Name: clinical application of single-surgeon, three-port, laparoscopic resection for colorectal cancer with natural orifice specimen extraction
Uploaded: 2023-03-24T14:25:00
Description: Watch this Scientific Journal Video about Clinical Application of Single-Surgeon, Three-Port, Laparoscopic Resection for Colorectal Cancer with Natural Orifice Specimen Extraction at JoVE.com

This research was supported by the Key R&#38;D Projects Medical and Health Key Technology Research and Application Program in Guangzhou, China (Project No. 202206010104).

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
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	<li>I...

<ol>
	<li>Wang, X. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Natural Orifice Specimen Extraction Surgery: Colorectal. , (2018).</li><li>Jiang, Z., Chen, Y., Wang, X. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+radical+resection+of+lower+rectal+cancer+through+transrectal+valgus+resection+without+abdominal+incisions.">Laparoscopic radical resection of lower rectal cancer through transrectal valgus resection without abdominal incisions.</a> Chinese Journal of Gastrointestinal Surgery. 17 (5), 499-501 (2014).</li><li>Liu, Z., Wang, G., Wang, X. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+median+radical+resection+for+rectal+cancer+through+the+rectum+to+pull+the+specimen+out+of+the+anus+without+abdominal+incision.">Laparoscopic median radical resection for rectal cancer through the rectum to pull the specimen out of the anus without abdominal incision.</a> Chinese Journal of Colorectal Diseases. 2 (6), 331-332 (2013).</li><li>Omori, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transumbilical+single-incision+laparoscopic+distal+gastrectomy+for+early+gastric+cancer.">Transumbilical single-incision laparoscopic distal gastrectomy for early gastric cancer.</a> Surgical Endoscopy. 25 (7), 2400-2404 (2011).</li><li>Song, J. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reduced+port+laparoscopic+surgery+for+colon+cancer+is+safe+and+feasible+in+terms+of+short-term+outcomes:+comparative+study+with+conventional+multiport+laparoscopic+surgery.">Reduced port laparoscopic surgery for colon cancer is safe and feasible in terms of short-term outcomes: comparative study with conventional multiport laparoscopic surgery.</a> Annals of Surgical Treatment and Research. 91 (4), 195-201 (2016).</li><li>Oh, J. R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+outcomes+of+reduced-port+laparoscopic+surgery+for+patients+with+sigmoid+colon+cancer:+surgery+with+1+surgeon+and+1+camera+operator.">Clinical outcomes of reduced-port laparoscopic surgery for patients with sigmoid colon cancer: surgery with 1 surgeon and 1 camera operator.</a> Annals of Coloproctology. 34 (6), 292-298 (2018).</li><li>Hu, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robot-assisted+total+mesorectal+excision+and+lateral+pelvic+lymph+node+dissection+for+locally+advanced+middle-low+rectal+cancer.">Robot-assisted total mesorectal excision and lateral pelvic lymph node dissection for locally advanced middle-low rectal cancer.</a> Journal of Visualized Experiments. (180), e62919 (2022).</li><li>Curcillo, P. G., Podolsky, E. R., King, S. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+road+to+reduced+port+surgery:+from+single+big+incisions+to+single+small+incisions,+and+beyond.">The road to reduced port surgery: from single big incisions to single small incisions, and beyond.</a> World Journal of Surgery. 35 (7), 1526-1531 (2011).</li><li>Inaki, N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reduced+port+laparoscopic+gastrectomy+for+gastric+cancer.">Reduced port laparoscopic gastrectomy for gastric cancer.</a> Translational Gastroenterology and Hepatology. 1, 38 (2016).</li><li>Takahashi, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prospective+multicenter+study+of+reduced+port+surgery+combined+with+transvaginal+specimen+extraction+for+colorectal+cancer+resection.">Prospective multicenter study of reduced port surgery combined with transvaginal specimen extraction for colorectal cancer resection.</a> Surgery Today. 50 (7), 734-742 (2020).</li><li>Zhou, H., Xu, K., Sun, Q., Wang, Z., Ruan, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Three-port+laparoscopic+sigmoidectomy+with+natural+orifice+specimen+extraction-a+video+vignette.">Three-port laparoscopic sigmoidectomy with natural orifice specimen extraction-a video vignette.</a> Colorectal Disease. 22 (11), 1782-1783 (2020).</li><li>Kim, A. C., Rist, R. C., Zureikat, A. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Technical+detail+for+robot+assisted+pancreaticoduodenectomy.">Technical detail for robot assisted pancreaticoduodenectomy.</a> Journal of Visualized Experiments. (151), e60261 (2019).</li></ol>

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<sup class='xre...

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 &#34;Expert Consensus on NOSES for Colorectal Tumors (2019 Edition)&#34; recommends NOSES with the five-port technique2,3.
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&#39;s location, the method of specimen collection, and the surgeon&#39;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.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>antibacterial polydioxanone</td>
			<td>Johnson &#38; Johnson</td>
			<td>8622H,SXPP1A403</td>
			<td></td>
		</tr>
		<tr>
			<td>Laparoscopic system</td>
			<td>STORZ</td>
			<td>26003BA</td>
			<td></td>
		</tr>
		<tr>
			<td>Ring stapler</td>
			<td>Johnson &#38; Johnson</td>
			<td>CDH29A</td>
			<td></td>
		</tr>
		<tr>
			<td>Straight cut closure</td>
			<td>Johnson &#38; Johnson</td>
			<td>EC45A</td>
			<td></td>
		</tr>
		<tr>
			<td>Trocar</td>
			<td>Johnson &#38; Johnson</td>
			<td>B5LT,B11LT,B12LT</td>
			<td></td>
		</tr>
	</tbody>
</table>

clinical application of single-surgeon, three-port, laparoscopic resection for colorectal cancer with natural orifice specimen extraction

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.

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 &#177; 35.6 min, the average bleeding volume was 40 &#177; 13.3 mL, the average postoperative exhaust time was 43.2 &#177; 22.1 h, the average number of lymph nodes dissected was 13.1 &#177; 8.6, and the average hospital stay was 13.2 &#177; 3.6 days. No anastomotic leakage or pulmonary/abdominal infections occurred after operation. A total ...

Watch this Scientific Journal Video about Clinical Application of Single-Surgeon, Three-Port, Laparoscopic Resection for Colorectal Cancer with Natural Orifice Specimen Extraction at JoVE.com

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

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

Reduced-port laparoscopic surgery (RPLS) has been widely used for the radical resection of gastrointestinal tumors. Single-surgeon, three-port, ...

Our protocol focus on the technical points of resection and reconstruction and improves on the procedure use for purse-string suture fixation after the proximal anvil is plating in the abdominal cavity. Protocol is easy to perform effectively, avoiding postoperative anastomotic leak and bleeding due to excessive intraoperative anastomotic tissue. And this could be widely promoted in primary hospital.Visual.The presentation of this protocol allows standard to understand the whole procedure more intuitively and efficiency. To perform the three-hole trocar insertion, first, make a 10-millimeter incision below the umbilicus, and insert a 10-millimeter trocar, then, make a 12-millimeter incision above the line connecting the right umbilicus and the anterior superior iliac spine, and insert a 12-millimeter trocar into it, next, make a 5-millimeter incision above the right flat umbilicus, and insert a 5-millimeter trocar. Perform a routine inspection of the abdominal cavity, then examine the upper abdominal liver and diaphragmatic peritoneum, and check the abdominal cavity counterclockwise.Probe the location of the tumor and adjacent structures. For female patients, use anastomosis needles to suspend the uterus to the front of the abdominal wall to expand the surgical field. To expose the dissection plane between the Toldt and the Gerota fascia, enlarge the cephalic space of Toldt by releasing the left lateral side to dissociate the sigmoid colon and its mesentery, then, adopt the medial dissociation 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 space until the lower part of the pancreas is reached, and then ligate the inferior mesenteric vein at a high position. Expand the Toldt space coddley and pull the inferior mesangium up freely.Carefully with the left hand, perform microexternal 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, separate the mesentery below the rectum for excision according to the distance from the tumor site, resulting in a naked intestine.To determine the extent of bowel resection, first, prepare an 8 to 10-centimeter 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 lens of the naked intestinal tube.Ensure that the distal rectal stump is flushed before 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. When the specimen is taken out from the vagina, have the assistant derogate the vagina and then insert an intestinal pressure plate.Next, make a 3 to 4-centimeter incision in the vagina under the guidance of the intestinal pressure plate. Repeatedly, disinfect the rectum or vagina with iodoform gauze. Insert a specimen bag into the abdominal cavity through the 12-millimeter trocar as protection during specimen retrieval.Place the staple anvil first and then take out the specimen to avoid possible contamination of the staple anvil. Then, 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.To place the stapler seat into the proximal bowel, incise the proximal intestinal canal, enlarge it to a 2 to 3-centimeter incision and sterilize it regularly with iodoform gauze. Place an anvil and suture the intestinal canal without knots with 3-0 polyglactin. 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. Press the anastomotic wrench tightly to complete the cutting and anastomosis.Then, suture the full circumference of the anastomosis in a 4-0 knot-free pattern. Flush the abdominal cavity and place a drainage tube. Also, place a rubber tube on the left or right side of the pelvis.After the surgery, no distal ileal prophylactic stoma was observed in any patient. The average operation time was approximately 169 minutes, and the average postoperative exhaust time was approximately 43 hours, with an average hospital stay of around 13 days. The average number of lymph nodes dissected was around 13, with no anastomotic leakage or pulmonary or abdominal infections after the operation.The position of the trocars in this surgery was extremely important, as trocars placed too close resulted in difficulty in the operation. Using this technique, surgeons skilled in laparoscopic techniques could easily dissect lymph nodes in anatomical groups 216 and 253 even on the surface of essential blood vessels. Moreover, the hypogastric nerve was protected during the surgery by elevating the proximal bowel tube, showing that this surgery is possible for patients with sigmoid colon or rectal cancer.This operation also effectively prevented anastomotic leakage and improved on an in-vitro anvil self-traction and fixation method. Following the operation, the patient only had postoperative abdominal wounds on the three holes, making this surgery treatment minimally invasive. The most important step in the protocol is to place the anvil and suture the intestinal canal.

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