NOTES rectosigmoid resection using transanal endoscopic microsurgery (TEM) with transgastric endoscopic assistance: A pilot study in swine

Introduction Transanal endoscopic microsurgery (TEM) provides direct endoscopic access to the rectum and peritoneal cavity. The feasibility of natural orifice translumenal endoscopic surgery (NOTES) rectosigmoid resection using TEM was evaluated in swine. Transgastric endoscopic assistance to extend transanal colon mobilization was also investigated. Full-thickness circumferential rectal dissection was performed and extended proximally. After maximal sigmoid mobilization, the specimen was exteriorized and transected, and the proximal colon was stapled to the distal rectum. In a subset of animals, transgastric endoscopic access was used to mobilize the colon further. Results Rectosigmoid resection using TEM was performed in two non-survival and seven swine cadavers (n=9). The mean procedure time was 3 h (2.5-4 h), and mean length of resected colon was 16.7 cm (10-25 cm). Transgastric endoscopic assistance was used in three cadavers and two non-survival swine (n=5) with a mean operative time of 3.5 h (3.5-3.75 h). The mean length of colon mobilized with transgastric and transanal endoscopic access was 24.4 cm (20-27 cm) vs. 16.7 cm which mobilized the transanal approach alone (p=0.016). A posterior anastomotic defect was noted in two animals. Conclusion Transanal rectosigmoid resection with TEM is feasible in swine. Combined transgastric and TEM access is a promising new technique for NOTES colorectal resection.