Basic Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Nov 16, 2020; 12(11): 451-458
Published online Nov 16, 2020. doi: 10.4253/wjge.v12.i11.451
Peroral traction-assisted natural orifice trans-anal flexible endoscopic rectosigmoidectomy followed by intracorporeal colorectal anastomosis in a live porcine model
Hong Shi, Su-Yu Chen, Zhao-Fei Xie, Rui Huang, Jia-Li Jiang, Juan Lin, Fang-Fen Dong, Jia-Xiang Xu, Zhi-Li Fang, Jun-Jie Bai, Ben Luo
Hong Shi, Su-Yu Chen, Zhao-Fei Xie, Rui Huang, Jia-Li Jiang, Juan Lin, Department of Digestive Endoscopy, Fujian Cancer Hospital, Fujian Medical University Cancer Hospital, Fuzhou 350014, Fujian Province, China
Fang-Fen Dong, School of Medical Technology and Engineering, Fujian Medical University, Fuzhou 350122, Fujian Province, China
Jia-Xiang Xu, Zhi-Li Fang, Jun-Jie Bai, Ben Luo, School of Clinical Medicine, Fujian Medical University, Fuzhou 350122, Fujian Province, China
Author contributions: Shi H and Chen SY contributed equally to this work; Shi H and Chen SY were responsible for the study concept and design, including endoscopic procedures; all authors conducted the endoscopic operations together; Chen SY drafted the manuscript; Shi H revised and finalized the manuscript.
Supported by Young and Middle-aged Mainstay Talent Training Program of Fujian Provincial Health System, China, No. 2014-ZQN-ZD-6.
Institutional review board statement: The study was reviewed and approved by the Institutional Review Board of Fujian Cancer Hospital, Fujian Medical University Cancer Hospital (Approval No. 2014-ZQN-ZD-6).
Institutional animal care and use committee statement: All procedures involving animals were reviewed and approved by the Institutional Animal Care and Use Committee of Beijing Pinggu Hospital and Fuzhou General Hospital of Nanjing Military Command (IACUC-2015-010).
Conflict-of-interest statement: To the best of our knowledge, no conflict of interest exists.
Data sharing statement: No additional data are available.
ARRIVE guidelines statement: The authors have read the ARRIVE Guidelines, and the manuscript was prepared and revised according to the ARRIVE Guidelines.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Hong Shi, MD, Chief Doctor, Department of Digestive Endoscopy, Fujian Cancer Hospital, Fujian Medical University Cancer Hospital, No. 420 Fuma Road, Fuzhou 350014, Fujian Province, China. endoshihong@hotmail.com
Received: July 16, 2020
Peer-review started: July 16, 2020
First decision: September 14, 2020
Revised: September 29, 2020
Accepted: October 20, 2020
Article in press: October 20, 2020
Published online: November 16, 2020
ARTICLE HIGHLIGHTS
Research background

Since 1991, an increasing number of minimally invasive surgical techniques, including single-incision laparoscopic surgery (SILS), needlescopic surgery (NS), and natural orifice transluminal endoscopic surgery (NOTES), have been developed rapidly. To date, all cases of NOTES colorectal resection have included a hybrid laparoscopic approach with the use of established rigid platforms.

Research motivation

Our research aimed to improve NOTES-related techniques.

Research objectives

Our study aimed to introduce the novel technique of peroral external traction-assisted transanal NOTES sigmoidectomy followed by intracorporeal colorectal end-to-end anastomosis by using only currently available and flexible endoscopic instrumentation in a live swine model.

Research methods

Three female pigs weighing 25-30 kg underwent NOTES rectosigmoid resection. The procedure of trans-anal NOTES rectosigmoidectomy included the following eight steps: (1) The rectosigmoid colon was tattooed with India ink by submucosal injection; (2) Creation of gastrostomy by directed submucosal tunneling; (3) Peroral external traction using endoloop ligation; (4) Creation of rectostomy on the anterior rectal wall by directed 3 cm submucosal tunneling; (5) Peroral external traction-assisted dissection of the left side of the colon; (6) Trans-anal rectosigmoid specimen transection, where an anvil was inserted into the proximal segment after purse-string suturing; (7) Intracorporeal colorectal end-to-end anastomosis using a circular stapler with a single stapling technique; and (8) Closure of gastrostomy using endoscopic clips.

Research results

The procedure was completed in all three animals, with the operation time ranging from 193 min to 259 min.  The length of the resected specimen ranged from 7 cm to 13 cm. With the assistance of a trans-umbilical rigid grasper, intracorporeal colorectal, tension-free, end-to-end anastomosis was achieved in the three animals.

Research conclusions

Peroral traction-assisted transanal NOTES rectosigmoidectomy followed by intracorporeal colorectal end-to-end anastomosis is technically feasible and reproducible in an animal model and is worthy of further improvements.

Research perspectives

The techniques of NOTES rectosigmoidectomy need to be improved for clinical application.