Performing surgical operations without leaving scars has ceased to be a chimera and has become a reality. This is demonstrated by the recent surgical advances made using NOTES (Natural Orifice Transluminal Endoscopy Surgery), an innovative surgical approach that allows surgical access using the body’s natural orifices. The results are all advantageous for the patient: lack of scars, shorter hospital stay and faster recovery. Currently, this type of minimally-invasive surgery is still in the research and development stage. Surgery through the mouth and vagina has been successfully used, but the transanal route (through the anus) is less utilized.
On November 9 2009, a team of surgeons carried out the first surgical removal of a rectal mass using the NOTES approach and TEM (Transanal Endoscopic Microsurgery) technique in the Hospital Clinic of Barcelona. The successful (deleted outcome) surgery was due to a collaboration between the Gastrointestinal Surgery team of the Hospital Clinic, headed by Dr. Antonio Mª de Lacy, and a team of surgeons from the Massachusetts General Hospital of Boston (Harvard University), headed by Dr. Patricia Sylla, Instructor of Surgery at the Harvard Medical School. This is the first time in the world that a rectal tumor has been excised using an approach through the anus.
The patient, a 76-year-old woman diagnosed with a malignant rectal tumor, was discharged home with no complications and excellent postoperative recovery on November 14 – only five days after surgery. During the operation, nearly all surgical instruments were introduced through the anus to avoid painful abdominal incisions. This new technique has been developed to achieve better results than laparoscopic surgery, and is a minimally-invasive technique with many advantages: less pain, shorter hospital stay and safe oncologic results. Thanks to the joint work of this international team of experts, surgery has taken a step forward, with a successful operation to excise a rectal mass without leaving surgical scars, whereas even laparoscopic surgery requires four or five minimal incisions.
Transanal Endoscopic Microsurgery (TEM) has many advantages
The transanal route presents many advantages. One essential point is that it can be used in both men and women, unlike the transvaginal route (through the vagina). Another advantage is the possibility of opening and closing the colon or rectum under direct vision. This is possible due to the use of techniques developed for the local treatment of rectal lesions, known as Transanal Endoscopic Microsurgery (TEM).
The TEM technique uses rectal endoscopy to introduce a specially-designed proctoscope connected to a CO2 insufflation system that dilates the rectum. This creates a working space that allows the instruments required to section and dissect the mass to be introduced. This route allows the dissection of the rectum and surrounding tissue until the abdominal cavity is reached, a wholly innovative technique.
The importance of international collaboration between hospitals
This landmark surgery, presented simultaneously today in the Hospital Clinic of Barcelona and Massachusetts General Hospital, was made possible due to the experience of the two surgical teams, who both specialize in minimally-invasive surgical approaches to treat diseases of the colon and rectum. Dr. Lacy has played a fundamental role in the widespread application of laparoscopic surgery, using small incisions in the abdomen, to treat colorectal cancer. Dr. Sylla has been developing techniques for application in colorectal surgery since 2007 in collaboration with Dr. David Rattner, Professor of Surgery at the Massachusetts General Hospital and Harvard Medical School, an authority on NOTES and co-founder of NOSCAR (Natural Orifice Surgery Consortium for Assessment and Research).
After demonstrating the safety and efficiency of the TEM technique in pigs, the two teams carried out studies on human cadavers. Unlike other NOTES procedures, which require incisions in order to access the surgical field, the transanal approach is the only route where the tissue perforated to gain access to the diseased area is part of the tissuethat will ultimately be excised.
In the future, this new technique will be available to treat other diseases of the colon and rectum.
Dr. Lacy states: “We are convinced that this type of surgery will bring additional advantages to those already shown by laparoscopic surgery, reducing surgical invasiveness by eliminating abdominal incisions, and resulting in fewer postoperative complications and a speedier recovery”.
Dr. Sylla states: “Based on this first case, I am encouraged that in the near future we will be able to offer this type of procedure to more patients. This approach could have wide use for patients with colorectal cancer, diverticulitis, and other diseases of the colon and rectum.”