cancer, the incidence and diagnosis rates of multiple primary colorectal cancer (MPCRC) are also increasing. Patients with right colon cancer complicated with rectal cancer need radical resection of both right colon cancer and rectal cancer, which involve many organs. In addition, since the right colon has many adjacent organs, complicated vasculature, and high incidence of anatomical variations, this procedure is a very difficult technique in NOSES. When NOSES is performed in the right colon alone, the vagina is the only applicable route of specimen extraction. When the patient is complicated with rectal cancer, the right colon specimen and the rectal specimen can be extracted through the anus. The main operating features of right colon cancer resection include complete dissection and transection of the right colon in abdominal cavity, totally laparoscopic functional end-to-end anastomosis between terminal ileum and transverse colon, and right colon specimen extraction from the rectum or vagina. The specimen extraction methods for rectal resection vary based on the different tumor locations, but the principles of TME should be strictly followed. Anatomy and dissection should be performed at the correct operating plane, which is a prerequisite for the rapid and safe operation. The operating difficulties of this procedure mainly involve three aspects. Firstly, the laparoscopic technical difficulties include the correct identification of anatomical landmarks, reasonable surgical approach and complete mesentery resection, ligation of vessels at the root of mesentery and dissection of lymph nodes, and exposure and protection of important tissues and organs. Secondly, the technical difficulty of NOSES in the right colon cancer and rectal cancer is totally laparoscopic digestive tract reconstruction for twice, which is more difficult than other procedures. Thirdly, this procedure G. Wang (*) · Q. Zhang Department of Colorectal Cancer Surgery, Cancer Hospital of the University of Chinese Academy of Sciences, Hangzhou, China

requires surgeons and assistants to have better cooperation. In the process of specimen extraction, the precise application of aseptic and tumor-free techniques is crucial.

1

Indications and Contraindications of NOSES

1.1

Indications (Fig. 35.1)

1 . Right colon tumor complicated with rectal tumor. 2. The largest circumferential diameter of tumor is less than 5 cm. 3. The tumor should not invade beyond the serosa.

1.2

Contraindications

1. The largest circumferential diameter of tumor is more than 5 cm. 2. Tumor invades adjacent tissues and organs. 3. Severely obese patients (BMI>35 kg/m2).

2

 nesthesia, Patient Positioning, A Trocar Placement, and Surgical Team Position

2.1

Anesthesia Method

General anesthesia or general epidural anesthesia.

2.2

Patient Positioning

The patient is placed in functional lithotomy position (Fig. 35.2).

T. Ma Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China © People’s Medical Publishing House, PR of China 2021 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-15-7925-7_35

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Fig. 35.1  CT virtual endoscopy: the tumors are located at the ascending colon and the rectum

Assistant’s Auxiliary Trocar (5 mm)

Camera Trocar (10 mm)

Assistant’s Main Trocar (12 mm)

Fig. 35.2  The patient’s position

2.3

Trocar Placement

1. Camera trocar (10  mm trocar) is located at any point from the umbilicus to 2 cm below the umbilicus, which takes the right colic and rectal operation into consideration. 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.

Surgeon’s Main Trocar (12 mm)

Surgeon’s Auxiliary Trocar (5 mm)

Fig. 35.3  Trocar placement (five-port method)

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. 35.3).

2.4

Surgical Team Position

Dissection 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 the same side of the surgeon or between two legs of the patient. Digestive tract reconstruction: 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. Specimen extraction: the surgeons’ positions are the same as those of the dissection and resection of the rectum (Fig. 35.4a).

35  Laparoscopic Right Hemicolectomy and Rectal Cancer Resection with Transrectal Specimen Extraction

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a Monitor

Assistant

Surgeon

Monitor Scrub Nurse Camera Holder

b

3.1.1 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. 35.5).

Camera Holder

Surgeon Assistant

Monitor

Scrub Nurse

Fig. 35.4 Surgical team position. (a) Right hemicolectomy. (b) Dissection and resection of the rectum and specimen extraction

Dissection of the rectum: 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. 35.4b).

2.5

Fig. 35.5  Exploration of the stomach and liver

Special Surgical Instruments

Ultrasonic scalpel, 60  mm linear Endo-GIA stapler, 29  mm circular stapler, barbed suture, sterile protective sleeve.

3

Surgical Procedure, Techniques, and Key Points

3.1

Exploration and Surgical Planning

Based on detailed preoperative examination and surgical planning, the exploration mainly includes three steps:

3.1.2 Tumor Exploration Tumors are located at the right colon and near the rectal peritoneal reflection, both tumors do not invade beyond the serosa, the circumferential diameter of tumor is less than 5 cm, and the specimens can be extracted through the anus. 3.1.3 Evaluation of Anatomical Structures The right hemicolectomy is complicated since the right colon has many adjacent organs. It is necessary to evaluate the ileocolic artery and vein, the right colic artery and vein, and the middle colic artery and vein. 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 artery and vein if the operation is difficult. In addition, it is necessary to evaluate the feasibility of laparoscopic functional end-to-end anastomosis between ileum and transverse colon after the dissection of transverse colon. Totally laparoscopic end-to-end or end-to-side anastomosis between the ileum and transverse colon with circular stapler is not feasible due to the limitation of the current equipment and technical conditions. Do not perform this procedure if the transverse mesocolon is too short. The feasibility of transrectal or transvaginal specimen extraction is evaluated by the length of ­sigmoid colon and mesorectal vessels and the thickness of middle mesorectum.

3.2

 natomy and Dissection of the Right A Colon

3.2.1 A  natomy and Transection of the Root of Ileocolic Artery and Vein The assistant pushes the small bowel and the greater omentum to the left upper abdomen, and the course of the superior mesenteric vessels can be exposed on the mesenteric surface.

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Experience sharing: (1) The medial approach should be taken, and the search for ileocolic artery and vein is essential. This approach is not difficult for thin patients. However, it is difficult for obese patients. (2) This requires a surgeon to have a spatial thinking in anatomy. The marks for evaluation include: 1) There is a ridge in the course of superior mesenteric vein. 2) The horizontal part of duodenum is often visible. 3) There is a ridge in the course the ileocolic artery and vein.

Fig. 35.6  The angle between superior mesenteric vein and ileocolic vessels

continued upward along the superior mesenteric vein to expose, double ligate, and transect the right colic artery at its origin (Figs. 35.10 and 35.11). The adjacent vessels of the right colic artery and vein can be identified (Fig. 35.12).

Fig. 35.7  Open the sheath of the superior mesenteric vein

A depressed and thin area at the angle between the ileocolic artery and vein and superior mesenteric vein can be seen (Fig.  35.6). With the ultrasonic scalpel, the mesentery is incised, and the vessels are isolated carefully. Then dissection is performed along the Toldt’s fascia upward from medial to lateral in a cavernous manner, and the identification of duodenum proves that the correct space has been entered. The sheath of the superior mesenteric vein is opened as far as possible at the root of the ileocolic artery and vein (Fig. 35.7). Following this, dissection is performed upward, and direct access to the posterior on the right side is obtained. The roots of the ileocolic artery and vein are isolated. After removing the lymphatic and adipose tissues, double ligation and transection are performed with vascular clips (Figs. 35.8 and 35.9).

3.2.2 M  anagement of the Root of the Right Colic Artery and Vein The surgeon continues to dissect the surface of the duodenum along the Toldt’s fascia. After careful dissection, the right colic vein, the right gastroepiploic vein, and Henle’s trunk which converges into the superior mesenteric vein can be identified. Double ligation and transection are performed at the root of the right colic vein. Subsequently, dissection is

3.2.3 M  anagement of the Root of the Middle Colic Artery and Vein After the dissection of the right colic vessels, the surgeon continues to dissect upward until the posterior wall of the gastric antrum is seen through the surface of the pancreatic neck. A small gauze is placed here. Following this, the surgeon dissects upward along the superior mesenteric vein and then double ligates the middle colic artery and vein at the inferior border of the pancreas. At this point, all vessels supplying the right colon have been transected. 3.2.4 Dissection of the Mesocolon Along the Toldt’s fascia, separation is continued up and down in a medial to lateral fashion. The dissection plane should be smooth, flat, and clean (Figs. 35.13 and 35.14). 3.2.5 Management of the Mesoileum Once the peritoneum below the cecum is opened, the attachment of the cecum is separated as much as possible to mobilize the ileum, so as to facilitate the laparoscopic anastomosis of bowel (Fig. 35.15). 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. Division is continued to the wall of terminal ileum, and approximately 2 cm of bowel wall is isolated. 3.2.6 Management of the Greater Omentum and Station 6 Lymph Nodes The surgeon should determine the intended resection line of the transverse colon before dissecting the greater omentum (Fig. 35.16). The ultrasonic scalpel is applied to divide the

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Experience sharing: This area has many blood vessels and the operation must be performed carefully. The surgeon may place a small gauze beside the surgical field, so that compression hemo-stasis can be performed quickly if bleeding occurs.

Fig. 35.8  Isolation of the root of the ileocolic vessels

Fig. 35.9  Ligation and transection of ileocolic vessels

Fig. 35.11  Ligation of the right colic artery

Fig. 35.12  Adjacent vessels of the right colic artery and vein Fig. 35.10  Isolation of the right colic artery

greater omentum to the transverse colon wall. After pulling the greater omentum to the right abdominal cavity, the assistant lifts the gastric wall with the forceps in the left hand, and the courses of the right gastroepiploic vessels are identified. Dissection of the gastrocolic ligament starts at the transverse colon, with subsequent entry into the omental cavity (Fig.  35.17). The dissection can be continued to the right along the lateral marginal vessels of the right gastroepiploic

artery and vein (Fig. 35.18). Following this, dissection proceeds to the head of the pancreas to see the right gastroepiploic vein and Henle’s trunk, and this plane connects the previous dissection plane.

3.2.7 Management of the Transverse Mesocolon After the dissection in the antroduodenal area, the gauze placed underneath the mesentery can be seen. The sur-

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Fig. 35.13  Smooth and flat dissection plane

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Fig. 35.16  Dissection of the greater omentum

Smart usage of the small gauze: Place a gauze parallelly underneath the dissected mesentery for indication and protection (Fig 35.14).

Fig. 35.14  Placing small gauze underneath the mesentery

Experience sharing: (1) The blood supply of the small intestine is abundant and the segmental blood supply is very obvious. The blood supply line of bowel can be clearly seen after the wall of the small intestine is isolated. (2) In the dissection of the terminal mesoileum, the bowel should be adequately mobilized to allow the bowel to be lifted to the upper abdomen, so as to facilitate the anastomosis.

Fig. 35.15  Opening the peritoneum posterior to the cecum

geon opens the mesentery transversely and dissects to the avascular area of the transverse mesocolon. The marginal vessels are ligated and transected, while the mesentery is divided toward the intended resection line of the transverse colon, and 1  cm of the bowel wall is isolated (Fig. 35.19).

3.3

 ight Colon Specimen Resection R and Digestive Tract Reconstruction

3.3.1 Specimen Resection The surgeon transects the bowel at the intended resection line of the transverse colon with a linear Endo-GIA stapler

35  Laparoscopic Right Hemicolectomy and Rectal Cancer Resection with Transrectal Specimen Extraction

Fig. 35.17  Dissection and transection of the gastrocolic ligament

Fig. 35.20  Transection of the transverse colon

Fig. 35.18  Dissection to the right along the lateral marginal vessels of the right gastroepiploic artery and vein

Fig. 35.21  Dissection downward along the right paracolic sulcus

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(Fig. 35.21). In the isolated area of ileum, the blood supply line is clearly visible. Following this, the surgeon transects the ileum medial to the blood supply line with a linear Endo-­ GIA stapler. At this point, the right hemicolectomy is completed, and the specimen is placed in the upper abdomen below the liver.

Fig. 35.19  Division of the transverse mesocolon and isolation of transverse colon

(Fig. 35.20). 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, and then the gauze underneath can be seen. The ultrasonic scalpel is applied to dissect along the right paracolic sulcus to the right iliac fossa with the indication and protection of the gauze, until the dissection plane is connected with the plane below

3.3.2 Digestive Tract Reconstruction The transverse colon is straightened, and terminal ileum is pulled up to the upper abdomen to be parallel with the transverse colon. The surgeon makes an incision of 10 mm in the antimesenteric side of the staple line in the terminal ileum stump (Fig.  35.22). 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. Similarly, another incision of 10 mm is made in the antimesenteric side of the staple line in the transverse colon stump. Then, the cartridge jaw is inserted into the colon lumen (Fig. 35.23). The stapler is fired to perform the side-to-side anastomosis between the ileum and transverse colon (Fig. 35.24). Anastomotic bleeding in the bowel lumen should be excluded. After confirming that there is no anastomotic leakage, the enterotomy is lifted and transversely closed with the linear stapler, and then the functional end-to-end anastomo-

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Fig. 35.24  Side-to-side anastomosis between the ileum and transverse colon Fig. 35.22  Making an incision on the terminal ileum

3.4.2 I solation and Ligation of the Root of Inferior Mesenteric Artery and Vein With the mesorectum lifted, the surgeon dissects to the root of the inferior mesenteric artery and vein and the left side of the mesentery. Meanwhile, the space is expanded along the Toldt’s fascia (Fig. 35.29), and the course and peristalsis of the left ureter can be identified. Care should be taken to protect the ureter and gonadal vessels (Fig. 35.30). The surgeon then places a small gauze underneath the inferior mesenteric vessels, which is the avascular area of the sigmoid mesocolon. The roots of the inferior mesenteric artery and vein are exposed layer by layer, then isolated, double ligated, and transected (Fig. 35.31). Fig. 35.23  Placing the cartridge jaw into the transverse colon

sis is completed (Fig.  35.25). The resected stump tissue is placed into the specimen retrieval bag and extracted through the 12 mm trocar. Following this, seromuscular layer s­ uturing of the anastomosis between the ileum and transverse colon is performed to reduce the tension of anastomosis (Fig. 35.26). At this point, the digestive tract reconstruction after right hemicolectomy is completed. The resected right colon specimen is placed in the right upper quadrant.

3.4

Anatomy and Dissection of the Rectum

3.4.1 The First Point of the Incision The patient is placed in the Trendelenburg position. The small intestine is moved to the upper abdomen, and the entire pelvic cavity is exposed, and the roots of the inferior mesenteric vessels are identified. Then, the surgeon performs the initial incision at the thin area 3–5 cm below the sacral promontory (Figs. 35.27 and 35.28).

3.4.3 Dissection of the Mesorectum When the inferior mesenteric artery and vein are transected, the avascular area of the sigmoid mesocolon can be partially opened (Fig.  35.32). The left ureter and the left gonadal vessel should be identified and protected (Fig. 35.33). The surgeon dissects downward to the bifurcation of the left common iliac artery in a medial to lateral fashion. Dissection is continued downward along the presacral space, the course of the inferior hypogastric nerves will be visible; perform separation at the bifurcation with an ultrasonic scalpel on the nerve surface at a uniform speed (Figs. 35.34 and 35.35). Following this, the presacral dissection proceeds in conjunction with the dissection of the left and right sides of the rectum, until 5 cm below the distal margin of tumor (Fig. 35.36). The extent of dissection should not be too large. 3.4.4 D  issection of the Sigmoid Colon and the Left Side of the Rectum The sigmoid colon is pulled to the right to detach the lateral adhesion of the sigmoid colon (Fig. 35.37). Along the Toldt’s

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Experience sharing:(1) Before the anastomosis between ileum and transverse colon, the apposition between ileum and transverse colon should be examined to avoid entrapment of mesentery and fatty appendices; (2) Close cooperation of the surgeon and assistant is required for the anastomosis between ileum and transverse colon.

Fig. 35.25  Closing the stump transversely

Fig. 35.26  Suture for the reinforcement of anastomosis

Fig. 35.27  The first point of the incision

Operating skills: (1) The ultrasonic scalpel generates heat and dissects the mesenteric space. The surgeon can dissect along the presacral fascia. The white cellular tissue is visible by moving the scalpel tip up and down. Dissect along this space so that the mesentery can be lifted to a certain extent (Fig 35.28); (2) The assistant lifts the anterior wall of the upper rectum and the root of the inferior mesenteric artery, so that the complete view and course of the pelvic cavity and inferior mesenteric vessels will be under full visualization.

Fig. 35.28  Entering the space anterior to Toldt’s fascia

fascia, dissection is performed in a lateral to medial pattern, and then the mesocolon is opened (Fig. 35.38). In most cases, mobilization of splenic flexure is not required. Then, the dissection of the left side of the rectum proceeds downward to the same level as the right side (Fig. 35.39).

3.4.5 Isolation of the Bowel Below the Tumor Confirm the tumor location and isolate approximately 3 cm of bowel wall within 5 cm below the distal edge of tumor. At the peritoneal reflection, the dissection is continued downward along the Denonvilliers’ fascia. The seminal vesicles

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can then be clearly exposed (Fig.  35.40). After that, in the left and right sides, the rectal wall is isolated, and the mesorectum is transected (Figs.  35.41 and 35.42). Isolation in both sides should reach the same level.

Fig. 35.29  Dissection of the root of the inferior mesenteric artery

3.4.6 Dividing the Sigmoid Mesocolon The sigmoid colon is flipped to the left; then the gauze underneath the sigmoid mesocolon can be seen. The intended resection line is determined (Fig. 35.43). By lifting the mesocolon, the courses of the inferior mesenteric artery and vein are exposed. The division of mesocolon is performed along the course of them, and several sigmoid colon vessels are ligated and transected (Fig.  35.44). Gradually, division is Smart usage of the small gauze: The gauze can be used to protect the ureter underneath it. Rotate the camera to see the gauze marking underneath the inferior mesenteric vessels (Fig 35.30).

Fig. 35.30  Placing the gauze on the left lateral side of the mesentery

Experience sharing: (1) Enbloc resection technique should be mastered in the dissection of lymph nodes at the root of mesentery; (2) The isolated length of blood vessel should not be longer than enough for ligation. When the inferior mesenteric artery and vein are adjacent to each tother, he artery and vein can be ligated at the same time. Otherwise, they can be ligated separately.

Fig. 35.31  Ligation and transection of the inferior mesenteric artery

Experience sharing: The sigmoid mesocolon should not be over -dissected. Otherwise, the mobility of sigmoid colon will be increased, and thereby affect the subsequent operation.

Fig. 35.32  Open the avascular area of sigmoid mesocolon

35  Laparoscopic Right Hemicolectomy and Rectal Cancer Resection with Transrectal Specimen Extraction

Fig. 35.33  Exposure and protection of ureters and gonadal vessels

Fig. 35.34  Dissection to the left from the presacral space

Fig. 35.36  Dissection of the right rectal wall

Fig. 35.37  Detachment of physiological adhesion of the sigmoid colon

3.5

Fig. 35.35  Dissection to the right from the presacral space

continued to the intended resection line, and approximately 2 cm of the bowel wall is isolated (Fig. 35.45). The length of the dissected sigmoid colon should be long enough to be extracted out of the anus.

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 pecimen Extraction and Digestive S Tract Reconstruction

3.5.1 Specimen Extraction After gentle anal dilation and rectal irrigation, iodoform gauze is introduced through the anus below the tumor. The assistant holds the suction in the right hand at 2 cm below the tumor to avoid the intestinal content entering into the abdominal cavity when the bowel is incised transversely. The surgeon applies the ultrasonic scalpel to open the rectal wall transversely 2 cm below the tumor under the guidance of the gauze in the lumen (Fig. 35.46). Afterward, the second assistant inserts the oval forceps through the anus to remove the iodoform gauze. The protective sleeve is placed in the abdominal cavity through the main trocar, and then one end of the sleeve is clamped with the oval forceps and pulled out of the anus (Fig. 35.47). The dissected right colon specimen is placed into the protective sleeve and pulled out of the anus with oval forceps (Fig. 35.48). Following this, the surgeon and the assistant place the rectal stump and the dissect rec-

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Smart usage of the small gauze: During the opening of sigmoid mesocolon, the small gauze placed underneath the mesentery can be used for marking and protection to prevent accidental damage.

Fig. 35.38  The sigmoid mesocolon is dissected in a lateral to medial fashion

Fig. 35.39  Dissecting the left rectal wall downward

Fig. 35.40  Dissection of the anterior rectal wall

Fig. 35.41  Isolation of the right rectal wall

Fig. 35.42  Isolation of the left rectal wall

Experience sharing: The length of the dissected sigmoid mesocolon should be long enough, i.e., the length of the rectal stump is about 5-7 cm, to facilitate the specimen extraction from the anus.

Fig. 35.43  Dividing the sigmoid mesocolon

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Fig. 35.44  Dissection, ligation, and transection of vessels of the sigmoid mesocolon

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Fig. 35.45  Isolation of wall of the sigmoid colon

Operating key points: Intraperitoneal incision of the bowel is a special step in this procedure. Improper operation may cause intestinal content to enter into the abdominal cavity. Therefore, the surgeon and assistant should cooperate closely during the operation and strictly follow the principle of aseptic operation.

Fig. 35.46  Transverse opening of the rectum

Operating skills:(1) The clamping of rectal stump with the oval forceps should be precise. Do not clamp other tissues that may result in secondary damage; (2) During the operation, avoid anal air leakage and maintain pneumoperitoneum; (3) The extraction of bowel out of anus should be performed gently and slowly; (4) Insertion of sterile plastic sleeve can provide lubrication, support and protection, and it is a key point of aseptic and tumor-free operation.

Fig. 35.47  Transanal placement of sterile plastic protective sleeve

tum into the protective sleeve (Fig.  35.49). The assistant clamps the proximal bowel stump with the oval forceps and slowly pulls it out of the anus. Once the bowel segment which needs to be removed is completely extracted, purse-­ string forceps is applied to clamp the proximal intended resection line of the sigmoid colon. The sigmoid colon is transected to remove the specimen.

3.5.2 Digestive Tract Reconstruction The anvil is introduced into the sigmoid colon stump and secured with the purse-string suture. After being rinsed and disinfected, the sigmoid colon stump is returned into the abdominal cavity with the oval forceps. The rectal stump is closed with a linear Endo-GIA stapler (Fig.  35.50). Dilute iodine solution is injected into the abdominal cavity for irri-

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gation. After anal dilation, the circular stapler is inserted transanally, and then the anvil is connected with the trocar of stapler to complete the end-to-end anastomosis (Figs. 35.51 and 35.52). Air leak test is performed to confirm the integrity of the anastomosis (Fig.  35.53). Two drainage tubes are placed in the pelvic cavity (Fig. 35.54).

3.6

Postoperative Abdominal Wall and Specimen Display (Figs. 35.55 and 35.56)

4

 ey Points, Difficulties, and Hotspots K Related to Surgery

4.1

 pplication of Minimally Invasive A Treatment in MPCRC

Fig. 35.48  Transanal extraction of right colon specimen

Fig. 35.49  Transanal extraction of rectal specimen

Fig. 35.50  Closing of the rectal stump

Fig. 35.51  The trocar of stapler is extended to pierce a corner of the rectal stump

For MPCRC of different bowel segments, traditional open surgery is very traumatic to patients, and a large abdominal incision across the upper and lower abdomen must be made to simultaneously complete the radical resection of double or multiple lesions. The popularization of laparoscopic surgery has brought a new procedure for the treatment of MPCRC. Under the laparoscopic surgery, not only the radical resection of tumor can be achieved; the trauma to the patients is smaller. However, conventional laparoscopic surgery leaves an incision of approximately 5–8 cm in addition to the trocar ports. In NOSES, the specimen is extracted through natural orifice like the anus or vagina, which makes it a minimally invasive surgical procedure with smaller trauma and better effects. With this technique, the development from small incision to incision-free is realized. There is no uniform standard for postoperative adjuvant therapy for multiple primary colorectal cancer. Adenocarcinoma is the most common pathological type of MPCRC, which is similar to that of single primary colorectal

Fig. 35.52  Sigmoid colorectal end-to-end anastomosis

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Experience sharing: Air or water leak test is essential in this procedure. If anastomotic leakage occurs, laparoscopic 8-figure suture can be performed.

Fig. 35.53  Air leak test

Fig. 35.54  Placement of drainage tube

Fig. 35.56  Specimen display

with multiple primary cancer is higher than that of patients with single primary cancer and the same patient has different pathological types and differentiated degrees, we tend to recommend chemotherapy regarding whether to adopt postoperative adjuvant chemotherapy for stage II patients without high-risk factors. Studies have shown that there is no significant difference in the prognosis of MPCRC and single primary colorectal cancer with the same pathological stage and radical resection treatment.

Fig. 35.55  Abdominal wall display

4.2

 ifferences Between Combined Organ D Resection and Multiple-Organ Resection

cancer. According to TNM classification (American Joint Committee on Cancer, 8th ed.), the tumor stage is determined by the highest stage of all lesions. Therefore, the selection of chemotherapy regimen is determined by the lesion with the highest TNM stage. Combined with our clinical experience, considering that the tumor load of patients

In order to accurately define the concept of combined organ resection and multiple-organ resection, it should be clarified that advanced colorectal cancer should be divided into two types: locally advanced and systemically advanced. For

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patients with systemically advanced disease, i.e., stage IV patients, multiple-organ resection is required to achieve the goal of radical treatment, e.g., radical resection of rectal cancer combined with partial hepatectomy for liver metastases, etc. For patients with locally advanced disease, it is necessary to resect the adjacent organs invaded by the tumor to achieve combined organ resection, e.g., the operation for partial liver invasion of hepatic flexure cancer. In other words, multiple-organ resection refers to the resection of more than two organs due to tumor metastasis to distant organs to meet the need for radical resection, while combined organ resection refers to the resection of more than two adjacent organs due to tumor invasion (inflammatory or cancerous) to adjacent organs. Clarification of the concepts of combined organ resection and multiple-organ resection can avoid confusion of clinical medical vocabulary. In the meantime, it can facilitate the

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accurate evaluation of the prognosis of patients and the management of multicenter clinical data to establish a unified standard. With the differentiation of subspecialties in clinical practice, more and more multiple-organ resection operations need to be performed by colorectal surgical oncologists in cooperation with hepatobiliary surgeons and thoracic surgeons, which is consistent with the principle and trend of multidisciplinary team (MDT) collaboration. In contrast, combined organ resection is usually performed independently by a colorectal surgical oncologist. However, because of the increasing differentiation of specialties, it is indeed difficult for most young surgeons to subjectively evaluate the feasibility of tumor resection. In addition, the potential risks of performing major surgeries in the current medical situation are self-evident. Therefore, the surgeons must obtain the informed consent as well as faith and understanding of the patients and their families before operation.

Laparoscopic Rectal Cancer Resection Combined with Liver Metastasis Resection with Transanal Specimen Extraction

36

Chuangang Fu

C. Fu (*) Department of Gastrointestinal Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China

1

Indications and Contraindications of NOSES

1.1

Indications (Figs. 36.1–36.4)

Middle Rectum

Lower Rectum

5cm

Upper Rectum

5cm

General requirements for primary rectal lesion: 1. Tumor is located in the rectum, the junction between the rectum and sigmoid colon, and the junction between the descending colon and sigmoid colon. 2. According to intraoperative evaluation, the largest diameter of the bowel along with the mesentery and tumor is less than 7 cm. 3. The tumor does not invade the adjacent organs and should not invade beyond the serosa. 4. BMI30kg/m2. For liver metastases: 1. Liver tumor located in the liver parenchyma that is difficult to be resected. 2. Invasion of the great vessels of liver and its secondary branch vessels.

Fig. 36.3  Rectal MRI: T2, maximum diameter of 5.3 cm

For liver metastases: 1. R0 resection of primary lesion and liver metastases can be achieved, and sufficient remnant liver function can be preserved (remnant liver volume is generally required to be >50%). 2. Diameter of liver metastases ≤3 cm, number ≤6. 3. The tumor is located on the surface or in the periphery of segments II, III, IVb, V, and VI of the liver and has no close relationship with the great vessels or secondary branch vessels of the liver. 4. Hilar lymph nodes need no dissection.

2

 nesthesia, Patient Positioning, A Trocar Placement, and Surgical Team Position

2.1

Anesthesia Method

General anesthesia.

2.2

Patient Positioning

The patient is placed in lithotomy position, with the right thigh slightly lowered (Fig. 36.5).

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Camera Holder

Assistant

Surgeon

Fig. 36.5  The patient’s position

Scrub Nurse Monitor Surgeon’s Auxiliary Trocar (5 mm)

Camera Trocar (10 mm)

Surgeon’s Main Trocar (12 mm)

Assistant’s Main Trocar (12 mm)

Assistant’s Auxiliary Trocar (5 mm)

Fig. 36.7  Surgical team position

and right side of the patient, respectively (Fig. 36.7). Liver tumor resection: The monitor should be placed on the right anterior side of the patient, the surgeon should stand between the patient’s legs, and the assistant and camera holder should stand on the left side of the patient.

Fig. 36.6  Trocar placement (five-port method)

2.5

2.3

Ultrasonic scalpel, spatula electrode, 45/60 mm linear Endo-­ GIA stapler, 28 mm circular stapler, sterile protective sleeve.

Trocar Placement (Fig. 36.6)

1. Camera trocar (10 mm trocar) is located 2 cm above the umbilicus. 2. The surgeon’s main trocar (12 mm trocar) is better located at the McBurney’s point and slightly medially located during ultralow rectal surgery. 3. The surgeon’s auxiliary trocar (5 mm trocar) is located at 5 cm above the intersection of the umbilicus level and the right midline. 4. The assistant’s auxiliary trocar (12 mm trocar) is located opposite the McBurney’s point. 5. The assistant’s main trocar (5 mm trocar) is located at the umbilical level at the lateral edge of the left rectus abdominis.

2.4

Surgical Team Position

Rectal tumor resection: The positions of the surgeon, assistant, and camera holder should be on the right side, left side,

Special Surgical Instruments

3

Surgical Procedure, Techniques, and Key Points

3.1

Exploration and Surgical Planning

3.1.1 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. 36.8). 3.1.2 Tumor Exploration The location and size of the tumor and whether it invades the serosal surface should be examined carefully. The thickness of the mesentery, the longest diameter of the tumor and mesentery, and whether the specimen can be extracted through the anus are evaluated (Fig. 36.9).

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Anatomy and Dissection

3.2.1 Opening the Sigmoid Mesocolon The surgery is performed with medial approach. An incision is made in the posterior peritoneum longitudinally along the Toldt’s fascia on the right of the sigmoid colon. Dissection is performed upward to the root of the inferior mesenteric artery and downward to 5 cm distal to the tumor or the peritoneum of the pelvic floor. The space anterior to the Toldt’s fascia is entered (Figs. 36.10–36.12). 3.2.2 E  xposure and Transection of the Root of the Inferior Mesenteric Artery The surgeon expands the space anterior to Toldt’s fascia to the left cephalad. After the root of the inferior mesenteric artery is exposed, it is ligated with Hem-o-lok clips and transected. Following this, dissection is continued to the lateral side of the descending paracolic sulcus, and attention should be paid to protect the gonadal vessels and the ureter (Figs. 36.13–36.15).

Fig. 36.8  Exploration of the liver

3.2.3 Dissection of the Rectum Dissection is performed downward along the Toldt’s fascia, and then the posterior, lateral, and anterior rectal walls are isolated. Attention should be paid to the protection of the hypogastric and pelvic nerves (Figs.  36.16–36.20). During the dissection of the anterior wall, the peritoneum is incised at 2 cm above the peritoneal reflection, and then the Denonvilliers’ fascia is opened to expose the seminal vesicle or vaginal wall. After the division of sigmoid mesocolon, the rectal wall is isolated to more than 2 cm below the tumor (Fig. 36.21).

3.3

 pecimen Resection and Digestive S Tract Reconstruction

3.3.1 R  ectal Specimen Resection and Extraction The intended anastomotic site is selected at about 10  cm proximal to the tumor. It is crucial to ensure that reserved bowel has sufficient length and anastomosis is tension-free. The surgeon isolates the proximal bowel wall and transects the bowel with a linear Endo-GIA stapler. Afterward, the bowel at 2–4 cm from the distal edge of tumor is isolated and ligated with a band (Fig.  36.22). The ultrasonic scalpel is used to transect the distal bowel wall approximately 1  cm distal to the tumor ligature, and local disinfection is performed with iodoform gauze (Figs. 36.23–36.24). A protective sleeve which is approximately 25 cm in length is inserted into the right lower abdomen through the main trocar (Figs. 36.25–36.26). Perineum group: Before the distal bowel is transected, the surgeon should fully dilate the anus to accommodate four fingers, irrigate the rectal lumen with normal saline repeatedly, and remove the excessive liquid in the lumen with clean gauze. After the transection of distal bower, the toothed

Experience sharing: Small tumor that does not invade the serosa is difficult to be located. The bowel can be clamped with forceps for localization, and intraoperative colonoscopy can be performed if necessary.

Fig. 36.9  Exploration of rectal tumor

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Kocher forceps is inserted through the anus to 4–5 cm above the rectal stump. The ligated end of the protective sleeve is clamped and pulled out through the rectum. Approximately 7–8 cm of protective sleeve is retained above the rectal stump in the abdominal cavity. The distal end of the transanally extracted protective sleeve is opened. A 28# or 29# anvil is held with the Kocher forceps and placed into the abdominal cavity through the protective sleeve (Fig. 36.27). The proximal bowel stump is also clamped by Kocher forceps and pulled out through the protective sleeve (Figs. 36.28–36.30).

Fig. 36.10  Identification of the Toldt’s fascia and making an incision at the level of sacral promontory

3.3.2 Digestive Tract Reconstruction After adequate pelvic irrigation, the distal rectal stump is lifted and closed with linear Endo-GIA stapler (Fig. 36.31).

Experience sharing: The assistant fully expands the sigmoid mesocolon, and the Toldt’s fascia can be easily identified with the effect of the ultrasonic scalpel.

Fig. 36.11  Searching and entering the space anterior to Toldt’s fascia

Experience sharing: The correct use of spatula electrode can achieve better dissection and ensure entering the correct plane.

Fig. 36.12  Expanding the space anterior to Toldt’s fascia

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Experience sharing: Transect the inferior mesenteric artery 2 cm from the root. Do not damage the inferior mesenteric plexus nerve around the sheath of blood vessels.

Fig. 36.13  Transection of the root of the inferior mesenteric artery

Experience sharing: Always dissect along the Toldt's fascia, and damage to the ureter can be avoided by preserving the thin membrane anterior to the ureter.

Fig. 36.14  Expanding the space anterior to Toldt’s fascia cephalad from medial to lateral

Experience sharing: Do notrush to transect the inferior mesenteric vein. Otherwise, the tent-like structure will be hard to form, which does not facilitate the expansion of the space anterior to Toldt's fascia.

Fig. 36.15  Transection of the inferior mesenteric vein

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Experience sharing: Attention should be paid to the protection of the bilateral hypogastric and pelvic nerves.

Fig. 36.16  Dissection of the posterior rectal wall

Fig. 36.17  Dissection of the posterior rectal wall

A clean gauze is placed underneath the proximal bowel stump for protection. The proximal bowel stump is opened with an incision, and then the bowel lumen is disinfected with iodoform gauze (Fig. 36.32). The stapler anvil is introduced into the stump lumen, and the bowel wall of the stump is closed with two to three Hem-o-lok clips (Fig. 36.33). The bowel wall of the stump is circularly fixed to the anvil shaft with a laparoscopic snare, and excessive bowel wall tissues should be removed with scissors (Figs. 36.34–36.35). A 28# circular stapler is inserted through the anus, and the middle of the distal rectal stump is penetrated by the trocar of the stapler. The anvil shaft is connected with the trocar to complete the anastomosis (Fig. 36.36).

Experience sharing: After the exposure of the seminal vesicle, it should be noted that the direction ofthe ultrasonic scalpel is always consistent with the "line between the seminal vesicle tail and the hypogastric nerve". By the dissection to the seminal vesicle tail, the direction of dissection should be medial to avoid damage to the urinary and gonadal neurovascular bundles.

Fig. 36.18  Dissection of the right rectal wall

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Experience sharing: When the location of the tumor is low, the left peritoneum should not be resected too much to avoid excessive tension when suturing the pelvic floor.

Fig. 36.19  Dissection of the left rectal wall

Experience sharing: There is a loose space between the seminal vesicle and Denonvilliers’ fascia, and the anatomy should be performed in this space. The Denonvilliers’ fascia should be transected when the anterior rectal space is dissected until full exposure of bilateral seminal vesicles. Otherwise, bleeding and damage to the nerves innervating the seminal vesicles are prone to occur.

Fig. 36.20  Dissection of the left rectal wall

For lower rectal cancer, especially when the anastomosis is less than 4 cm from the dentate line, if the distal stump is difficult to be closed with the stapler, purse-string suture with barbed suture can be used instead of stapler (Figs. 36.37– 36.38). In most cases, the anastomosis can be performed with the circular stapler. After checking the integrity of the anastomosis, the distal and proximal mesentery posterior to the anastomosis is sutured in a continuous pattern with V-Loc barbed suture. The seromuscular layer suture of the anterior wall and bilateral bowel can also be performed. For lower rectal cancer, the peritoneum of the pelvic floor should be sutured to be closed (Fig. 36.39). Fig. 36.21  Dividing the sigmoid mesocolon

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Experience sharing: Ligate the bowel with a band is firm, and can reduce the use of stapler cartridge.

Fig. 36.22  Ligation of bowel distal to the tumor with gauze

Fig. 36.23  Transection of proximal bowel with linear Endo-GIA stapler

Fig. 36.24  Disinfection of the opened bowel lumen with iodoform gauze

Experience sharing: The sterile protective sleeve is introduced intraperitoneally and then pulled out of the anus from the rectal stump, which effectively avoids retrograde contamination in the abdominal cavity.

Fig. 36.25  Placement of plastic protective sleeve through the main trocar

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Experience sharing: The protective sleeve is cut from the laparoscopic protective sleeve manufactured by 3L Medical Products Group Co., Ltd in China. 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. Lubricate the sleeve with approximately 5 mL of paraffin oil during the preparation.

Fig. 36.26  Placement of protective sleeve

3.4

Fig. 36.27  Inserting the anvil through the protective sleeve in the rectum

Resection of Liver Metastases

The surgeon uses the ultrasonic scalpel to transect the ligamentum teres hepatis and falciform ligament to adequately expose the liver metastases (Figs. 36.40–36.41). For tumors located at the costal margin of the liver, the ultrasonic scalpel is used to resect the metastatic tumors one by one, with resection margin of 0.5  cm. The resected tumors are placed in a specimen retrieval bag and temporarily placed in the upper abdomen (Figs. 36.42–36.43). During the resection and dissection, the obvious hepatic ducts should be ligated with titanium or Hemo-lok clips. Hemostasis is ensured with bipolar electrocoagulation, and hemostatic gauze can also be used (Fig. 36.44). For tumors that are visible on the surface of the liver, the intended resection line may be marked with a cautery hook

Experience sharing: The dissected thinner proximal bowel stump is clamped by the Kocher forceps. The surgeon and assistant apply forceps to pull the edge of the rectal stump upwards to prevent it from being flipped into the lumen, which may interfere with the specimen extraction.

Fig. 36.28  Placement of resected specimen into the protective sleeve

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Experience sharing: After the specimen is fully placed in the protective sleeve, tighten the ligating band at the opening of the proximal side of protective sleeve, and close it with the large Hemolock forceps. The protective sleeve is extracted along with the specimen.

Fig. 36.29  Transanal extraction of specimen and protective sleeve

Fig. 36.30  Transanal extraction of specimen and protective sleeve of the perineal group

Fig. 36.32  Open the proximal stump

Fig. 36.31  Closure of rectal stump with stapler

Fig. 36.33  Insertion of the anvil

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Fig. 36.34  Fixation of the anvil with vascular clip and snare

C. Fu

Fig. 36.35  Trimming of excessive tissue

Experience sharing: For the middle and higher rectum, if the anastomosis is unsatisfying, continuous seromuscular suturing of anastomosis can be performed for reinforcement with barbed suture.

Fig. 36.36  Inserting the circular stapler from the anus to perform anastomosis

Experience sharing: If the distal rectal stump is not long enough and there is difficulty in closing the stump with stapler, the distal end can be closed with continuous purse-string suture using the barbed suture.

Fig. 36.37  Continuous suture of rectal stump with barbed suture

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or spatula electrode 0.5 cm around the tumor, and then the tumor is resected with the ultrasonic scalpel (Figs.  36.45– 36.47). For multiple metastases on the surface of the liver, cauterization of tumors with a spatula electrode can achieve good effects as well (Fig. 36.48).

Fig. 36.38  Continuous suture of rectal stump with barbed suture

4

 ey Points, Difficulties, and Hotspots K Related to Surgery

4.1

 urgical Strategies for Liver Metastases S of Colorectal Cancer

For patients with liver metastases of colorectal cancer, if the primary and metastatic lesions are resectable, whether to

Experience sharing: For tumors below the peritoneal reflection, the pelvic floor should be closed to prevent postoperative pelvic floor hernia and to prevent abdominal infection caused by the anastomotic leakage.

Fig. 36.39  Closing the pelvic floor

Experience sharing: For liver metastases of colorectal cancer, it is generally recommended to resect the liver metastases first, and then change the position of monitor to resect the primary lesion.

Fig. 36.40  Transection of the falciform ligament

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perform simultaneous resection or staged resection remains controversial. There are three strategies available: (1) classic staged resection, i.e., resection of the primary rectal lesion followed by chemotherapy and resection of liver metastases, (2) simultaneous surgical resection, and (3) the principle of “liver first approach,” i.e., resection of the liver metastases followed by resection of the primary lesion. With the development of technology, the size, number, location, and distribution of liver metastases are no longer the single determinant of whether patients with liver metastases of colorectal cancer are suitable for surgery. Whether to perform simultaneous resection should be based on the characteristics of the primary and metastatic lesions, the patient’s physical condition, the surgery difficulty, and the experience of the surgical team, etc. Individualized decision should be made after adequate discussion by the multidisciplinary team. Simultaneous resection generally requires the following criteria: (1) The primary colorectal cancer can be radically resected. (2) According to the anatomical basis of the liver and the extent of lesion, R0 resection of liver metastases and adequate pres-

ervation of liver function (remnant liver volume ≥ 50%) can be achieved. (3) The patient’s physical condition can tolerate the procedure, with no unresectable extrahepatic metastases, or only with nodular lesions in the lung, which does not interfere with the decision of liver metastases resection. Simultaneous surgery for liver metastases of colorectal cancer includes the following: conventional open surgery, laparoscopic resection of rectal cancer combined with open resection of liver lesions, combined conventional laparoscopic-­ assisted resection of rectal cancer and liver metastases, and NOSES combined with liver metastasis resection. For patients with liver metastases of rectal cancer, the indications of NOSES should be strictly followed, especially for liver metastases. The indications generally include the following: the diameter of liver tumor should be ≤ 3 cm, single or a few lesions, located on or around the liver surface, and easy to operate under laparoscopy. Patients in need of anatomical hepatectomy, hemihepatectomy, or hilar lymph node dissection should be selected with caution. In addition, attention should be paid to ensure R0 resection as much as possible.

Fig. 36.41  Transection of the ligamentum teres hepatis

Fig. 36.43  Complete tumor resection

Experience sharing: The ultrasonic scalpel remains in a semi-closed position, and the jaws are gradually closed while making the incision. In addition, care should be taken to ensure negative resection margin.

Fig. 36.42  Marking of 0.5 cm from the tumor edge

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Experience sharing: Laparoscopic radiofrequency ablation is performed to metastases d 3 cm in diameter located deep in the liver or near major blood vessels indicated by preoperative liver MRI.

Fig. 36.44  Wound hemostasis

Fig. 36.45  Tumor located on the surface of the liver

Fig. 36.46  Marking of intended resection extent with a cautery hook

Fig. 36.47  Complete tumor resection

Fig. 36.48  Cauterization of tumors with a spatula electrode

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4.2

C. Fu

 iscussion on the Resection Margin D of Liver Metastases

For the resection of liver metastases, most previous guidelines have recommended resection margin of more than 1 cm as the criterion. However, recent studies have found that even the resection at less than 1 cm from the edge of tumor does not increase the risk of local recurrence as long as the resection margin is negative. Their overall survival and disease-­free survival are not different from those with resection margin more than 1 cm. Studies have shown that even R1 resection has better long-term efficacy than that of chemotherapy alone. Particularly, laparoscopic resection of liver metastases mainly adopts energy platform tools such as the ultrasound scalpel, which has a good intraoperative hemostatic effect. Moreover, the cauterization of tissue at the resection margin can be as deep as 1 cm, which can effectively reduce positive resection margin and achieve R0 resection as much as possible.

4.3

Specimen Extraction Skills

1. Clamping the proximal stump with forceps to pull it out. 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 the abundant mesenteric fat surrounding the rectal ampulla, the diameter of the distal bowel stump 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 should be avoided during extraction, and the smaller proximal bowel should be clamped and pulled out through the protective sleeve firstly. 2. If the specimen is thick in diameter and difficult to be pulled out, the Kocher forceps can be used to transversely clamp the bowel that has been pulled out of the body to assist in the extraction. If the specimen has been completely placed in the protective sleeve, the proximal ligating band can be ligated, and the perineal specimen and the protective sleeve can be pulled together, which facilitates the specimen extraction and maintains the integrity of the tumor specimen. 3. For specimen with a long resected bowel and residue gas or liquid in the bowel lumen, the left part in the body may develop bowel dilatation after part of the bowel has been extracted out of the body, which makes it difficult for the subsequent extraction. In this case, a small incision can be made on the side of the 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. The abovementioned measures can effectively avoid intraperitoneal contamination, reduce the incidence of postoperative infection, and facilitate the extraction of large specimens.

4.4

Nerve Preservation

1. Dissection of the retrorectal space. Entering the correct retrorectal space is the key to protect the nerves. As has been noted, after entering the retrorectal space, the posterior wall of the rectum is dissected first, and the rotatable camera of the 3D laparoscopy can be placed deep in the pelvic floor to identify the planes. After the tunneling dissection along the retrorectal space, the dissection is turned to the bilateral sides, and large bilateral hypogastric nerves are usually seen when the folds of the bilateral pararectal sulcus are approached. They are usually located 1–2 cm away from the ureter and accompany it. “Active dissection” of hypogastric nerves is not recommended for patients whose nerves are not obviously exposed, which is prone to cause “man-made damage.” The correct approach is to always follow the correct dissection plane of the retrorectal space. 2. Management of the Denonvilliers’ fascia. The skill of anterior rectal wall dissection is to follow the sequence of “posterior wall-bilateral sides-anterior wall,” i.e., dissect downward from the retrorectal space to the rectosacral fascia (Waldeyer’s fascia), and then further dissect to the plane of levator ani muscle. Note that the rectum inherent fascia and the presacral fascia fuse with each other below the S4 level, where the rotatable camera of the 3D laparoscopy should be adjusted to dissect carefully under direct vision. Pay attention not to damage the venous plexus and nerves posterior to the presacral fascia. When dissecting from the posterior wall to the bilateral sides, an incision is made along bilateral pararectal sulcus to the peritoneal reflection. After the exposure of the seminal vesicle, it should be noted that the direction of the ultrasonic scalpel is always consistent with the “line between the seminal vesicle tail and the hypogastric nerve.” By the dissection to the seminal vesicle tail, the direction of dissection should be medial, because the urinary and gonadal neurovascular bundles are located lateral to the prostatic capsule at the lateral edge of the Denonvilliers’ fascia, where the nerve damage is prone to cause erectile dysfunction. In addition, violent traction of 2 o’clock and 10 o’clock direction should be avoided to prevent damage to the nerves.

Laparoscopic Right Hemicolectomy Combined with Pancreaticoduodenal Resection with Natural Orifice Specimen Extraction

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Gang Yu

Colon cancer is one of the common malignant tumors of the digestive tract. The invasion of the pancreatic head and duodenum is rare. In order to achieve R0 resection, the extent of resection must be increased and pancreaticoduodenectomy should be combined. Nowadays, the minimally invasive technique is subverting traditional surgical methods and concepts. Total laparoscopic D3 right hemicolectomy combined with pancreaticoduodenectomy by NOSES is the most complex procedure. The operating difficulties of this procedure mainly involve four aspects. Firstly, the laparoscopic technical difficulties include the correct identification of anatomical landmarks, reasonable surgical approach and complete mesentery resection, ligation of vessels at the root of mesentery and dissection of lymph nodes, and the exposure and protection of important tissues and organs. Secondly, the totally laparoscopic digestive tract reconstruction is far more difficult than that in other procedures. Thirdly, the special NOSES operations require strict compliance with aseptic and tumor-free principles. Fourthly, with the wide extent of resection and high degree of difficulty in digestive tract reconstruction, this procedure not only requires high skills of the surgeon, but also puts forward high requirements for team cooperation.

1

Indications and Contraindications of NOSES

1.1

Indications (Fig. 37.1)

1. Locally advanced right colon cancer, invading the pancreatic head and duodenum, without distant metastasis. 2. The circumferential diameter of the tumor is less than 5 ~ 6 cm.

G. Yu (*) Department of General Surgery, Qilu Hospital of Shandong University (Qingdao), Qingdao, China e-mail: [email protected]

Fig. 37.1  Tumor location

1.2

Contraindications

1 . The tumor is too large to be pulled out. 2. Distant metastasis. 3. Severely obese patients (BMI>30 kg/m2). 4. Patients with poor physical condition that cannot tolerate the complex surgery.

2

 nesthesia, Patient Positioning, A Trocar Placement, and Surgical Team Position

2.1

Anesthesia Method

General anesthesia or general epidural anesthesia.

2.2

Patient Positioning

The patient is placed in the functional lithotomy position (Fig. 37.2).

© People’s Medical Publishing House, PR of China 2021 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-15-7925-7_37

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Scrub Nurse

Assistant

Fig. 37.2  The patient’s position

Surgeon

Camera Holder Assistant’s Auxiliary Trocar (5 mm) Assistant’s Main Trocar (12 mm)

Surgeon’s Main Trocar (12 mm)

Camera Trocar (10 mm)

Surgeon’s Auxiliary Trocar (5 mm)

Fig. 37.4  Surgeons’ positions

Surgeon’s Auxiliary Trocar 5mm Surgeon’s Main Trocar 12mm

Fig. 37.3  Trocar placement (Five-ports method)

2.3

Assistant’s Main Trocar 12mm

Trocar Placement

1. Camera trocar (10 mm trocar) is located 5 cm below the umbilicus. 2. The surgeon’s main trocar (12 mm trocar) is located in the left upper quadrant at 2 cm below the costal margin of the left anterior axillary line. 3. The surgeon’s auxiliary trocar (5 mm trocar) is located in the left lower quadrant at the umbilical level of the left midclavicular line. 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 2 cm below the costal margin of the right midclavicular line (Fig. 37.3).

2.4

Camera Trocar 12mm

Surgical Team Position

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

Fig. 37.5  Changes in trocar function during specimen extraction

holder stands on the same side of the surgeon or stands between the patient’s legs (Fig. 37.4). Transvaginal or Transanal 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 assistant. In this step, the monitor should be placed on the side of the patient’s left foot (Figs. 37.5 and 37.6).

2.5

Special Surgical Instruments

Ultrasonic scalpel, 60  mm linear Endo-GIA stapler, 3-0 barbed suture, 4-0 absorbable suture, sterile protective sleeve.

37  Laparoscopic Right Hemicolectomy Combined with Pancreaticoduodenal Resection with Natural Orifice Specimen Extraction

3

Surgical Procedure, Techniques, and Key Points

3.1

Exploration and Surgical Planning

3.1.2 Tumor Exploration The size, location, and mobility of the tumor, and invasion of the serosa (Fig. 37.8).

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

3.1.1 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. 37.7a, b). Camera Holder Surgeon

Assistant

Monitor Scrub Nurse

Assistant for Specimen Extraction

Fig. 37.6  Surgical team position

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3.1.3 Evaluation of Anatomical Structures The right hemicolectomy is complicated since the right colon has many adjacent organs. At the same time, the size of the specimen and the feasibility of natural orifice specimen extraction should be evaluated. In addition, it is necessary to evaluate whether total laparoscopic digestive tract reconstruction can be performed. This surgery is not suitable if the mesentery is too short for anastomosis (Figs. 37.9 and 37.10).

3.2

Dissection and Separation

3.2.1 A  natomy and Transection of the Root of Ileocolic Artery and Vein The patient is placed in the left-leaning position. Push the small bowel and the greater omentum to the left abdomen, dissect along the course of the superior mesenteric vein to fully expose the mesenteric surface. A depressed and thin area at the angle between the ileocolic artery and vein and superior mesenteric vein can be seen. Apply the ultrasonic scalpel to open the mesentery and isolate the vessels. Dissect along the Toldt’s fascia upwards from medial to lateral in a cavernous manner, and the horizontal part of the duodenum is seen by dissection upwards, which proves that the correct space has been entered. Dissect the superior mesenteric vein at the root of the ileocolic artery and vein, dissect upwards and give direct access to the rear on the right side. Isolate the root of the ileocolic artery and vein, dissect the lymphatic

a

Fig. 37.7 (a) Exploration of the liver, (b) Exploration of the pelvic cavity

b

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Fig. 37.8  Exploration of tumor location

G. Yu

Fig. 37.9  Evaluate the status of the right colon and its mesentery

Experience sharing: This procedure is suitable for women with small tumors who have no fertility plan in the future.

Fig. 37.10  Exploration of rectum and posterior vaginal fornix

Cooperating skills: The assistant applies the forceps in the left hand to lift the transverse mesocolon,lift the ileocolic mesentery with the forceps in the right hand, and adequately flatten the right mesocolon.

Fig. 37.11  The first point of the incision

and adipose tissues, ligate and transect the ileocolic vessels (Figs. 37.11, 37.12, and 37.13).

3.2.2 M  anagement of the Root of Right Colic Artery and Vein Dissect along the right side of the superior mesenteric vein, and dissect the lymphatic and adipose tissues.

Pancreaticoduodenectomy is combined in this procedure, so the dissection of the right colic vein, the right gastroepiploic vein, and the anterior superior pancreaticoduodenal vein are not needed, and the Henle’s trunk can be directly ligated at the root. On the left side of the superior mesenteric vein, the right colic artery is derived from the superior mesenteric artery, and ligation is performed at the root (Figs. 37.14 and

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3.2.3 M  anagement of the Middle Colic Artery and Vein Dissect upwards along the superior mesenteric vein after the transection of the right colic artery. Dissect the middle colic artery and vein at the inferior border of the pancreas, and determine the site of the transection of vessels based on the tumor location (Fig. 37.16).

3.2.4 Management of the Mesoileum The assistant lifts the ileocecum upwards anteriorly, tension the junction between the mesocolon and the mesoileum, make an incision to enter the space anterior to the Toldt’s fascia, and give direct access to the upper plane, dissect adequately to the left, extend the mobilization of ileum, so as to facilitate the laparoscopic anastomosis of the bowel. Apply the ultrasonic scalpel to divide the mesoileum to the bowel wall. Attention should be paid to the direction of the mesentery and the blood supply of the bowel. The ileum is transected for the preparation of anastomosis (Figs. 37.17 and 37.18).

Fig. 37.12  Searching for the space anterior to Toldt’s fascia

3.2.5 M  anagement of the Stomach and Greater Omentum Determine the intended resection line of the transverse colon and dissect the greater omentum. Since the tumor is locally advanced and the resection of the gastric antrum is required in this procedure, dissection in the gastric side of the ­gastroepiploic arcade is generally used. The assistant lifts the gastric wall, and the surgeon applies the ultrasonic scalpel to divide the right greater omentum to the transverse colon wall. The course of the right gastroepiploic vein is visible, the gastrocolonic ligament is transected, the dissection can be continued in the gastric side of the right gastroepiploic vein, and the stomach is transected with a linear Endo-GIA stapler. Transection of the right gastroepiploic artery is not

37.15). Dissect posteriorly below the horizontal part of the duodenum and enter the posterior pancreaticoduodenal space.

Operating skills: The isolated ileocolic vessels should be long enough to accommodate two vascular clips.

ICA

ICV

Fig. 37.13  Isolation and transection of ileocolic vessels

Operating skills: Blunt and sharp dissection may be combined in the expansion of space anterior to Toldt's fascia.

Fig. 37.14  Expanding the space anterior to Toldt’s fascia

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required. Instead, the transection is performed at the root of the gastroduodenal artery to ensure en bloc resection (Figs. 37.19, 37.20, 37.21, and 37.22).

3.2.6 Management of the Transverse Mesocolon Open the mesentery along the direction of the intended resection line of the transverse colon, dissect to the avascular

RCA

SMV

MCA

SMA

Fig. 37.15  Exposure of the right colic artery

area of the transverse mesocolon, ligate, and transect the marginal vessels, isolate the transverse colon at the intended resection line, and transect the transverse colon (Figs. 37.23 and 37.24).

3.2.7 Management of the Duodenum At this point, the medial side of the right colon has been completely dissected and the surgical field is expanded. Open the peritoneum lateral to the ascending colon, continue to dissect from lateral to medial, and rendezvous with the posterior pancreaticoduodenal space, further explore the posterior of the pancreas, and expand the posterior pancreaticoduodenal space by blunt dissection with the ultrasonic scalpel (Fig. 37.25). 3.2.8 Management of the Jejunum Lift the transverse colon, find the Treitz’s ligament, identify the initial segment of the jejunum, dissect the proximal jejunum along the bowel wall, and transect the jejunum 10–15 cm away from the Treitz’s ligament with the stapler. The proximal jejunum can be lifted to the right through the tunnel posterior to the superior mesenteric vessel so as to facilitate the resection of the pancreatic head, and get ready for the dissec-

Experience sharing: If the tumor is located in the ascending colon, the right branch of the middle colic artery can be ligated and transected to ensure the blood supply of the distal bowel.

MCA SMA Henle's Trunk

Fig. 37.16  Ligation and transection of the middle colic vessels

Fig. 37.17  Dissection of the terminal ileum

Fig. 37.18  Transection of the ileum

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Operating skills: The ultrasonic scalpel is generally set to minimum mode for transection, with no need to use the vascular clips.

Fig. 37.19  Dissection of the greater curvature

tion of the uncinate process of the pancreas (Figs. 37.26 and 37.27).

Fig. 37.20  Transection of the right gastroepiploic vessel

3.2.9 Transection of the Pancreas Pull the right colon and duodenum to the right upper abdomen to expose the pancreas. The pancreatic neck anterior to the superior mesenteric vein is set as the intended resection line. Dissect along the superior border of the pancreas, expose the common hepatic artery and portal vein, find the superior mesenteric vein at the inferior border of the pancreatic neck, carefully dissect anterior to the pancreatic neck and give direct access to the retropancreatic space. For the transection of the pancreas, apply the ultrasonic scalpel to transect the lower part of the pancreatic neck. Transect the pancreas with scissors when the main pancreatic duct of the

Experience sharing: Attention should be paid to the protection of the proper hepatic artery.

Fig. 37.21  Ligation and transection of the gastroduodenal artery

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Experience sharing: The size of the linear Endo-GIA stapler should be determined based on the thickness of the gastric wall.

Fig. 37.22  Transection of the stomach

Fig. 37.23  Division of the transverse mesocolon and isolation of the bowel wall

upper part of the pancreatic neck is close, so as to prevent the stump of the main pancreatic duct from closing. After the transection, observe the cross-section, and carefully identify the main pancreatic duct. The posterior inferior pancreatic artery and the uncinate process artery should be carefully managed when the uncinate process is dissected. The first jejunal vessel and the posterior inferior pancreatic vein should be carefully identified to prevent laceration and bleeding (Figs. 37.28, 37.29, 37.30, 37.31, and 37.32).

3.2.10 Management of the Gallbladder Lift the gallbladder, expose the Calot’s triangle and open it, expose the cystic artery and the cystic duct, and respectively ligate and transect them. Dissect the gallbladder from the gallbladder bed, continue to dissect downwards along the cystic duct to expose the common bile duct. The common bile duct can be ligated in advance to prevent the abdominal cavity from being contaminated by the overflow of bile (Figs. 37.33 and 37.34).

3.3

Digestive Tract Reconstruction

For the pancreaticojejunal anastomosis, windows are opened in the antimesenteric side of the jejunum with the cautery

hook. The jejunal seromuscular layer is sutured with the pancreatic stump in an interrupted pattern with 4-0 prolene suture for 3 stitches, and then the posterior wall of the main pancreatic duct is sutured with the jejunum in an interrupted pattern. A pancreatic duct drainage tube of 4  ~  5  cm is inserted through the stump of the main pancreatic duct, and the drainage tube is then inserted into the bowel lumen 5 ~ 6 cm through the jejunal window to achieve the precise alignment between the main pancreatic duct mucosa and the jejunal mucosa. Then the full-thickness interrupted suture of the anterior wall of the main pancreatic duct and the jejunum wall is performed. Lastly, the pancreatic parenchyma is sutured with the seromuscular layer of the jejunum in an interrupted pattern anterior to the anastomosis (Figs. 37.35, 37.36, 37.37, and 37.38). For the choledochojejunal anastomosis, the posterior wall of the common bile duct is sutured with 4-0 absorbable or 4-0 prolene suture in an interrupted or continuous pattern, followed by interrupted suture of the anterior wall with a stitch length of 2 mm after the placement of a biliary supporting tube through the anastomosis (Fig. 37.39). Gastrojejunal anastomosis: Open the stump of the remnant stomach on the side of the greater curvature, open the jejunum at 40 cm distal to the choledochojejunal anastomosis, perform side-to-side anastomosis with a 60  mm linear Endo-GIA stapler to close the common opening (Fig. 37.40). Ileocolic anastomosis: Open the stump of the ileum and transverse colon, respectively, align the stumps of the ileum and transverse colon according to the direction of the mesentery. Side-to-side anastomosis between ileum and transverse colon is performed with a 60 mm linear Endo-GIA stapler to close the common opening (Fig. 37.41).

3.4

Specimen Extraction

3.4.1 Transvaginal Specimen Extraction The patient is placed in the Trendelenburg position, and the uterus is suspended to fully expose the posterior vaginal fornix. After adequate disinfection, the assistant inserts the abdominal spatula into the vagina to withstand the posterior

37  Laparoscopic Right Hemicolectomy Combined with Pancreaticoduodenal Resection with Natural Orifice Specimen Extraction

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Experience sharing:Keep the direction of transection of transverse colon perpendicular to the longitudinal axis of the bowel.

Fig. 37.24  Transection of the transverse colon

Experience sharing: Identify the planes and avoid entering the space posterior to the adipose capsule of kidney.

Fig. 37.25  Open the lateral peritoneum to enter the space anterior to the Toldt’s fascia

Experience sharing: During the dissection of the proximal jejunum, care should be taken to protect the blood supply of the intended preserved bowel.

Fig. 37.26  Dissection of the proximal jejunum

Fig. 37.27  Transection of jejunum

vaginal fornix as a marker. A transverse incision is made in the posterior vaginal fornix, then an incision retractor is inserted into the vaginal incision for better exposure. The assistant inserts the oval forceps through the incision, clamps the specimen, and extracts it out of the body through the vaginal incision (Figs.  37.42, 37.43, and 37.44). After the specimen extraction, the pelvic cavity is irrigated repeatedly with distilled water, dilute iodine solution, and normal saline. The incision in the posterior vaginal fornix is closed by continuous suture with 3-0 barbed suture (Fig. 37.45). The trocar sites are closed, the gauze and all instruments are counted before the completion of surgery.

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Operating skills: The anatomy should be performed at the inferior border of pancreas to expose the superior mesenteric vein. Dissect cephalad to give direct access to the retropancreatic space.

Fig. 37.28  Dissection of the pancreas

Experience sharing: Adjust the direction of transection to maintain a neat cross section. V

Fig. 37.29  Transection of the pancreas

Experience sharing: Apply the ultrasonic scalpel to transect the pancreas and change to transect the pancreas with scissors when the main pancreatic duct is close. This facilitates the identification of the main pancreatic duct and the preparation for pancreaticoje- junal anastomosis.

Fig. 37.30  Transection of the main pancreatic duct

37  Laparoscopic Right Hemicolectomy Combined with Pancreaticoduodenal Resection with Natural Orifice Specimen Extraction

Posterior Inferior Pancreaticoduodenal Vein

Fig. 37.31  Dissection of the posterior inferior pancreaticoduodenal vein

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3.4.2 Transanal Specimen Extraction The patient is placed in the functional lithotomy Trendelenburg position. The assistant disinfects the perineal area and rectal lumen with iodoform gauze. The distal sigmoid colon is stretched by the assistant to fully expose the upper rectum. Then the surgeon makes a longitudinal incision of 5–6 cm in the anterior wall of the rectum. A sterile protective sleeve is introduced into the abdominal cavity through the main trocar, and one end of it is extracted out of the rectal incision. The assistant inserts the oval forceps through the protective sleeve, clamps the specimen, and extracts it out of the body through the rectum. The rectal incision is continuously sutured with a 3-0 barbed suture

Experience sharing: The surgeon should stand on the right side during the dissection of the uncinate process of pancreas.

Fig. 37.32  Dissection of the uncinate process

Fig. 37.33  Ligation of the cystic artery

Fig. 37.34  Transection of the common bile duct

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Experience sharing: Child's method is adopted for digestive tract reconstruction and pancreatic duct-to-mucosa anastomosis is adopted for pancreaticojejunal anastomosis.

Fig. 37.35  Pancreaticojejunal anastomosis

Experience sharing: Double J stent may be used to facilitate insertion in the absence of dilatation of the main pancreatic duct.

Fig. 37.36  Insertion of pancreatic duct drainage tube through the main pancreatic duct

Operating skills: When pancreaticojejunal anastomosis is performed, the precise alignment between the main pancreatic duct mucosa and the jejunal mucosa should be performed to achieve precise anastomosis.

Fig. 37.37  Alignment of the main pancreatic duct to the jejunum

37  Laparoscopic Right Hemicolectomy Combined with Pancreaticoduodenal Resection with Natural Orifice Specimen Extraction

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(Figs. 37.46, 37.47, 37.48, and 37.49). After the closure of the incision, the pelvic cavity is irrigated repeatedly with distilled water, dilute iodine solution, and normal saline. Close the trocar sites and count the gauze and all instruments before the completion of surgery.

3.5

Postoperative Abdominal Wall and Specimen Pictures (Figs. 37.50 and 37.51)

Fig. 37.38  Interrupted suture of the jejunal seromuscular layer with the pancreatic stump

Operating skills: Good exposure is the key to the end-to-side cholangio-jejunal anastomosis at 5 ~ 10 cm distal to the pancreaticojejunal anastomosis.

Fig. 37.39  Cholangio-­jejunal anastomosis

Experience sharing: In general, anti-peristaltic anastomosis is used to keep the course of the bowel smooth.

Fig. 37.40  Gastric jejunal anastomosis

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Operating skills: Attention should be paid to the direction of mesentery during anastomosis. The antimesenteric side should be anastomosed to avoid mesenteric volvulus.

Fig. 37.41  Ileocolic anastomosis

Operating skills: After making an incision in the posterior vaginal fornix, the assistant temporarily occludes the external orifice of the vagina to avoid air leakage and maintain the pneumoperitoneum.

Fig. 37.42  Opening the posterior vaginal fornix

Experience sharing: Insertion of incision retractor can shorten the distance of specimen extraction,reduce resistance, and avoid contamination.

Fig. 37.43  Internal view of transvaginal specimen extraction

37  Laparoscopic Right Hemicolectomy Combined with Pancreaticoduodenal Resection with Natural Orifice Specimen Extraction

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Operating skills: The assistant should perform gently and smoothly during the specimen extraction.

Fig. 37.44  External view of transvaginal specimen extraction

Operating skills: 3-0 barbed suture can be applied for the laparoscopic suture, which can avoid knotting and accelerate the suture speed.

Fig. 37.45  Suturing of vaginal incision under laparoscopy

4

 ey Points, Difficulties, and Hotspots K Related to Surgery

The operating difficulties of this procedure are mainly manifested in the combined organ resection, digestive tract reconstruction, and the route of specimen extraction. Whipple operation is considered the most complex classic operation in general surgery. Total laparoscopic D3 right hemicolectomy combined with pancreaticoduodenectomy by NOSES is the most complex procedure in the field of abdominal surgery. Therefore, it is important to strictly follow the surgical indications. For locally Fig. 37.46  Opening the anterior rectal wall

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Operating skills: Insert the protective sleeve and the tumor-free principle should be strictly followed.

Fig. 37.47  Transanal specimen extraction

Operating skills: The assistant should perform gently and smoothly during the specimen extraction through the anus

Fig. 37.48  Transanal specimen extraction

Fig. 37.49  Suturing the anterior rectal wall

advanced tumors invading the pancreatic head and duodenum without distant metastasis, combined organ resection can bring benefits for the patients. The prognosis of patient is not only dependent on the en bloc radical resection but also related to the stage of the tumor. Therefore, the location, size, and depth of tumor invasion should be evaluated before operation. Detailed surgical plan should be developed. In the selection of patients, the patient’s age, obesity degree, marital, and reproductive status should be taken into consideration. NOSES is not only a test of the overall control and skilled operation, but also puts forward high requirements for team cooperation. The posterior vaginal fornix is a common route for gynecological operation and specimen extraction.

37  Laparoscopic Right Hemicolectomy Combined with Pancreaticoduodenal Resection with Natural Orifice Specimen Extraction

Fig. 37.50  Appearance of abdominal wall after operation

Because of the strong vaginal extensibility, there is no risk of serious complications such as intestinal leakage and stenosis of the bowel lumen after making an incision in the rectum. The safety of specimen removal is high. The vagina should be the preferred route of specimen extraction for women. However, for female patients with fertility requirements or gynecological disease should not adopt this approach. Instead, transanal specimen extraction can be adopted. It should be noted that in the perineal group, the posterior vaginal fornix should be held up as far as possible after the irrigation of the vagina, and the surgical field should be fully

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Fig. 37.51  Specimen display

exposed to avoid damage to other pelvic organs during incision. The operation requires strict compliance with aseptic and tumor-free principles. The pelvic cavity should be irrigated repeatedly with distilled water, dilute iodine solution, and normal saline before opening the rectum (or posterior vaginal fornix), after specimen extraction, and after the suture. The incision protector should be used to avoid tumor rupture, which may lead to tumor cell dissemination. After the specimen extraction, the incision in the posterior vaginal fornix should be sutured in a continuous pattern.

Part V Complications and Management of NOSES

Complications and Management of NOSES for Gastrointestinal Tumor

38

Yinggang Chen, Yantao Tian, and Qian Liu

As a surgical technique, NOSES is unique in terms of specimen extraction and digestive tract reconstruction, but it is otherwise similar to open surgery and conventional laparoscopic surgery in terms of surgical complications. In this chapter, the causes, clinical manifestations, and management of complications associated with gastrointestinal surgery are illustrated.

1

Intra-Abdominal Infection

Most of the pathogenic bacteria caused by gastrointestinal surgery come from the gastrointestinal tract, of which the Gram-negative bacilli are the dominant bacteria. Causes of intra-abdominal infection of NOSES include the following: insufficient preoperative preparation, nonstandard intraoperative aseptic operation, postoperative anastomotic leakage, insufficient abdominal drainage, concomitant diseases (e.g., diabetes, malnutrition, long-term use of glucocorticoids, etc.), and elderly patients. Therefore, these risk factors must be avoided in the prevention of intra-abdominal infection to reduce the incidence of intra-abdominal infection. The main clinical manifestations of intra-abdominal infection are fever, abdominal pain, and signs of peritonitis, which are often accompanied by nausea, vomiting, abdominal distension, hypotension, tachycardia, shortness of breath, leukocytosis, and other sepsis symptoms. In the late stage, systemic inflammatory response syndrome like severe dehyY. Chen (*) Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Shenzhen Center, Shenzhen, China Y. Tian Department of Colorectal Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China Q. Liu Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China

dration, metabolic acidosis, septic shock, and organ dysfunction will appear. In addition to the medical history and clinical manifestations, the diagnosis of intra-abdominal infection should be primarily based on the characteristics of the drainage fluid and auxiliary examinations. The characteristics of drainage fluid should be closely observed if the patient has fever, abdominal pain, and other symptoms. If the drainage fluid is yellow and purulent, the possibility of intra-abdominal infection should be considered. If the intra-abdominal infection is caused by anastomotic leakage, drainage fluid would contain fecal sediment with foul-smelling. Auxiliary examinations include laboratory tests (white blood cell count and neutrophil percentage, biochemical analysis), imaging examination (X-ray, ultrasound, or CT), drainage biochemical analysis, and bacterial culture to determine the nature of drainage. If the patient is not indwelled with the drainage tube or drainage tube is removed, peritoneocentesis could be performed. The principles of treatment include general treatment, systemic support therapy, anti-infection therapy, abdominal drainage, and surgical treatment. General treatment: Patients can take bed rest in the 30° ~ 45° semi-reclining position, which facilitates the accumulation of intra-abdominal exudate in the pelvic cavity for drainage, relax the abdominal musculature, and prevent diaphragm compression, which facilitates the improvement of respiration and circulation. Fasting and gastrointestinal decompression could reduce bowel distention, improve the blood circulation of the bowel wall, reduce bowel content exudation when bowel perforation occurs, and promote the recovery of intestinal peristalsis. Systemic support therapy: Electrolyte and acid-base imbalances should be promptly corrected. Parenteral and enteral nutrition therapy could be given to improve the patient’s physical status and enhance immunity. Blood transfusion can be given if necessary. Anti-infective therapy mainly aims at Gram-negative bacilli, for which beta-lactam and aminoglycoside drugs can

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be applied. Necessary adjustments should be made according to the results of bacterial culture and drug sensitivity tests. The drainage of the abdominal cavity is critical in the presence of anastomotic leakage. The open drainage is prone to cause retrograde or exogenous infection, which could be solved through regular flushing of the drainage tube with normal saline. The accumulated liquid can also be suctioned by negative pressure so that the capsule area can shrink rapidly. If the symptoms of intra-abdominal infection are serious or abdominal abscess is formed and cannot be solved by conservative treatment, surgical treatment is required. According to a multicenter (79 centers) retrospective study of NOSES in China, only 0.8% of patients developed intraabdominal infection after surgery. The result also indicates that NOSES can meet the aseptic principle as long as sufficient preparation is made and operating skills are mastered.

2

Anastomotic Bleeding

Anastomotic bleeding is one of the early complications after surgery. Generally, stapled anastomosis is performed in laparoscopic surgery, and the main cause of anastomotic bleeding is incomplete occlusion of blood vessels resulting from insufficient bowel wall isolation in the anastomotic site. Anastomotic bleeding usually occurs within 48 hours after the operation, while bleeding due to pelvic hematoma breaking into the anastomosis wall usually occurs 7 days after the operation. According to the multicenter (79 centers) retrospective study of NOSES in China, only 0.9% of patients developed anastomotic bleeding after surgery. Prevention is the key to the management of anastomotic bleeding. During the intraoperative anastomosis of the digestive tract, air, or water leak test should be conducted to check the integrity of the anastomosis. If possible, laparoscopy could be used to detect the anastomotic status in operation. Anastomosis, especially the ‘danger triangle of the anastomosis’, could be sutured to reinforce if necessary. Early symptoms of the majority of patients are persistent hematochezia, and the color varies from bright red to dark red depending on the location of anastomosis and the amount of bleeding. Physical examination may reveal that the drainage fluid is light pink or red. Some patients may be complicated with local tenderness. If anastomotic bleeding is severe or secondary infection occurs and anastomotic leakage is induced, clinical manifestations of anastomotic leakage, including rigor, hyperpyrexia, abdominal pain, peritoneal irritation, etc., may occur. The vast majority of anastomotic bleeding can resolve spontaneously, and only a small number of patients require interventions. Intervention measures mainly include drug therapy, colonoscopy treatment, and surgical treatment. Drug therapy includes oral or intramuscular administration of hemostatic drugs. When there is a large amount of bleeding,

the bleeding point can be endoscopically visualized and clipped with hemostatic clips. If the colonoscopy treatment fails, surgical treatment, ligation of bleeding point, and suture of anastomosis could be performed. In addition, for lower and ultra-low anus-preserving anastomotic bleeding, transanal reinforcement and suture of the anastomosis can be performed to stop the bleeding.

3

Intra-Abdominal Bleeding

Postoperative intra-abdominal bleeding of NOSES is usually caused by the insecurity of surgical hemostasis or vascular ligation, untreated coagulation dysfunction caused by blood system or other systemic diseases, or spontaneous hemorrhage caused by tissue necrosis or falling off of vascular clips. The key to the prevention of intra-abdominal hemorrhage is to operate carefully and make sure that the ligation of vessels is properly performed. The operation should not be rushed at the cost of quality. For the elderly or patients with arteriosclerosis, avoid excessive isolation of blood vessels, and avoid intraoperative and postoperative blood pressure fluctuation in patients with hypertension. When bleeding occurs intraoperatively, exact hemostasis, particularly to large vessels, must be performed. For example, in the radical resection of rectal cancer, the management of inferior mesenteric artery bleeding requires relevant experience and skills. Different treatment methods should be taken according to different situations. The clinical manifestation of intra-abdominal bleeding is determined by the site, amount, and duration of bleeding. Patients may be complicated with abdominal discomfort and mild abdominal distension. Bleeding sites have localized swelling, which may be accompanied by mild tenderness and increased local dullness. If the amount of bleeding is large, the patient may be positive for shifting dullness on percussion, and complicated with unstable vital signs, including increased pulse and respiratory rate, decreased blood pressure, with continued (or increased) bright red drainage. In general, bloody drainage often indicates active bleeding. It is not difficult to make the diagnosis according to the clinical manifestations. In the event of mild bleeding after operation, hemostatic drugs can be orally or intramuscularly administered, and the patient’s condition should be closely observed. In the event of massive bleeding, blood pressure, pulse, and other vital signs should be closely observed and preparation should be ready for surgical exploration. Once active intra-abdominal bleeding is detected and the amount of bleeding is large, a second surgery should be timely conducted and surgical hemostasis should be performed. If surgical exploration is necessary, blood and blood clots should be suctioned as soon as possible. Check the original surgical site for bleeding points, clip or suture them, and then check the surgical site

38  Complications and Management of NOSES for Gastrointestinal Tumor

again. Bleeding points cannot be found in about 60–70% of the patients, but the intra-abdominal blood should be completely cleared, and the abdomen should be irrigated and checked to make sure there is no active bleeding before the abdomen is closed.

4

Anastomotic Leakage

The occurrence of anastomotic leakage is associated with local factors, systemic factors, and technical factors. Systemic factors include poor nutritional status, long-term use of corticosteroids, preoperative radio-chemotherapy, concomitant diabetes, and other chronic diseases. Local factors include insufficient blood supply, excessive anastomotic tension, anastomosis infection, and anastomosis bowel edema. Technical factors include suture is not tight, excessive tissue compression, and improper choice of stapler. Therefore, attention should be paid to the abovementioned points for the prevention of anastomotic leakage. Besides, air or water leak test is needed to check the integrity of the anastomosis. If possible, an intraoperative colonoscopy should be applied for confirmation, which is safer and more reliable. The initial symptom of most of the patients with anastomotic leakage is fever or abdominal pain, which may be complicated with peritoneal irritation. Patients with severe intra-abdominal infection may develop systemic inflammatory response syndrome. Fever can occur at any time, and some patients with anastomotic leakage shows sustained high body temperature postoperatively. Abdominal pain can be manifested as flatulence in the lower abdomen in the early stage or sudden onset of serious abdominal pain, which is complicated with tenderness, rebound tenderness, and other symptoms and signs of acute peritonitis. If the abdominal inflammation is limited, localized peritonitis or palpable swelling mass may occur. If there is a drainage tube, intestinal contents can be released from the drainage tube. A sudden increase in drainage liquid, turbidity, fecal matters, putrefactive odor, redness, and swelling around the drainage port, and sometimes air bubbles may appear. Once diagnosed, the treatment of anastomotic leakage should be given as soon as possible. Local unobstructed drainage and infection control are the keys to early treatment. Most anastomotic leakage can be cured by drainage and irrigation. If the anastomotic leakage cannot heal for a long time, surgical treatment such as fecal diversion or bowel resection and anastomosis remake should be considered. Reasonable treatment can convert leakage into a controllable or localized leakage until it is healed. According to the multicenter (79 centers) study of NOSES in China, 3.5% of patients developed anastomotic leakage after surgery. Although NOSES does not increase the incidence of anastomotic leakage, the surgeons must take good precautions. The key to its prevention is to ensure a tension-­

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free and infection-free anastomosis with good blood supply. Moreover, surgeons should pay attention to the intestinal peristalsis tension. We do not encourage the common application of diverting colostomy for all patients with rectal cancer, as the stoma does not reduce the incidence of postoperative anastomotic leakage. Instead, it may cause a series of problems. However, diverting colostomy is recommended for the following situations: poor preoperative bowel preparation, with incomplete obstruction; elderly patients with underlying diseases such as diabetes; patients with severe anemia and malnutrition; preoperative neoadjuvant chemo-radiotherapy; patients with narrow pelvis which is difficult to operate or high-risk constitution such as obesity, etc.; the location of the tumor is low, for which ultra-low anastomosis in anus-preserving surgery is required.

5

Rectovaginal Fistula

Transvaginal specimen extraction has long been performed in laparoscopic surgery. In early studies, auxiliary incisions in the abdominal wall were needed. After more than two years of practice and follow-up, our team has validated the feasibility and safety of transvaginal specimen extraction. The extraction of the specimen from the vagina is mainly affected by the following two factors: (1) the vagina’s elasticity; (2) the circumferential diameter of the specimen. The circumferential diameter is mainly composed of the transverse diameter of the tumor, the thickness of the bowel wall, and the amount of surrounding fat of the bowel. Therefore, the feasibility of specimen extraction should not be simply determined based on the diameter of the tumor. There is a risk that intestinal content may flow out when the bowel is transected, which increases the incidence of intra-abdominal infection. When the specimen is extracted, the intestinal content may flow into the abdominal cavity due to the squeeze of the bowel, which also increases the risk of intra-abdominal infection. If anastomotic leakage occurs on this basis with the presence of vaginal incision, the risk of the rectovaginal fistula is increased. The causes of rectovaginal fistula can be divided into iatrogenic and patient factors. Iatrogenic factors, especially surgical operation, are more closely related to the onset of rectovaginal fistula. Generally, lower location of rectal cancer, surgical traction, and vague visual field may increase the probability of the vagina’s posterior wall being injured or being stapled in the anastomosis. Therefore, clear surgical field and confirmation of the location of the posterior vaginal wall before firing the stapler are important for the prevention of rectovaginal fistula. In addition, it should be noted that during the reinforcement and suture, the posterior vaginal wall and the anastomosis should not be sutured together. Although the incidence of the rectovaginal fistula is not high, this complex complication should not be ignored.

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Surgery timing for the repairment of postoperative rectovaginal fistula, especially iatrogenic rectovaginal fistula, should be carefully chosen. Do not perform immediate surgery under the urgent demand of the patient. Surgery should be performed after local and systemic inflammation is subsided, the scar is softened, and 3 months after injury or previous surgery.

6

Intestinal Obstruction

Intestinal obstruction is a common complication after abdominal surgery. Postoperative adhesion, internal hernia, distortion, infection, and other factors can lead to intestinal obstruction. Early postoperative symptoms concerning intestinal obstruction are mostly paralytic ileus. It is also associated with a poor physical condition, intra-abdominal infection, liquid and electrolyte, and acid-base imbalances, etc. Late postoperative intestinal obstruction is often caused by intestinal adhesion, which is manifested as mechanical intestinal obstruction. Mechanical intestinal obstruction in the minority of patients may also be caused by intestinal volvulus or intussusception. According to the multicenter (79 centers) study of NOSES in China, 0.6% of patients developed intestinal obstruction after surgery. The main manifestations include abdominal pain, abdominal distension, vomiting, the arrest of exhaust and defecation, and other symptoms. Since the cause, type, location, and degree of intestinal obstruction vary, the clinical manifestations are different as well. In the event of strangulated intestinal obstruction, the disease progresses rapidly, and shock may occur. Therefore, early monitoring of the symptoms and signs of patients can provide an important basis for the treatment of obstruction. As for the prevention of postoperative intestinal obstruction, intestinal contents flowing out should be avoided as far as possible on the technical level. Once contamination occurs in operation, the abdominal cavity should be flushed thoroughly. Before the closure of the abdomen, careful examination should be performed to make sure that no foreign bodies are left in the abdominal cavity, and the small intestine is replaced in normal physiological order and position then covered by the greater omentum. Early ambulation should be encouraged to reduce the incidence of postoperative intestinal adhesions. In addition, some studies have reported cases of intestinal obstruction caused by trocar site hernia. Therefore, the closure of the trocar is also important. Intestinal obstruction is a common complication of colorectal surgery, and its diagnosis and treatment are not difficult. The principle of treatment is to relieve the obstruction and correct the internal environment disorder. The selection of a therapeutic method should be made based on the cause, nature, location, the systemic condition, and the severity of the disease.

7

Intestinal Volvulus

Intestinal volvulus can occur both in the early and late postoperative period. Usually, a bowel segment or even the total small bowel and its mesentery twist 360°–720° along the mesenteric axis. Therefore, both intestinal obstruction and mesenteric ischemia may occur. This is one of the most dangerous, most rapidly progressing, and most serious postoperative complications. Postoperative bowel adhesions and too much intestinal contents are potential factors for the formation of volvulus. Strong intestinal peristalsis or sudden position change will lead to unsynchronized bowel loop movement, thereby causing volvulus of bowel loops. The prevention of postoperative intestinal volvulus should focus on the postoperative education to avoid the occurrence of intestinal volvulus caused by a sudden increase of abdominal pressure. Intestinal volvulus can induce intestinal strangulation and necrosis in a short term. Timely surgical treatment can return the intestinal loop to normal position and reduce the mortality rate. It can also avoid short bowel syndrome due to the massive resection of the small bowel. For patients without obvious signs of peritonitis, colon necrosis, or intestinal wall necrosis (detected by colonoscopy), the soft catheters can be placed through the obstruction site with the guide of colonoscopy to reverse intestinal loops, exhaust large amount of gas and feces, and replace the twisted bowel into normal position. However, surgery is needed if partial of the bowel wall is proved to be necrotic. If signs of peritonitis are obvious and the colon is considered necrotic, surgical treatment should be performed decisively. Surgical treatments contain separation of adhesion, resection of the necrotic colon and lengthy colon, and replacement of the colon into normal position.

8

Internal Abdominal Hernia

The internal abdominal hernia occurs when the small bowel goes through congenital or secondary visceral intraperitoneal aperture. Internal hernia lacks obvious clinical manifestation and it is therefore prone to be misdiagnosed. Abdominal distension, pain, and discomfort are the main manifestations of internal hernia, and some are complicated with chronic intestinal obstruction. Therefore, appropriate preoperative imaging examinations are the keys to improve the diagnosis rate and contribute to make proper surgical decisions. In order to prevent the occurrence of internal abdominal hernia, the mesenteric hiatus may be closed in the operation. X-ray examination shows only intestinal obstruction signs like air-fluid levels and bowel dilatation. Thus, CT scan is generally recommended to help determine the location and extent of internal hernia. Even if the hernia location is concealed, CT scan can still provide an accurate reference for the diagnosis.

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Once the diagnosis is clear, timely surgical treatment is required to avoid intestinal ischemia and necrosis. The prevention of internal abdominal hernia lies in fine operation and closure of the mesenteric hiatus as far as possible. Surgeons cannot be overconfident. After the operation is completed, careful inspection should be made to eliminate risk factors.

9

 umor Implantation of Trocar Sites T and Vaginal Incision

Due to the absence of auxiliary incision in the abdominal wall, the trocar sites and vagina incision become the potential location of tumor implantation. It is generally believed that the pneumoperitoneum could cause the tumor cells to spray and promote the tumor metastasis. During the operation, preventive measures include the application of a sterile protective sleeve to isolate the tumor during specimen extraction, and intra-abdominal gas should be released slowly through the suction connected with the valve of the trocar. At the end of the operation, trocars are pulled out only when the gas is completely released to avoid the gas pass through the unprotected trocar sites directly . Threaded but not smooth trocars should be used to prevent the trocar from sliding. If there is air leak around the trocar, the trocars should be replaced or fixed to the abdominal wall to maintain the air-­tightness of the pneumoperitoneum. In addition, in order to reduce the incidence of abdominal implantation, NOSES is not recommended for T4 stage patients. The author usually irrigates the abdominal cavity and vagina with dilute iodine solution and distilled water. Distilled water is hypoosmotic and irrigation of the abdominal cavity can lead to tumor cell swelling, rupture, and thus inactivation. At the same time, tumor tissues are affected by the heat and develop microvascular embolization, which causes lysis of cancer cells due to hypoxia, acidosis, and metabolic disorders, while normal tissue cells can remain normal through vasodilation and heat dissipation, etc. The strict tumor-free procedure is not only the basic requirement of NOSES, but also one of the key points to improve the prognosis of patients.

10

Duodenal Stump Leakage

Duodenal stump leakage occurs in patients with gastric cancer undergoing Billroth II anastomosis or total gastrectomy by NOSES.  Duodenal stump fistula is one of the main factors affecting postoperative recovery or even the cause of death. In addition to anemia, malnutrition, and other systemic factors, duodenal stump fistula may be caused by the falling off of stapler cartridge from the stump, thermal injury of the duodenum by ultrasonic scalpel, incomplete obstruction of the afferent loop, and excessive tension in the NOSES for gastric cancer. Correct management of the duodenal stump is one of the keys

to prevent duodenal stump fistula. For skilled surgeons, perform purse-string suture to embed the duodenal stump with barbed suture under laparoscopy is a simple and effective approach. Duodenal stump leakage usually occurs 3 ~ 8 days after the operation, with sudden onset of epigastric pain or distension, accompanied by fever and tachycardia, abdominal tenderness and rigidity in the right upper abdomen, and leukocytosis. For patients with drainage tube in the abdominal cavity, bile-containing intestinal fluid can be drained out, ascites is detectable by ultrasonography, and yellow bile or pus can be obtained by paracentesis. For the treatment, most patients can be cured by conservative treatment such as adequate abdominal drainage and parenteral nutrition. If the duodenal stump leakage is caused by afferent loop obstruction, the second operation is required to perform Roux-en-Y anastomosis.

11

Afferent Loop Obstruction

Afferent loop obstruction after gastric cancer resection is rare. It is a special high intestinal obstruction that occurs after gastric cancer resection. It is mainly caused by the stasis of bile, pancreatic, and intestinal secretions in the bowel lumen above the anastomosis. As a closed-loop mechanical bowel obstruction, it is prone to cause strangulation of the bowel, which requires surgery to relieve the obstruction. Typical symptoms include sudden and severe epigastric pain, frequent nausea, vomiting of small amount of bile-free gastric contents, tenderness in the right upper quadrant, with possible palpable mass. Digestive tract radiography shows that the contrast medium can enter the efferent loop jejunum smoothly through the anastomosis, but cannot enter the afferent loop jejunum, or only a small amount of contrast medium can slowly enter the afferent loop and shows obvious dilatation changes. Ultrasonography reveals dilatation of the duodenum with a liquid anechoic area. For patients without strangulation of the bowel, the principle of operation is to eliminate the etiology, relieve the obstruction, and establish a physiological channel. For patients with strangulation of bowel, the affected intestinal segments should be resected, the obstruction should be relieved, and the drainage should be strengthened during the operation. Pancreatoduodenectomy is inevitable if the second and third segments of the duodenum are necrotic.

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Efferent Loop Obstruction

Efferent loop obstruction after gastric cancer resection is uncommon. Its causes include angulation of the efferent loop caused by intra-abdominal adhesions or compression of the bowel by the adhesive band, retrograde intussusception of the efferent loop, angulation of the bowel segment of the efferent loop and the anastomosis, and internal hernia of the efferent

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loop, etc. The main manifestations are the signs of high small bowel obstruction, including epigastric fullness, accompanied by nausea and vomiting of food and bile. The diagnosis is made based on upper gastroenterography, and CT can show the dilated bowel. Conservative treatment can be performed first. If there is no improvement after conservative treatment or mechanical intestinal obstruction cannot be ruled out, surgical exploration can be considered. The principle of operation is to eliminate the cause of intestinal obstruction, perform resection of necrotic bowel segment, and restore bowel patency.

13

Postoperative Pancreatitis and Pancreatic Fistula

With the extensive development and popularization of laparoscopic D2 radical gastrectomy for gastric cancer in China, the incidence rates of postoperative pancreatic fistula and pancreatitis have been increasing with the application of high-frequency electric scalpel and ultrasonic scalpel in NOSES for gastric cancer. It has been reported that the incidence of pancreatic fistula after laparoscopic gastrectomy is 0.9%. Complications such as organ perforation, bleeding, and serious infection caused by pancreatic fistula corrosion have been reported. Pancreatitis after gastric cancer surgery is difficult to diagnose, and delay in treatment is prone to cause aggravation of the condition or even death. In the gastric cancer surgery, the anatomical characteristics of the operative area and the iatrogenic mechanical injury of the operation itself may lead to the onset of postoperative pancreatic fistula and pancreatitis. The clinical symptoms of postoperative pancreatitis and pancreatic fistula lack specificity. They usually occur on day 3 to 10 after operation. They are mainly manifested as epigastric pain, but the location of the pain is vague and often accompanied by radiating pain in the lower back. Other manifestations include nausea, vomiting, and abdominal distension. The recovery of gastrointestinal function is slow, which is not consistent with the recovery of the disease course. Patients may also experience persistent fever or leukocytosis. In severe cases, systemic inflammatory response syndrome may occur. The diagnosis of the pancreatic fistula is mainly based on peritoneal drainage fluid amylase, serum and urine amylase and clinical symptoms. Elevation of peritoneal drainage fluid amylase is defined as amylase concentration in the peritoneal drainage fluid being more than 3 times the upper limit of normal serum amylase concentration at or more than 3 days after the operation. Dynamic contrast-enhanced CT is the gold standard for clinical diagnosis of necrosis and the degree of necrosis in the pancreatitis of after gastric cancer resection. Once pancreatic fistula occurs, unobstructed abdominal drainage should be established, fasting, gastrointestinal decompression, and drugs that inhibit pancreatic secretion should be applied promptly. Surgical drainage and lavage should be performed if necessary.

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Postoperative Lymphatic Leakage

The chylous effusion caused by the breakage of the main branches of lymphatic vessels after the gastric cancer resection is called lymphatic leakage, which is also referred to as chyle leakage. NOSES of gastric cancer applies ultrasonic scalpel for transection and dissection. In theory, the incidence of lymphatic leakage is lower than that of conventional surgery. The occurrence of lymphatic leakage is closely related to the intraoperative management of lymphatic vessels. Therefore, intraoperative prevention is essential. Diagnosis is confirmed by an increase in milk-like drainage with no concomitant symptoms (e.g., fever, pain), elevated triglyceride levels, and presence of chylomicrons in drainage fluid when the patient starts feeding after operation. The treatment is mainly non-surgical, including total parenteral nutrition, internal environment maintenance, albumin supplementation, and tentative closure of catheter for observation. Most cases of lymphatic leakage heal within 2 weeks after conservative treatment and rarely require surgery.

15

Postoperative Gastroparesis

Postoperative delayed gastric emptying is a syndrome of gastric emptying disorder after gastrointestinal surgery. It mainly occurs in gastric surgery, but also occurs in the intestinal, pancreatic, and other abdominal and gynecological operations. The incidence of delayed gastric emptying varies from 0.6% to 7.4% in foreign literatures and 5.0% to 10.0% in Chinese literatures due to different surgical methods, the extent of resection, and other factors. The pathogenesis of postoperative delayed gastric emptying is still unclear, which may be related to the changes of normal neurohormones and myogenic factors on gastric emptying. It usually occurs 2–3  days after operation, when the diet is changed from fasting to liquid or from liquid to semiliquid. Patients experience nausea and vomiting of remnant gastric contents. The diagnostic criteria of postoperative gastroparesis have not been unified, but the core criterion is to exclude the mechanical obstruction of the remnant gastric outflow tract. In terms of treatment, fasting, continuous gastrointestinal decompression, promotion of gastrointestinal peristalsis, strengthening of parenteral nutrition, and other measures are taken, and communications with patients are conducted to establish their confidence. The patients can be cured after conservative treatment. In recent years, traditional Chinese medicine has achieved some success in the treatment of postoperative delayed gastric emptying. Acupuncture, moxibustion, and application of traditional Chinese medicine can be combined to accelerate the recovery of postoperative gastroparesis.

Part VI Collection of Expert Experience on NOSES

Experience Sharing in NOSES for Colorectal Cancer

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Qingchao Tang, Haipeng Chen, and Xishan Wang

1

 xperience Sharing on Aseptic E and Tumor-Free Operation in Modified NOSES II

2. After gentle anal dilation, the second assistant irrigates the distal bowel stump with a dilute iodine solution and introduces an iodoform gauze through the anus. The surgeon applies the ultrasonic scalpel to cut open the distal NOSES II is mainly applicable to patients with the long sigbowel stump and disinfect the lumen with iodoform moid colon and small tumors located in the middle rectum. gauze. The first assistant holds the suction in the right As with conventional laparoscopic radical resection of rectal hand and promptly suctions the intestinal contents when cancer, NOSES II should strictly follow the principles of the surgeon is applying the ultrasonic scalpel to open the total mesorectal excision (TME). Anatomy and dissection bowel (Fig. 39.1d). should be performed at the correct operating plane, which is 3. The second assistant inserts the oval forceps and pulls one a prerequisite for rapid and safe operation. The operating end of the sterile plastic protective sleeve out of the anus. procedures of conventional NOSES II include transanal The surgeon and the first assistant place the transected extraction of the rectal lesion under the protection of self-­ bowel (Fig. 39.1e) and all gauzes in the abdominal cavity made protective sleeve, extracorporeal resection of tumor, into the protective sleeve (Fig. 39.1f) and tighten the inner purse-string suture, and insertion of anvil, as well as totally opening of the protective sleeve (Fig. 39.1g). laparoscopic end-to-end anastomosis between the sigmoid 4. The second assistant pulls the protective sleeve and its colon and rectum. In the conventional NOSES II, attention contents out through the anus with oval forceps. has been paid to the aseptic and tumor-free operation, but 5. All used laparoscopic instruments are disinfected, and a this is an approach still has some drawbacks. The surgical new protective sleeve is inserted through the main trocar procedure of a modified NOSES II, which is more in line again (Fig.  39.1h). The second assistant disinfects the with the aseptic and tumor-free principle, is presented as oval forceps with iodophor and inserts the oval forceps follows: again through the anus, pulls out one end of the sterile protective sleeve. The surgeon and the first assistant place the stump of the sigmoid colon into the protective sleeve, 1.1 Specimen Resection and Extraction and the second assistant applies the oval forceps to slowly pull the stump out of the anus under the protection of the 1. The surgeon transects the distal bowel at least 2 cm from sleeve. the distal edge of the tumor with a linear Endo-GIA stapler (Fig. 39.1a), transects the proximal bowel at approximately 15 cm from the proximal edge of the tumor (Fig. 39.1b), 1.2 Digestive Tract Reconstruction and places a sterile plastic protective sleeve into the abdominal cavity through the main trocar (Fig. 39.1c). 1. The surgeon introduces the anvil into the sigmoid colon stump and performs purse-string suture to secure. Then, the sigmoid colon is reintroduced into the abdominal cavQ. Tang ity with the oval forceps after being rinsed and disinfected Department of Colorectal Cancer Surgery, The Second Affiliated (Fig. 39.2a). Hospital of Harbin Medical University, Harbin, China 2 . The rectal stump is closed with a linear Endo-GIA stapler H. Chen · X. Wang (*) (Fig. 39.2b), and the resected rectal stump is placed into Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China © People’s Medical Publishing House, PR of China 2021 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-15-7925-7_39

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Fig. 39.1  Surgical procedures. (a) Transection of the distal bowel with linear Endo-GIA stapler; (b) Transection of the proximal bowel with linear Endo-GIA stapler; (c) Insertion of the sterile protective sleeve through the main trocar; (d) Opening the distal bowel stump trans-

versely; (e) Placing the transected bowel into the protective sleeve; (f) Placing the intra-abdominal gauze into the protective sleeve; (g) Tightening the inner opening of the protective sleeve; (h) Introduction of a new protective sleeve again

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Fig. 39.2  Surgical procedures. (a) The anvil is introduced into the proximal sigmoid colon; (b) Closing of the rectal stump; (c) Removal of the resected rectal stump; (d) Sigmoid colorectal end-to-end anastomosis

39  Experience Sharing in NOSES for Colorectal Cancer Fig. 39.3 (a) Functional side-to-side anastomosis of colon and colon; (b) Functional side-to-side anastomosis of the colon and small intestine

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specimen retrieval bag and extracted through the main trocar (Fig. 39.2c). 3. A circular stapler is inserted through the anus. The trocar of stapler is extended to pierce one corner of the rectal stump (Fig. 39.2d). The anvil shaft is connected to the trocar of the stapler to complete the end-to-end anastomosis. In conclusion, the modified NOSES II is performed under the protection of the sterile protective sleeve during specimen extraction and anvil insertion, which ensures the aseptic and tumor-free operation. Moreover, instruments exposed to tumors will be changed or require a second disinfection. Therefore, the modified NOSES II can not only ensure the radical resection of tumors, but also reduce the damage to organs and tissues. Being more in compliance with the aseptic and tumor-free operation, this is an ideal procedure that fully satisfies the requirements of functional surgery.

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 unctional Side-to-Side Anastomosis F for Digestive Tract Reconstruction of NOSES

Digestive tract reconstruction is one of the crucial procedures in colorectal surgery. The digestive tract reconstruction of NOSES should be performed under total laparoscopy, which is an important procedure different from conventional laparoscopic surgery. In this section, the application of functional side-to-side anastomosis in NOSES is introduced. With this method, the direction of peristalsis of the proximal and distal bowel is the same, therefore the continuity of peri-

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stalsis is maintained. This method is referred to as “functional” side-to-side anastomosis (Fig.  39.3). The detailed operation of this anastomotic technique is introduced as follows. The transverse colon is straightened, and the sigmoid colon is pulled up to the upper abdomen to be placed overlapped with the transverse colon (Fig. 39.4a). Suture is performed between the transverse colon stump and the bowel wall at 8  cm from the terminal ileum stump for fixation (Fig. 39.4b). Afterwards, the surgeon checks the blood supply of both sides of the bowel and estimates 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, respectively (Fig. 39.4c, d); then both bowel lumens are disinfected with iodoform gauze. The linear Endo-GIA stapler is introduced through the surgeon’s main trocar, and the cartridge jaw and the anvil jaw are inserted into the two bowel lumens separately. With the necessary adjustment, the stapler is fired to create the side-to-side anastomosis between the transverse colon and sigmoid colon (Figs. 39.4e, f and 39.5a). The bowel lumen is disinfected with iodoform gauze again, and the integrity of the anastomosis is confirmed. After excluding anastomotic leakage, traction suture is fixed in the enterotomy in the transverse colon wall and sigmoid colon stump (Fig.  39.5b). The surgeon and assistant grasp the tail of the traction suture to keep the enterotomy straight and close the enterotomy with linear Endo-GIA stapler. Digestive tract reconstruction with isoperistaltic functional side-to-side anastomosis is completed (Fig. 39.5c, d). Eight-­ figure suture is performed for the reinforcement of anastomosis (Fig. 39.5e).

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Fig. 39.4 Operating Procedures of Functional Side-to-Side Anastomosis. (a) Overlapping of the sigmoid colon with transverse colon; (b) Suture of the transverse colon stump with the bowel 8 cm from the sigmoid colon stump; (c) Making an incision of 1 cm long on

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Fig. 39.5 Operating Procedures of Functional Side-to-Side Anastomosis. (a) Completion of side-to-side anastomosis between the sigmoid colon and transverse colon; (b) Fixing traction suture in the

the sigmoid colon stump; (d) Making an incision of 1 cm long on the antimesenteric side of the transverse colon; (e) Insertion of linear Endo-­ GIA stapler into the sigmoid colon; f. Insertion of linear Endo-GIA stapler into the two sides of bowel

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enterotomy; (c) Closing the enterotomy; (d) Digestive tract reconstruction with isoperistaltic functional side-to-side anastomosis; (e) 8 figure suture for the reinforcement of anastomosis

39  Experience Sharing in NOSES for Colorectal Cancer

In theory, digestive tract reconstruction with isoperistaltic functional side-to-side anastomosis maintains the continuity of the peristaltic direction between the proximal bowel and distal bowel and makes bowel peristalsis more smooth, which plays an important role in the postoperative recovery of patients. According to the results of our center, digestive tract reconstruction with isoperistaltic side-to-side anastomosis would neither increase the operating time nor increase the incidence of perioperative complications. However, as a novel anastomotic technique, studies with larger scale are in need for more convincing results to support the application and popularization of this technique.

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verse colon. The terminal ileum stump is opened with a 1-cm incision close to staple lines on the antimesenteric border with laparoscopic scissors (Fig. 39.7a). 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 ileal lumen (Fig.  39.7b). Similarly, the sigmoid colon stump is opened with a 1-cm incision close to staple lines on the antimesenteric border (Fig. 39.7c), and the cartridge jaw is placed into the colonic lumen (Fig. 39.7d). The stapler is fired to create the side-to-side anastomosis between the ileum and transverse colon. The surgeon inserts the linear Endo-GIA stapler through the 12 mm troca, closes the enter-

 unctional End-to-end Anastomosis F for Digestive Tract Reconstruction of NOSES

End-to-side anastomosis between ileum and transverse colon is the anastomotic technique in conventional right hemicolectomy. However, in NOSES VIII, the digestive tract reconstruction is performed by a functional end-to-end anastomosis between ileum and transverse colon (Fig. 39.6). This method only applies four linear Endo-GIA staplers. It is not only a safe and feasible approach for laparoscopic digestive tract reconstruction after right hemicolectomy, but also the most common anastomotic technique in NOSES VIII. Surgical procedures: After the dissection of the right colon, the transverse colon and the terminal ileum are transected at the intended resection line, respectively. The transverse colon is straightened, and the sigmoid colon is pulled up to the upper abdomen to be placed parallel with the trans-

Fig. 39.6  Functional end-to-end anastomosis of colon and small intestine

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Fig. 39.7  Operating procedures of functional end-to-end anastomosis. (a) Making an incision in the terminal ileum; (b) Placing the anvil jaw into the ileum; (c) Making an incision in the transverse colon; (d)

Placing the cartridge jaw into the transverse colon; (e) Closing the enterotomy transversely; (f) Suture for the reinforcement of anastomosis

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otomy to complete the functional end-to-end anastomosis (Fig.  39.7e). The resected stump tissue is placed into the specimen retrieval bag 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. 39.7f). Compared with the end-to-side anastomosis, functional end-to-end anastomosis mainly has the following advantages (Fig. 39.8): (1) To reduce the anastomotic stenosis. With this approach, the diameter of anastomosis is large, which not only avoids anastomotic stenosis but also solves the problem of uneven intestinal diameter between the ileum and colon. (2) Operation is simpler, which can further shorten the operation time and reduce the risk of intraoperative contamination. (3) The ileal blind pouch formed by end-to-side anastomosis is avoided. End-to-side anastomosis forms a blind pouch in the colon, which is often a main cause for postoperative complications. 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 the anastomosis can be reduced. The right colon has a large amount of intestinal contents, which may

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leak into the abdominal cavity due to inappropriate operation, resulting in intra-abdominal infection. Therefore, during the digestive tract reconstruction, strict aseptic principles should be followed, including timely suction of intestinal contents, disinfection with iodoform gauze, etc. These operations put forward higher requirements for the cooperation between the surgeons and assistants.

4

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 tumor-­ free 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,

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Fig. 39.8  Sharing on details of aseptic and tumor-free techniques of NOSES. (a) Removing gauze through the trocar may contaminant the abdominal cavity; (b) Gauze is damaged when passing through the tro-

 ow to Perfectly Follow the Aseptic H and Tumor-Free Principles in NOSES

car; (c) Extraction of resected specimen with resected glove finger; (d) Unprotected resected specimen stump

39  Experience Sharing in NOSES for Colorectal Cancer

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.  39.8a); (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; (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. 39.8b). 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. 39.8c, d). In most cases, the specimen is extracted through the protective sleeve together with the used gauze (Fig. 39.9).

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3. Iodoform gauze can be applied to sterilize the rectal stump and other potentially contaminated 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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 he Concept and Application T of Passing by-NOSES and Like-NOSES

NOSES is defined as a surgical procedure performed intracorporeally equipped with laparoscopic instruments, TEM, or flexible endoscopy, followed by specimen extraction through a natural orifice (anus, vagina, or mouth). Compared with the conventional laparoscopic surgery, NOSES is equipped with a specimen extraction feature through a natural orifice, to avoid the abdominal incision and only leaving a few tiny trocar scars on the abdominal wall after the surgery. 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

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Fig. 39.9 (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

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tract reconstruction, and extraction of the resected specimen. Passing by-NOSES: A series of surgical procedures performed intracorporeally equipped with laparoscopic instruments, TEM, or flexible endoscopy, including tumor resection, regional lymph node dissection, division, and isolation of mesentery, digestive tract reconstruction are other procedures. The specimen is extraction by passing by the necessary incisions, such as the incision of the diverting ileostomy (Fig.  39.10) and the incision of multiple organ resection (e.g., resection of rectal cancer combined with partial hepatectomy for liver metastases) (Fig. 39.11), which

manifests the potential advantage of NOSES in minimizing surgical trauma and maximizing benefits for patients. Like-NOSES: A series of surgical procedures performed intracorporeally equipped with laparoscopic instruments, TEM, or flexible endoscopy, including tumor resection, regional lymph node dissection, division and isolation of mesentery, digestive tract reconstruction are other procedures. When the auxiliary incision in the abdominal wall cannot be avoided, the specimen is extracted through a concealed incision in the abdominal wall (mostly small transverse incision in the lower abdomen), the original surgical incision (cesarean section, appendectomy incision), or other

Fig. 39.10  Extraction of the rectal specimen through the ileostomy incision

Fig. 39.11  Extraction of colon specimen through the incision of liver surgery in the right lower costal margin

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Fig. 39.12  Specimen extraction and abdominal wall incision of Like-­ NOSES. (a) Placing the resected specimen and all gauzes in the protective sleeve; (b) Removing the resected specimen and gauze under the

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“double protection” of the incision protector and the protective sleeve in strict accordance with the aseptic and tumor-free principles; (c) Postoperative abdominal incision

39  Experience Sharing in NOSES for Colorectal Cancer

concealed incisions in the abdominal wall (Fig.  39.12). Similar to NOSES, all operations of this procedure are performed under laparoscopy and the specimen is extracted through the concealed incision in the abdominal wall. This procedure has many advantages include lighter pain, quicker recovery, and better cosmetic effect.

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 pplication of “Reverse Parallel A 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 the 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.

6.1

 ivision of the Sigmoid Mesocolon D (Reverse Parallel Division)

The division of the sigmoid mesocolon should meet the following requirements: (1) to ensure the safety of the proximal

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resection margin; (2) to ensure the extent of regional lymph node dissection; (3) to ensure the adequate length of bowel; (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. First, the assistant pulls the sigmoid colon to the left, inserts a gauze underneath the sigmoid mesocolon (Fig. 39.13a), evaluates the extent of division, determines the intended resection line, and then performs the division of sigmoid mesocolon by “reverse parallel division” (Fig. 39.13b). 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 tension-­ free 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, then ligates and transects several sigmoid colon vessels (Fig. 39.13c). 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.  39.13d). The ­division is further continued to the intended resection line to cut the mesentery and then proceeds toward the wall of the sigmoid colon (Fig.  39.13e). Vascular clips are not recommended to be used near the bowel wall to avoid affecting the

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Fig. 39.13  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 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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anastomosis (Fig. 39.13f). Apply ultrasonic scalpel to dissect to the bowel wall and isolate 2–3 cm of the bowel.

6.2

I solation of the Mesorectum (Wang’s Isolation)

Laparoscopic isolation of the mesorectum has always been a difficulty in the radical resection of lower rectal cancer, especially the isolation of the left rectal wall and thick mesentery. It is necessary not only to ensure the safety of the 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 the 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.  39.14a, 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. 39.14c) and the dissection is gradually extended posteriorly to the midline of the posterior wall (Fig.  39.14d). 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.  39.14e–g), gradually extend to the posterior rectal wall and eventually rendezvous with the right side (Fig. 39.14h). In general, the bowel should be isolated for 3 cm. Isolation of the rectal wall by “Wang’s isolation” has less bleeding and clearer anatomical structure. This method has more advantages 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

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Fig. 39.14  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 the rectum; (g) Isolation of the left rectal wall; (h) Complete isolation of rectum

39  Experience Sharing in NOSES for Colorectal Cancer

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.

7

 he Past and Present of NOSES T with Enhanced Recovery After Surgery

Enhanced recovery after surgery (ERAS) was firstly proposed by Danish surgeon H. kehlet in 1997. After more than 20 years of continuous practice, a set of the whole course perioperative management system based on evidence-based medicine has been gradually formed and gained more and more recognition in clinical practice, especially in surgery, with extensive development and continuous improvement. The core objectives of ERAS are to reduce traumatic stress, shorten the length of stay, and accelerate recovery. Analgesia and minimally invasive are the two core contents of ERAS. They are necessary to achieve the perioperative optimization management system of ERAS. As a new force of modern minimally invasive surgery, NOSES has exhibited great vitality since its proposal by Professor Wang Xishan and continuous clinical practice. The core concept of NOSES is “minimally invasive of minimally invasive.” The goal of NOSES is incision-free, painless, maximization of the patient’s physical function, and promotion of the patient’s rapid recovery. Therefore, NOSES and ERAS have the same original purpose and highly consistent goals. With the rapid development of modern surgery, NOSES and ERAS complement and combine with each other to create mutual support and growth. As a surgical perioperative optimization system, ERAS embodies a macroscopic concept and guiding strategy, while NOSES is a practical surgical technique that truly embodies the concept of “minimally invasive of minimally invasive”. The core goals of reducing trauma, shortening the length of stay, and accelerating recovery of ERAS can only be realized through minimally invasive techniques such as

NOSES.  NOSES is the prerequisite and necessary measure for the successful implementation of ERAS.  Similarly, the goals of incision-free, painless, protection of organ function, and rapid recovery of NOSES can only be achieved under the guidance of ERAS with the continuous integration of NOSES with ERAS. Only in this way can the concept of ERAS be continuously extended and developed. Therefore, NOSES and ERAS have the same origin and consistent goals. With the organic combination, their theoretical system and connotation can be truly understood, and their advantages of homologous coexistence can be exerted, which can bring benefits to more patients, save health resources, and benefit the society.

8

 xperience Sharing on NOTES: E Transvaginal Radical Resection of Rectal Cancer Through Rigid Endoscopy (Rectal Tv-NOTES)

Under the impact of the NOTES concept, Professor Wang Xishan took the lead in conducting two cases of NOTES for rectal tumor in 2010. The surgery went smoothly, the patients had a quick recovery and showed good short-term efficacy. The successful completion of this operation fills the gap of NOTES in the treatment of rectal cancer. The patients have survived with high quality of life for 9 years after operation. The followup data showed that there is no indication of tumor recurrence or metastasis in the two patients. The results also confirm that NOTES through rigid endoscopy not only has good short-term efficacy, but its long-term efficacy is guaranteed as well. The operating procedures of transvaginal NOTES with rigid endoscopy for rectal cancer is introduced in detail in this section.

8.1

Anesthesia and Surgical Preparation

The patient is anesthetized by intravenous general anesthesia. The patient is placed in a functional lithotomy position b Mo

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Fig. 39.15  Placement of trocar and surgeons’ position. (a) Placement of trocar on the posterior fornix; (b) The surgeons’ position

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with both thighs flexed and abducted, which facilitates to perform the operation for the surgeon. The surgeons’ position: The surgeon and the camera holder are seated between the patient’s legs, with the surgeon on the right side and the assistant on the left side, and the second assistant stands on the left side of the patient (Fig. 39.15a). Trocar sites: Camera trocar (10 mm trocar) is located at the umbilicus. The pneumoperitoneum is established and the camera torcar is placed. Under the direct vision of the camera, 5 mm and 10 mm trocars are placed on the left side and right side of the posterior vaginal fornix as the main trocar and auxiliary trocar, respectively (Fig. 39.15b).

8.2

Surgical Procedures and Techniques

Abdominal exploration: The abdominal exploration is performed firstly. No metastatic lesions are observed in the liver and pelvic cavity, no abnormalities are observed in the uterus or bilateral adnexa, and the lesion is located at the upper rectum. Lymph node dissection and vascular ligation: The uterine manipulator is used to lift the uterus upwards to facilitate surgical operation. With the ultrasonic scalpel, the peritoneum on the right side of the rectum is opened, and dissection is gradually performed to the root of the inferior mesenteric artery. The inferior mesenteric artery is isolated at the root, then the peritoneum on the left side of the rectum is incised. Dissection is continued upwards to the lateral side of the sigmoid colon, then proceeds to the level of the junction between the descending colon and sigmoid colon.

Subsequently, the dissection is performed in a lateral to the medial pattern to rendezvous with the contralateral side. After that, the superior rectal artery is isolated at the root, then the lymph nodes at the root of the inferior mesenteric artery are removed (Fig. 39.16a), and the inferior mesenteric artery and vein are transected (Fig.  39.16b). Then the ­mesentery is divided downwards, and the mesorectum is dissected to approximately 5 cm below the tumor. Specimen resection and digestive tract reconstruction: The surgeron should evaluate to confirm that the sigmoid mesocolon is long enough to be extracted after being divided and dissected. The pneumoperitoneum is released, and the posterior vaginal fornix is opened transversely. An incision protector is introduced through the vaginal stump, and the lower segment of the sigmoid colon and the upper segment of the rectum is pulled out. The curved stapler is used to transect the rectum at 5 cm from the distal edge of the tumor (Fig. 39.16c). Following this, the rectum and the tumor are pulled out through the vagina, and the bowel is transected at 8  cm from the proximal edge of the tumor to remove the specimen. The anvil is inserted into the proximal bowel stump and secured with purse-string suture. After the proximal bowel stump is returned into the abdominal cavity, the pneumoperitoneum is established again. A circular stapler is inserted through the anus, the trocar of the stapler is carefully extended to connect with the anvil and create the anastomosis(Fig. 39.16d). Closure of vaginal incision: After confirming the integrity of the anastomosis, the abdominal cavity is irrigated and the pneumoperitoneum is released. A drainage tube is

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Fig. 39.16  The main surgical procedures of NOTES. (a) Dissection of lymph nodes at the root of the inferior mesenteric artery; (b) Transection of the inferior mesenteric artery and vein; (c) Extracorporeal closure of

the bowel above the tumor with a curved stapler; (d) End-to-end anastomosis between the sigmoid colon and rectum; (e) Extracorporeal suture of the vaginal incision; (f) Postoperative abdominal wall

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placed through the vagina to the pelvic floor, then the vaginal stump is closed by interrupted suture with absorbable sutures (Fig.  39.16e). The umbilical trocar incision is sutured, and the operation is completed. The patient has no incision scar on the abdominal wall after the operation (Fig. 39.16f).

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 kills and Experience Sharing S 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 the surgeon, assistant, and camera holder in the process of an 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.

9.1

Action One “Block”

9.1.1 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. 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.

Fig. 39.17  Using gauze strips to push the small intestine to the upper abdomen

Fig. 39.18  Applying a gauze pad to the posterior wall of the rectum

9.1.2 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. 39.17).

9.2

Action Two “Pad”

9.2.1 Applicable Scene 1. While performing operations such as withstanding and supporting on the easily punctured tissue, such as in the 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. 9.2.2 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

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Fig. 39.19  Clamping the small gauze to hold the tissue and pull to the right side to form tension

Fig. 39.20  Assistant uses gauze steadying anvil to assist puncture

supported or pulled to increase the local contact area, thereby reducing the local pressure to avoid stabbing the tissue (Fig. 39.18).

9.3

Action Three “Press”

9.3.1 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. 9.3.2 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. 39.19).

9.4

Action Four “Steady”

9.4.1 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. 9.4.2 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

Fig. 39.21  Supporting the gauze to the dorsal side of the mesentery

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. 39.20).

9.5

Action Five “Support”

9.5.1 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 the mesentery are processed in the posterior transverse colon space.

39  Experience Sharing in NOSES for Colorectal Cancer

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9.5.2 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. 39.21).

9.6

Action Six “Blunt Dissection”

Fig. 39.23  Placing the gauze yarn on the surface of the ureter for protection

9.6.1 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. 9.6.2 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. 39.22).

9.7

Action Seven “Protect”

9.7.1 Applicable Scene In the NOSES radical resection of colorectal cancer, it is important to expose the ureter and protect it. The gauze can

Fig. 39.22  Clamping the gauze mass for blunt dissection in the space anterior to Toldt’s fascia

Fig. 39.24  Gauze markings around the sides of the rectal mesangial area

be placed on the surface of the dissected ureter to protect it, which can facilitate accurate positioning and avoid damage during the contralateral operation.

9.7.2 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, 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. 39.23).

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9.8

Q. Tang et al.

Action Eight “Mark”

9.8.1 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 the 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. 9.8.2 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. 39.24).

9.9

Action Nine “Sterilize”

9.9.1 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.

Fig. 39.25  Using small iodoform gauze to disinfect the posterior vaginal incision and extract it through the vagina

9.9.2 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 perform vaginal bimanual examination to take out the gauze through the vagina (Fig. 39.25).

9.10

Action Ten “Suction”

9.10.1 Applicable Scene In order to avoid the loss of pneumoperitoneum that may affect the operation and avoid the tissue damage caused by 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. 9.10.2 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. 39.26).

Fig. 39.26  The suction device draws the flushing liquid on the surface of the gauze

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ceps, 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. 39.27).

9.12

Fig. 39.27  Using forceps to clamp the gauze to push the transverse colon to the cephalic side

Fig. 39.28  Clamping the gauze to withstand the mesorectum and dissect the presacral space

9.12.1 Applicable Scene Fully expose the surgical area to reduce collateral damage to the tissue. 9.12.2 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.  39.28). In right hemicolectomy, when dissecting in 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. 39.29). 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 twelve 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.

10

Fig. 39.29  Clamping the gauze to withstand the mesentery of the right colon

9.11

Action Eleven “Spread”

9.11.1 Applicable Scene Fully expose the surgical area to reduce collateral damage to the tissue. 9.11.2 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 for-

Action Twelve “Withstand”

 OSES for Total Laparoscopic Left N 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 0.45–24%. 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 follow.

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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, then the root of the inferior mesenteric artery is exposed. Following this, the left colic artery is isolated and transected. The station

Q. Tang et al.

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. 39.30).

a

b

c

d

e

f

g

h

Fig. 39.30  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 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

39  Experience Sharing in NOSES for Colorectal Cancer

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 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

a

585

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.  39.31). The specimen can be extracted via rectum in male patient, or via the vagina in female patient (Fig. 39.32).

b

Fig. 39.31  Intracorporeal colocolonic anastomosis type. (A) Side-to-side anastomosis; (B) End-to-end anastomosis

a

b

Fig. 39.32  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

40

Totally Laparoscopic Colectomy for Colorectal Cancer with Natural Orifice Specimen Extraction Combined with Reduced-Port Surgery: Japanese Experience Atsushi Nishimura, Mikako Kawahara, Yasuyuki Kawachi, Shigeto Makino, Chie Kitami, and Keiya Nikkuni

Natural orifice specimen extraction surgery (NOSES) has become an alternative approach for the treatment of colorectal cancer without additional incisions on the abdominal wall. However, previous studies showed that multiport technique was used when carrying out NOSES.  We applied reduced-port surgery (RPS) technique in performing totally laparoscopic colectomy with transanal specimen extraction (TASE) and transvaginal specimen extraction (TVSE) from 2012. The points of our procedures are as follows: (1) In TASE cases, we attached the multiport access platform into the navel and inserted two to three ports in it to reduce the number of abdominal incisions. (2) In TVSE cases, we attached the same platform to the transvaginal route for transvaginal assistance and smooth specimen extraction. (3) We used needlescopic devices as far as possible. The technique is rather complicated and requires advanced surgical skills. We documented two examples of this ultimately minimal invasive surgery.

1

Indications

TASE was indicated for patients with colorectal cancers located in the sigmoid or rectosigmoid colon. TVSE was indicated for menopausal women who previously underwent vaginal delivery with colorectal cancers located from the cecum to the upper rectum. Both procedures were performed for the tumor covered less than half of the colon circumference and clinical stage T3 or lower. However, our opinion is that NOSE with RPS should be indicated only for patients with primary tumors of clinical stage Tis and T1. As the complicated procedures lead to longer operation time, we had better operate with multiport technique in advanced A. Nishimura (*) · M. Kawahara · Y. Kawachi · S. Makino C. Kitami · K. Nikkuni Nagaoka Chuo General Hospital, Niigata, Japan e-mail: [email protected]

Table 40.1  Indications of NOSES

C-D

T1

T2, 3

TVSE

LAC

S, RS

TVSE/TASE

Ra

TVSE/TASE or LAC

Rb- P

LAC (With TaTME)

T4a

LAC

LAC laparoscopic assissted colectomy, TaTME transanal total mesorectal excision

cases. What is important is to select the optimal operation method for the individual patient. We decide it according to the location and depth of the tumor (Table 40.1). Because of the difficulty of colon washing, we do not adopt TVSE with intracorporeal functional end to end anastomosis to advanced right-sided colon cancer to avoid a potential risk of cancer cell dissemination.

2

Technique

2.1

 otally Laparoscopic Sigmoidectomy T with TASE (NOSES IV)+ RPS

1. The patient was positioned in the modified lithotomy position. 2. A GelPOINT® Mini advanced access platform (Applied Medical, Rancho Santa Margarita, CA, USA) was placed through a 1.5–2  cm-long minilaparotomy in the navel (Fig. 40.1). A 12-mm port for a laparoscope or linear stapling device and a 3-mm port for the assistant’s forceps were placed in the GelPOINT (Fig. 40.2). The assistant’s forceps were used to obtain adequate exposure. The third

© People’s Medical Publishing House, PR of China 2021 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-15-7925-7_40

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3mm

15-20mm for GelPOINT

5mm

Fig. 40.1  A GelPOINT® Mini placed through a 1.5–2 cm-long minilaparotomy in the navel

Fig. 40.3  Port placement

Fig. 40.2  Placement of 12- and 3-mm ports in the GelPOINT

and the fourth ports were a 5-mm surgeon’s operating port in the right lower quadrant, and a 3-mm surgeon’s left-hand port in the right middle abdomen (Fig. 40.3). 3. The inferior mesenteric artery was ligated at its point of origin from the aorta (Fig.  40.4). After irrigation with 2  liters of diluted povidone-iodine solution, the rectum was transected. Then, the proximal colon was also transected to achieve colectomy. As we needed to insert linear stapler through the navel to transect the colon and rectum, we changed the position of a laparoscope to the 5-mm port in the right lower quadrant (Fig. 40.5). 4. We inserted a “special retractor” through the navel. The transected rectum stump was then opened using laparoscopic coagulation shears. A long Babcock grasper was carefully inserted transanally and one of a pair of retrac-

Fig. 40.4  The inferior mesenteric artery was ligated at its point of origin from the aorta

tor’s rings was held and pulled out of the anus. The anvil head attached to the circular stapling device was inserted into the abdominal cavity (Fig. 40.6). Then the specimen was extracted transanally (Fig.  40.7). The retractor was also delivered transanally. Re-close of the rectal opening with a linear stapler through the navel was often difficult. In such cases, adopting the stapler longitudinally will bring good results (Fig. 40.8). 5. The proximal colon was clamped with a detachable clip to set intracorporeal purse-string sutures (Fig. 40.9). The anvil head was inserted into the proximal colon. We used an Endo-loop to fix the anvil (Fig. 40.10). An end to end

40  Totally Laparoscopic Colectomy for Colorectal Cancer with Natural Orifice Specimen Extraction Combined with Reduced-Port… 589

Fig. 40.5  The rectum was transected by a linear stapler inserted through the navel Fig. 40.8  Re-close of the rectal opening longitudinally with a linear stapler

Fig. 40.6  The anvil head was inserted into the abdominal cavity Fig. 40.9  Intracorporeal purse-string sutures at the proximal colon

Fig. 40.7  The specimen was extracted transanally

Fig. 40.10  The anvil head was fixed by an endo-loop

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Fig. 40.12  Visible scars were 3-mm and 5-mm port incision

Fig. 40.11  A pelvic drain was inserted using the incision for a 5-mm port

colorectal anastomosis was then performed by using circular stapler. After irrigating the pelvic cavity with 3 liters of saline, a pelvic drain was inserted (Fig. 40.11). 6. As a result, visible scars were 3-mm and 5-mm port incision (Fig. 40.12).

2.2

 otally Laparoscopic Ileocecal T Resection with TVSE (NOSES VII)+ No Minilaparotomy Fig. 40.13  The surgeon was on the patient’s left side, while the assis-

1. The patient was positioned in the lithotomy position to tant sat between the legs allow adequate exposure for the transvaginal procedure. The surgeon stood on the patient’s left side, while the a colpotomy at optimal position by the guidance. A assistant sits between the legs (Fig. 40.13). GelPOINT’s white ring was placed outside the vagina and 2. We inserted a 5-mm port in the navel using optical covered with gel seal cap. We inserted a laparoscope, method. This was for surgeon’s operating port. The secassistant’s forceps, gauzes, and stapling devices through ond port was a 5-mm port for surgeon’s left hand in the it. The view of laparoscope inserted through the vagina is left lower quadrant (Fig. 40.14). quite natural as if the scope was inserted from suprapubic 3. We developed a special instrument, namely “new vagi-­ location. pipe” to insert the GelPOINT mini into the abdominal 4. Transverse colon was lifted and fixed on the abdominal cavity transvaginal without losing the pneumoperitoneum wall with detachable clips (Fig.  40.18) and mesocolon (Figs. 40.15 and 40.16). We made about 3cm-long transwas grasped and lifted by forceps inserted through the verse posterior colpotomy using a vessel sealing devices vagina (Fig. 40.19). Reduced-port surgery has several disunder new vagi-pipe guidance (Fig. 40.17). We can make advantages such as the clashing of instruments, the lack

40  Totally Laparoscopic Colectomy for Colorectal Cancer with Natural Orifice Specimen Extraction Combined with Reduced-Port…

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5mm

3 or 5mm

Fig. 40.17  Posterior colpotomy under new Vagi-Pipe guidance

Fig. 40.14  Port placement

Fig. 40.18  Transverse colon was lifted and fixed on the abdominal wall with detachable clips

Fig. 40.15  New Vagi-Pipe

Fig. 40.19  Mesocolon was grasped and retracted by forceps inserted through vagina Fig. 40.16  Insertion of a GelPOINT

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of tension, and inadequate exposure. Detachable organ retractor and transvaginal assistance can help resolve these problems. 5. Superior mesenteric vein and artery were exposed. Ileocolic vein and artery were ligated at its point of origin from SMV and SMA (Fig. 40.20). We must not reduce the quality of dissection in NOSES.  The mesentery was divided under transvaginal assistance. We must operate marginal vessels very carefully to maintain good blood circulation. Recently, we can use an infrared laparoscope system with indocyanine green (ICG). The case in which the bowel wall is dyed with ICG within one minute, we judge it good circulation (Fig.  40.21). I believe this method is objective and promising. Then the colon and the ileum were transected by a linear stapling device inserted from the vagina (Figs. 40.22 and 40.23). Because of the appropriate distance from the vagina to the intestine, handling is not difficult. The specimen is extracted through the vagina (Fig. 40.24).

A. Nishimura et al.

Fig. 40.22  The colon was transected by a linear stapling device inserted from the vagina

Fig. 40.23  The ileum was transected by a linear stapling device inserted from the vagina

Fig. 40.20  Ileocolic vein and artery were ligated at its point of origin from SMV and SMA

Fig. 40.21  We can use an infrared laparoscope system with indocyanine green to evaluate the circulation of intestines

Fig. 40.24  The specimen was extracted through the vagina

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6. The next step was the intracorporeal functional end to end anastomosis (Figs. 40.25 and 40.26). The assistant must play a very important role in this step. He or she had to manipulate both a laparoscope and a stapling device through the vagina simultaneously (Fig.  40.27). This needs good skills. 7. We always irrigate the abdominal cavity with 3 liters of saline. Gauzes and a GelPOINT were removed and the posterior colpotomy was closed by single-layer running sutures (Fig. 40.28). We have not experienced postoperative complications related to posterior colpotomy. 8. Visible scar was only 5-mm in the left lower quadrant (Fig. 40.29).

Fig. 40.27  The assistant manipulated both a laparoscope and a stapling device through the vagina simultaneously

Fig. 40.25  Intracorporeal functional end to end anastomosis Fig. 40.28  Posterior colpotomy was closed by single-layer running sutures

Fig. 40.26  Closure of the entry hall Fig. 40.29  Visible scar was only 5-mm in the left lower quadrant

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Conclusion

tant. Painless and scarless may not be as important as the above. However, these relate directly to the patient’s satisfacNOSES with RPS acquired less wound pain, less wound-­ tion. And only laparoscopic surgery can pursue and achieve related complications, better comprehensive quality of life, these. Therefore, I will carry on with practice and investigation of colorectal surgery with NOSES. and satisfactory cosmetic outcomes. What are the elements of the ideal operation? First of all, cure as well as safety. Functional preservation is also impor-

Laparoscopic-Assisted Natural Orifice Specimen Extraction Colectomy Using a Cai Tube for Left-Sided Colonic Carcinomas

41

Jianchun Cai and Shuzhen Xu

It is a novel technique of laparoscopic-assisted natural orifice specimen extraction (LA-NOSE) colectomy whereby laparoscopic colonic mobilization, transection, and anastomosis are performed intracorporeally. The specimen is then delivered through the rectum using the Cai Tube (Homemade Invention: CN201420203735.X, Fig.  41.1), precluding the need for mini-laparotomy. Left-sided colonic carcinomas are defined as carcinomas located in the middle rectum, upper rectum, sigmoid colon, descending colon, and the splenic flexure of the colon. The operating team had undertaken 160 cases of LA-NOSE radical left-sided colectomies using a Cai Tube. The technique of LA-NOSE using a Cai Tube has been described in our previous literature (Cai and Hong 2016). In this study, we made some improvements. Here, we introduce the application of Cai Tube and how to ensure the LA-NOSE aseptic and tumor-free operation effectively. To facilitate the insertion of the Cai Tube, the patient is placed in the modified lithotomy position. Sacral support is used to raise the pelvis so that the tip of the coccyx is readily palpable from below. A five-port technique is used (Fig. 41.2). The operation is started with a medial approach. Mobilization of the left-sided colon, lymph node dissection, and excision of the mesentery are performed laparoscopically in the usual manner. If necessary, the splenic flexure of the colon can also be mobilized. After the dissection of the mesentery, the left mesentery is cut, which is a bleeding-prone and time-consuming procedure during LA-NOSE.  Accordingly, we summarized our experience and propose “Cai’s LA-NOSE 3-step maneuver for proximal bowel isolation” (Fig.  41.3). The steps are as follows: (1) Mark: A titanium clip is applied to mark the proximal resection margin of the tumor (distance  =  10  cm). J. Cai (*) · S. Xu Department of Gastrointestinal Surgery, Zhongshan Hospital of Xiamen University, Xiamen, China

Starting from the titanium clip, the ultrasonic scalpel is applied to make a marker line in the proximal mesentery along the projection line of each branch of the inferior mesenteric artery; (2) Cut: Cut the mesentery from far to near. The first step is to find the mesenteric arteriovenous trigone formed by the inferior mesenteric artery and the left colonic artery, dissecting and transecting the left colonic artery from the apex of the trigone and then following the marker line, transecting the branches of the inferior mesenteric arteriovenous branches all the way to the marginal vessels. (3) Nake: 3 cm of bowel is separated from the distal end to the proximal end. The proximal colonic tube is occluded using a vasculature band just close to the proximal line of resection (Fig. 41.4). The advantages of the vasculature band are as follows: Firstly, it facilitates the subsequent traction of the bowel; secondly, the ligation is tight and not easy to slip off, which prevents tumor contamination in the abdominal cavity. Presacral dissection is carried out distal to the tumor. A point of 5 cm distal to the tumor is chosen as the level of the distal division. Similarly, the mesorectum at this level is divided until the rectal tube is exposed like the proximal mesocolon isolated. The rectal tube is also occluded using a vasculature band below the distal edge of the tumor, and distal rectal lavage is carried out by surgeon in the perineal position (Fig.  41.5). The anus is dilated to accommodate four fingers. The guide tube is smeared with paraffin oil and placed through the anus. After the endoscope is guided, the guide tube is slowly rotated under direct vision and enters the corresponding position of the rectum (Fig.  41.6). After reaching the isolated rectal wall, two laparoscopic iodoform gauzes are placed on both sides of the isolated rectal tube. The abdominal surgeon then makes a small enterotomy above the edge of the Cai Tube, applies the laparoscopic iodoform gauze to disinfect the anvil, and applies the other laparoscopic iodoform gauze to disinfect abdominal

© People’s Medical Publishing House, PR of China 2021 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-15-7925-7_41

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596 Fig. 41.1 Auxiliary incision-free tube—the Cai Tube. (a) Diagram of the auxiliary incision-free tube after assembly, (b) guide tube, (c) outer tube, (d) rear cover, (e) instrument hole cover

J. Cai and S. Xu

a

b

c

d

rin Pe

or

eal

onit

al M

.1)

g (Fi

m tfor Pla

ine Per

Abdominal Assistant

e

Mirror Assistant

MCL MID

5mm 12mm

MCL

5UL

Abdominal Monitor

5mm

12mm

Perineal Surgeon

5UL 5mm

o

Abd min a rm

atfo

l Pl

Chief Surgeon

Fig. 41.2  Port sites for the LA-NOSE. Positions of surgeons, platforms, and monitors

­contamination (Fig. 41.7). The anvil of a 28-mm circular stapler is then passed by the perineal surgeon to the abdominal surgeon via the Cai Tube and the opened rectal stump (Fig. 41.8). Two laparoscopic iodoform gauzes are placed on both sides of the colonic wall. A small colotomy is made below the isolated colonic wall, and the anvil is introduced into the proximal colon. Two Hemolock clips are applied to secure the anvil to prevent it from slipping into the proximal colon. The proximal colon is then transected. The endoloop

(the advantage of the endoloop is that it can avoid the use of a linear Endo GIA stapler, thereby reducing the risk of anastomotic bleeding and anastomotic leakage; in addition, it is easy to operate and very reliable for the fixation of the anvil) is applied to further secure the anvil. The scissor is applied to cut extra colons underneath two Hemolock clips for an endto-end anastomosis (Fig. 41.9). After traversing the rectum, the outer tube extends out of the rectum under the guidance of the guide tube (Fig. 41.10).

41  Laparoscopic-Assisted Natural Orifice Specimen Extraction Colectomy Using a Cai Tube for Left-Sided Colonic Carcinomas

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Fig. 41.3  Cai’s LA-NOSE 3-step maneuver for proximal bowel isolation

Fig. 41.4  The proximal colonic tube occluded using a vasculature band just close to the proximal line of resection

Fig. 41.5  Distal rectal lavage is carried out by surgeon in the perineal position

Fig. 41.6  Inserting the Cai Tube into the anus by surgeon in the perineal position

Fig. 41.7  Two laparoscopic iodoform gauzes placed on both sides of the isolated rectal tube; using one of the two laparoscopic iodoform gauzes to disinfect abdominal contamination

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J. Cai and S. Xu

Fig. 41.11  When the specimen is small, it can be removed directly through Cai Tube Fig. 41.8  The anvil of a 28-mm circular stapler is then passed by the perineal surgeon to the abdominal surgeon via the Cai Tube

Fig. 41.9  Using the endoloop to further secure the anvil

Fig. 41.10  After traversing the rectum, the outer tube extends out of the rectum under the guidance of the guide tube

The specimen should be turned over prior to its extraction. The mesenteric vessel pedicle and proximal colon are first inserted into the Cai Tube, thus reducing the volume of the specimen that has not entered the Cai Tube. If the specimen is small, it can be removed directly through Cai Tube (Fig. 41.11). For larger specimens, especially when it is estimated that specimens cannot be fully stuffed into the Cai Tube, the protective specimen bag is used to assist. The abdominal surgeon sends a specimen bag that is not closed at

Fig. 41.12  The specimen bag is knotted and pulled out of the abdominal cavity together with the outer tube, which is used to dilate the rectum

Fig. 41.13  Removing the specimen bag with rectal stump through the 12-mm port

both ends to the abdominal cavity via the 12-mm port. After the specimen is introduced into the bag, the perineal surgeon grasps the intestine. The abdominal surgeon lifts the specimen bag. The specimen bag is knotted and pulled out of the abdominal cavity together with the outer tube, which is used to dilate the rectum (Fig. 41.12). The rectal stump is closed with another stapler. Any tiny rectal tissue remnants packed in a specimen bag are easily removed via the 12-mm port (Fig.  41.13). All laparoscopic gauzes are removed through

41  Laparoscopic-Assisted Natural Orifice Specimen Extraction Colectomy Using a Cai Tube for Left-Sided Colonic Carcinomas

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After anastomosis, the pelvic cavity is rinsed with 1000 mL of dilute iodine solution. A pelvic drainage tube is placed around the anastomosis postoperatively.

Reference Cai JC, Hong XY.  Laparoscopic-assisted natural orifice specimen extraction radical descending colectomy using a Cai Tube. World J Surg. 2016;40(11):2803–7.

Fig. 41.14  All laparoscopic gauzes are removed through the Cai Tube

the Cai Tube (Fig. 41.14). At the last operation stage, the Cai Tube is removed. Finally, a colorectal end-to-end anastomosis is performed intracorporeally using a circular stapler.

Laparoscopic Total Colectomy Combined with NOSES: Turkish Experience

42

Cuneyt Kayaalp

1

Introduction

Rectal resection, right hemicolectomy, and sigmoid colectomy are the most frequently performed colorectal resections. Left hemicolectomy and transverse colectomy are used less frequently. All these surgeries can be performed with minimally invasive techniques, and specimens can be removed through a natural orifice that is called natural orifice specimen extraction surgery (NOSES). These surgeries involve only a part of the large intestine and related one or two quadrants of the abdomen. Total colectomy or total proctocolectomy involves the four quadrants of the abdomen. These are one of the most extensive surgeries in colorectal surgery with huge specimen sizes, and even they can be performed by laparoscopy. The removal of the large specimen through the natural orifices following laparoscopic resection is not a well-known procedure. In this chapter, we aimed to share our experiences about removing the specimen through the natural orifices in our patients undergoing laparoscopic total colectomy or total proctocolectomy.

2

Material and Method

The laparoscopic colorectal surgery database, performed between January 2013 and January 2020  in the Gastrointestinal Surgery Department, was examined. Patients who underwent ileorectal anastomosis with total colectomy (TC + IRA) or ileoanal pouch with total proctocolectomy (TPC + IPAA) were analyzed. Patients without anastomosis and complementary total colectomy (patients who had previously colon resection) were excluded. In

C. Kayaalp (*) Department of Gastrointestinal Surgery, Inonu University, Malatya, Turkey

suitable patients, the specimen was taken out from a natural orifice. At first the transanal route was preferred for NOSES; if this was unsuccessful, then the transvaginal route was used. The reason for this was to prevent enlarging the surgical area and to decrease the rate of rectovaginal fistula. Indications are mainly rounded up under two headings. The first was the patient’s acceptance and the second was technical suitability. Technically, anal stenosis, wide specimen diameter, vaginal stenosis, virginity, and previous pelvic surgery were considered as the most important limitations. Malignancy and morbid obesity were not considered as a contraindication for NOSES.  Previous pelvic surgery was accepted as relative contraindication and NOSES was applied in selected cases. Indications, surgical procedures, and results, as well as the patient demographics, were summarized in results.

3

Surgical Technique

Surgery was performed in the French position. Since positional changes were required during the surgery, patients were securely fixed to the operating table. Socks were dressed for deep vein thrombosis. A urine catheter was routinely applied. The stomach was decompressed with a nasogastric tube. Abdominal skin was widely cleaned with antiseptic solution. The placement of the monitors was changed according to the dial worked during the operation. Pneumoperitoneum was provided with a Veres needle placed from the umbilicus. A total of five trocars of 12  mm were placed in the umbilicus and four quadrants (Fig. 42.1). The procedure was first started from the distal colon or rectum. Total mesocolic resection was performed in patients diagnosed with preoperative cancer. In resections performed for prophylactic purposes, the mesentery was not always removed (Fig.  42.2). First, the sigmoid and descending colons were dissected from the lateral abdominal wall, and the mesocolon was divided by LigaSure 10 mm (Medtronic, USA). The splenic flexure of the colon and its mesentery was

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mobilized and divided. The greater omentum was not removed, and the remaining colon segments (transverse, hepatic flexure, ascendant, and cecum) were all separated from the mesocolon in the same way. The recto-sigmoid junction (or anorectal junction) and distal ileum were transected separately using 60  mm linear endoscopic staplers (Blue cartridge, Ethicon, Johnson & Johnson, USA). The distal rectal stump was opened with scissors, and the free abdominal specimen was taken out of the anus by an oval forceps (Fig. 42.3).

Fig. 42.1  Trocar placements

Fig. 42.2  Preserving or removing the mesocolon

C. Kayaalp

4

Results

Of the 305 cases performed by laparoscopy, 162 (53%) were planned to be removed by NOSES. A total of 16 (10%) cases failed with NOSES and were removed with an abdominal incision. Of all laparoscopic surgeries, a total of 35 (11.5%) patients underwent TC + IRA or TPC + IPAA. In 19 patients, the specimen was removed from the abdominal incision. In the remaining 16 (46%) patients, the specimen was removed with NOSES (14 transanal, 2 transvaginal). The transanal route was used for benign tumors and small-sized malignant tumors; the transvaginal route was used for larger tumors or large-sized specimens. The median age was 41.5 (16–70) and there were eight patients in both genders. The median body mass index was 23.5 kg/m2 (16–35.5). The etiology was familial adenomatous polyposis (FAP) (n:12), attenuated FAP (n:2), multifocal colon cancer (n:1), and colonic inertia (n:1). Thirteen patients underwent TC  +  IRA, while 3 patients underwent TPC  +  IPAA.  The conversion was required in one patient (6%). In this case, following TPC, the specimen was removed transanally, and the distal stump was closed. After the J pouch was formed, when it was not possible to deliver the pouch to the anus, the intestine was released with a vertical lower abdominal incision, and anastomosis was performed. A diverting loop ileostomy was created to this patient, and this stoma was reversed several months later. Apart from this case, no protective ileostomy was used in any patient. Median operation time was 300 (150–720) minutes. Median blood loss was 30 ml (0–300 ml). The first bowel movement is on Day 2 (1–4). The duration of hospital stay was a median 9 days (3–18). Excised intestinal lengths were median 108 cm (77–185).

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Fig. 42.3  Total colectomy specimen extraction through the anus (Servet Karagul archive)

Early postoperative complications were defined as those within the first 90 days. Complications were given according to the Dindo-Clavien classification. In the early period, a total of 8 (50%) patients had complications. There were one grade 1 (self-limiting hematuria), one grade 2 (hematochezia, improved with medical therapy and blood transfusion), two grade 3a (two intra-abdominal abscesses, both treated by percutaneous drainage and antibiotics), and two grade 3b complications (on the second postoperative day, laparotomy and hemostasis were performed due to intra-abdominal bleeding; another patient required reoperation due to intraabdominal abscess and intestinal perforation on postoperative 75th day). Late complications (>90 days) were seen in four patients. Two patients had an intra-abdominal abscess and required surgical treatment (one with intestinal fistula and ileus). One of them developed pouchitis in the late period and improved with medical treatment. In one FAP patient, a desmoid tumor developed in the small intestine mesentery and abdominal wall. In this patient, intestinal resection and bladder repair were performed. This is the only patient who has to live with a stoma. One patient had advanced obstructed gastric cancer with extensive colon cancer. TC  +  IRA and subtotal gastrectomy were performed in the same session, and both specimens were removed by transanal way. This patient died later due to advanced disease and cachexia in the postoperative third month. All patients, except this patient, are still alive.

5

Discussion

Following TC  +  IRA and TPC  +  IPAA combined with NOSES, we observed intra-abdominal abscess in five patients (31%) in our series. This was a higher rate than other colorectal surgeries combined with NOSES. In one patient, the abscess was secondary to omental ischemia in the splenic flexure and drained by laparoscopy. While the other two collections improved with percutaneous treatments, two cases of intra-abdominal abscesses that appeared in the late period (after 3 months) were treated by laparotomy. Intestinal obstruction after TC + IRA is not an uncommon complication. The compression of small intestines under the mesenterium of the terminal ileum or intra-abdominal abscesses are the main causes of postoperative ileus. In our patients, only partial ileus findings were encountered in the presence of intra-abdominal collections. Diverting ileostomy was required in only one case in our series. Anastomosis leakage was not observed in any patient. Transanal rectal tube placement is a known technique to decrease the pressure in the anorectal region following the anastomosis. We performed decompression with a transanal rectal tube in five of our cases. There is not enough information on whether it is necessary to remove the mesocolon when performing prophylactic TC or TPC. The common practice is to remove the mesentery in accordance with the principles in oncological surgery. However, preserving the mesentery can help NOSES, as its

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specimen size is reduced. The increased risk of postoperative ileus related to the left colonic mesentery has been discussed but has not been proved. Desmoid is a rare but serious complication of FAP, and leaving the mesocolon may raise a concern about increasing the risk of desmoid. However, desmoids generally do not originate from the remaining mesocolon but from the small intestine mesentery. More information is needed on the risk of incidental colorectal cancer in prophylactic colectomy in FAP patients who have no preoperative cancer diagnosis. Additional surgical procedures can be performed with total colectomy and may be a part of NOSES.  Additional surgery was performed in our three cases: one subtotal gastrectomy and two cholecystectomies. In all three cases, specimens were removed from the natural orifices without any problem. Open or laparoscopic TPC + IPAA is a well-known procedure; however, TPC + IPAA combined with NOSES was performed only in three cases, and all are reported here. Laparoscopic pouch creation intracorporeally showed some difficulties in our experiences. After the first stapler firing (60  mm laparoscopic linear stapler), the ongoing staplers continued firing, but this was not easy, and in the first case, we had to use a total of six cartridges. As far as we know, NOSES combined with laparoscopy is not available in the literature except for our cases. Recently, transanal TPC + IPAA (with or without laparoscopy) has been reported, and this new technique may have more widespread acceptance than NOSES combined with laparoscopic TPC + IPAA. It is well-known that laparoscopic surgery reduces both general complications and wound-related complications compared to open surgery. One of the most important causes of this trend is to minimize incision length. NOSE-assisted laparoscopic techniques are considered to provide less and less incision-related risks. NOSE-assisted surgical techniques are predicted to extend the operation time, but in our

C. Kayaalp

comparison, the operation time did not show a significant difference between the two groups, but a bit longer in the transabdominal group. This was attributed to the higher rate of malignant patients in the transabdominal group and to two complicated cases (distal anastomotic tension) in the transabdominal group. The amount of bleeding did not show significant differences between the two groups. Postoperative pain closely affects patient comfort and recovery process. The pain score increases with the increasing length of the incision. In our study, it was found that the VAS scores on postoperative days 1 to 3 were significantly lower in the NOSE group. Laparoscopic TC is an extensive laparoscopic colorectal surgery involving the four quadrants of the abdomen, and postoperative pain was significantly reduced by NOSE in laparoscopic TC. One of the major advantages of minimally invasive surgery is reduced incision-related complications. The incidence of incisional hernia and wound infection is known to be significantly lower in laparoscopic colon surgery. These rates are expected to decrease further with NOSE-assisted laparoscopic surgery. When the complication rates in our study were examined, no wound complications were observed in the NOSE group as expected. In the transabdominal group, two patients had wound infections, and one patient had a late incisional hernia. The greatest concern for NOSE-assisted laparoscopic surgery consists of anal sphincter damage, sexual dysfunction, and pelvic organ damage. However, the incidence of these complications is very low and it was zero in our series. As a conclusion, NOSES combined with TC  +  IRA or TPC + IPAA are feasible procedures. TC + IRA is a more suitable procedure for NOSES because TPC  +  IPAA with NOSES is more challenging. Postoperative intestinal obstruction related to an intra-abdominal abscess in the early or late period is the most common concern. When compared to conventional laparoscopic TC  +  IRA, NOSES provided less postoperative pain and better late cosmetic satisfaction.

Operating Points of Aseptic and Tumor-­ Free Operation in NOSES for Rectal Cancer

43

Chuangang Fu

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. The operating points of aseptic and tumor-free operation during surgery are summarized as follows: 1. Adequately irrigate the distal rectum. After closing the bowel above the tumor, the perineum group irrigates the rectum repeatedly with chlorhexidine (0.05% chlorhexidine acetate), and dry it with dry gauze, which can effectively reduce the intestinal contamination during anastomosis. 2. 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. 43.1). 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

C. Fu (*) Department of Gastrointestinal Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China

Fig 43.1  Self-made protective sleeve

one end, which can be tightened to avoid contamination caused by compression of lumen during specimen extraction. 3. 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. 4. 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. 5. 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 should be avoided to be

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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 bowel 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 the bowel that

C. Fu

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 Puncture Technique to Place Anvil for Laparoscopic Colorectal Resection with NOSES

44

Qingsi He and Hui Qu

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.

1

Data and Methods

1.1

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 was performed using the reverse puncture technique and with insertion of the anvil through 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.

Q. He (*) · H. Qu Department of General Surgery, Shandong University Qilu Hospital, Jinan, China

1.2

Operative Technique

1.2.1 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, and the trocar was placed in accordance with conventional laparoscopic colorectal surgery. 1.2.2 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 extracorporeally: eversion-resection (Figs. 44.1, 44.2, 44.3, 44.4, 44.5, 44.6, 44.7, 44.8, 44.9, 44.10, 44.11, 44.12, 44.13, 44.14, and 44.15) or resection-extraction (Figs. 44.16, 44.17, 44.18, 44.19, 44.20, 44.21, 44.22, 44.23, 44.24, 44.25, 44.26, and 44.27). Then a linear stapler was used to close the distal bowel. Subsequently, the circular stapler was placed from the anus, anastomosis was completed under laparoscopy, and the abdominal drainage tube was indwelled.

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Fig. 44.1  Cut open the distal bowel

Fig. 44.4  Place the anvil through the reverse puncture technique

Fig. 44.2  Cut open the distal bowel

Fig. 44.5  Place the anvil through the reverse puncture technique

Fig. 44.3  Insert the anvil through the anus

Fig. 44.6  Close and transect the distal bowel with Endo GIA stapler

44  Application of Reverse Puncture Technique to Place Anvil for Laparoscopic Colorectal Resection with NOSES

Fig. 44.7  Sponge forceps clamp the closed end of the bowel

Fig. 44.8  Pull out the specimen by anal eversion

Fig. 44.9  Pull out the specimen by anal eversion

Fig. 44.10  Pull out the specimen by anal eversion

Fig. 44.11  Contour close and transect the bowel specimen

Fig. 44.12  Anal placement of a circular stapler

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Fig. 44.16  Cut open the distal bowel

Fig. 44.13  Bowel anastomosis

Fig. 44.17  Cut open the distal bowel

Fig. 44.14  Interrupted suture

Fig. 44.18  Remove the anvil

Fig. 44.15  Place pelvic drainage tube

Fig. 44.19  Place the anvil into the proximal bowel

44  Application of Reverse Puncture Technique to Place Anvil for Laparoscopic Colorectal Resection with NOSES

Fig. 44.20  The anvil passes through the bowel

Fig. 44.24  The stapler passes through the distal bowel

Fig. 44.21  Close the proximal bowel

Fig. 44.25 Anastomosis

Fig. 44.22  Extract the specimen out through the anus

Fig. 44.26  Interrupted suture

Fig. 44.23  Close the distal bowel

Fig. 44.27  Place pelvic drainage tube

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1.2.3 Summary of Technical Points (1) Principles: 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) Puncture the anvil from the proximal bowel reversely and close of the proximal bowel. (4) The specimen is extracted from the anus. (5) During the extraction process, the protective sleeve should be applied to protect the specimen from the natural orifice.

1.3

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.

2

Results

All patients were successfully operated, and no conversion to laparotomy or other emergency occurred during the operation. 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 were 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 tumor-related death occurred in 61 patients.

3

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, which 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. NOSES becomes more standardized after unification. Most surgeons choose to extract specimen via anus, since extracting specimen through vagina might lead to organ damage, and there is no sufficient evidence to indicate whether that performance will affect women’s 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’s 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 found only 20% positive, but none of the patients showed complications related to bacterial infection. Peng Jian in China cultivated abdominal lavage fluid of 30 cases of colorectal NOSE operation, and the bacterial positive rate was 33%. No patients had symptoms of abdominal and pel-

44  Application of Reverse Puncture Technique to Place Anvil for Laparoscopic Colorectal Resection with NOSES

vic 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 NOTES 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

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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.

New Method of Modified NOSES I

45

Junhong Hu

1

 urgical Procedure of a Modified S 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 in the intended resection line proximal to the tumor (Fig. 45.1a). 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. 45.1b). Dilute iodine solution is used for the repeated irrigation of the everted rectum (Fig. 45.1c); then purse-string forceps is used to clamp the rectum at 1–2 cm distal to the tumor under direct vision (Fig. 45.1d). 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. 45.1e). 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. 45.1f). Subsequently, the anvil is inserted into the distal sigmoid colon, and the purse-string suture is tightened (Fig.  45.1g).The distal sigmoid colon with the anvil is returned to the abdominal cavity; then the sigmoid rectal end-toend anastomosis is performed after tightening the purse-string suture at the rectal stump (Fig. 45.1h). No auxiliary incision is made in the abdominal wall (Fig. 45.1i) (Hu et al. 2019).

2

Discussion

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. And only one 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 45.1f 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 continuous improvement of this procedure (Hu et al. 2019). 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 (Hu et al. 2019).

J. Hu (*) Department of General Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China © People’s Medical Publishing House, PR of China 2021 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-15-7925-7_45

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b

c

d

e

f

g

h

i

Fig. 45.1 (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 several times. (d) Under direct vision, the purse-string forceps is used to clamp the rectum at 1 to 2 cm below the

Reference Hu JH, Li XW, Wang CY, et al. Short-term efficacy of natural orifice specimen extraction surgery for low rectal cancer. World J Clin Cases. 2019;7(2):122–9.

tumor. (e) 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 (Hu et al. 2019)

Laparoscopic Resection of Tumors of Left Colon, Sigmoid Colon, and Upper Rectum with Transanal Specimen Extraction (NOSES IV and VI): Portuguese Experience

46

Joaquim Manuel da Costa Pereira and Carlos Costa Pereira

The technical variations in transanal NOSE colon surgery exist to overcome the restrictions caused by the absence of minilaparotomy and the transanal extraction itself. Without the minilaparotomy there is a need for intra-abdominal anvil delivery and its positioning in the proximal colon by laparoscopy. The way to position the anvil in the proximal colon defines the type of anastomosis created (end-to-end or side-­ to-­end). Because the specimen is extracted through the rectum and anus, the rectum is opened and must be closed before the anastomosis. In low rectal cancer, the rectal stump might be difficult to close, but in tumors of the sigmoid or upper rectum, it is easily achieved. The aim of this chapter is to explain the steps for NOSES for resection of tumors of the left colon, sigmoid colon, and upper rectum with transanal extraction. Fig. 46.1  Position of the patient

1

Patient Positioning

The patient is in the modified Lloyd-Davis position with Trendelenburg and right tilt (Fig. 46.1).

2

Trocar Placement

10 mm trocar at the umbilicus for the camera 12 mm trocar at right lower quadrant 5 mm trocar at upper right quadrant 5 mm trocar at the transition of left quadrants (Fig. 46.2)

Fig. 46.2  Trocar positions J. M. da Costa Pereira (*) · C. Costa Pereira Department of Surgery, Hospital de Braga, Braga, Portugal © People’s Medical Publishing House, PR of China 2021 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-15-7925-7_46

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3

Steps of Surgery

3.1

Left Colon Mobilization

In most cases we perform a full mobilization of splenic flexure of colon. This needs three steps: 1. Medial approach to the inferior mesenteric vein with dissection of the mesocolic plane (Fig. 46.3a) 2. Dissection of the mesocolon from the pancreas (Fig. 46.3b)

a

3. Transection of the gastrocolic ligament to enter the lesser sac (Fig. 46.3c)

3.2

 edial Approach and Ligation M of the Inferior Mesenteric Artery at Its Origin

3.3

 ection of the Mesentery of Upper S Rectum to Define the Transection Zone of the Rectum

b

c

Fig. 46.3 (a) Medial approach to the inferior mesenteric vein next to the pancreatic border; the mesocolic plane is developed and the inferior mesenteric vein is ligated at this position. (b) The mesocolon is separated from the pancreas in medial to lateral approach; the lesser sac is

entered from below. (c) To complete the full mobilization of the splenic flexure, the gastrocolic ligament is transected next to the gastroepiploic vessels. The lesser sac is entered from above. And care must be taken in the final steps of dissection not to injure the left gastroepiploic vessels

46  Laparoscopic Resection of Tumors of Left Colon, Sigmoid Colon, and Upper Rectum with Transanal Specimen Extracti…

3.4

 ection of the Mesentery of the Left S Colon to Define the Proximal Transection Area

The section of left colon mesentery starts at the mesenteric border immediately proximal to the ligature of the inferior mesenteric vein toward the mesenteric border of the splenic flexure, allowing an anastomosis to the distal transverse colon.

3.5

Occlusion of the Distal Colon

This is done to prevent intra-abdominal soiling and to allow for washing of the rectum. The rectum is occluded just above the level of desired distal transection with a silk suture, a cotton tape, or even a linear stapler (Figure 46.4).

3.6

Transanal Washing of the Rectum with Saline

3.7

Transection of the Colorectal Transition

3.9

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 tart the Extraction of the Specimen S Through the Anus

The goal is a partial extraction placing the proximal part of the specimen at the left lower quadrant of the abdomen. At this time the surgeon has a good perception of the ischemic line marking the border between the proximal colon for anastomosis and the distal colon of specimen to be extracted.

3.10

Anvil Placement in the Proximal Colon

A colotomy is performed 1  cm distal to the ischemic line (Fig. 46.7), at the antimesenteric border of the specimen, and the anvil is inserted in the colonic lumen (Fig. 46.8a and b).

The rectum is transected completely in the level previously defined (Fig.  46.5). A protective plastic sleeve is inserted through the rectum, usually a small Alexis® device (Fig. 46.6).

3.8

Anvil Delivery

The anvil of the circular stapler is introduced into abdominal cavity transanally. The spike must be attached to the anvil.

Fig. 46.4  A silk suture is used to occlude the colon lumen proximal to the desired distal transection location

Fig. 46.5  A complete transection of the distal bowel is done

Fig. 46.6  A plastic wound protector is used to protect the rectum, allow for anvil delivery, and facilitate extraction of the specimen by reducing the length of the rectum

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The spike of the anvil extrudes at the antimesenteric border of the proximal colon, about 5 cm proximal to the ischemic line, allowing the performance of a side-to-end colorectal anastomosis (Fig. 46.9).

3.11

Colon Transection

The colon is transected proximal to the previous colotomy (Fig.  46.10) with an endoscopic linear stapler, closing the proximal colon and freeing the specimen that can now be extracted transanally.

Fig. 46.7  The anvil is introduced through the colotomy of the proximal colon

a

3.12

Complete the Extraction of the Specimen and Removal of the Alexis® Device

3.13

 he Rectal Stump Is Closed T with an Endoscopic Linear Stapler (Fig. 46.11)

At this step extra care must be taken to ensure complete closure of the rectal stump. We suspend both borders of the rectum with graspers and make sure the entire border of the rectum is above the stapler line.

Fig. 46.9  Final position of the anvil in the proximal colon

b

Fig. 46.8 (a) Tension is used to perforate the colon with the spike at the antimesenteric border. (b) The anvil is gently positioned inside the colon

46  Laparoscopic Resection of Tumors of Left Colon, Sigmoid Colon, and Upper Rectum with Transanal Specimen Extracti…

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Fig. 46.10  Endostapler is used to cut the colon; the colotomy used for anvil insertion is distal to the transection line

Fig. 46.12  The spike is removed from the anvil and extracted from the abdominal cavity

Fig. 46.11  After extraction of the specimen and removal of the plastic wound protection device, the rectum is closed with a linear endoscopic stapler

Fig. 46.13  A side-to-end anastomosis is performed

3.14

 emoval of the Spike of the Anvil R Through the 12 mm Port (Fig. 46.12)

3.15

 ash the Pelvis with Saline W and Perform a Side-to-End Colorectal Anastomosis (Fig. 46.13)

3.16

 est the Anastomosis for Leaks T (Fig. 46.14) and Placement of a Transanal Tube

4

Postoperative Care

In the first 18 to 24  hours of surgery, the patient is given intravenous analgesia, intravenous glucose, and saline and can drink clear liquids.

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On the first postoperative day, the patient starts liquid diet and oral analgesics, intravenous medication is suspended, and Foley catheter is removed. On the second postoperative day, regular diet is introduced; the transanal tube is removed after the first bowel movement. Between the third and fifth postoperative days, the patient is discharged. The criteria used for safe discharge are the following: 1. patient is ambulatory and tolerates diet; 2. patient has bowel movements; 3. the pain is controlled with oral analgesics; and 4. blood tests are normalizing.

Fig. 46.14  Air leak test

NOSES in Colorectal Surgery: Vietnamese Experience

47

Joel Leroy, Frederic Bretagnol, and Dan Nguyen

With the general acceptance of laparoscopy as a surgical tool treating colorectal diseases, digestive surgeons, in the early 1990s, began to change the strategies in surgical procedures. By obligations due to unsuitable equipment (only ILS® circular stapler existed, and no Endo GIA® was available before 1993 on French market (Fig. 47.1)) we performed in November 1991 the first world’s rectal TME with ISR and transanal specimen extraction with coloanal manual anastomosis. Rapidly we performed 12 rectal resections with TME for mid/high rectal cancers performing totally laparoscopic rectal and left colonic dissection followed by a transanal distal rectal division before pulling the specimen transanally using the pull-through technique (eversion) described (1950) by Toupet in open procedure (Fig.  47.2). After laparoscopic colorectal dissection, ILS® stapler was introduced and open into the rectum. A ligature was done outside the rectum around the shaft of ILS®. The stapler was then closed, to trap the rectal wall, and pulled through the anus (Fig.  47.2b). Distal rectal stump reversed was divided and the rectosigmoid extracted transanally (Fig.  47.2c). EEA® anvil was then introduced into the proximal colon and secured with a loop. Before performing the anastomosis, the distal rectal stump was reversed and closed with TA® linear stapler (Fig. 47.2e, f). It was a NOSE procedure without knowing I was doing it. We published our experience and technique in 1994 (French book). To improve post-operative morbidity (particularly related to the size of the abdominal incision as wound infection, incisional hernia, cosmetic), laparoscopic colorectal surgeons developed procedures reducing abdominal incisions and number/sizes of trocars. Since the beginning, many modified surgical procedures have occurred because of a lack of adequate instrumentation.

J. Leroy (*) · F. Bretagnol · D. Nguyen High Tech Digestive Center, Saint Paul University Hospital, Hanoi, Vietnam

The procedures reported herein are our mind development as minimally invasive colorectal surgeon to achieve and standardize totally laparoscopic procedures. In 1993, Franklin ME described a totally laparoscopic sigmoidectomy performing a complete dissection by laparoscopy following by the extraction of the sigmoid through the anus via the rectum before doing colorectal mechanical anastomosis with ILS® stapler (Fig. 47.3a, b). In 2008, Palanivelu C introduced the concept of “NOSE” (natural orifice specimen extraction), using transvaginal specimen extraction after totally laparoscopic proctocolectomy in female patients. In fact, many colorectal surgeons were performing “NOSE” without knowledge. Rapidly we understood that NOSE was not only a mind’s step for removing specimen, but a real step integrated in procedures for preparing anastomosis and later performing procedures totally by natural orifice (NOTES, natural orifice transluminal endoscopic surgery). In laparoscopic colorectal surgery, NOSE can be done by transrectal, transanal, and transvaginal routes.

1

Transrectal NOSE

Transrectal NOSE was developed for extraction of colonic specimen (Figs. 47.3, 47.4, 47.5, and 47.6). We published in BJS, September 2011, our technique and experience of totally laparoscopic sigmoidectomy (in benign diseases), with transrectal NOSE (Fig. 47.4). After dissecting the sigmoid laparoscopically, the sigmoid may be pulled through the anus via the rectum using different solutions (Fig.  47.7). Above the stenotic colonic specimen exteriorized, anvil of PCEEA® stapler is introduced in the proximal colon before dividing it under laparoscopy (Fig.  47.8). Rectal stump is closed with Endo GIA® stapler and anastomosis performed under laparoscopy (Fig.  47.8d). Some procedures were performed doing

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b

c

d

Fig. 47.1 (a) ILS® stapler from Ethicon™ company. Anvil is fixed on the shaft. (b) CEEA® Premium Plus from Covidien™, (c) PCEEA® from Covidien™ company. Disposable anvil, (d) Endo GIA® from Covidien™ company. Disposable cartridge reloadable

l­aparoscopic dissection through trans-umbilical single port (Fig. 47.9).

2

Transanal NOSE

Transanal NOSE is performed, since a long time, by colorectal surgeons when they performed totally laparoscopic rectal TME for cancer with or without intersphincteric resection (IRS) and after proctocolectomy. The colorectal specimen is retrieved transanally, and the proximal colon (or small bowel) is either divided with or without a linear stapler for doing manual or mechanical suture in end-to-end or side-toend fashion (Fig. 47.10). In March 2013, we published the first totally pure transanal bottom-up laparoscopic taTME. But the most popular is the technique of Lacy that performed the first hybrid NOTES using transanal video assistance for the dissection of the distal rectum and laparoscopic up-to-down colorectal and vascular dissection.

3

Transvaginal NOSE

Transvaginal NOSE (Figs. 47.11, 47.12, 47.13, and 47.14) in colorectal laparoscopic procedures was selected in our experience for benign gynecologic disease (endometriosis) with colorectal involvement. We imagined a lot of procedures for doing anastomosis associating both route (transrectal/transvaginal). Some authors proposed to use transvaginal route for huge specimen as right colon.

4

Indications and Contraindications

Potential advantages of NOSE during laparoscopic colorectal procedures consist in lower complications rate, faster recovery, and shorter hospital stay, but there are some limitations. Huge specimens (acute diverticulitis, obesity with bulky mesocolon, advanced rectal tumors) are specific exclusion criteria for NOSE.  Anal or vaginal strictures are potential

47  NOSES in Colorectal Surgery: Vietnamese Experience

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a

b

c

d

e

f

Fig. 47.2  NOSE transanal rectal resection: laparoscopic modified Toupet technique (Leroy 1992). ILS® is introduced opened into the rectosigmoid (a); rectal wall is ligated and trapped around ILS® shaft by laparoscopy (b); distal rectum is reversed by traction on ILS® closed

(c), and rectal wall reversed divided; rectosigmoid is pulled through the rectal stump reversed and the anus (d); proximal colon closed on EEA® anvil; distal reverse stump closed with TA® stapler (e); circular mechanical anastomosis done (f)

contraindications, and abdominal extraction must be selected. It is why we highly recommend doing a complete pelvic imaging exploration with CT scan and pelvic MRI to discuss indication of NOSE. Disadvantages of this approach are the risks of infection and cancer cell contamination due to the squeezing of the

specimen during the extraction through a narrow orifice. Rapidly authors proposed solutions (protective trocars, TEO®, plastic bag as Endocatch II®, plastic sleeve (Figs. 47.7 and 47.15)). Bowel washout with oral antibiotics the day prior surgery is done systematically to prevent infection and facilitate endoluminal exploration. Rectal stump

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Fig. 47.3  Type A: NOSE transrectal sigmoidectomy (Franklin), pure intraperitoneal technique. (a) Specimen is extracted through the rectum. (b) Anastomosis is created with circular stapler

a

b

b

a

c

Fig. 47.4  Type B: NOSE transrectal sigmoidectomy (Personal, BJS 2011, (5))

d

e

47  NOSES in Colorectal Surgery: Vietnamese Experience

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Fig. 47.5  Type C: NOSE transrectal sigmoidectomy

a

b

c

d

Fig. 47.6  Type D: NOSE transrectal sigmoidectomy (modified Franklin)

was also washed out with Betadine solution. Bacterial abdominal contamination was not different than classical laparoscopic procedure with trans-parietal specimen removal in our paper published in 2012. Benefits of laparoscopy may be improved, reducing pain and wound-related complications developing of NOSE surgery. NOSE surgery is too a bridge between true NOTES and

conventional laparoscopic surgery. Hybrid procedures combining laparoscopic resection and NOSE surgery currently play an important role in minimally invasive colorectal surgery (Figs.  47.9b and 47.16). Feasibility and benefits of NOSE have been demonstrated in the literature. Not all the patient can benefit from those procedures and take full advantage of this evolution in minimally invasive surgery.

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a

c

e

J. Leroy et al.

b

d

f

Fig. 47.7 (a) Transrectal Endocatch® II (Covidien™). (b) Transrectal plastic sleeve. (c) Transrectal traction through the anus for sigmoid extraction. (d) TEO® (STORZ™), sigmoid extraction. (e) Proctocolectomy, specimen extraction. (f) Proctocolectomy, Colorectal specimen

47  NOSES in Colorectal Surgery: Vietnamese Experience

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a

b

c

d

Fig. 47.8 (a) Transrectal anvil introduction. (b) Laparoscopic anvil colonic introduction. (c) Anvil introduction into sigmoid. (d) Rectal closure with Endo GIA®

a

b

Fig. 47.9 (a) Umbilical SILS® for sigmoidectomy, (b) umbilical scar, D-8

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a

b

c

d

e

Fig. 47.10 (a) Transanal recto-colonic extraction. (b) Colonic division with Endo GIA®. (c) Side-to-end coloanal anastomosis. (d) Manual sideto-end anastomosis. (e) Rectal TME, transanal extraction

47  NOSES in Colorectal Surgery: Vietnamese Experience

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d

Fig. 47.11 (a) Transvaginal sigmoid extraction. (b) Transvaginal specimen extraction. (c) Mechanical anastomosis with PCEEA®. (d) Rectal endometriosis: stenotic nodule

a

b

c

d

e

f

Fig. 47.12  TYPE E: Nose Trans-Vaginal Recto Sigmoidectomy (limited mobilization sigmoid)

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a

b

c

d

e

f

g

h

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Fig. 47.13  TYPE F: NOSE transvaginal rectosigmoidectomy (if no colorectal stenosis, no mobilization sigmoid)

a

b

c

d

e

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Fig. 47.14  TYPE G: NOSE transvaginal rectosigmoidectomy (in case of colorectal stenosis, mobilization sigmoid limited)

47  NOSES in Colorectal Surgery: Vietnamese Experience Fig. 47.15  Solutions to prevent infection and contamination in NOSE transanal/transrectal specimen extraction

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NOSE TRANSANAL/TRANSRECTAL SPECIMEN EXTRACTION

Trans-Rectal Pull-through Transanal traction (after TME with ISR) Laparoscopic Trans-Rectal Reverse Transrectal Sleeve TEO® device Big Trocar Plastic Bag (Endocatch®, CovidienTM)

Fig. 47.16  Hybrid 3 trocars + NOSE sigmoidectomy

TOUPET (open technique), 1950 LEROY Joël, 1991 LEROY Joël, 1992 FRANKLIN Morice, 1992 Michael LI, 2008 KNOL J, 2009 LEROY Joël, 2009

Robotic Radical Resection for Lower Rectal Carcinoma with Transanal Pullout of Rectum Eversion and Extracorporeal Resection Technique

48

Taiyuan Li and Lei Xiong

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 averted 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 the 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. 48.1). 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 an coccygeal ligament, left

T. Li (*) · L. Xiong Department of General Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, China

and right to the septum between sphincter internus and externus, and anteriorly to the transection of lower segment of the vagina for female or the seminal vesicle for male. Then the mesentery of the 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 the sigmoid colon lumen from the contralateral side of the tumor and sutured to the isolated rectum (Fig.  48.2). The rectum is slowly pulled down and gently everted out transanally (Fig. 48.3). 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 proximal colon with a string suture fixed, and then the proximal colon is returned back to the pelvic cavity (Fig.  48.4). Subsequently, the distal rectum is transected with a linear stapler according to the directly measured length (Fig. 48.5). An end-to-end anastomosis of the sigmoid colon and rectum is performed by circular stapler under the observation of da Vinci laparoscopy (Fig. 48.6). This modified NOSES I technique is different from NOSES IA and IB which have been described before. In NOSES IA or IB, the incision of the 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 the 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. This technique can also reduce the risk of an 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

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Fig. 48.1  The types of IMA. Left colonic artery is either divided or not, depending on the type of IMA after removal of lymph nodes

Fig. 48.2  The sponge forceps is sutured to the intended resection line of dissected rectum

Fig. 48.3  The rectum is everted outside transanally

48  Robotic Radical Resection for Lower Rectal Carcinoma with Transanal Pullout of Rectum Eversion and Extracorporeal Resecti…

Fig. 48.4  The anvil is introduced into the lumen of the sigmoid colon after the rectum is cut open

Fig. 48.5  Distal rectum is transected with linear stapler according to the directly measured length

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Fig. 48.6  An end-to-end anastomosis of the sigmoid colon and rectum is performed with circular stapler

mesocolon should be long and thin enough. 3. The ­infiltration depth of tumor should not exceed the muscularis propria. 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 infiltrations 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 clinic-pathological parameters.

Application of OrVil™ and NOSES in Total Laparoscopic Gastrectomy for Female

49

Dan Ma

At present, in laparoscopy-assisted gastrectomy (Roux-en-Y method), gastric resection is commonly performed under laparoscopy, while a large abdominal incision is needed for 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 gastro-jejunostomy) 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 time-consuming 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 OrVil™ system, a newly emerged double stapling and transoral anvil delivery system, to perform the esophago-jejunal (or gastro-jejunal) anastomosis. 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. Afterward, the transvaginal-­ NOSES method is adopted to extract the specimen. An incision is made in the posterior vaginal fornix to remove the specimen; then a barbed suture is applied to close the incision. In conclusion, by performing total laparoscopic gastrectomy with the OrVil™ and transvaginal-NOSES, the extra-­ abdominal 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 OrVil™ system should be placed into the oral cavity. 2. Laparoscopic five-port 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 esophago-­jejunostomy (or gastro-jejunostomy) and jejuno-jejunostomy. (1) Esophago-jejunal (or gastro-jejunal) anastomosis is created with a 25 mm OrVil™ 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 the 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. The following steps of esophago-jejunal anastomosis are described in the figures (Figs. 49.1, 49.2, 49.3, 49.4, 49.5, 49.6, 49.7, 49.8, 49.9, 49.10, 49.11, 49.12, 49.13, and 49.14).

D. Ma (*) Department of General Surgery, Xinqiao Hospital, The Third Military Medical University, Chongqing, China © People’s Medical Publishing House, PR of China 2021 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-15-7925-7_49

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Fig. 49.4  Disinfection of the intestinal lumen of jejunal stump Fig. 49.1  Cutting one of the OrVil™ anvil retaining sutures

Fig. 49.2  Taking anvil shaft out of the stump under the guidance of delivery tube

Fig. 49.5  Lubrication of the intestinal lumen with paraffin oil cotton balls

Fig. 49.3  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 Fig. 49.6  Expansion of the upper left trocar site

49  Application of OrVil™ and NOSES in Total Laparoscopic Gastrectomy for Female

Fig. 49.7  The body of stapler is inserted through the upper left trocar site

Fig. 49.8  Inserting the body of stapler into the intestine lumen for about 10 cm

Fig. 49.9  Extending the trocar of stapler and penetrating the intestinal wall in the antimesenteric side

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Fig. 49.10  Connecting the trocar of stapler with the OrVil™ anvil

Fig. 49.11  Confirming that the mesentery is not twisted and has no tension

Fig. 49.12  Firing the stapler

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Fig. 49.13  Pulling out the anvil

Fig. 49.16  Inserting a 21 mm anvil

Fig. 49.14  Closing the jejunal stump with linear Endo GIA stapler

Fig. 49.17  Using the barbed suture for purse-string suture

Fig. 49.15  Making an incision in the intestine at 40 cm distal to the anastomosis with an ultrasonic scalpel

Fig. 49.18  The closure staple line of proximal jejunum is resected

(2) The jejuno-jejunal anastomosis is performed with 21 mm circular stapler.

(3) Specimen is removed from the incision in the posterior vaginal fornix.

The detailed steps of jejuno-jejunal anastomosis are described as follows (Figs. 49.15, 49.16, 49.17, 49.18, 49.19, 49.20, 49.21, and 49.22):

The detailed steps of specimen removal are described as follows (Figs. 49.23, 49.24, 49.25, 49.26, 49.27, and 49.28):

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Fig. 49.19  Inserting the stapler body into the intestine lumen

Fig. 49.22  Closing the proximal jejunum stump with linear Endo GIA stapler

Fig. 49.20  Connecting trocar with the anvil of the stapler

Fig. 49.23  Opening the posterior vaginal fornix

Fig. 49.21  Firing the stapler

Fig. 49.24  The specimen is placed in the protective sleeve

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Fig. 49.25  Extraction of specimen from the vagina

Fig. 49.27  Specimen appearance (the stomach is cut open)

Fig. 49.26  Closing the posterior vaginal fornix with barbed suture

Fig. 49.28  Postoperative abdominal wall appearance

Experience Sharing of Key Points in NOSES for Colorectal Cancer

50

Xuejun Sun

As a new minimally invasive surgery, NOSES has become a hot topic in the field of colorectal cancer in China. Our team has completed a total of 49 cases of NOSES for colorectal cancer between July 2017 and September 2019 and accumulated relevant experience to share with readers.

1

 septic Principle and Tumor-Free A Technique

The key of NOSES is specimen extraction through natural orifice, so the aseptic principle and tumor-free technique must be strictly practiced. NOSES, open surgery, and conventional laparoscopic surgery are equally required to strictly follow the aseptic principle. The focus of the following article is on tumor-free technique. Tumor-Free Technique 1. Completely dissect the lymph nodes and blood vessels to ensure the specimen has no blood supply at the time of transection and extraction. 2. The intended resection line is selected at about 10  cm above the tumor (Fig. 50.1). Isolate the bowel at the resection line for about 3  cm where the blood supply line is obvious (Fig. 50.2). 3. The bowel to be resected is extracted from the abdominal cavity through a sterile protective sleeve (Fig. 50.3) which could protect the intestine aseptically. 4. The intrarectal and intravaginal pressure is slight, and the bowel lumen is only opened for approximately 2–3s. Therefore, there is small risk of tumor cells spreading into the upper abdominal wall due to the pressure change. After the bowel is fully mobilized, the application of ster-

Fig. 50.1  Intended resection line (10 cm above the tumor)

Fig. 50.2  Isolate the bowel at the intended resection line

ile protective sleeve plays a very important role in the tumor-free technique in NOSES (Fig. 50.4).

X. Sun (*) Department of General Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China e-mail: [email protected] © People’s Medical Publishing House, PR of China 2021 X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-15-7925-7_50

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Fig. 50.3  Sterile protective sleeve

Fig. 50.5  Lower rectal resection

Fig. 50.4  The application of sterile protective sleeve Fig. 50.6  Closure line

2

 he Skills and Tips in the Application T of Stapler in Rectal Resection

The selection of different length of stapler cartridge should be dependent on the diameter of the intestine. In the low and ultra-low rectal resection, stapler should be used which abides by the following principles: (1) articulating staplers are better for the pelvis; (2) the resection line should form a vertical angle to the bowel, to avoid affecting the blood supply and follow-up operation (Figs. 50.5 and 50.6); and (3) if the closure cannot be completed with one stapler, try to ensure that the closure line is at the same level. According to our experiences, a 60 mm stapler could complete the transection of the rectum in the lower rectal resection. But for some obese patients, the transection of the rectum cannot be com-

pleted at one time, with 5–10  mm of the bowel residual. Here, this part of the residual bowel tissue is used as the anvil shaft piercing point which can reduce a “dog ear” and the risk of anastomotic leakage and also avoid the use of one more stapler. The stapler should be selected according to the diameter of the bowel. The use of circular stapler should comply with the following points: (1) adjust the spacing appropriately; tightening the bowel wall with forceps is the key to ensure the safety of anastomosis; (2) after firing the stapler, reduce the trauma to the tissue by minimizing the compression time; (3) reduce the anastomotic tension; (4) when taking the stapler out of the rectum, slow rotation could prevent the tearing of the anastomosis mucosa.

Experience and Skill Sharing on NOSES in the Left and Right Colon

51

Guiyu Wang

In recent years, the theoretical system and operating techniques of NOSES have been continuously improved. In 2017, the first Chinese Consensus on NOSES was initially compiled. However, there are still some problems in practical application. In particular, there are still some technical difficulties in the NOSES for the left and right colon tumor. Our center has taken the lead in developing a series of NOSES for colorectal cancer in China, and relevant experience has been accumulated.

1

NOSES for Left-Sided Colon Cancer

The relative low morbidity of left colon cancer, with most cases of sclerotic type accompanied by obstructive symptoms, leads to a lower amount of experience in NOSES.

1.1

Preoperative Localization

Since the patients suitable for NOSES in the left colon usually have early stage of disease and small lesions, it is difficult to determine the tumor location under laparoscopy, and preoperative localization is particularly important. Three-­ dimensional CT and colonoscopic titanium clip marking may be applied preoperatively, and decubitus abdominal plain film can be performed to observe the location of the titanium clips. For patients who need radical resection after colonoscopic local excision, localization with titanium clip should be timely performed in case that the scar after local treatment cannot be identified by colonoscopy after long intervals. For patients who require accurate intraoperative localization, submucosal injection of carbon nanotube

G. Wang (*) Department of Colorectal Cancer Surgery, Cancer Hospital of the University of Chinese Academy of Sciences, Hangzhou, China

through colonoscopy on the day before surgery or submucosal injection of methylthioninium chloride 1 h before surgery is indicated.

1.2

Surgical Approach

The planes formed during embryogenesis of the left and right colon are similar, and the approach for the right colon is also applicable to the left colon. According to our experience, the left border of the abdominal aorta serves as the anatomical landmark (Fig. 51.1a), and the space anterior to the Toldt’s fascia serves as the operational plane. Management of the vessels at the root of mesentery is prioritized in this approach, which is more in compliance with the principle of tumor-free, and facilitates the protection of the ureter and gonadal vessels, etc. In the process of dissection from the medial side to the lateral side, the assistant should provide appropriate tension to the mesentery, which facilitates the smooth dissection of the mesentery and maintains the integrity of the mesentery.

1.3

Mobilization of Splenic Flexure

In this procedure, the greater omentum should be preserved. This method not only preserves the function of the greater omentum but also facilitates the extraction of specimen through natural orifice. The surgeon dissects the middle transverse colon to the left to transect the attachment of the greater omentum (Fig. 51.1b) until the lower pole of spleen and the peritoneum lateral to the splenic flexure are exposed for the entering of omental bursa. The greater omentum is flipped upward, the adhesions between the stomach and the transverse mesocolon are detached, and dissection is performed leftward to the lower pole of spleen. During the operation, the assistant provides tension in the opposite direction of the forceps in the left hand of the surgeon. Attention should be paid to avoid the secondary damage to the spleen

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a

b

c

Fig. 51.1  Operating procedures of functional end-to-end anastomosis. (a) The left border of the abdominal aorta serves as the anatomical landmark for the surgical approach for the resection of the left colon. (b)

Mobilization of the splenic flexure with the greater omentum preserved. (c) Transanal extraction of the left colon specimen

and blood vessels. The transverse colon is lifted, the ­transverse mesocolon is transected at the level of pancreas to give direct access to the omental bursa, and then the dissection is continued leftward to the lower pole of the spleen.

2

1.4

Specimen Extraction

Transanal specimen extraction is preferred to avoid unnecessary vaginal injuries. A protective sleeve with an opening that can be tightened should be applied, which is inserted through the main trocar and removed from the abdominal cavity through the anus. After the placement of the resected bowel segment, the protective sleeve is tightened to avoid contamination by compression of the bowel during the specimen extraction (Fig. 51.1c).

NOSES for Right-Sided Colon Cancer

The right colon has many adjacent organs, complicated vasculature, and large anatomical variations. Therefore, the right hemicolectomy by NOSES is a difficult procedure.

2.1

Indications

The vagina is an applicable route of specimen extraction in the resection of the right colon specimen, so this procedure is only applicable to female patients. Adequate informed consent of the patient must be obtained, and ethical review by the unit must be performed before this procedure can be conducted. Caution should be exercised in applying this procedure in female patients with history of pelvic surgery and

51  Experience and Skill Sharing on NOSES in the Left and Right Colon

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b

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Fig. 51.2 (a) The superior mesenteric vein serves as the anatomical landmark for the approach of the right hemicolectomy. (b) Side-to-side anastomosis of the stumps of transverse colon and ileum is performed

with a linear Endo GIA stapler. (c) The “crotch” of the anastomosis is sutured for reinforcement under laparoscopy

with fertility plan. Tumor stage and the extent of invasion should be evaluated preoperatively. This procedure is not recommended for patients with acute cancerous intestinal obstruction or perforation, obvious local invasion of adjacent tissues and organs, or risk of serious intra-abdominal adhesions. The size of the mass should not be too large to facilitate transvaginal extraction.

Attention should be paid to the variation of blood vessels in the right colon and the middle colon, so as to avoid secondary damage. The integrity of the mesentery should be maintained during the dissection, and important tissues and organs are exposed and protected.

2.2

The totally laparoscopic digestive tract reconstruction is performed by functional end-to-end anastomosis between terminal ileum and transverse colon. Since end-to-end and end-to-side anastomosis cannot be performed with the circular stapler under total laparoscopy, the transverse colon and ileum must be adequately dissected. The two jaws of the linear Endo GIA stapler are inserted into the stumps of the transverse colon and ileum, respectively. Then the stapler is fired to complete the side-to-side anastomosis of the antimes-

Surgical Approach

In our center, the medial approach is routinely taken for the right hemicolectomy with the superior mesenteric vein which serves as the anatomical landmark (Fig. 51.2a) and the space anterior to the Toldt’s fascia which serves as the operation plane. High ligation of the blood vessels is performed for the dissection of lymph nodes. The sheath of blood vessels is opened during the dissection of blood vessels.

2.3

Digestive Tract Reconstruction

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enteric side (Fig. 51.2b). Lastly, the stump is closed with a linear Endo GIA stapler or sutured under laparoscopy. The “crotch” of the anastomosis is sutured for reinforcement under laparoscopy (Fig. 51.2c).

2.4

Specimen Extraction

Bowel preparation and vaginal irrigation are performed before operation. In the process of specimen extraction, attention should be paid to the use of iodoform gauze,

and the tumor-free and aseptic principles should be followed. The posterior vaginal fornix should be carefully irrigated and disinfected again during the operation to avoid intra-­abdominal infection. The assistant applies the small S-shaped retractor for marking before opening the posterior vaginal fornix, so as to avoid damage to the rectum and vagina. The specimen should be extracted through the protective sleeve after the protective sleeve is inserted into the natural orifice. The operation should be gently performed to prevent the iatrogenic implantation of tumor cells.

Natural Orifice Specimen Extraction in Laparoscopic Anterior Resection (NOSE-LAR): Taiwanese Experience

52

Ming Li Leonard Ho and William Tzu-Liang Chen

1

Introduction

NOSE surgery was created as a result of continual developments in minimally invasive surgical techniques. As the rectum is a convenient conduit through which the specimen can be removed from the abdomen, NOSE can be incorporated in patients undergoing laparoscopic anterior resection. This removes the need to extend or create a new incision, and as such, risks of infection and hernia are reduced. Additionally, patients experience less post-operative pain, reduced duration of hospital stay, and improved cosmesis.

2

Surgical Indications

Common inclusion criteria for NOSE-LAR include (1) benign or malignant conditions of the sigmoid colon or upper rectum. On imaging, the lesion should be (3)  35 kg/m2) or mesocolon hypertrophy, which could produce difficulty during specimen retraction via the natural lumen

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Key Surgical Points

3.1

 nterior Rectal Resection Combined A with Right Hemicolectomy Complex NOSES Surgery

(1) Trocar locations The patient takes the modified lithotomy position. Trocars are implanted as five-port method: 10 mm trocar implanted beneath the umbilicus as observation port, 12 mm trocar at the McBurney’s point, and 10 mm trocar at the level of the umbilicus or higher through the left midclavicular line as primary operating port and 5 mm trocars at reverse McBurney’s point and the level of the umbilicus or higher through the right midclavicular line as auxiliary operating port.

Fig. 56.1  Cut open the junction of ileocolic mesentery

(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 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 mesocolic 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. 56.1). 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 upward to the duodenum bulb. Then dissection along the superior mesenteric vein is continued, with the ileocolic artery and vein, the right colon artery and vein, and the middle colon artery and vein ligated successively at the root (Fig. 56.2). Following the management of vessels, the right part of greater omentum is cut along the outer edge of right gastroepiploic vessels, and then the transverse colon mesenterium is opened at the planned dissected line, removing the colic mesentery from its adhering site from left to right, superior to posterior, till the ileocecal region. After the right hemicolon has been completely dissected, the transverse colon is transected at the approximate middle segment, and the terminal ileum is transected at 15  cm proximal to the ileocolic valve utilizing the endoscopic stapler. Pulling the terminal ileum to the upper abdomen, placing in parallel with the free end of the transverse colon, a small orifice is cut at the opposite mesenteric edge of the 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’s no blood oozing, the resected right half of the colon is placed in the right upper abdomen, and the resection of the rectum then continues.

Fig. 56.2  Ligation at the root of supplying vessels

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 mesorectal excision (TME). Lymph nodes around the root of the inferior mesenteric artery (IMA) are removed. By ligating the inferior mesenteric artery under the origin of the left colic artery (LCA), the left colic artery is routinely preserved, and meanwhile, the inferior mesenteric 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.

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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 planned 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.

implanted beneath the umbilicus as observation port, 12 mm trocar at the McBurney’s point, and 10 mm trocar at the level of the umbilicus or higher through the left midclavicular line as primary operating port and 5  mm trocars at reverse McBurney’s point and the level of the umbilicus or higher through the right midclavicular line as assistant ports.

(3) Specimen extraction

(2) Surgical techniques

The rectal and sigmoid colic lumen is irrigated and sterilized with diluted iodophor solution, and 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 long-handled toothed oval forceps are inserted again, clamping the ileal end of the right colon specimen and pulling it 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 direct vision, and the rectal tumor and specimens are removed.

The dissection is initiated in a counterclockwise order after abdominal and pelvic exploration. The chief surgeon stands on the right side of the patient while the assistant on the left side and the endoscopy holder on the same side with the chief surgeon on the cephalic side. Then the dissection of the 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 the right colon and ileocecal segment. The dissection of the rectum follows TME principle and proceeds to the pelvic floor. The dissection of the left and right colon follows CME principle, and the corresponding blood supply vessels are ligated and transected at the root. When the dissection of the whole colon and rectum is completed, the ileum is cut about 15 cm from the proximal part of the ileocecal valve with an endoscopic linear stapler, and the sigmoid colon is also transected 10  cm from the proximal edge of the rectal tumor using the endoscopic linear stapler.

(4) Reconstruction of the digestive tract

(3) Specimen extraction

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 the 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.

The specimen extraction is completed step-by-step with the order as eversion of the rectum and tumor first and then extraction of the sigmoid colon and proximal specimen in a transectional and drag-out way. 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. 56.3). Then the stapled end of the 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.  56.4). Under direct vision, the rectum is closed and severed 2 cm distal to the lower edge of the rectal tumor with a curved stapler, and then the rectal tumor specimen is removed.

3.2

 ubtotal Colectomy Complex NOSES S Surgery

(1) Trocar locations The patient is placed in a modified lithotomy position, and trocars are implanted as five-port method: 10 mm trocar

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Fig. 56.3  Washing the rectum with diluted iodophor solution

Fig. 56.5  Making purse suture in stapled situation

Fig. 56.4  Extraction of colic specimen via protective sleeve

Fig. 56.6  Reconstruction of the pelvic floor

(4) Reconstruction of digestive tract

4

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.  56.5). 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.  56.6). One or two abdominal drainage tubes are retained according to the situation before the ending of surgery.

The concept of complex NOSES surgery is a combination of 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

Notifications

56  Laparoscopic Complex NOSES Surgery of Colorectal Tumor

is necessary to do full bowel preparation before the operation, and 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 skillfully using 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

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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 harming the interests of patients but also driving the surgeons into passive situations.

 ppendix A: International Consensus on Natural A Orifice Specimen Extraction Surgery (NOSES) for Colorectal Cancer

Original source: Guan X, Liu Z, Longo A, et al. International consensus on natural orifice specimen extraction surgery (NOSES) for colorectal cancer. Gastroenterol Rep (Oxf). 2019;7(1):24– 31. https://doi.org/10.1093/gastro/goy055 Xu Guan1, Zheng Liu1, Antonio Longo2, Jian-Chun Cai3, William Tzu-Liang Chen4, Lu-Chuan Chen5, Ho-Kyung Chun6, Joaquim Manuel da Costa Pereira7, Sergey Efetov8, Ricardo Escalante9, Qing-Si He10, Jun-Hong Hu11, Cuneyt Kayaalp12, Seon-Hahn Kim13, Jim S. Khan14, Li-Jen Kuo15, Atsushi Nishimura16, Fernanda Nogueira7, Junji Okuda17, Avanish Saklani18, Ali A.  Shafik19, Ming-Yin Shen4, Jung-­ Tack Son6, Jun-Min Song20, Dong-Hui Sun21, Keisuke Uehara22, Gui-Yu Wang23, Ye Wei24, Zhi-Guo Xiong25, Hong-­ Liang Yao26, Gang Yu27, Shao-Jun Yu28, Hai-Tao Zhou1, Suk-­ Hwan Lee29, Petr V.  Tsarkov30, Chuan-Gang Fu31, Xi-Shan Wang1; The International Alliance of NOSES Xu Guan and Zheng Liu contributed equally to this work 1. 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, China 2. Department of Coloproctology and Pelvic Diseases, Humanitas Gavazzeni, Bergamo, Italy 3. Department of Gastrointestinal Surgery, Zhongshan Hospital of Xiamen University, Xiamen, China 4. Department of Surgery, China Medical University Hospital, Taichung, China 5. Department of Abdominal Surgery, Fujian Medical University Cancer Hospital, Fuzhou, China 6. Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea 7. Department of Surgery, Hospital de Braga, Braga, Portugal 8. Colorectal Surgery Department, Sechenov First Moscow State Medical University, Moscow, Russia 9. Universidad Central de Venezuela, Centro Medico Loira, Caracas, Venezuela 10. Department of General Surgery, Shandong University Qilu Hospital, Jinan, China

11. Department of General Surgery, Huaihe Hospital of Henan University, Kaifeng, China 12. Department of Gastrointestinal Surgery, Inonu University, Malatya, Turkey 13. Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea 14. Department of Colorectal Surgery, Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Portsmouth, UK 15. Division of Colorectal Surgery, Taipei Medical University Hospital, Taipei, China 16. Department of Surgery, Nagaka Chuo General Hospital, Nagaoka City, Japan 17. Innovation Unit / Colorectal Cancer, Osaka Medical College Hospital Cancer Center, Osaka, Japan 18. Department of GI Surgical Oncology, Tata memorial hospital, Mumbai, India 19. Department of Colorectal Surgery, Cairo University, Cairo, Egypt 20. Department of Anorectal Surgery, First Affiliated Hospital, Zhengzhou University, Zhengzhou, China 21. Department of Gastric and Colorectal Surgery, Jilin University First Hospital, Changchun, China 22. Division of Surgical Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan 23. Department of Colorectal Cancer Surgery, the Second Affiliated Hospital of Harbin Medical University, Harbin, China 24. Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China 25. Department of Gastrointestinal Surgery, Hubei Provincial Cancer Hospital, Wuhan, China 26. Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, China 27. Department of Surgery, People’s Hospital of Linzi District, Affiliated to Binzhou Medical College, Zibo, China 28. Department of Surgical Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China

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Appendix A: International Consensus on Natural Orifice Specimen Extraction Surgery (NOSES) for Colorectal Cancer

29. Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, South Korea 30. Clinic of Colorectal and Minimally Invasive Surgery, Sechenov First Moscow State Medical University, Moscow, Russia 31. Department of Gastrointestinal Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China Abstract In recent years, natural orifice specimen extraction surgery (NOSES) in the treatment of colorectal cancer has attracted widespread attention. The potential benefits of NOSES including reduction in postoperative pain and wound complications, less use of postoperative analgesic, faster recovery of bowel function, shorter length of hospital stay, and better cosmetic and psychological effect have been described in colorectal surgery. Although significant decrease in surgical trauma of NOSES has been observed, the potential pitfalls of this technique have been demonstrated. Particularly, several issues including bacteriological concerns, oncological consequences, and patient selection are raised with this new technique. Therefore, it is urgent and necessary to reach a consensus as an industry guideline to standardize the implementation of NOSES in colorectal surgery. After three discussions by all members of the International Alliance of NOSES, the consensus is finally completed, which is also of great significance to the long-­ term progress of NOSES worldwide. Keywords: Colorectal cancer; Natural orifice specimen extraction surgery (NOSES); Laparoscopy; Natural orifice transluminal endoscopic surgery (NOTES); Transanal total mesorectal excision (TaTME)

Introduction Great advances in minimally invasive surgery over the last decade have led to development of various techniques extending the benefits of minimal access surgery to patients with colorectal cancer (Bonjer et  al. 2015; Fleshman et  al. 2015; Stevenson et al. 2015). However, current laparoscopic approach requires an extra incision at the abdominal wall for specimen extraction, which is associated with postoperative pain, increased wound complications including infection, hernia formation, and scarring (Kamiński et  al. 2014; Winslow et  al. 2002). Natural orifice specimen extraction surgery (NOSES) is featured with the removal of surgical specimen from natural orifice in the avoidance of abdominal incision, which has been considered as an alternative

approach to open surgery and conventional laparoscopic surgery in selected patients (Wolthuis et al. 2014; Guan et al. 2017). Although the safety and feasibility of NOSES in colorectal surgery have been well proved, there are still many unresolved issues that need to be unified and standardized (Park et al. 2011; Costantino et al. 2012; Karagul et al. 2017). The International Alliance of NOSES is an international academic organization which aims to improve the profession level and clinical application for NOSES. To achieve a unified consensus of NOSES, all members of this international group participated in drafting this consensus to provide a full introduction of the theoretical and technical aspects of NOSES for colorectal cancer and provide a reliable basis for the development of NOSES involved in this field of colorectal surgery. The following will introduce the details of this consensus from several aspects.

Definition In recent years, based on the introduction of natural orifice transluminal endoscopic surgery (NOTES), a series of concepts related to NOTES have been gradually proposed by combining different instruments and different operative methods, for example, pre-NOTES, hybrid-NOTES, like-­ NOTES, and so on (Senft et  al. 2014; Nau et  al. 2011). Although the terminology is different, all techniques are aimed at achieving a common goal, namely, the pursuit of minimally invasive effects, avoidance of abdominal wall incisions, and reduction of abdominal dysfunction. However, this complex nomenclature may cause confusion in literature retrieval and academic exchanges. Combining internationally accepted presentation methods and language habits, it is recommended that the technique is named “natural orifice specimen extraction surgery”; the abbreviation is “NOSES.” The definition of NOSES is as follows: the surgical specimen resection is performed intra-abdominally, and then 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 NOSES for colorectal surgery involve specimen extraction from a natural orifice and complete intra-abdominal digestive tract reconstruction, which avoid the additional incision on the abdominal wall. In addition to colorectal surgery, it can also be applied to the fields of gastrointestinal, hepatobiliary, urinary, gynecological surgery, etc. Because NOTES is also taking specimen through natural orifice, it therefore should be one part of NOSES.  Furthermore, recently developed transanal total mesorectal excision (TaTME) is also a type of NOTES, so it also belongs to NOSES (Wang 2018).

Appendix A: International Consensus on Natural Orifice Specimen Extraction Surgery (NOSES) for Colorectal Cancer

Classification According to the routes for specimen extraction in colorectal surgery, NOSES is divided into two categories including transanal- and transvaginal-NOSES (China NOSES Alliance 2017). 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 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). However, transvaginal specimen extraction presents the following limitations: firstly, this technique is only confined to female patients; secondly, opening the vaginal wall may increase the risk of postoperative complications and sexual dysfunction; thirdly, transvaginal-NOSES is also limited by ethics. The orifice selection for specimen extraction is mainly based on the size of the specimen, especially the maximum circumferential diameter (CDmax). The transanal-NOSES is mainly applicable to patients with small tumors, and the transvaginal-­ NOSES is available for female patients with a bulky specimen that cannot be removed through the anus. Furthermore, gynecologic tumor resection can also be completed simultaneously by transvaginal specimen extraction (Nishimura et al. 2013). According to the procedures of specimen extraction, NOSES can be classified into three categories: (1) Transanal specimen eversion and extra-abdominal resection technique; this technique is mainly used to lower

rectal resection; the main surgical procedure is shown in Fig. A1. (2) Transluminal specimen extraction and extra-abdominal resection technique; this technique is mainly used for middle rectal resection; the main surgical procedure is shown in Fig. A2. (3) Intra-abdominal specimen resection and transluminal extraction technique; this technique is mainly used for upper rectal resection and colectomy; the main surgical procedure is shown in Fig. A3. To further refine the classification, ten different NOSES approaches, from NOSES I to NOSES X, were proposed for the treatment of colorectal neoplasms. Five approaches were used for rectal resection, and five approaches were used for colectomy (Table A1). Furthermore, NOSES I includes five different 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, and NOSES IE is Bacon technique (China NOSES Alliance 2017; Wang 2018).

Indications According to existing literature and current clinical practice, the indication of NOSES directly contributes to the feasibility of this technique. There are many requirements that should be carefully considered before the implementation of NOSES in colorectal surgery. Firstly, basic requirements for NOSES should be followed. NOSES should be performed by experienced surgeons for conventional laparoscopic colorectal surgery. This is a very important prerequisite for surgeons to start NOSES.  A more experienced surgeon in

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Fig. A1  Transanal specimen eversion and extra-abdominal resection technique. (a) The anvil is introduced into the bowel lumen of rectum till to the proposed resection line of sigmoid colon. (b) Proximal bowel division is performed using linear stapler, leaving the anvil inside of

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sigmoid colon. (c) The rectal stump is everted out transanally. (d) The distal rectal resection is performed extra-abdominally. (e) The rectal stump is delivered back to pelvic cavity. (f) The circular stapler is introduced transanally, and an end-to-end anastomosis is performed

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Appendix A: International Consensus on Natural Orifice Specimen Extraction Surgery (NOSES) for Colorectal Cancer

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Fig. A2  Transluminal specimen extraction and extra-abdominal resection technique. (a) The rectal wall is cut off at the distal resection line. (b) The distal side of specimen is gently pulled outside of the patient body transanally. (c) The proximal rectal resection is performed extra-­ abdominally. (d) The anvil is introduced into the bowel lumen and

closed with a purse string, and the sigmoid colon is delivered back to pelvic cavity. (e) The open rectal stump is closed by using linear stapler. (f) The circular stapling device is introduced into the rectum, and an end-to-end anastomosis is performed

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Fig. A3  Intra-abdominal specimen resection and transluminal extraction technique. (a) The anvil is introduced into the bowel lumen of rectum till to the proposed resection line of sigmoid colon. (b) The proximal bowel division is performed using linear stapler, leaving the anvil inside of sigmoid colon. (c) The rectal wall is cut off at the distal

resection line. (d) The specimen is extracted through the anus. (e) The open rectal stump is closed with a linear stapler. (f) The circular stapling device is introduced into the rectum, and an end-to-end anastomosis is performed

laparoscopic surgery may achieve a shorter learning curve for NOSES. Secondly, the indication of NOSES should follow the indication of conventional laparoscopic colorectal resection. Locally advanced tumor, acute bowel obstruction, and perforation from cancer are not recommended to perform laparoscopy. Thirdly, NOSES also has specific indication requirements, including the depth of tumor invasion should be T2 or T3, the CDmax of specimen should be