gms | German Medical Science

Introduction: Laparoscopic rectum resection is on the way to become a standard procedure. Further progress in minimal invasive surgery have allowed transvaginal approach for Hybrid NOTES as well as single port procedures to be performed. This didactic video demonstrates a step by step combined Hybrid NOTES – single port laparoscopic low anterior resection via the ileostomy position.

Material and methods: After open approach via the planned ielostomy positiona Single Port system is inserted. These devices allow use of 5 to 25mm instruments and specimen extraction through an in-build wound protector. A single incision of 3.5 cm length is required. Furthermore, a 12 mm vaginal trocar is brought in after lifting up the uterus. The key steps and potential pitfalls inherent to any colorectal resection are demonstrated, while the specifics of single port surgery are highlighted.

Results: A medial to lateral mobilisation of the colon is performed, identifying the left ureter and the inferior mesenteric artery divided at its origin. The inferior mesenteric vein is taken at the pancreas border. Left flexure and omentum are released and the rectum is mobilized and divided with a linear stapler. The descending colon was divided as well and the specimen was put into a retrieval bag brought in from transvaginal. Specimen extraction through the vagina followed and closure performed transvaginally. The purstring suture and insertion of the anvil is done through the single port system. The bowel is returned into the abdomen and a side-to-end colorectal stapled anastomosis is fashioned. The donuts are checked. A drain is put in via an additional trocar. For completion a diverting ileostomy is performed after removing the port system.

Conclusion: Combined Hybrid transvaginal NOTES – Single port laparoscopic low anterior resection via the ileostomy is a safe and efficient procedure with minimal trauma to the abdominal wall. Patient selection and advanced laparoscopic skills are paramount in order to perform increasingly complex procedures. It is hoped that this video will contribute to a wider and safer practice of laparoscopic surgery.