title: NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance.
abstract: BACKGROUND
  The feasibility and safety of Natural Orifice Translumenal Endoscopic Surgery (NOTES) transanal endoscopic rectosigmoid resection using transanal endoscopic microsurgery (TEM) was previously demonstrated in human cadavers and a porcine survival model. We report the first clinical case of a NOTES transanal resection for rectal cancer using TEM and laparoscopic assistance, performed by a team of surgeons from Barcelona and Boston with extensive experience with NOTES and minimally invasive approaches to colorectal diseases.
  
  
  METHODS
  Transanal endoscopic rectal resection with total mesorectal excision using the TEM platform was performed in a 76-year-old woman with a T2N2 rectal cancer treated with preoperative chemoradiation. Laparoscopic visualization and assistance with retraction and exposure during rectosigmoid mobilization was provided through one 5-mm port, which was later used as the stoma site, and 2-mm needle ports, one of which was used as a drain site. The specimen was transected transanally followed by handsewn coloanal anastomosis.
  
  
  RESULTS
  The procedure was completed successfully with an operative time of 4 hours and 30 minutes. Mesorectal excision was complete. The postoperative course was uneventful, and the patient was discharged on the fourth postoperative day. The final pathology demonstrated pT1N0 with 23 negative lymph nodes and negative proximal, distal, and radial margins.
  
  
  CONCLUSIONS
  NOTES transanal endoscopic rectosigmoid resection using TEM and laparoscopic assistance is feasible and safe. Careful patient selection and improvement in NOTES instrumentation are critical to optimize this approach before widespread clinical application.
authors.affiliation: Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
authors.forename: Patricia
authors.initials: P
authors.lastname: Sylla
authors.forename: David W
authors.initials: DW
authors.lastname: Rattner
authors.forename: Salvadora
authors.initials: S
authors.lastname: Delgado
authors.forename: Antonio M
authors.initials: AM
authors.lastname: Lacy
mesh_terms: D000230:Adenocarcinoma / Q000175:diagnosis / Q000601:surgery*; D000368:Aged; D000714:Anastomosis, Surgical; D001706:Biopsy; D012809:Colon, Sigmoid / Q000601:surgery*; D004724:Endoscopy / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007081:Ileostomy / Q000379:methods; D010535:Laparoscopy / Q000379:methods*; D008279:Magnetic Resonance Imaging; D008866:Microsurgery / Q000379:methods*; D009666:Nose; D012004:Rectal Neoplasms / Q000175:diagnosis / Q000601:surgery*; D012007:Rectum / Q000601:surgery*; D014057:Tomography, X-Ray Computed