title: True NOTES TME resection with splenic flexure release, high ligation of IMA, and side-to-end hand-sewn coloanal anastomosis.
abstract: Natural orifice transluminal endoscopic surgery (NOTES) represents the ultimate expression of minimally invasive surgery. We have developed and present here an initial feasibility and safety study of transanal total mesorectal excision (TME) with splenic flexure release, high ligation of the IMA and IMV, and side-to-end coloanal anastomosis with temporary diverting ileostomy for rectal cancer.
  
  
  
  A program of full NOTES TME resection with release of the splenic flexure, high ligation of the IMA/IMV, with side-to-end coloanal anastomosis was performed transanally from December 2013 to July 2014. Demographics, preoperative, perioperative, and postoperative data were prospectively obtained. Operative components were broken into TME, colonic mobilization, splenic flexure release, IMA/IMV transection, transanal extraction of specimen, and coloanal anastomosis for analysis of performance completion.
  
  
  
  There were 3 women and 1 man on whom we operated. Mean age was 56 (46-65). Mean BMI was 26 (23.8-30.2). The operation was completed entirely transanally in 2 patients. Transanal component completion of the operation was as follows: TME in 3/4; colonic mobilization in 4/4; splenic flexure release in 3/4; IMA/IMV transection in 3/4; transanal specimen extraction in 4/4; coloanal anastomosis in 4/4. Abdominal time for completion of component parts was: splenic flexure release 4:53 (min:s), IMA/IMV 19:43, completion of TME 13:41. Mean EBL was 194 cc (25-500). Aside from stoma site, there were no abdominal incisions. There were no mortalities. Mesorectum was intact in all 4 patients and with negative circumferential and distal margins.
  
  
  
  This experience supports the feasibility and safety of a true NOTES TME. The critical anatomic views demonstrated on video affirm the potential of this approach for distal rectal cancer. Colorectal surgery represents the most logical application for NOTES. While highly promising, a great deal of work remains to develop the technique and applicability of NOTES colorectal surgery.
authors.affiliation: Marks Colorectal Surgical Associates, Lankenau Institute for Medical Research, Wynnewood, PA, USA. marksj@mlhs.org.|Lankenau Medical Center, Medical Office Building West, Suite 330, 100 East Lancaster Avenue, Wynnewood, PA, 19096, USA. marksj@mlhs.org.
authors.forename: John H
authors.initials: JH
authors.lastname: Marks
authors.affiliation: Marks Colorectal Surgical Associates, Lankenau Institute for Medical Research, Wynnewood, PA, USA.
authors.forename: Nicolas
authors.initials: N
authors.lastname: Lopez-Acevedo
authors.affiliation: Marks Colorectal Surgical Associates, Lankenau Institute for Medical Research, Wynnewood, PA, USA.
authors.forename: Barath
authors.initials: B
authors.lastname: Krishnan
authors.affiliation: Marks Colorectal Surgical Associates, Lankenau Institute for Medical Research, Wynnewood, PA, USA.
authors.forename: Matthew N
authors.initials: MN
authors.lastname: Johnson
authors.affiliation: Marks Colorectal Surgical Associates, Lankenau Institute for Medical Research, Wynnewood, PA, USA.
authors.forename: Grace A
authors.initials: GA
authors.lastname: Montenegro
authors.affiliation: Marks Colorectal Surgical Associates, Lankenau Institute for Medical Research, Wynnewood, PA, USA.
authors.forename: Gerald J
authors.initials: GJ
authors.lastname: Marks
mesh_terms: D000368:Aged; D001003:Anal Canal / Q000601:surgery*; D000714:Anastomosis, Surgical / Q000379:methods*; D002277:Carcinoma / Q000601:surgery*; D003106:Colon / Q000601:surgery*; D044684:Colon, Transverse / Q000601:surgery; D013505:Digestive System Surgical Procedures / Q000379:methods; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D007081:Ileostomy / Q000379:methods*; D008026:Ligation; D008297:Male; D017537:Mesenteric Artery, Inferior / Q000601:surgery; D008643:Mesentery / Q000601:surgery*; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures; D057605:Natural Orifice Endoscopic Surgery / Q000379:methods*; D012004:Rectal Neoplasms / Q000601:surgery*; D000067368:Transanal Endoscopic Surgery
keywords: Laparoscopic; NOTES; Rectal cancer; TATA; Transanal TME
references.citation: JAMA Surg. 2013 Mar;148(3):226-30; discussion 231
references.pmid: 23682369
references.citation: Ann Surg. 2007 Dec;246(6):916-21; discussion 921-2
references.pmid: 18043092
references.citation: Surg Endosc. 2014 Nov;28(11):3150-7
references.pmid: 24879139
references.citation: Surg Endosc. 2013 Dec;27(12):4469-77
references.pmid: 24057070
references.citation: Endoscopy. 1987 Nov;19 Suppl 1:38-42
references.pmid: 3428240
references.citation: Int J Radiat Oncol Biol Phys. 1988 Nov;15(5):1065-8
references.pmid: 3182339
references.citation: Surg Laparosc Endosc Percutan Tech. 2008 Jun;18(3):294-8
references.pmid: 18574421
references.citation: Dis Colon Rectum. 2014 Jan;57(1):105-9
references.pmid: 24316953
references.citation: Surg Endosc. 2010 Sep;24(9):2200-5
references.pmid: 20174935
references.citation: Gastrointest Endosc. 2005 Aug;62(2):293-6
references.pmid: 16046998
references.citation: Surg Endosc. 2010 Nov;24(11):2700-7
references.pmid: 20414681
references.citation: J Clin Oncol. 2005 Dec 20;23(36):9257-64
references.pmid: 16361623
references.citation: Gastrointest Endosc. 2004 Jul;60(1):114-7
references.pmid: 15229442
references.citation: Ann Surg Oncol. 2012 Jul;19(7):2095-101
references.pmid: 22350601
references.citation: Surg Endosc. 2013 Sep;27(9):3396-405
references.pmid: 23572214
references.citation: Surg Endosc. 2013 Jan;27(1):127-32
references.pmid: 22833263
references.citation: Dig Endosc. 2014 Jan;26 Suppl 1:29-42
references.pmid: 24033375
references.citation: J Gastrointest Surg. 2011 Aug;15(8):1313-5
references.pmid: 21647768
references.citation: Dis Colon Rectum. 2013 Apr;56(4):408-15
references.pmid: 23478607
references.citation: Tech Coloproctol. 2014 May;18(5):473-80
references.pmid: 24272607
references.citation: Dis Colon Rectum. 2012 Sep;55(9):996-1001
references.pmid: 22874608
references.citation: Surg Endosc. 2013 Sep;27(9):3165-72
references.pmid: 23519489
references.citation: Lancet. 1986 Nov 1;2(8514):996-9
references.pmid: 2430152