Abstract
Back ground
During laparoscopic colectomy, the specimen is retrieved through substantial incisions, which increase postoperative pain, wound infections, and incisional hernias [1–3]. In the era of natural orifice transluminal endoscopic surgery (NOTES), incisionless transrectal approaches for colon resections have been investigated with promising results [4–6]. Transanal retrieval of the colonic specimen in laparoscopic colectomy has been described but not widely adopted [7–12], although it seems to be an appealing step towards NOTES colectomy. We have used the TEM rectoscope (Richard Wolf Medical Instruments Corporation, Vernon Hills, IL, USA) as a retrieval conduit, which facilitates transanal extraction of the specimen, and protects the rectal edge and anal sphincter during laparoscopic left colectomy.
Technique
After standard laparoscopic dissection and vascular control, the colon is divided distally, whereas the proximal colonic end is ligated to prevent fecal spillage. The TEM rectoscope is advanced through the rectal stump. The proximal colon is grasped and withdrawn through the rectoscope. The colon is stapled off proximally, and the specimen is removed transanally. An anvil is introduced into the pelvis through the rectoscope and inserted in the descending colon through a colotomy, which is subsequently sealed with an endo-loop. The rectoscope is withdrawn, and the rectal stump edge is stapled off. A circular stapler is introduced in the rectum, and end-to-end anastomosis is performed.
Discussion
The extraction incisions in laparoscopic colectomy increase invasiveness and compromise the “purity” of the laparoscopic approach. Retrieval of the specimen through natural orifices constitutes a stepping stone in the transition to future incisionless NOTES colectomy. These techniques have not been widely adopted because of technical difficulties and concerns regarding trauma. In our experience, transanal retrieval of the colonic specimen is hampered by friction between the specimen and the rectum, which requires countertraction to the edges of the open rectal stump. These manipulations are time consuming and increase the risk of injury, even when retrieval bags are used [13, 14]. The TEM rectoscope allows gentle dilation of the anus, provides stability during extraction, and protects the edges of the rectum, therefore decreasing the risk of rectal or anal canal injuries. It maintains pneumoperitoneum and eases retrieval of the specimen through the large-caliber metal conduit. Alternative options in the form of a rigid conduit would be the use of the transanal endoscopic operation device (Karl Storz, Tuttlingen, Germany) [15], the plastic McCartney tube (Tyco Healthcare, Norwalk, CT, USA) used for transvaginal operations [16], or an anecdotally reported, “homemade” rectoscope from a customized polyvinyl chloride tube. Potential limitations of this technique include the increased cost of acquiring and using the TEM rectoscope, although this should not be significant if this reusable system is already available for transanal procedures. The 4 cm diameter of the TEM rectoscope can also be a limiting factor in the case of large, bulky, incompressible specimens or large colonic tumors. We have also avoided using this technique in patients with preexisting anal sphincter dysfunction and fecal incontinence, as well as in the presence of severe perianal disease (i.e., fistulae or fissures). Naturally, the open lumen in the peritoneal cavity raises concerns regarding bacterial contamination and potential tumor cell seeding in cases of cancer. Preliminary evidence on these issues comes from TEM and NOTES research without obvious signs of increased risk currently [17, 18]. We do not perform preoperative bowel preparation for our colectomies, but we do perform rectal enema with Betadine solution at the beginning of the procedure.
Conclusions
Use of the TEM system facilitates transanal removal of the specimen and protects the anorectum during laparoscopic colectomy.
Similar content being viewed by others
References
Desouza A, Domajnko B, Park J, Marecik S, Prasad L, Abcarian H (2010) Incisional hernia, midline versus low transverse incision: what is the ideal incision for specimen extraction and hand-assisted laparoscopy? Surg Endosc 25(4):1031–1036
Singh R, Omiccioli A, Hegge S, McKinley C (2008) Does the extraction-site location in laparoscopic colorectal surgery have an impact on incisional hernia rates? Surg Endosc 22(12):2596–2600
Winslow ER, Fleshman JW, Birnbaum EH, Brunt LM (2002) Wound complications of laparoscopic vs open colectomy. Surg Endosc 16(10):1420–1425
Whiteford MH, Denk PM, Swanström LL (2007) Feasibility of radical sigmoid colectomy performed as natural orifice translumenal endoscopic surgery (NOTES) using transanal endoscopic microsurgery. Surg Endosc 21(10):1870–1874
Sylla P, Rattner DW, Delgado S, Lacy AM (2010) NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance. Surg Endosc 24(5):1205–1210
Zorron R (2010) Natural orifice surgery applied for colorectal diseases. World J Gastrointest Surg 2(2):35–38
Akamatsu H, Omori T, Oyama T, Tori M, Ueshima S, Nakahara M, Abe T, Nishida T (2009) Totally laparoscopic sigmoid colectomy: a simple and safe technique for intracorporeal anastomosis. Surg Endosc 23(11):2605–2609
Cheung HY, Leung AL, Chung CC, Ng DC, Li MK (2009) Endo-laparoscopic colectomy without mini-laparotomy for left-sided colonic tumors. World J Surg 33(6):1287–1291
Ooi BS, Quah HM, Fu CW, Eu KW (2009) Laparoscopic high anterior resection with natural orifice specimen extraction (NOSE) for early rectal cancer. Tech Coloproctol 13(1):61–64
Franklin ME Jr, Diaz-E JA (2000) Laparoscopic left hemicolectomy with transanal extraction of the specimen. In: Ballantyne GH (ed) Atlas of laparoscopic surgery, 1st edn. WB Saunders, Philadelphia, pp 386–404
Franklin ME, Kazantsev GB, Abrego D, Diaz-E JA, Balli J, Glass JL (2000) Laparoscopic surgery for stage III colon cancer: long-term follow-up. Surg Endosc 14(7):612–616
Leroy J, Costantino F, Cahill RA, Donnatelli GF, Kawai M, Wu HS, Marescaux J (2010) Fully laparoscopic colorectal anastomosis involving percutaneous endoluminal colonic anvil control (PECAC). Surg Innov 17(2):79–84
Nishimura A, Kawahara M, Suda K, Makino S, Kawachi Y, Nikkuni K (2011) Totally laparoscopic sigmoid colectomy with transanal specimen extraction. Surg Endosc 25(10):3459–3463
Wolthuis AM, Penninckx F, D’Hoore A (2011) Laparoscopic sigmoid resection with transrectal specimen extraction has a good short-term outcome. Surg Endosc 25(6):2034–2038
Saad S, Hosogi H (2011) Laparoscopic left colectomy combined with natural orifice access: operative technique and initial results. Surg Endosc 25(8):2742–2747
Saad S, Hosogi H (2010) Natural orifice specimen extraction for avoiding laparotomy in laparoscopic left colon resections: a new approach using the McCartney tube and the tilt top anvil technique. J Laparoendosc Adv Surg Technol A 20(8):689–692
Gavagan JA, Whiteford MH, Swanstrom LL (2004) Full-thickness intraperitoneal excision by transanal endoscopic microsurgery does not increase short-term complications. Am J Surg 187(5):630–634
Leroy J, Costantino F, Cahill RA, D’Agostino J, Morales A, Mutter D, Marescaux J (2011) Laparoscopic resection with transanal specimen extraction for sigmoid diverticulitis. Br J Surg 98(9):1327–1334
Author information
Authors and Affiliations
Corresponding author
Electronic supplementary material
Below is the link to the electronic supplementary material.
Supplementary material 1 (WMV 51768 kb)
Rights and permissions
About this article
Cite this article
Makris, K.I., Rieder, E., Kastenmeier, A.S. et al. Transanal specimen retrieval using the transanal endoscopic microsurgery (TEM) system in minimally invasive colon resection. Surg Endosc 26, 1161–1162 (2012). https://doi.org/10.1007/s00464-011-2021-6
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00464-011-2021-6