title: No-scar transanal total mesorectal excision: the last step to pure NOTES for colorectal surgery.
abstract: OBJECTIVE
  Because of the concerns over the operative platform, accidental organ injury, and viscerotomy closure, natural orifice transluminal endoscopic surgery (NOTES) currently remains an experimental technique. Transanal NOTES for colorectal surgery overcomes all of these issues; however, all of the reports to date have used hybrid laparoscopic techniques. We demonstrate herein the first case, to our knowledge, of pure transanal NOTES colorectal surgery.
  
  
  METHODS
  Case report.
  
  
  METHODS
  University hospital.
  
  
  METHODS
  The patient was a 56-year-old woman with a midrectal neoplasia.
  
  
  METHODS
  Pure transanal NOTES total mesorectal excision with a coloanal anastomosis and without a diverting stoma. Using a transanal endoscopic operation device as a surgical platform, we created a viscerotomy distal to an endoluminal purse-string suture. We performed a total mesorectal excision using a “bottom-up” approach. The sigmoid colon was mobilized by a posterior, retroperitoneal approach and the colon was divided intraperitoneally. A hand-sewn, side-to-end, coloanal anastomosis was performed. Because the viscerotomy was incorporated into the anastomosis, the concerns of both accidental organ damage and viscerotomy closure were abrogated.
  
  
  RESULTS
  The procedure was completed entirely by a transanal fashion. We successfully mobilized the rectum, mesorectum, and sigmoid colon. The specimen length was more than 20 cm. The patient required minimal analgesia and her pain was nonabdominal.
  
  
  CONCLUSIONS
  To our knowledge, the first pure transanal NOTES total mesorectal excision with retroperitoneal sigmoid mobilization and coloanal, side-to-end anastomosis was successfully performed using what we called a peri-rectal oncologic gateway for retroperitoneal endoscopic single site surgery (PROGRESSS). This monumental case could pave the way for a new era in pure transanal NOTES for colorectal surgery.
authors.affiliation: IRCAD/EITS, 1 Place de l’Hôpital, 67091 Strasbourg, France. joel.leroy@ircad.fr
authors.forename: Joël
authors.initials: J
authors.lastname: Leroy
authors.forename: Brian Donncha
authors.initials: BD
authors.lastname: Barry
authors.forename: Armando
authors.initials: A
authors.lastname: Melani
authors.forename: Didier
authors.initials: D
authors.lastname: Mutter
authors.forename: Jacques
authors.initials: J
authors.lastname: Marescaux
mesh_terms: D001003:Anal Canal; D002921:Cicatrix / Q000517:prevention & control; D003107:Colorectal Surgery / Q000379:methods; D013505:Digestive System Surgical Procedures / Q000009:adverse effects / Q000379:methods; D005260:Female; D006801:Humans; D008875:Middle Aged; D057605:Natural Orifice Endoscopic Surgery / Q000379:methods*; D012004:Rectal Neoplasms / Q000601:surgery*