Transanal single port access to facilitate distral rectal mobilization: a step towards colorectal NOTES surgery

Objective of the study: Laparoscopic rectal mucosal or intersphincteric sleeve resection is challenging and technically demanding, especially exposure and mobilization of the most distal part of the rectum can be hazardous. The use of a single port access device placed in the muscular anal canal after incision of the sleeve at the appropriate level is proposed to facilitate dissection without sphincter damage. Furthermore, if transanal mobilization of the rectum can be progressed maximally in a cranial way, a complete trans? anal NOTES rectal resection might become possible. This pilot-study assessed the feasibility of a single port transanal rectal mobilization.

Patients and methods: All patients treated by a laparoscopic-assisted transal single port rectal mobilization were included in the study. Incision of the endopelvic fascia and mobilization of the distal rectum and mesorectum was performed via the single port device under direct control. The created pneumo-retroperitoneum further facilitates laparoscopic dissection of the more proximal part.

Results: Four female patients with a median age of 54 years (range: 51–83) had this procedure. Indications were intractable supralevatoric fistula, Crohn rectitis with tubulovillous adenoma and faecal incontinence. In 3 patients a hand-sewn coloanal anastomosis was made and in 1 patient a proctectomy was performed. In one patient, a pure transanal rectal sleeve resection was performed without laparoscopic assistance. There were no postoperative complications and median hospital stay was 7.5 days (range: 3–9). Pathology showed tubulovillous adenoma in 2 cases. None of the patients reported any anal dysfunction at a median follow-up of 4 months.

Conclusion: The aforementioned procedure is a promising tool in the armamentarium of the colorectal surgeon. It can enable distal rectal mobilization under direct visualisation. The proposed technique could be a step towards transanal colorectal NOTES surgery.