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A 75-year-old female with no relevant medical record presented altered bowel movements and underwent a colonoscopy that showed a stenotic lesion 25cm from the anal verge. The biopsy was compatible with adenocarcinoma.
Colono-TC ruled out synchronous lesions and distant metastasis.
Surgical treatment by Hybrid NOTES was performed. The patient was placed in the supine position with open legs, with two assistant surgeons located at the right of the patient and the leading surgeon between the legs.
The pneumoperitoneum was performed using a Veress needle at the umbilicus. A 3 mm trocar was placed at the right iliac fossa for a 30° scope, and two 2 mm instruments were also placed, one at the right iliac fossa and the other one at the umbilicus.
The trans vaginal access port was a 12mm trocar that was placed through the dome using direct laparoscopic vision. The first thing that stands out is the poorer image quality. The mesosigmoid was assessed to identify the IMV.
The hook was introduced through the vaginal trocar and was used to open the peritoneum and begin a medial to lateral mobilization. The root of the IMA was individualized. In this approach the leading surgeon works from below and the assistant surgeons are the ones in charge of traction and exposure, the left ureter was identified and respected.
Blunt dissection was performed to create a window that would surround the IMV and be used as a landmark to introduce the mechanical suture for future section. Two clips were placed to improve hemostasis and complete the section of the vessels.
Medial to lateral dissection was performed using the LigaSure™. With this instrument arrangement, the leading surgeon works in parallel to the mesosigmoid and the other surgeons’ assistance is crucial.
The posterior aspect of the colon was mobilized at the level of the promontory, lateral detachment was performed using the hook. The planes were more evident at this stage of the surgery as a good medial mobilization was performed.
Lateral mobilization of the rectosigmoid junction was carried out to prepare the distal section margin. The Ligasure™ was used to anatomize the colon. A roticulated EndoGIA™ was introduced through the vaginal port and was used to section the colon.
A protective bag was placed on the vaginal wound and the specimen was extracted. The proximal margin was sectioned and a purse string was created to set the anvil shaft.
The maneuvers to perform the colorectal anastomosis are also different in this approach, as the assistant surgeon must bring together the anvil and the mechanical suture device using 2mm instruments that are not so strong.
As always, the orientation of the colon is verified before firing the mechanical suture and performing a lavage using an iodine solution. The vaginal wound was closed using separate Vicryl knots. No drain was left.
The surgery took 180 minutes and was uneventful; the longest part was the mesenteric dissection. The patient started oral intake on the second postoperative day and left the hospital 4 days after surgery.
The pathological examination revealed an R0 resection of a low-grade pT3N2 lesion and the patient underwent adjuvant therapy with FOLFOX 4.
