Total mesorectal excision with natural orifice specimen extraction for rectal cancer with laparoscope

Objective To discuss the feasibility of the laparoscopic radical colorectal cancer resection combined with natural orifice surgery extraction (NOSE). Methods From March 2011 to July 2011, the NOSE operations were performed on 12 patients with primary cancer of the low rectum, including 8 cases in low rectal cancer group and 4 cases in high rectal cancer group. Seven women and 5 men were enrolled. The mean age was 61.18±7.5 years. In the low rectal cancer group, the inferior mesenteric vessels were high ligated and clipped. Then, the Ⅰ-Ⅲ branches of left colon vessel and sigmoid vessels were cut and the Edge aortic arch was reserved. The marginal arteries were cut at the superior margin of tumor. The proximal and distal colon were closed with Endo.CIA. The distal rectum was closed at the low margin of tumor via anus. In high rectal cancer group, the rectum was cut at the low margin via abdomen. In low rectal cancer group, the distal rectum and anus canal were isolated circumferentially. The rectum was cut off at the proxiral end pulled out through and canal. After that, the specimen was dragged out through the anus with the protection of specimen bag, while the anal was dilated to 5-6 cm. The proximal rectum was implanted with the stapler head and closed with purse-string suture. While the distal rectum was exposed with an anorectal dilator, we did another purse-string suture to close the stump of distal rectum. Finally, the colorectal anastomosis was completed by the laparoscopy via abdomen and anus. Results The mean blood loss was 81ml. No patient was converted to open surgery. The average length of hospital stay was 8 days. One case occurred anastomotic leakage, and no complications were occured, such as pelvic infection, intestinal obstruction, abdominal and pelvic bleeding, anastomotic obstruction and bleeding. Postoperative specimen evaluation showed that all the cases were TME with negative circumferential resection margin and R0 dissection. The average lymph nodes number was 16.7±4.6, while the positive lymph nodes number was 4.6±1.8. In all the cases, 8 were high-differentiated adenocarcinoma. 4 were low-differentiated adenocarcinoma or mucious adenocarcinoma. At the same time, 5 cases were stageⅡ and 7 cases were stage Ⅲ in TNM stage. Conclusions This technique is a safe and effective procedure for successfully performing laparoscopic TME of lower (or ultra-low) rectal cancer. It is not against the cancer radical dissection principle. The procedure was smoothly completed without any extra abdominal incision. Key words: Rectal neoplasme; Laparoscopes; Surgical procedures, mininally invasive