title: Transanal endoscopic total mesorectal excision combined with single-port laparoscopy.
abstract: BACKGROUND
  Rectal dissection using a conventional multiport laparoscopic approach involves risks due to technical difficulties, particularly in patients with a low tumor, a narrow pelvis, or obesity.
  
  
  OBJECTIVE
  We describe a technique of transanal endoscopic low and middle rectal dissection with subsequent coloanal anastomosis via single-port laparoscopy, with the aim of reducing technical problems, increasing safety, and improving cosmesis after resection of rectal cancer.
  
  
  METHODS
  This was an observational study conducted in a large, tertiary care cancer center in France.
  
  
  METHODS
  Consecutive patients with rectal adenocarcinoma requiring total mesorectal excision with a coloanal anastomosis were evaluated for eligibility to undergo the procedure. Patients were selected if they had 1 or more of the following risk factors: narrow pelvis, a voluminous prostate, or obesity.
  
  
  METHODS
  After an anal mucosectomy, the rectal wall was circumferentially transected above the external sphincter and a transanal trocar was introduced. The dissection of the mesorectum was completely performed via endoscopy up to the Douglas rectovesical pouch. A single port was inserted at the future site of the transient ileostomy, and a left colectomy and a lymphadenectomy were performed. The upper rectum dissection enabled joining the transanal rectal plane of dissection. Then the splenic flexure was completely mobilized and the specimen was extracted through the site of the future ileostomy.
  
  
  METHODS
  Operative time, blood loss, duration of hospital stay, and histopathologic variables (margins, number of harvested lymph nodes, grade of the mesorectal fascia dissection) were recorded, and the quality of the surgical plane was assessed. The Cleveland Clinic Florida (Wexner) fecal incontinence questionnaire was administered after ileostomy closure.
  
  
  RESULTS
  Four consecutive male patients with rectal cancer in a narrow pelvis were treated with this new approach. No conversion (by laparotomy or multiport laparoscopy) was necessary. The pathologic variables were satisfactory and the Wexner scores indicated no severe incontinence after ileostomy closure. The postoperative follow-up was uneventful except for an anastomotic fistula which developed in 1 patient and was treated without reoperation.
  
  
  CONCLUSIONS
  The study was limited by the small number of patients and the fact that no women and no obese patients were included.
  
  
  CONCLUSIONS
  Rectal resection via the transanal approach combined with single-port laparoscopic assistance may be easier and safer than the traditional approach, especially in male patients who have a narrow pelvis. More data are needed in order to draw conclusions concerning oncologic results and before selecting the most appropriate indications for this technique.
authors.affiliation: Department of Digestive Oncological Surgery, Institut Gustave Roussy, Villejuif, France. Frederic.Dumont@igr.fr
authors.forename: Frédéric
authors.initials: F
authors.lastname: Dumont
authors.forename: Diane
authors.initials: D
authors.lastname: Goéré
authors.forename: Charles
authors.initials: C
authors.lastname: Honoré
authors.forename: Dominique
authors.initials: D
authors.lastname: Elias
mesh_terms: D000230:Adenocarcinoma / Q000601:surgery*; D000368:Aged; D001003:Anal Canal / Q000601:surgery*; D000714:Anastomosis, Surgical; D003106:Colon / Q000601:surgery*; D013505:Digestive System Surgical Procedures / Q000379:methods*; D006801:Humans; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D012004:Rectal Neoplasms / Q000601:surgery*; D012007:Rectum / Q000601:surgery*