A case of total laparoscopic sigmoidectomy involving the use of needle forceps and transanal specimen extraction for sigmoid colon cancer.

A 76-year-old male underwent endoscopic mucosal resection for a stage T1 tumour of the sigmoid colon. We performed laparoscopic sigmoidectomy through 5 ports using needlescopic instruments. The resected specimen was extracted from the abdominal cavity transanally. After attaching an anvil to the sigmoidal stump, the rectal stump was reclosed using an endoscopic linear stapler, and then, colorectal anastomosis was conducted using the double stapling technique. Performing transanal specimen extraction using needlescopic forceps improves aesthetic outcomes and reduces post-operative pain and the risk of abdominal incisional hernias. This method is an easy to introduce a form of reduced-port surgery because of its feasibility and conventional port arrangement. Hence, we consider that it is an option for minimally invasive surgery.

INTRODUCTION

Recently, laparoscopic surgery has often been used to treat colorectal cancer. However, extraction of the surgical specimens and anastomosis usually require a mini-laparotomy involving an incision of about 4 cm in length, which carries a risk of post-operative infections and abdominal incisional hernias.[1] We performed transanal specimen extraction (TASE) using needlescopic instruments. This approach allowed us to carry out laparoscopic sigmoidectomy less invasively.

CASE REPORT

A 76-year-old male underwent endoscopic mucosal resection for a T1 tumour of the sigmoid colon. We performed laparoscopic sigmoidectomy to dissect the regional lymph node. A port for the camera was created at the umbilicus, a 12-mm port was inserted in the lower right abdomen, and a 5-mm port was made in the upper right abdomen. In addition, 2.4-mm needlescopic forceps (EndoRelief™, Hope Denshi, Japan) were inserted into the upper and lower left abdomen [Figure 1].

Figure 1

The port locations. Two sets of needlescopic forceps were inserted into the left upper and lower quadrants

The superior rectal artery and inferior mesenteric vein were ligated with the clip, and then, Colonic mobilisation is performed using a medial to lateral approach. After transanal colon preparation, the rectum was transected using an endoscopic linear stapler. The mesentery of the sigmoid colon was resected at 10 cm proximal from the tumour to preserve the marginal artery. The sigmoid colon was transected in the abdominal cavity.

After the transected rectal stump was opened, an Alexis® wound retractor (Applied Medical, Rancho Santa Margarita, CA, USA) was pulled out of the anus and placed into the rectal lumen. The resected specimen was then extracted from the abdominal cavity transanally through this route [Figure 2a]. After an anvil was attached the proximal sigmoid colon, in the abdominal cavity [Figure 2b], the rectal opened stump was reclosed using an endoscopic linear stapler, and then, colorectal anastomosis was performed using the double stapling technique.

Figure 2

(a) The resected specimen was transanally extracted from the abdominal cavity. (b) The anvil was attached the stump of the proximal sigmoid colon intracorporealy

DISCUSSION

Reduced-port surgery, such as single-port surgery and needlescopic surgery, has recently been introduced.[23] However, extraction of the surgical specimens and anastomosis usually require a mini-laparotomy involving an incision measuring about 4 cm long. Performing TASE using needlescopic forceps not only improves aesthetic outcomes but can also reduce post-operative pain and the risk of abdominal incisional hernias.

However, TASE can also cause cancer cells to become implanted in other tissues. Ooi et al.[4] reported that the use of a specimen bag or protective barrier reduced the risk of cancer cell implantation and local recurrence. In the present case, the colon was thoroughly lavaged, and a wound retractor was inserted along the specimen extraction route to prevent the colon from coming into contact with the anus, as described by Nishimura et al.[5] As a result, the implantation of cancer cells was prevented. However, the patient requires long-term post-operative follow-up.

The indications for the current technique need to be determined. In cases involving bulky tumours, a thick mesentery, or a narrow rectum or anus, the resected part of the intestine cannot be passed through the rectum/anus. Forcing the removed tissue through the rectum/anus could damage these structures. Appropriate patients should be selected by taking the location and size of the tumour, the patient's physique and the surgeon's skill into account.

TASE surgery involving needlescopic forceps is an easy to introduce form of reduced-port surgery because of its feasibility and conventional port arrangement. Hence, we consider that it is an option for minimally invasive surgery. It will be important to verify this surgical method repeatedly to consolidate the technique and establish its indications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.