Laparoscopic left colectomy combined with natural orifice access: operative technique and initial results

Minimally invasive surgery for colon resection has improved patient outcome, but a minilaparotomy still is necessary to extract the specimen and place the anvil of the circular stapler into the proximal colon. This wound can cause postoperative pain, wound infection, and hernia. This report describes a new approach that combine classical laparoscopic left colon resection and natural orifice access using an operating rectoscope, with the aim to minimize abdominal wall trauma. Laparoscopic left colon dissection for diverticular disease or small tumors was performed using a standard four-port technique. An operating rectoscope was transanally inserted into the rectum to remove the specimen and to pass the anvil of the circular stapler into the abdominal cavity. A straight needle was tied to the rod of the anvil to simplify its placement into the proximal colon so that a double-stapled anastomosis could be performed in the usual manner. Outcome parameters such as complications, conversions, operative time, and postoperative pain were prospectively recorded in a database. Surgery was performed for 15 patients with diverticular disease or small tumors. No intraoperative complications or conversions occurred. The median operating time was 145 min. The postoperative pain level was low, and only 3 of 15 patients needed opioid analgesia on postoperative day 1. The median postoperative hospital stay was 7 days. Blood oozing from the anastomotic site in one patient was the only recorded adverse event. For malignancies, tissue margins and lymphadenectomy were oncologically adequate. The 4-week follow-up period was uneventful. The described technique, a combination of laparoscopic and natural orifice surgery, has the potential to avoid incision-related morbidity of the minilaparotomy in laparoscopic left colon resections.