S0935 Peroral Traction-Assisted Transanal NOTES Rectosigmoidectomy Followed by Intracorporeal Colorectal Anastomosis in a Live Porcine Model

Abstract

INTRODUCTION: To introduce one novel technique of peroral external traction-assisted transanal NOTES sigmoidectomy followed by intracorporeal colorectal anastomosis by using only currently available and flexible endoscopic instrumentation in a live swine model. METHODS: Three female swine weighing 25–30 kg underwent NOTES rectosigmoid resection. After preoperative work-up and bowel preparation, general anesthesia combined with endotracheal intubation was achieved. One dual-channel therapeutic endoscope was used. Carbon dioxide insufflation was performed during operation. The procedure of trans-anal NOTES rectosigmoidectomy included 8 steps as follows: (1) rectosigmoid colon tattooed with India ink by submucosal injection; (2) creation of gastrostomy by directed submucosal tunneling; (3) peroral external traction using endoloop ligation; (4) creation of rectostomy on the anterior rectal wall by directed 3 cm submucosal tunneling; (5) peroral external traction-assisted left side of the colon dissection; (6) trans-anal rectosigmoid specimen transection, an anvil was inserted into the proximal segment after a purse-string suture; (7) intracorporeal colorectal end-to-end anastomosis using a circular stapler with a single stapling technique; (8) closure of gastrostomy using endoscopic clips. All animals were euthanized immediately after the procedure, abdominal exploration was performed and the air-under-water leak test was done. RESULTS: The procedure was completed in all three animals, with the operation time ranging from 193 to 259 minutes. Neither intraoperative major complications nor hemodynamic instability occurred during operation. The length of the resected specimen ranged from 7cm to 13cm. With the assistance of a trans-umbilical rigid grasper, intracorporeal colorectal, tension-free, end-to-end anastomosis was achieved in the three animals. CONCLUSION: Peroral traction-assisted transanal NOTES sigmoidectomy followed by intracorporeal colorectal anastomosis is technically feasible and reproducible in an animal model, worthy of further improvement.Figure 1.: a The anterior wall of rectosigmoid colon tattooed with India ink by submucosal injection b An endoloop was placed over the anti-mesenteric side of one colonic segment for traction c Dissection of the inferior mesenteric vessels d The mobilized rectosigmoid colon was exteriorized and transected trans-anally.Figure 2.: a A purse-string suture was placed around the top of the open proximal colonic segment after an stapler anvil was inserted b An endoloop was used to ligate the lateral rectostomy by endoscopy c The anvil was approached to the stapler with the assistance of rigid grasper d Endoscopic observation of colorectal anastomotic tissue ring e. View via laparotomy of the lower abdomen and pelvis showing colorectal end-to-end anastomosis f The resected sigmoid colon specimen.