Totally laparoscopic anterior resection with transvaginal assistance and transvaginal specimen extraction: a technique for natural orifice surgery combined with reduced-port surgery

Abstract

Background: Natural orifice specimen extraction (NOSE) has been developed as a means of decreasing the incidence of surgical wound complications. However, NOSE performed using a conventional multiport technique has been reported previously. The current authors performed totally laparoscopic anterior resection with transvaginal specimen extraction (TVSE) using the reduced-port surgery (RPS) technique. The Alexis wound retractor (Applied Medical, Rancho Santa Margarita, CA, USA) and Free Access (Top Corporation, Tokyo, Japan) were attached to the transvaginal route for transvaginal assistance and smooth specimen extraction. The authors documented this simple and safe technique and its short-term results.

Methods: Data were prospectively collected for five patients who underwent totally laparoscopic anterior resection with TVSE for colorectal cancer between June 2012 and December 2012. A multiport access device (GelPOINT advanced-access platform; Applied Medical) was inserted into the navel, and a 5-mm port was inserted into the right lower quadrant to be used as a drain site. Transverse transvaginal posterior colpotomy then was performed. One ring of an Alexis ring pair was inserted into the peritoneal cavity through the vagina. The other white ring was placed outside of the vagina and then covered with a Free Access to maintain the pneumoperitoneum for insertion of a 12-mm port. Lymph node dissection and transection of the distal colon were performed with transvaginal assistance. The specimen then was extracted transvaginally. After the Alexis had been removed, the vaginal incision was closed transvaginally. End-to-end colorectal anastomosis was performed using the double-stapling technique.

Results: Transvaginal extraction was completed in all five cases. The median operation time was 235 min. One case was complicated by chyloperitoneum. The median hospital stay was 6 days. Only one patient required intravenous analgesics once on postoperative day 1. All the patients remained disease free.

Conclusion: Totally laparoscopic anterior resection using TVSE with RPS appears to be feasible, safe, and oncologically acceptable for selected cases.

Fig. 1

A A GelPOINT advanced-access platform placed through a 2-cm-long minilaparotomy in the navel. B Placement of 12- and 3-mm ports in the GelPOINT

Fig. 2

Abdomen of the patient showing the port incision scars 2 weeks after surgery

Fig. 3

One ring of an Alexis ring pair inserted into the abdominal cavity transvaginally through the colpotomy. The other white ring was placed outside the vagina

Fig. 4

White ring of the Alexis covered with a Free Access to maintain the pneumoperitoneum for insertion of a 12-mm port to be used by the assistant

Fig. 5

Sigmoid colon retracted by laparoscopic forceps inserted through the vagina

Fig. 6

A Transvaginal specimen extraction. B Anvil head of the circular stapling device inserted into the proximal colon through the vagina