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

Our protocol focus on the technical points of resection and reconstruction and improves on the procedure use for purse-string suture fixation after the proximal anvil is plating in the abdominal cavity. Protocol is easy to perform effectively, avoiding postoperative anastomotic leak and bleeding due to excessive intraoperative anastomotic tissue. And this could be widely promoted in primary hospital.Visual.

The presentation of this protocol allows standard to understand the whole procedure more intuitively and efficiency. To perform the three-hole trocar insertion, first, make a 10-millimeter incision below the umbilicus, and insert a 10-millimeter trocar, then, make a 12-millimeter incision above the line connecting the right umbilicus and the anterior superior iliac spine, and insert a 12-millimeter trocar into it, next, make a 5-millimeter incision above the right flat umbilicus, and insert a 5-millimeter trocar. Perform a routine inspection of the abdominal cavity, then examine the upper abdominal liver and diaphragmatic peritoneum, and check the abdominal cavity counterclockwise.

Probe the location of the tumor and adjacent structures. For female patients, use anastomosis needles to suspend the uterus to the front of the abdominal wall to expand the surgical field. To expose the dissection plane between the Toldt and the Gerota fascia, enlarge the cephalic space of Toldt by releasing the left lateral side to dissociate the sigmoid colon and its mesentery, then, adopt the medial dissociation 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 space until the lower part of the pancreas is reached, and then ligate the inferior mesenteric vein at a high position. Expand the Toldt space coddley and pull the inferior mesangium up freely.

Carefully with the left hand, perform microexternal 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, separate the mesentery below the rectum for excision according to the distance from the tumor site, resulting in a naked intestine.

To determine the extent of bowel resection, first, prepare an 8 to 10-centimeter 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 lens of the naked intestinal tube.

Ensure that the distal rectal stump is flushed before 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. When the specimen is taken out from the vagina, have the assistant derogate the vagina and then insert an intestinal pressure plate.

Next, make a 3 to 4-centimeter incision in the vagina under the guidance of the intestinal pressure plate. Repeatedly, disinfect the rectum or vagina with iodoform gauze. Insert a specimen bag into the abdominal cavity through the 12-millimeter trocar as protection during specimen retrieval.

Place the staple anvil first and then take out the specimen to avoid possible contamination of the staple anvil. Then, 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.

To place the stapler seat into the proximal bowel, incise the proximal intestinal canal, enlarge it to a 2 to 3-centimeter incision and sterilize it regularly with iodoform gauze. Place an anvil and suture the intestinal canal without knots with 3-0 polyglactin. 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. Press the anastomotic wrench tightly to complete the cutting and anastomosis.

Then, suture the full circumference of the anastomosis in a 4-0 knot-free pattern. Flush the abdominal cavity and place a drainage tube. Also, place a rubber tube on the left or right side of the pelvis.

After the surgery, no distal ileal prophylactic stoma was observed in any patient. The average operation time was approximately 169 minutes, and the average postoperative exhaust time was approximately 43 hours, with an average hospital stay of around 13 days. The average number of lymph nodes dissected was around 13, with no anastomotic leakage or pulmonary or abdominal infections after the operation.

The position of the trocars in this surgery was extremely important, as trocars placed too close resulted in difficulty in the operation. Using this technique, surgeons skilled in laparoscopic techniques could easily dissect lymph nodes in anatomical groups 216 and 253 even on the surface of essential blood vessels. Moreover, the hypogastric nerve was protected during the surgery by elevating the proximal bowel tube, showing that this surgery is possible for patients with sigmoid colon or rectal cancer.

This operation also effectively prevented anastomotic leakage and improved on an in-vitro anvil self-traction and fixation method. Following the operation, the patient only had postoperative abdominal wounds on the three holes, making this surgery treatment minimally invasive. The most important step in the protocol is to place the anvil and suture the intestinal canal.