title: Minilaparoscopy-assisted natural orifice total colectomy: technical report of a minilaparoscopy-assisted transrectal resection.
abstract: BACKGROUND
  Experimental experience and the technological evolution of minimally invasive surgical devices have allowed initial reports describing the clinical applicability of natural orifice translumenal endoscopic surgery (NOTES). Colorectal resections are an interesting target for the NOTES platform. Theoretically, the transrectal approach could overcome the proposed limitations of transvaginal access, increasing NOTES clinical applicability. Hybrid procedures such as minilaparoscopy-assisted natural orifice surgery (MA-NOS) are the safe progression to pure NOTES. This report describes the first clinical case of a transrectal MA-NOS total colectomy.
  
  
  METHODS
  The patient was a 36-year-old man with severe ulcerative colitis (UC) who experienced failure of immunosuppressive therapy. The standard steps of laparoscopic total colectomy were respected, with basic triangulation maintained throughout the case. A transrectal endoscopic device was used for optic assistance, colon dissection, ileum section, and specimen retrieval. Transrectal MA-NOS total colectomy was assisted by three laparoscopic ports: a 12-mm port used as the terminal ileostomy site, a 2-mm needle epigastric port, and a 5-mm umbilical port used as a drain site at the final intervention. No intraoperative complications occurred.
  
  
  RESULTS
  The total operative time was 240 min. Oral intake was initiated on postoperative day 2. Because of UC rectal activity, a course with azathioprine was completed, and the patient was discharged receiving 1 g of rectal mesalazine for maintenance. The final pathology demonstrated pancolonic inflammatory bowel disease in the form of UC with severe activity.
  
  
  CONCLUSIONS
  Transrectal MA-NOS total colectomy was feasible and safe in the reported case. Improvement in NOTES instrumentation and selective clinical applications are mandatory before clinical trials.
authors.affiliation: Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases, Hospital Clínic, University of Barcelona, Villarroel 170, 08036 Barcelona, Spain. alacy@clinic.ub.es
authors.forename: Antonio M
authors.initials: AM
authors.lastname: Lacy
authors.forename: David
authors.initials: D
authors.lastname: Saavedra-Perez
authors.forename: Raquel
authors.initials: R
authors.lastname: Bravo
authors.forename: Cedric
authors.initials: C
authors.lastname: Adelsdorfer
authors.forename: Montserrat
authors.initials: M
authors.lastname: Aceituno
authors.forename: Jaume
authors.initials: J
authors.lastname: Balust
mesh_terms: D003082:Colectomy / Q000379:methods*; D003093:Colitis, Ulcerative / Q000601:surgery*; D005240:Feasibility Studies; D006801:Humans; D007081:Ileostomy / Q000379:methods; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D057605:Natural Orifice Endoscopic Surgery / Q000379:methods*; D012007:Rectum; D013048:Specimen Handling; D055815:Young Adult