Mesenteric Pedicle Research Articles

Anatomical Variants of the Jejunal Veins and Their Technical Implications in Pancreaticoduodenectomy: A Systematic Review and Meta-Analysis.

One of the most common causes of bleeding during pancreaticoduodenectomy is a dissection of the pancreatic head from the superior mesenteric vein and superior mesenteric artery. Knowledge of the anatomical variants of the veins draining the proximal jejunum may allow better control of bleeding during detachment of the uncinate process and pancreatic head from the mesenteric pedicle and division of the mesopancreas. The aim of this systematic review and meta-analysis was to evaluate the anatomical variations of the first jejunal vein (FJV) and jejunal trunk (FJT). Fourteen studies (1,888 patients) were included. We performed a systematic review of the available literature according to PRISMA guidelines. The analysis has shown that the posterior course of the FJT and FJV represents the most frequent topographical location (pooled prevalence estimate [PPE] 79.6%) with the anterior jejunal trunk having a lower rate (PPE 20.4%). Few articles reported the variations with separate trunks for the first and second jejunal veins. A thorough preoperative radiological assessment of the anatomical variation of FJT and FJV may confer some advantage to establish the best therapeutic strategy and the best surgical approach in case of pancreatic head carcinoma as it can allow a better estimate of the extent of the neoplasm and improve the accuracy of surgical dissection with potential for reduced bleeding.

Strangulation of the caecum by a pedunculated lipoma in a Rocky Mountain Horse gelding

SummaryA 19‐year‐old Rocky Mountain Horse gelding was presented for emergency evaluation of colic. A pedunculated lipoma was found to be strangulating the caecum and ileocaecal junction at surgery. Following the resolution of the incarceration, it was found that the pedicle originated on the jejunal mesentery, but the stalk did not appear long enough to have formed a half‐hitch around both the caecum and ileum. The horse was euthanised due to complete caecal devitalisation. A second pedunculated lipoma was identified at necropsy, located on the transverse colon with an area of ischaemia on the mesenteric pedicle (the abnormal stalk of tissue connecting the lipoma to the colonic mesentery), consistent with pressure from being entwined with the jejunal mesenteric pedicle. This report is the first to describe caecal and ileal incarceration and strangulation by a pedunculated lipoma in a horse.

The duodenal window approach to pancreatoduodenectomy.

The pancreatoduodenectomy (PD) technique is yet to be standardized. One of the most difficult passages in PD is the mobilization of the second, third, and fourth parts of the duodenum. This maneuver is classically performed from the supramesocolic space after the division of the gastrocolic ligament, but traction on the transverse mesocolon and the superior mesenteric pedicle can cause bleeding from the venous and arterial branches of the pancreatic head and uncinate process. We hereby describe a technique to access and mobilize the distal duodenum and proximal jejunum (D2 to J1) through the duodenal window and the Treitz's foramen, performing an almost complete Kocher's maneuver before opening the gastrocolic ligament and mobilizing the hepatic flexure. The anatomical basis and the surgical technique of the duodenal-window-first PD are discussed. The duodenal-window-first approach is a standardizable step of PD that allows an easy and safe mobilization of D2 to J1. This technique has been applied to 15 cases of PD, both open and robotic, with no specific morbidity. Therefore, we propose the adoption of the duodenal-window-first technique as a routine standardized step of PD.

Cecal Volvulus: Case Series Study

Cecal volvus (CV) is considered to be a rare cause of intestinal obstruction, it occurs when the ascending colon and the terminal ileum are twisted around their mesenteric pedicle, resulting in a closed-loop obstruction, CV counts about 1- 1,5% of all intestinal obstructions [1]. Its clinical features are those of the other forms of intestinal obstruction which make the imaging screening crucial for a prompt diagnosis in order to reduce the high mortality rate due to the intestinal necrosis or perforation [2]. We report a case series of 6 patients who were admitted mostly for abdominal pain and vomiting and for whom radiological investigations confirmed a cecal volvulus which was successfully managed by the surgical teams, no recurrence has been noted so far.

Cecal volvulus with intestinal malrotation: a rare cause of bowel obstruction

Introduction:Cecal volvulus is a rare cause of acute abdomen in adults. It accounts for less than 1% of intestinal obstructions and 25-30% of cases of colonic volvulus. Congenital intestinal malrotation is a complex disorder due to incomplete or faulty rotation and fixation of the gut during the fetal life.Cecal volvulus associated with intestinal malrotation is a very rare presentation. Over 16 cases were reported in the literature. Case report:A 44-year-old man with no medical history, presented to the emergency department with a 2-day history of abdominal pain and bloating. On clinical examination, the abdomen was distended and tympanic to percussion, with diffuse abdominal tenderness. Abdominal X-ray (standing) showed a distended large intestine with an airfluid colonic level. CT scan showed a markedly dilated cecum measuring up to 14 cm, which were located in the left hypochondrium. A “whirl sign” and a superior mesenteric pedicle swirl were also noted. Emergency surgery was performed. Intraoperative exploration revealed a cecal volvulus with a largely distended hypermobile cecum located in the left hypochondrium, with preischemic signs within its wall. All the small gut was right-sided and the large gut left-sided, suggestive of mesenterium commune and intestinal malrotation. A right hemicolectomy withileo-transverse anastomosis was done. The postoperative course was uneventful. The patient is on regular follow up and is doing well. Conclusion:We describe a rare case of surgical management of cecal volvulus associated with intestinal malrotation in a middle-aged patient with no medical history. This case highlights the importance of early diagnosis by physical examination and radiological findings to prevent serious complications. Emergent surgery was the key to this successful management and surgical resection could offer better results with lesser recurrence rate. Bangladesh Journal of Medical Science Vol. 22 No. 02 April’23 Page : 445-448

Cecal volvulus: A rare post-partum complication.

Introduction and importanceCecal volvulus is a rare clinical condition. It is characterized by axial twist of caecum, terminal ileum and the ascendant right colon around their mesenteric pedicles. The main pathophysiologic mechanism is cecal hyper mobility associated to precipitating factor such as colonic tumor, abdominal mass or pregnancy. Cecal volvulus during pregnancy was reported, but it remains exceptional during postpartum period.Clinical presentationWe report a case of cecal volvulus occurring in 37-year-old woman ten days after cesarean section delivery. She presented an acute abdominal pain associated to vomiting and nausea. X ray imaging and abdominal CT showed a large colonic obstruction, the caecum was dilated and located in the left hypochondrium. An open surgery was performed showing twisted bowels involving the caecum, the ileocecal junction and the right colon. There were necrotic areas on the colonic wall. Right hemicolectomy was performed with end to side ileo-colostomy. The evolution was marked by a serious septic shock causing patient's death.Clinical discussionCecal volvulus is a rare condition. Its suggested mechanism associates cecal hyper mobility to a precipitating factor. Increased uterine volume may explain cecal volvulus during pregnancy. In post-partum period, it may be explained by rapid uterine size variation. Cecal volvulus diagnosis is challenging. In fact, its symptoms can be confused with post operative ileus after cesarean section delivery. Delayed management leads to worst prognosis.ConclusionCecal volvulus during post-partum period is a rare condition, it may be serious in case of delayed diagnosis.

Cecal volvulus in an adult male: A rare cause of intestinal obstruction: A case report

Introduction and importanceCecal volvulus is uncommon cause of intestinal obstruction. It affects the ascending colon and the terminal part of the ileum which are twisted around the mesenteric pedicle.Case presentationWe report the case of 37-year-old male who underwent emergency laparotomy for intestinal obstruction and found a twisted cecum with ileal knotting and anterior part of cecum necrosed. Resection of cecum and terminal ilium followed by end-to-end anastomosis of ileum to ascending colon were performed.Clinical discussionCecal volvulus remains an uncommon cause of intestinal obstruction with a surgical incidence of 2.8–7.1 cases per year per 1 million people. Delay in diagnosis can lead to complications such as necrosis and perforation of the cecum.ConclusionWe present a rare case of cecal volvulus in a 37-year-old male with necrosed part of the cecum without perforation. Early diagnosis and management can prevent perforation and reduce morbidity related to the cecal perforation.

Importance of the Duodenal Window and Fredet’s Fascia in Laparoscopic Right Hemicolectomy: Technical Note

Background: Laparoscopic right hemicolectomy requires a precise anatomical dissection to mobilise the right and proximal transverse mesocolon, following the avascular fusion planes of Toldt and Fredet. Fredet’s plane is crucial to the preparation of the origin of vessels. Easy access to Fredet’s and Toldt’s fasciae can be obtained through the “duodenal window”, a flimsy area of the root of the proximal transverse mesocolon, the margins of which are the right border of the superior mesenteric pedicle, the ileocolic pedicle, the right colic pedicle and the marginal artery. Method: We propose that dissection of the duodenal window should be the first step in laparoscopic right hemicolectomy, to obtain easy access to the duodenopancreatic plane and prepare the fascia. Results: This “duodenal window-first” technique has been applied in 45 laparoscopic right hemicolectomies and 14 laparoscopic extended right hemicolectomies, with only two conversions to open surgery. The duodenal window was easily identified in all but 3 cases with significant visceral obesity. No significant intra- or postoperative morbidity was recorded in these cases and the median postoperative length of stay was 4 days. All resections were R0 and an adequate number of retrieved lymph nodes were obtained in almost all cases. Conclusion: The duodenal window-first approach is a feasible and safe technique to standardise the first steps of radical laparoscopic right hemicolectomy, allowing prompt and complete anatomical identification and dissection.

Cecal Volvulus: Rare Presentation of Intestinal Obstruction-Case Report

Introduction: Cecal volvulus is a rare cause of intestinal obstruction that occurs 1% - 1.5% of all intestinal obstructions. Causes of volvulus are usually unknown but it can be due to a defective peritoneal fixation of the ascending colon and cecum in 10% and secondary causes (surgical adhesions, colonic carcinoma or diverticulitis). Case Presentation: A 56-year-old woman presented with colicky abdominal pain, bilious vomiting and abdominal distention for two days, who has no history of previous surgery and no other gastrointestinal symptoms or chronic illness. On examinations, she looks ill, dehydrated, abdomen massively distended with exaggerated bowel sound but no signs of peritonitis. CT abdomen with contrast finding: type 11 cecal volvulus seen in midline to the left above the umbilicus reaching 8 cm with ileocecal junction as well as the elongated appendix is reaching the right iliac fossa. Emergency exploratory laparotomy was done and the finding was, obstructing rectosigmoid tumor with cecal volvulus. Discussion: Cecal volvulus is one of the rare causes of mechanical intestinal obstruction which required urgent surgical intervention, and it occurs due to an axial twist of the caecum, ascending colon and terminal ileum around the mesenteric pedicle. Conclusion: Radiological imaging helps in the diagnosis of cecal volvulus especially CT scan with contrast as gold standard for both diagnosis and assessment for complications. However, this should not delay the time of intervention especially if patient presented at late stage with evidence of peritonitis or bowel ischemia and surgical right hemicolectomy is the most effective treatment option. The colonic pathology always should be assessed, as it could be the primary cause of cecal volvulus.

Recurrent volvulus after late onset midgut volvulus in a patient with isolated elongated mesenteric pedicle

Recurrent volvulus after late onset midgut volvulus in a patient with isolated elongated mesenteric pedicle

A comprehensive study of the mesopancreas as an extension of the pancreatic circumferential resection margin

Data on required excisions to achieve clear margins in pancreatic cancer are conflicting. Similarly, there are inconsistent protocols on aggressive lymphadenectomy. We review retropancreatic tissues, common metastatic lymph nodes and the mesopancreas with respect to pancreatic resection margins to improve our understanding of major sites for relapse that can be specifically targeted for effective treatments. This work is two-fold: keywords/phrases identified relevant publications on the mesopancreas and lymphadenectomy in PubMed databases; RCTs, original studies, prospective and retrospective studies were reviewed and results analysed. Retropancreatic tissues including the mesopancreas are major sites for incomplete resections and relapse. Nomenclature for the mesopancreas is moot; nonetheless, its contents form a network of a neurolymphovascular-rich microenvironment that furnishes pathways for invasion and metastasis. The “mesopancreas” is a rectangular prism-shaped, primary micrometastasis site that overlaps with pancreatic resection margins and common metastatic lymph nodes. Most common infiltrated lymph nodes in 599 patients were stations 13, 17, 14, 12, 8, 16 and 6. Extended lymphadenectomy offers no survival benefit but promotes accurate staging. A better understanding of the relationship between the anatomical position of the mesopancreas, common metastatic lymph nodes and the pancreatic circumferential resection margin offers important future applications for targeted treatment approaches to control tumour spread, stage nodal disease and reduce disease burden in retropancreatic tissues, frequently infiltrated lymph nodes and other anatomically complex sites such as the superior mesenteric neurovascular pedicle. Excision of common metastatic lymph node stations can improve outcomes.

Malrotation with midgut volvulus and bowel gangrene in a 45-year-old man

Midgut volvulus due to intestinal malrotation is a rare occurrence in adult life. Malrotation is a congenital, developmental anomaly that results from an arrest of the physiological rotation of the gut through 270°. It is often thought that complications due to it, present themselves early during childhood and rarely occur among adults. However, a few cases have occurred and have been reported among adults. When it does occur in adults, it is often associated with catastrophic consequences. We present the case of a 45-year-old man with malrotation resulting in midgut volvulus. Our patient is a 45-year-old man, who presented with sudden onset of colicky abdominal pain and abdominal swelling of 24 h duration. He had been having recurrent abdominal pain since childhood. Physical examination revealed a patient in shock with markedly distended abdomen and anterior abdominal wall edema. Plain abdominal X-ray showed multiple air-fluid levels with thickened bowel outline. A diagnosis of intestinal obstruction was made. The patient was fully resuscitated and planned for emergency exploratory laparotomy under general anesthesia. Intraoperative findings revealed a 360° clockwise rotation of the small bowel around the mesenteric pedicle of the superior mesenteric artery and vein including about 350 cm of bowel gangrene. Resection and anastomosis were done. The early postoperative period was uneventful. However, he had anastomotic dehiscence on the 5th postoperative day and had to be reoperated but sadly he died 24 h later due to complications of anesthesia. Nonspecific recurrent abdominal complaints in adults of any age should raise suspicion of the possibility of a midgut malrotation or malfixation with or without intermittent volvulus. This case highlights the importance of early diagnosis and treatment.

Laparoscopic Management of Intestinal Malrotation With Cocoon Deformity: A Case Report

Intestinal malrotation is diagnosed and treated mostly in infancy and childhood, but it is rarely encountered in adults. Here, we present a case of adult intestinal malrotation with cocoon deformity that was managed by a laparoscopic procedure. A 71-year-old man presented with intermittent abdominal pain, nausea, and vomiting. Preoperative findings from abdominal computed tomography, upper gastrointestinal contrast imaging, and enema examination showed intestinal malrotation without volvulus. Diagnostic laparoscopy revealed nonrotation of the midgut, and most of the small bowels were contained in a large peritoneal sac without strangulation. With a definitive diagnosis of intestinal malrotation with cocoon deformity, further laparoscopic repair was performed by widely opening the peritoneal sac, and widening the base of the mesenteric pedicle to prevent future volvulus. There were no postoperative complications. The laparoscopic approach for intestinal malrotation with cocoon deformity can be a safe and useful technique. With the advantage of its minimal invasiveness, it can be an alternative to laparotomy.

Mesenteric root dissection with individualized ileo-colic vessel ligation versus mesenteric pedicle stapling.

Numerous factors have been associated with the number of lymph nodes retrieved during laparoscopic colectomy. This study compared the impact of vascular pedicle ligation method on the number of retrieved lymph nodes in patients undergoing laparoscopic right hemicolectomy for cancer. Mesenteric root dissection with individualized vessel ligation was compared to en bloc vascular root stapling. Data were retrospectively collected from a database of patients' charts including operative and pathological reports. All patients that underwent laparoscopic colectomy in a single department were identified. Patients that underwent elective laparoscopic right hemicolectomy for cancer were further evaluated. The impact of the method used for ileo-colic vascular transection, age, gender, nodes status, T stage, BMI and the operating surgeon on the number of retrieved lymph nodes was studied. Among 239 laparoscopic colectomies, 75 patients underwent elective laparoscopic right colectomy for cancer. Ileo-colic vascular transection was routinely performed at the level of the inferior border of the pancreas. In total, 34 patients underwent ileo-colic vascular root dissection with individualized vessel ligation and 41 underwent vascular root stapling. No difference was found in the mean number of retrieved lymph nodes between pedicle dissection and vascular root stapling (18.7±5.9 vs. 19.6±7.9, P=0.396), and in the rate of patients who had 12 nodes or more (97.1 vs. 92.7%, P=0.401). BMI above 30 was associated with decreased number of retrieved nodes (P=0.001). No difference was found in the number of retrieved lymph nodes between ileo-colic vascular root dissection with individual vessel ligation and vascular root stapling in patients undergoing laparoscopic right hemicolectomy for cancer. High BMI was associated with decreased number of retrieved nodes in both groups. A standard approach regarding the level of mesenteric root transection, regardless of the ligation approach, leads to adequate lymph node harvesting by different surgeons.

Analysis of Risk Factors and Management of Anastomotic Leakage After Rectal Cancer Surgery: An Indian Series.

The primary objective of this study was to determine whether sphincter preservation is possible among patients who develop anastomotic leakage after rectal cancer surgery. The secondary objective was to determine the factors that may contribute to anastomotic leakage. This is a retrospective review of a prospectively maintained database. All patients with rectal cancer who underwent restorative proctectomy over 1year were included in the study. The parameters analyzed were age, preoperative hemoglobin and albumin, neoadjuvant therapy, type of surgery, level of ligation of inferior mesenteric pedicle, technique of anastomosis, and defunctioning proximal stoma. In this study, 176 cases of anterior resection were included,of which15 (8.5%) had anastomotic leakage. None of the factors contributing to anastomotic leakage reached statistical significance on univariate analysis. Among the patients who had proximal defunctioning ileostomy (n=9), five (56%) required re-surgery whereas other four were managed with antibiotics and presacral drainage alone (44%). Among the patients who didnot have proximal defunctioning ileostomy (n=6), all (100%) required re-surgery. Among the 12 eligible patients, stoma reversal was successful in eight (67%) patients. This study highlights the importance of defunctioning proximal stoma in reducing the incidence and severity of anastomotic leakage as well as the need and extent of re-surgery for low rectal cancer. Sphincter preservation is possible in majority of patients who develop anastomotic leakage after rectal cancer surgery.

Modified Seromuscular Patch Flap for Reinforcing an Anastomosis Site in Hypopharyngeal Reconstruction Using Free Jejunal Transfer

Free jejunal transfer is commonly used as a reliable reconstructive method after total pharyngolaryngectomy. An anastomotic fistula is the most common complication in the early postoperative period, occurring in 5% to 35% of cases. There have been several studies regarding surgical techniques for minimizing fistula formation. Specifically, the vascularized seromuscular patch flap has been used for reinforcing the anastomosis site; however, this flap does not yield a sufficient range of motion because of traction on the vascular pedicle. Between 2004 and 2011, 4 patients underwent vascularized seromuscular patch flaps with free jejunal transfer. A short segment of jejunum on a mesenteric pedicle is usually opened longitudinally along the antimesenteric border to make a patch flap; however, we made a longitudinal incision along 1 side of the mesenteric border. To investigate the vascular anatomy of the flap, a lead oxide-gelatin mixture was injected into the arterial system of 4 fresh cadavers. The flap had increased mobility without traction on the vascular pedicle and adequate circulation. In the injection study, it was shown that the modification guaranteed adequate circulation across the antimesenteric border and from the proximal to the distal end of the flap. In conclusion, an incision along 1 side of the mesenteric border produces increased mobility of the jejunal seromuscular patch flap. Angiography can demonstrate clear evidence of a reliable circulation.

PD20-11 RESULTS OF VAGINOPLASTY

You have accessJournal of UrologySexual Function/Dysfunction/Andrology: Surgical Therapy1 Apr 2014PD20-11 RESULTS OF VAGINOPLASTY christoper wright and Moneer Hanna christoper wrightchristoper wright More articles by this author and Moneer HannaMoneer Hanna More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1701AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Introduction and Objectives The use of bowel for vaginal construction is a well established procedure. The purpose of this presentation is to review the outcomes of vaginoplasty using either a segment of small bowel or the sigmoid colon, in the form of a pedicled tube or in a detubularized reconfigured fashion. We will discuss the lessons learned from 35 vaginoplasties over a 32 year period. Methods Between 1980 and 2012 thirty-five children and young adults between 1-21 years old underwent vaginal construction. The diagnoses were Meyer-Rokitansky Syndrome (19), micropenis (5), complete androgen insensitivity (3), 46XY cloacal exstrophy (3), aphallia (3), 46XY bladder exstrophy (1) and true hermaphrodite (1). The sigmoid colon was used in (22), small bowel (12) and urothelium (1). In 12 patients (5 ileum and 7 sigmoid) the bowel segments were detubularized and reconfigured into a pouch. This technique was advocated in cases where the mesentery was short and did not allow the distal end of the bowel to reach the perineum without tension. This surgical method was helpful in avoiding traction on the vascular mesenteric pedicle, but added some operative time. An inverted V-shaped perineal skin flap was incorporated into the posterior wall of the neo-vagina in 26/35 patients. In 9 patients the sigmoid colon was anastomosed in a circumferential manner to the short blind ending vaginal dimple. Results 28 patients were followed for at least one year, 10 for 5 years, 7 for 17 years and 1 for 30 years. Seven patients from abroad were followed by their local surgeon for at least 1 year. 2/9 sigmoid vaginas in which the perineal skin flap was omitted developed stenosis. Both underwent Y-V plasty, one restenosed and a second revision was done followed by daily dilation. Both had patent introitus when last seen. One patient with an ileal pouch vagina developed stenosis 10 years after the onset of puberty and was successfully corrected. One child developed mucosal prolapse and is awaiting revision. 19/28 are sexually active and report no dyspareunia. Conclusions Intestinal segments can be used to provide a cosmetic self-lubricating neovagina. Detubularization and reconfiguration to form a pouch reduces the traction on the mesentery of the bowel segment, which ensures adequate blood supply to the distal entero-cutaneous junction. The inverted V-shaped perineal skin flap should be incorporated in the anastomosis to avoid circumferential suture line and introital stenosis. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e615 Advertisement Copyright & Permissions© 2014MetricsAuthor Information christoper wright More articles by this author Moneer Hanna More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Caecal volvulus a rare presentation of acute intestinal obstruction in a 22 year old female

Acute intestinal obstruction due to cecal volvulus forms an uncommon cause when there is axial twist of the cecum, ascending colon and terminal ileum around their mesenteric pedicles. There are many etiologies and predisposing factors for cecal volvulus, but the exact etiology is most likely to be multifactorial in presence of mobile cecum. It is the rarity and non specific presentation that makes the preoperative diagnosis to be rarely achieved in most cases.

Small Intestinal Submucosa Segments as Matrix for Tissue Engineering: Review

Tissue engineering (TE) is an emerging interdisciplinary field aiming at the restoration or improvement of impaired tissue function. A combination of cells, scaffold materials, engineering methods, and biochemical and physiological factors is employed to generate the desired tissue substitute. Scaffolds often play a pivotal role in the engineering process supporting a three-dimensional tissue formation. The ideal scaffold should mimic the native extracellular environment providing mechanical and biological properties to allow cell attachment, migration, and differentiation, as well as remodeling by the host organism. The scaffold should be nonimmunogenic and should ideally be resorbed by the host over time, leaving behind only the regenerated tissue. More than 40 years ago, a preparation of the small intestine was introduced for the replacement of vascular structures. Since then the small intestinal submucosa (SIS) has gained a lot of interest in TE and subsequent clinical applications, as this material exhibits key features of a highly supportive scaffold. This review will focus on the general properties of the SIS and its applications in therapeutical approaches as well as in generating tissue substitutes in vitro. Furthermore, the main problem of TE, which is the insufficient nourishment of cells within three-dimensional, artificial tissues exceeding certain dimensions is addressed. To solve this issue the implementation of another small intestine-derived preparation, the biological vascularized matrix (BioVaM), could be a feasible option. The BioVaM comprises in addition to SIS the arterial and venous mesenteric pedicles and exhibits thereby a perfusable vessel bed that is preserved after decellularization.

Transanal rectosigmoid resection via natural orifice translumenal endoscopic surgery (NOTES) with total mesorectal excision in a large human cadaver series

The authors' group has previously described successful transanal rectosigmoid resection via natural orifice translumenal endoscopic surgery (NOTES) in both porcine and cadaveric models using the transanal endoscopic microsurgery platform. This report describes the largest cadaveric series to date as optimization of this approach for clinical application continues. Between December 2008 and September 2011, NOTES transanal rectosigmoid resection with total mesorectal excision (TME) was successfully performed in 32 fresh human cadavers using transanal dissection alone (n = 19), with transgastric endoscopic assistance (n = 5), or with laparoscopic assistance (n = 8). The variables recorded were gender, body mass index (BMI), operative time, length of the mobilized specimen, integrity of the mesorectum and the resected specimen, and complications. Univariate statistical analysis was performed. Of the 32 cadavers, 22 were male with a mean BMI of 24 kg/m(2) (range 16.3-37 kg/m(2)). The mean operative time was 5.1 h (range 3-8 h), and the mean specimen length was 53 cm (range 15-91.5 cm). After the first five cadavers, specimen length significantly improved, and a trend toward decreased operative time was demonstrated. The mesorectum was intact in 100% of the specimens. In nine cadavers, endoscopic dissection was complicated by organ injury. Evaluation by the operative approach demonstrated a significantly longer specimen with laparoscopic assistance (67.7 cm) than with transgastric assistance (45.4 cm) or transanal dissection alone (49.2 cm) (p = 0.013). Comparison of the technique used for inferior mesenteric pedicle division demonstrated both significantly decreased operative time (4.8 vs 6 h; p = 0.024) and increased specimen length (57.7 vs 39.6 cm; p = 0.025) when a stapler was used in lieu of a bipolar cautery device. Transanal NOTES rectosigmoid resection with TME is feasible and demonstrates improvement in specimen length and operative time with experience. Transitioning to clinical application requires laparoscopic assistance to overcome limitations related to NOTES instrumentation, as well as procedural training with fresh human cadavers.