title: Combined NOTES total mesorectal excision and single-incision laparoscopy principles for conservative proctectomy: a single-centre study.
abstract: BACKGROUND
  Surgery for low rectal cancer remains a challenge when a standard laparoscopic approach is used. Transanal endoscopic total mesorectal excision (TME) has been shown to be feasible and to be associated with a low conversion rate. Combining the transanal and transabdominal single-port approaches (with an abdominal single port implanted in the future stoma and extraction site) could allow TME with minimal wound trauma, low morbidity, and faster recovery. The aim of the current study was to assess the short- and mid-term results of this technique.
  
  
  METHODS
  We conducted a prospective single-centre study of consecutive patients presenting with low rectal cancer requiring a conservative proctectomy with a manual coloanal anastomosis between January 2012 and April 2015.
  
  
  RESULTS
  During the study period, 41 patients were recruited. Conversion to open surgery was required in only one patient (2.4%). The median operating time was 358.5 min (range 300-600 min). Partial intersphincteric resection was necessary for 15 patients (36.6%). The specimens were mostly extracted via the abdominal access (n = 34) without wound complications. The mean number of lymph nodes harvested was 12.7 (range 6-24 lymph nodes). Specimens were graded as complete (n = 31) or nearly complete (n = 10) in all of the patients, and the circumferential resection margin positivity was 4.9%. Intraoperative morbidity rate was 4.9%, and the 30-day morbidity rate was 24.4% (n = 10). Sixty per cent (n = 6) of the patients with 30-day morbidity were Dindo I-II. At a median follow-up of 29 months, overall and disease-free survival rates were 97.5 and 80.5%, respectively. The stoma-free survival rate was 95.1%.
  
  
  CONCLUSIONS
  Combining an endoscopic transanal TME and a single laparoscopic ileostomy-site proctectomy is a promising minimally invasive approach for the treatment of low rectal cancer.
authors.affiliation: Department of Digestive Surgical Oncology, Paoli Calmettes Institute, 232 Bd de Sainte Marguerite, 13009, Marseille, France. meillath@ipc.unicancer.fr.
authors.forename: H
authors.initials: H
authors.lastname: Meillat
authors.affiliation: Department of Digestive Surgical Oncology, Paoli Calmettes Institute, 232 Bd de Sainte Marguerite, 13009, Marseille, France.
authors.forename: C
authors.initials: C
authors.lastname: de Chaisemartin
authors.affiliation: Department of Biopathology, Paoli Calmettes Institute, Marseille, France.
authors.forename: F
authors.initials: F
authors.lastname: Poizat
authors.affiliation: Digestive Endoscopy Unit, Paoli Calmettes Institute, Marseille, France.
authors.forename: E
authors.initials: E
authors.lastname: Bories
authors.affiliation: Department of Digestive Surgical Oncology, Paoli Calmettes Institute, 232 Bd de Sainte Marguerite, 13009, Marseille, France.
authors.forename: R
authors.initials: R
authors.lastname: Fara
authors.affiliation: Department of Digestive Surgical Oncology, Paoli Calmettes Institute, 232 Bd de Sainte Marguerite, 13009, Marseille, France.
authors.forename: J R
authors.initials: JR
authors.lastname: Delpero
authors.affiliation: Department of Digestive Surgical Oncology, Paoli Calmettes Institute, 232 Bd de Sainte Marguerite, 13009, Marseille, France.
authors.forename: B
authors.initials: B
authors.lastname: Lelong
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001003:Anal Canal / Q000601:surgery*; D000714:Anastomosis, Surgical; D003106:Colon / Q000601:surgery*; D061887:Conversion to Open Surgery; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D007081:Ileostomy; D010535:Laparoscopy / Q000379:methods*; D008197:Lymph Node Excision; D008297:Male; D000072662:Margins of Excision; D008875:Middle Aged; D018365:Neoplasm, Residual; D061646:Operative Time; D011183:Postoperative Complications / Q000209:etiology; D011446:Prospective Studies; D012004:Rectal Neoplasms / Q000601:surgery*; D015996:Survival Rate; D000067368:Transanal Endoscopic Surgery / Q000379:methods*
keywords: Natural orifice specimen extraction; Rectal cancer; Single-port laparoscopic surgery; Transanal total mesorectal excision