Clinical Application of Single-Surgeon, Three-Port, Laparoscopic Resection for Colorectal Cancer with Natural Orifice Specimen Extraction

Summary

Here, we present a protocol to successfully perform single-surgeon, three-port, laparoscopic resection for colorectal cancer with natural orifice specimen extraction.

Abstract

Reduced-port laparoscopic surgery (RPLS) has been widely used for the radical resection of gastrointestinal tumors. Single-surgeon, three-port, laparoscopic radical resection for sigmoid colon or high rectal cancer with natural orifice specimen extraction surgery (NOSES) has the advantage of a small incision, quick postoperative recovery, and short hospital stay. Yet, there are still only a few reports on NOSES. This paper describes the indications, preoperative preparations, surgical steps, and precautions for single-surgeon, three-port, laparoscopic radical resection of the sigmoid colon and high rectal cancer, and intraoperative specimen collection through the natural orifice.

The protocol focuses on the steps of radical dissection and the main technical points of resection and reconstruction. At the same time, a procedure for fixing an anvil seat by self-traction of extracorporeal silk thread, used for purse-string suture fixation after the proximal anvil was placed in the abdominal cavity, was creatively improved. This operation could effectively avoid problems such as an insufficient proximal intestinal tube, shaking off the anvil seat, and weak purse-string suture during a single operation. The surgical care had less variability and was easy to perform, effectively avoiding postoperative anastomotic leakage and bleeding due to excessive intraoperative anastomotic tissue. This surgery could be widely promoted in primary hospitals.

Introduction

Natural orifice specimen extraction surgery (NOSES) is a modified approach to open surgery and conventional laparoscopic surgery, which relies on laparoscopic or robotic techniques. Its major advantages include a shorter length of hospital stay, reduction in wound complications and postoperative pain, faster recovery of bowel function, and better cosmetic and psychological effects. During NOSES, the surgical specimen is removed from a natural orifice (rectum or vagina) without requiring an auxiliary incision in the abdominal wall¹. The "Expert Consensus on NOSES for Colorectal Tumors (2019 Edition)" recommends NOSES with the five-port technique^2,3.

Omori et al.⁴ first applied reduced-port laparoscopic surgery (RPLS) to treat gastric cancer. In 2016, Kim et al. proposed that porosity reduction laparoscopic surgery was technically feasible and safe for the treatment of colorectal cancer and was comparable to conventional multiport laparoscopic surgery (CMLS) in terms of postoperative pain⁵. Oh et al., 2 years later, discussed the perioperative clinical outcomes of sigmoid colon cancer patients undergoing RPLS and traditional multiport laparoscopic surgery (MPLS); the results suggested that single-surgeon, three-port, laparoscopic radical sigmoidectomy was a feasible and safe surgical option for patients with favorable tumor characteristics⁶. However, the surgeries for sigmoid colon or high rectal cancer and specimen extraction through NOSES were mainly performed by one chief surgeon without the help of other assistants during intraoperative separation.

Currently, there are still only a few reports on NOSES. In NOSES, the placement and fixation of the anvil seat, which mainly depends on the tumor's location, the method of specimen collection, and the surgeon's ability, may be challenging. At present, a number of anvil fixation methods have been proposed, including the fixed extrusion method, reverse puncture method, snare ligation method, and manual purse-string suture method. Each method has its unique advantages and shortcomings. This study retrospectively analyzed the clinical data of 10 patients who underwent single-surgeon, three-port, laparoscopic surgery for sigmoid colon or high rectal cancer with NOSES to explore the safety and feasibility of this operation. The external anvil seat self-traction and fixation method was creatively improved, which could be used for manual purse-string suture fixation after placement of the anvil seat. Following the principle of tumor-free asepsis, the risk of anastomotic leakage and bleeding could be effectively avoided, and this surgicalprocedure could be widely promoted in primary hospitals.

Protocol

All laparoscopic surgical procedures and postoperative treatments in this study were performed in accordance with the guidelines established by the Laparoscopic Operation Ethics Committee of the First Affiliated Hospital of Sun Yat-Sen University, China. The research protocol and content were explained to all patients, and informed consent was obtained. This study was conducted under the guidance of the ethics committee of the hospital.

1. Case inclusion criteria

1. Include patients who have been diagnosed with sigmoid colon or high rectal adenocarcinoma (10-15 cm from the anus), who have undergone single-surgeon, three-port laparoscopy with NOSES in the study. Adopt the following inclusion criteria:
   1. Ensure diagnosis of sigmoid colon or high rectal adenocarcinoma by preoperative colonoscopy and pathological examinations.
   2. Ensure that enhanced computed tomography (CT) and magnetic resonance imaging (MRI) tests do not reveal any tumor invasion into the surrounding tissues, or bowel obstruction due to distant metastasis.
   3. Ensure that the tumor circumference is <5 cm.
   4. Ensure the T stage is ≤T4a.
   5. Ensure that the patients have no major organ diseases and can tolerate surgical treatment.
   6. Ensure that the patients do not have excessive obesity or mesenteric hypertrophy (BMI < 35 kg/m²).
   7. Ensure that the patients have not undergone any previous abdominal surgery and do not have pelvic floor adhesions.

2. Preparation for surgery

1. Administer oral laxatives and slag-free semi-liquid or liquid food and oral compound polyethylene glycol electrolyte powder (137.12 g) 3 days before the operation to prepare the patients for intestinal surgery.
2. Perform an enema the night before and early in the morning of surgery.
3. Place the patient in a modified lithotomy position, with the head lowered 15°-20° and the body tilted 15° on the right side.

3. Surgical procedure

1. To perform the three-hole trocar insertion, make a 10 mm incision below the umbilicus and insert a 10 mm trocar. Insert a 12 mm trocar into a 12 mm incision above the line connecting the right umbilicus and the anterior superior iliac spine. Next, insert a 5 mm trocar into a 5 mm incision above the right flat umbilicus. These latter two holes are considered the operating holes.
2. After a routine inspection of the abdominal cavity, examine the upper abdominal liver and diaphragmatic peritoneum and check the abdominal cavity counterclockwise. Probe the location of the tumor and adjacent structures. Use anastomosis needles to suspend the uterus (in female patients) to the front of the abdominal wall to expand the surgical field, assist single-surgeon operation, and facilitate the removal of specimens through the vagina and insertion of the stapler seat.
3. Dissociate the sigmoid colon and its mesentery, usually done by releasing the left lateral side first, or use a medial dissociation approach, to expose the dissection plane between the Toldt and Gerota fascia.
   NOTE: However, due to mesangial hypertrophy or lack of help from an assistant, fully exposing the operating field may be challenging. Therefore, the lateral separation approach was preferred in this study.
4. Enlarge the cephalic space of Toldt and ligate the inferior mesenteric artery and vein. After releasing the lateral side of the sigmoid mesocolon, adopt the medial approach. Next, lift the mesentery with gastric forceps to expose the mesenteric junction, dissociating it from bottom to top until the horizontal segment of the duodenum is reached, including the dissection of lymph nodes in 253 and 216 groups. After exposing the inferior mesenteric artery, ligate the vessels to expand the Toldt's space until the lower part of the pancreas is reached, and then ligate the inferior mesenteric vein at a high position.
5. Expand the Toldt's space caudally and pull the inferior mesangium up freely. Pay attention to the movements of the left hand: perform micro-external rotation of the intestinal forceps and pull the proximal colon backward and upward. Expose the hypogastric nerve while protecting it under appropriate tension. After adequate separation of the mesentery, according to the distance from the tumor site, separate the mesentery below the rectum for excision, resulting in a naked intestine.
   NOTE: Since the lateral mesentery is dissociated first, when the inferior mesentery is released, the sigmoid colon can be lifted smoothly using gastric forceps, properly exposing to show the tension.
6. To determine the extent of bowel resection, first prepare an 8-10 cm length of silk thread in vitro, and mark the position of the proximal resection of the intestinal tube with the silk thread on the upper edge of the tumor. Dissociate the proximal bowel canal and expose it using an ultrasonic scalpel. Use an endoscopic linear cut stapler to sequentially transect the proximal and distal ends of the naked intestinal tube.
7. Insertion of the stapler anvil seat and specimen removal
   1. Ensure that the distal rectal stump is flushed when removing the specimen from the rectum. Incise the distal rectal stump and place a clean endoscopic gauze under it to prevent contamination of the surgical field.
   2. When the specimen is taken out from the vagina, have the assistant irrigate the vagina, and then insert an intestinal pressure plate. Next, make a 3-4 cm incision in the vagina under the guidance of the intestinal pressure plate. Repeatedly disinfect the rectum or vagina with iodophor gauze.
   3. Insert a specimen bag into the abdominal cavity through the 12 mm trocar as protection during specimen retrieval to prevent tumor seeding or contamination of the rectum or vagina. During this process, place the staple anvil first and then take out the specimen to avoid possible contamination of the staple anvil.
8. Sutures of the vaginal wall and rectal stump
   1. Suture the vaginal wall directly with 3-0 antibacterial polydioxanone. After the rectal stump is sutured, lift the thread and close the rectal stump again with an endoluminal cutting and closure device to avoid the possibility of contamination and anastomotic leakage.
9. Placement of the stapler seat into the proximal bowel
   1. Incise the proximal intestinal canal, enlarge a 2-3 cm incision, and routinely sterilize it with iodophor gauze. Place an anvil and suture the intestinal canal without knots with 3-0 polyglactin.
10. Bowel anastomosis and reinforced stitching
    1. Perform routine end-to-end anastomosis of the bowel through the anus. Insert the ring stapler trigger handle through the anus, pierce the center piercing device of the stapler trigger handle, connect the center rod of the proximal stapler to the nail seat, and rotate the intestinal wall near the proximal and distal ends.
    2. Press the anastomotic wrench tightly to complete the cutting and anastomosis.
    3. Suture the full circumference of the anastomosis in a 4-0 knot-free pattern.
11. Flush the abdominal cavity, place a drainage tube, and place a rubber tube on the left or right side of the pelvis.

Results

No patient had any distal ileal prophylactic stoma. Specimens from six cases were taken from the rectum, and four case specimens from the vagina. The average operation time was 169.5 ± 35.6 min, the average bleeding volume was 40 ± 13.3 mL, the average postoperative exhaust time was 43.2 ± 22.1 h, the average number of lymph nodes dissected was 13.1 ± 8.6, and the average hospital stay was 13.2 ± 3.6 days. No anastomotic leakage or pulmonary/abdominal infections occurred after operation. A total ...

Discussion

With the improvement in surgical skills and the advancement in surgical equipment, especially the development of visualization devices, robotic surgery is often considered a reasonable choice for complex procedures, such as lateral pelvic lymph node dissection⁷. Reduced-port laparoscopic surgery is an emerging procedure, characterized by reduced incision number and size, making the operation less invasive than traditional laparoscopic surgery⁸. In 2016, Inaki

Materials

Name	Company	Catalog Number	Comments
antibacterial polydioxanone	Johnson & Johnson	8622H,SXPP1A403
Laparoscopic system	STORZ	26003BA
Ring stapler	Johnson & Johnson	CDH29A
Straight cut closure	Johnson & Johnson	EC45A
Trocar	Johnson & Johnson	B5LT,B11LT,B12LT