Clinical Application of Single-Surgeon, Three-Port, Laparoscopic Resection for Colorectal Cancer with Natural Orifice Specimen Extraction

Summary

Here, we present a protocol to successfully perform single-surgeon, three-port, laparoscopic resection for colorectal cancer with natural orifice specimen extraction.

Abstract

Reduced-port laparoscopic surgery (RPLS) has been widely used for the radical resection of gastrointestinal tumors. Single-surgeon, three-port, laparoscopic radical resection for sigmoid colon or high rectal cancer with natural orifice specimen extraction surgery (NOSES) has the advantage of a small incision, quick postoperative recovery, and short hospital stay. Yet, there are still only a few reports on NOSES. This paper describes the indications, preoperative preparations, surgical steps, and precautions for single-surgeon, three-port, laparoscopic radical resection of the sigmoid colon and high rectal cancer, and intraoperative specimen collection through the natural orifice.

The protocol focuses on the steps of radical dissection and the main technical points of resection and reconstruction. At the same time, a procedure for fixing an anvil seat by self-traction of extracorporeal silk thread, used for purse-string suture fixation after the proximal anvil was placed in the abdominal cavity, was creatively improved. This operation could effectively avoid problems such as an insufficient proximal intestinal tube, shaking off the anvil seat, and weak purse-string suture during a single operation. The surgical care had less variability and was easy to perform, effectively avoiding postoperative anastomotic leakage and bleeding due to excessive intraoperative anastomotic tissue. This surgery could be widely promoted in primary hospitals.

Introduction

Natural orifice specimen extraction surgery (NOSES) is a modified approach to open surgery and conventional laparoscopic surgery, which relies on laparoscopic or robotic techniques. Its major advantages include a shorter length of hospital stay, reduction in wound complications and postoperative pain, faster recovery of bowel function, and better cosmetic and psychological effects. During NOSES, the surgical specimen is removed from a natural orifice (rectum or vagina) without requiring an auxiliary incision in the abdominal wall¹. The "Expert Consensus on NOSES for Colorectal Tumors (2019 Edition)" recommends NOSES with the five-port technique^2,3.

Omori et al.⁴ first applied reduced-port laparoscopic surgery (RPLS) to treat gastric cancer. In 2016, Kim et al. proposed that porosity reduction laparoscopic surgery was technically feasible and safe for the treatment of colorectal cancer and was comparable to conventional multiport laparoscopic surgery (CMLS) in terms of postoperative pain⁵. Oh et al., 2 years later, discussed the perioperative clinical outcomes of sigmoid colon cancer patients undergoing RPLS and traditional multiport laparoscopic surgery (MPLS); the results suggested that single-surgeon, three-port, laparoscopic radical sigmoidectomy was a feasible and safe surgical option for patients with favorable tumor characteristics⁶. However, the surgeries for sigmoid colon or high rectal cancer and specimen extraction through NOSES were mainly performed by one chief surgeon without the help of other assistants during intraoperative separation.

Currently, there are still only a few reports on NOSES. In NOSES, the placement and fixation of the anvil seat, which mainly depends on the tumor's location, the method of specimen collection, and the surgeon's ability, may be challenging. At present, a number of anvil fixation methods have been proposed, including the fixed extrusion method, reverse puncture method, snare ligation method, and manual purse-string suture method. Each method has its unique advantages and shortcomings. This study retrospectively analyzed the clinical data of 10 patients who underwent single-surgeon, three-port, laparoscopic surgery for sigmoid colon or high rectal cancer with NOSES to explore the safety and feasibility of this operation. The external anvil seat self-traction and fixation method was creatively improved, which could be used for manual purse-string suture fixation after placement of the anvil seat. Following the principle of tumor-free asepsis, the risk of anastomotic leakage and bleeding could be effectively avoided, and this surgicalprocedure could be widely promoted in primary hospitals.

Protocol

All laparoscopic surgical procedures and postoperative treatments in this study were performed in accordance with the guidelines established by the Laparoscopic Operation Ethics Committee of the First Affiliated Hospital of Sun Yat-Sen University, China. The research protocol and content were explained to all patients, and informed consent was obtained. This study was conducted under the guidance of the ethics committee of the hospital.

1. Case inclusion criteria

1. Include patients who have been diagnosed with sigmoid colon or high rectal adenocarcinoma (10-15 cm from the anus), who have undergone single-surgeon, three-port laparoscopy with NOSES in the study. Adopt the following inclusion criteria:
   1. Ensure diagnosis of sigmoid colon or high rectal adenocarcinoma by preoperative colonoscopy and pathological examinations.
   2. Ensure that enhanced computed tomography (CT) and magnetic resonance imaging (MRI) tests do not reveal any tumor invasion into the surrounding tissues, or bowel obstruction due to distant metastasis.
   3. Ensure that the tumor circumference is <5 cm.
   4. Ensure the T stage is ≤T4a.
   5. Ensure that the patients have no major organ diseases and can tolerate surgical treatment.
   6. Ensure that the patients do not have excessive obesity or mesenteric hypertrophy (BMI < 35 kg/m²).
   7. Ensure that the patients have not undergone any previous abdominal surgery and do not have pelvic floor adhesions.

2. Preparation for surgery

1. Administer oral laxatives and slag-free semi-liquid or liquid food and oral compound polyethylene glycol electrolyte powder (137.12 g) 3 days before the operation to prepare the patients for intestinal surgery.
2. Perform an enema the night before and early in the morning of surgery.
3. Place the patient in a modified lithotomy position, with the head lowered 15°-20° and the body tilted 15° on the right side.

3. Surgical procedure

1. To perform the three-hole trocar insertion, make a 10 mm incision below the umbilicus and insert a 10 mm trocar. Insert a 12 mm trocar into a 12 mm incision above the line connecting the right umbilicus and the anterior superior iliac spine. Next, insert a 5 mm trocar into a 5 mm incision above the right flat umbilicus. These latter two holes are considered the operating holes.
2. After a routine inspection of the abdominal cavity, examine the upper abdominal liver and diaphragmatic peritoneum and check the abdominal cavity counterclockwise. Probe the location of the tumor and adjacent structures. Use anastomosis needles to suspend the uterus (in female patients) to the front of the abdominal wall to expand the surgical field, assist single-surgeon operation, and facilitate the removal of specimens through the vagina and insertion of the stapler seat.
3. Dissociate the sigmoid colon and its mesentery, usually done by releasing the left lateral side first, or use a medial dissociation approach, to expose the dissection plane between the Toldt and Gerota fascia.
   NOTE: However, due to mesangial hypertrophy or lack of help from an assistant, fully exposing the operating field may be challenging. Therefore, the lateral separation approach was preferred in this study.
4. Enlarge the cephalic space of Toldt and ligate the inferior mesenteric artery and vein. After releasing the lateral side of the sigmoid mesocolon, adopt the medial approach. Next, lift the mesentery with gastric forceps to expose the mesenteric junction, dissociating it from bottom to top until the horizontal segment of the duodenum is reached, including the dissection of lymph nodes in 253 and 216 groups. After exposing the inferior mesenteric artery, ligate the vessels to expand the Toldt's space until the lower part of the pancreas is reached, and then ligate the inferior mesenteric vein at a high position.
5. Expand the Toldt's space caudally and pull the inferior mesangium up freely. Pay attention to the movements of the left hand: perform micro-external rotation of the intestinal forceps and pull the proximal colon backward and upward. Expose the hypogastric nerve while protecting it under appropriate tension. After adequate separation of the mesentery, according to the distance from the tumor site, separate the mesentery below the rectum for excision, resulting in a naked intestine.
   NOTE: Since the lateral mesentery is dissociated first, when the inferior mesentery is released, the sigmoid colon can be lifted smoothly using gastric forceps, properly exposing to show the tension.
6. To determine the extent of bowel resection, first prepare an 8-10 cm length of silk thread in vitro, and mark the position of the proximal resection of the intestinal tube with the silk thread on the upper edge of the tumor. Dissociate the proximal bowel canal and expose it using an ultrasonic scalpel. Use an endoscopic linear cut stapler to sequentially transect the proximal and distal ends of the naked intestinal tube.
7. Insertion of the stapler anvil seat and specimen removal
   1. Ensure that the distal rectal stump is flushed when removing the specimen from the rectum. Incise the distal rectal stump and place a clean endoscopic gauze under it to prevent contamination of the surgical field.
   2. When the specimen is taken out from the vagina, have the assistant irrigate the vagina, and then insert an intestinal pressure plate. Next, make a 3-4 cm incision in the vagina under the guidance of the intestinal pressure plate. Repeatedly disinfect the rectum or vagina with iodophor gauze.
   3. Insert a specimen bag into the abdominal cavity through the 12 mm trocar as protection during specimen retrieval to prevent tumor seeding or contamination of the rectum or vagina. During this process, place the staple anvil first and then take out the specimen to avoid possible contamination of the staple anvil.
8. Sutures of the vaginal wall and rectal stump
   1. Suture the vaginal wall directly with 3-0 antibacterial polydioxanone. After the rectal stump is sutured, lift the thread and close the rectal stump again with an endoluminal cutting and closure device to avoid the possibility of contamination and anastomotic leakage.
9. Placement of the stapler seat into the proximal bowel
   1. Incise the proximal intestinal canal, enlarge a 2-3 cm incision, and routinely sterilize it with iodophor gauze. Place an anvil and suture the intestinal canal without knots with 3-0 polyglactin.
10. Bowel anastomosis and reinforced stitching
    1. Perform routine end-to-end anastomosis of the bowel through the anus. Insert the ring stapler trigger handle through the anus, pierce the center piercing device of the stapler trigger handle, connect the center rod of the proximal stapler to the nail seat, and rotate the intestinal wall near the proximal and distal ends.
    2. Press the anastomotic wrench tightly to complete the cutting and anastomosis.
    3. Suture the full circumference of the anastomosis in a 4-0 knot-free pattern.
11. Flush the abdominal cavity, place a drainage tube, and place a rubber tube on the left or right side of the pelvis.

Representative Results

No patient had any distal ileal prophylactic stoma. Specimens from six cases were taken from the rectum, and four case specimens from the vagina. The average operation time was 169.5 ± 35.6 min, the average bleeding volume was 40 ± 13.3 mL, the average postoperative exhaust time was 43.2 ± 22.1 h, the average number of lymph nodes dissected was 13.1 ± 8.6, and the average hospital stay was 13.2 ± 3.6 days. No anastomotic leakage or pulmonary/abdominal infections occurred after operation. A total of 5.0 ± 4.0 lymph nodes in the central group and 3.8 ± 2.9 lymph nodes in the middle group were dissected. There were nine cases with moderately differentiated adenocarcinoma, and no patients with poorly differentiated adenocarcinoma. The average tumor size was 3.6 ± 1.3 cm (Table 1).

In this study, the insertion of the trocars of the single-surgeon, three-port laparoscopy was relatively fixed but extremely important. When the distance between the trocars was too close, the operation was difficult to perform (Figure 1A). A 10 mm trocar was chosen for the observation hole and was placed on or below the umbilicus for observation. The size of the main operation hole was 12 mm, and that of the auxiliary operation hole was 5 mm, with the distance between the two holes ideally being the size of a fist. The chief surgeon stood on the patient's right side, the mirror holder on the right side of the patient's head, and the instrument nurse on the far-left side of the patient (Figure 1B).

Given the limitations of single-surgeon, three-port, laparoscopic operation and the radicalism of the treatment, the main controversy is whether it could meet the requirements of a radical cure. Adequate bowel resection and complete lymph node dissection are the basic requirements for radical surgery (Figure 2A,B); we believe that lymph node dissection is not difficult in single-surgeon, three-port, laparoscopic radical resection for sigmoid colon or high rectal cancer. Based on the images and videos, we concluded the following: (1) lymph node dissection was technically feasible, and surgeons skilled in laparoscopic techniques could easily dissect lymph nodes in anatomical groups 216 and 253, even on the surface of important blood vessels. Figure 3 also suggests that this laparoscopic procedure met the criteria for lymph node dissection; (2) lymph nodes in groups 216 and 253 were dissected above the abdominal aorta. With the help of muscle relaxants, appropriate body position, and gauze use, they were exposed even with a single manipulative procedure.

The single-surgeon, three-port, laparoscopic procedure has some limitations, including a lack of assistants and tension. Further, it is unclear whether it can achieve membrane anatomical layer prioritization or protect nerve function. The surgeon in this study followed the principle of layer priority in conventional multiport laparoscopic surgery (CMLS) and performed surgery with the help of assistants. However, due to the lack of help from assistants and insufficient tension in the single-surgeon, three-port, laparoscopic operation, the lateral (left) approach was given priority. The connection between the left mesentery and the abdominal wall of the sigmoid colon was first separated, and gauze was placed on the outside of the ureter as a guide after exposing it (Figure 3A). Afterward, medial and lateral approaches were used to open the Toldt's space and expose the ureter (Figure 3B). During this process, the adhesion or connection between the sigmoid colon and the pelvic side wall was preferentially released, reducing the difficulty of recognizing the sigmoid mesentery, especially for obese patients. When the medial approach is used, excess sigmoid mesocolon could sink, making layer manipulation difficult.

The protection of nerve function is the focus of surgeries when treating patients with sigmoid colon or rectal cancer (Figure 4A). Under the clear laparoscopic view, the operator lifted the proximal bowel tube as high as possible to expand the tension by rationally using left-hand laparoscopic bowel forceps, thereby protecting the hypogastric nerve.

Anastomotic reinforcement is a key step in reducing anastomotic leakage. In traditional, five-port, laparoscopic surgery, the surgeons only performed prophylactic fistulas in patients with low and ultra-low rectal cancer. The anastomotic stoma was typically reinforced in patients with sigmoid colon and high rectal cancer (Figure 4B). The "horn" of the right distal bowel could be embedded when the anterior anastomosis was sutured. The main anastomotic leakage mostly occurred behind the anastomotic stoma. The single-surgeon, three-hole operation also involved reinforcement sutures on the front and rear sides of the anastomotic stoma, which effectively prevented anastomotic leakage (Figure 5).

The placement and fixation of the anvil seat was the most difficult point in this laparoscopic operation. Traditional placement and fixation methods include fixed extrusion, reverse puncture, snare ligation, and manual purse-string sutures. The reverse puncture method was relatively easy in routine, double-person, five-hole laparoscopic surgery, but it was also possible that the anvil seat would slide into the proximal intestinal tube, and it was difficult to push the puncture back. The same happened in a single-surgeon, three-hole operation, so the surgeon performed manual purse-string suturing. However, because the proximal intestinal tube was easy to swing after cutting, it was difficult to suture and fix it after placing the anvil seat. Previously, this operation took a lot of time. However, we creatively improved an in vitro anvil self-traction and fixation method, which was used for suture fixation after placement of the proximal anvil (Figure 6A,B).

Following the operation, the patient quickly recovered, and there were no differences in passing gas or defecation time compared with the traditional five-hole procedure. The principle of tumor-free sterility was followed during the operation, and there was no obvious increase in abdominal infection after the operation. The patient only had postoperative abdominal wounds on the three holes, as shown in Figure 7. Therefore, this surgical treatment was truly minimally invasive.

Figure 1: Three-hole trocar insertion and positions of surgeons. (A) Three-hole trocar insertion. (B) Positions of the mirror holder (1), chief surgeon (2), assistant, and instrument nurses (3, 4). Please click here to view a larger version of this figure.

Figure 2: Bowel resection and lymph node dissection. (A) Dissection of lymph nodes in 216 groups. (B) Ligation of the inferior mesenteric artery. Please click here to view a larger version of this figure.

Figure 3: Expansion of the Toldt's space. (A) The lateral approach was given priority and the ureter was exposed. (B) Medial approaches were used to open the Toldt's space and expose the ureter. Please click here to view a larger version of this figure.

Figure 4: Nerve protection and reinforcement of the anastomotic stoma. (A) Nerve protection. (B) Reinforcement of the anastomotic stoma and the "horn" of the right distal bowel could be embedded. Please click here to view a larger version of this figure.

Figure 5: Reinforcement suture on the rear sides of the anastomotic stoma. Please click here to view a larger version of this figure.

Figure 6: In vitro anvil self-traction and fixation. (A) The silk thread is drawn out through the 12 mm trocar, and the proximal intestinal canal is stabilized by external traction. (B) Purse-string to fix the anvil seat after in vitro silk thread external traction. Please click here to view a larger version of this figure.

Figure 7: Patient's wound after operation. Please click here to view a larger version of this figure.

Patient			1	2	3	4	5	6	7	8	9	10
Age (year)			55	56	69	54	59	59	61	63	60	66
Sex (F/M)			F	F	M	F	F	F	F	F	M	F
Operation time (min)			115	180	150	180	155	250	157	175	145	188
Hospital stay (days)			17	15	15	19	8	11	9	13	10	15
Postoperative exhaust time (days)			48	24	24	96	24	24	48	48	48	48
Bleeding volume (mL)			50	50	50	30	50	20	50	50	20	30
Anastomotic leakage			No	No	No	No	No	No	No	No	No	No
Ileal prophylactic stoma			No	No	No	No	No	No	No	No	No	No
Pulmonary infections			No	No	No	No	No	No	No	No	No	No
Abdominal infections			No	No	No	No	No	No	No	No	No	No
lymph nodes			2	10	5	19	5	29	20	19	8	14
central group			0	8	0	9	3	10	10	4	5	1
middle group			1	2	4	4	1	6	6	3	1	10
T stage			1	2	2	2	-	3	3	3	1	3
N stage			0	1	0	0	-	2	0	0	0	0
Positive margin			No	No	No	No	No	No	No	No	No	No
Differentiated degree			M	M	M	M	W	M	M	M	M	M
Tumor size (cm)			-	-	2	3.8	3	4.4	4	5	1.5	4.8
Specimen extraction (R/V)			R	R	R	R	R	V	V	V	R	V
Tumor location (S/R)			S	R	R	S	S	S	S	S	R	R

Table 1: Clinicopathologic data of the patients. Abbreviations: F = female; M = male; Differentiated degree: W = well differentiated; M = moderately differentiated; P = poorly differentiated; Specimen extraction: R = rectum; V = vagina; Tumor location: S = sigmoid colon; R = rectum.

Discussion

With the improvement in surgical skills and the advancement in surgical equipment, especially the development of visualization devices, robotic surgery is often considered a reasonable choice for complex procedures, such as lateral pelvic lymph node dissection⁷. Reduced-port laparoscopic surgery is an emerging procedure, characterized by reduced incision number and size, making the operation less invasive than traditional laparoscopic surgery⁸. In 2016, Inaki⁹ proposed that gastrectomy could be completed by porosity reduction laparoscopic surgery. Due to the lack of a long-term radical cure effect on gastric cancer, the laparoscopic procedure should be carefully selected. Prospective multicenter studies should be conducted to establish porosity reduction laparoscopic surgery as a true evidence-based practice, which not only addresses cosmetic concerns but also strikes the right balance between minimal invasiveness and radical cure. Takemasa¹⁰ prospectively analyzed the feasibility of pore-reducing laparoscopy combined with transvaginal specimen collection. Previous retrospective and prospective studies have confirmed that porosity reduction laparoscopic surgery with improved minimally invasive surgical skills is feasible in the radical resection of gastrointestinal tumors. In the present study, the statistical analysis of 10 patients (Table 1) showed that transvaginal specimen extraction (TVSE) combined with reduced port surgery (RPS) for colorectal cancer was feasible with less postoperative pain.

Due to the relatively fixed anatomical characteristics of the sigmoid colon and high rectum, radical operation for tumors at these sites can be combined with porosity reduction laparoscopic surgery and natural orifice specimen collection, effectively avoiding additional abdominal incisions. Minimally invasive laparoscopic surgery can effectively reduce postoperative pain and infection, as shown in Table 1. Patients can recover more quickly, and gastrointestinal function is quickly recovered, thereby shortening the hospital stay. However, single-surgeon, three-port, laparoscopic surgery for sigmoid colon or high rectal cancer with NOSES is associated with increased operation time and single-surgeon operational difficulty. Therefore, there is still controversy in the development of this technology. There are currently few reports available on this procedure; although relevant videos are available, no data analysis has been provided¹¹. Some experts believe that adding one or two more trocars can form a good tension with the help of assistants, which is helpful to complete the operation faster, more effectively, and more safely. Compared with the traditional, five-port, laparoscopic surgery, the operative time and incision length are shorter in porosity reduction laparoscopic surgery⁶.

There are still different opinions regarding this operation. First, the choice of surgical approach depends on whether it is focused on layer priority or blood vessel priority, and whether it adopts the medial or lateral approach or a combination of these two approaches. In this study, the surgeon first used the lateral (left) approach to facilitate the expansion of the rear Toldt's space when operated by one person, favoring the layer-priority surgical idea.

Due to the limitations of single-surgeon three-hole operation, whether radical resection and lymph node dissection were sufficient remains unclear. We found that applying muscle relaxants and laparoscopic bowel forceps with a large opening and skillful gauze use might be required for the successful dissection of lymph nodes.

Because the operation was suitable for sigmoid colon and high rectal cancer, it remains unclear whether there is a need for routine reinforcement and sutures after anastomosis. We believe that all anastomoses must be reinforced. Thus, we suggest adopting enforcement skills, including applying a laparoscopic mirror and performing reinforcement from the right to the left side. Reinforcement and suturing after anastomosis have been proposed by many experts. This operation's difficulty lies in treating the left "horn" and rear reinforcement and stitching. Our principle was to suture to the serosa or mesentery as far as possible, so it was not necessary to suture on the serosa. This experience has also withstood the test in clinical practice.

The principle of tumor-free asepsis was the focus of controversy when the NOSES operation was promoted. Based on our experience, we propose the following: (1) preoperative preparation should be sufficient to reduce the residual intestinal contents; (2) it is better to increase the frequency of use of linear cutting and closure devices and reduce the number of exposures of the bowel; (3) strict surgical indications, especially for patients with too large tumors and hypertrophic mesangium, when taking specimens could easily lead to tumor implantation.

The placement and fixation of the staple anvil are difficult procedures and controversial points of this operation, since no assistant wasavailable to help fix the bowel. In addition, the operations could easily cause intra-abdominal contamination after a proximal intestinal incision.

Furthermore, when the staple anvil was placed in the abdominal cavity, the swing of the staple anvil might easily have led to a poor suture or incomplete exposure of the staple anvil, excessive cutting content during anastomosis, bleeding, and even fistula. In early practice, using the reverse puncture method to place the bowel could have led to the possibility of the anvil seat sliding into the proximal bowel, and it was not easy to push the anvil seat out by a single operation. In addition, it was difficult for one person to operate and fix the anvil when cutting it simultaneously. After reviewing the literature and studying the videos showing operations by other experts, we made some improvements by tying a No. 4 silk thread to the head end of the anvil before placing it in the abdominal cavity. When suturing the bowel, the thread had to be pulled out of the 12 mm trocar and lifted by the assistant to fix the anvil seat and the bowel, which was beneficial for suturing the bowel. Full-thickness purse-string suture around the staple anvil should be performed. While this method is rarely applied in current clinical operations, it is not complicated to perform and can be widely promoted in primary hospitals.

This operation also has certain limitations. Patients with obesity, excessive mesentery, intestinal edema, large tumor, and external tumor invasion are not suitable for this operation. Moreover, as mentioned before⁶, there are still problems such as surgical feasibility, tumor effectiveness, and training and education in porosity reduction laparoscopic surgery for malignant tumors. Similar to robotic pancreaticoduodenectomy (RPD), the most difficult pancreaticoduodenectomy, plotting a learning curve and establishing detailed rules are required¹². Therefore, performing single-surgeon, three-port, laparoscopic surgery with NOSES requires training.

In summary, after a proper selection of patients and completion of long-term learning, surgeons with independent laparoscopic skills are suitable for performing this operation. This type of operation can reduce the trauma and achieve a more minimally invasive surgical treatment effect. Moreover, fixing the staple anvil by self-traction of external silk thread is simple and practical, and can be widely carried out in primary hospitals.

Materials

Name	Company	Catalog Number	Comments
antibacterial polydioxanone	Johnson & Johnson	8622H,SXPP1A403
Laparoscopic system	STORZ	26003BA
Ring stapler	Johnson & Johnson	CDH29A
Straight cut closure	Johnson & Johnson	EC45A
Trocar	Johnson & Johnson	B5LT,B11LT,B12LT