Modification of the anastomotic technique in completely laparoscopic resection rectopexy with NOSE — a case report

Introduction. We have come a long way from the era of conventional rectal surgery, with most high-volume centres now practising various degrees of laparoscopy assisted colorectal surgeries, via extracorporeal suturing, ex vivo anastomoses, hand-assisted laparoscopic resection anastomoses to robotic rectal resections. However, the limitation to most such techniques remains the fact that these are not ‘completely’ laparoscopic, with varying degrees of open assistance being required, from mobilization, suturing and anastomoses to specimen extraction via separate abdominal incisions or port-site enlargements. These ‘large’ incisions negate some of the advantages of minimal access surgery and lead to complications at such sites, such as wound breakdown, infections, and incisional herniae. This led to the origin of NOTES (Natural Orifice Translumenal Endoscopic Surgery) and the still fairly new concept of NOSE (Natural Orifice Specimen Extraction).Aim. We aim to describe our application of this new frontier in laparoscopic colorectal surgery, doing away with large scars prone to complications.Materials and methods. We describe a case of completely laparoscopic resection rectopexy and trans-rectal extraction of the specimen, with a modified technique of anvil insertion, enabling the faster creation of a larger anastomosis with probably lower anastomotic morbidity.Results and discussion. The patient underwent a ‘completely’ laparoscopic resection rectopexy and had an uneventful immediate post-operative recovery. She had no delayed post-operative complications or recurrence of the rectal prolapse and remained free of constipation as well, over a follow-up period of 6 months.Conclusion. We conclude that this modification of the surgical technique reduces operative time, allows use of larger circular staplers, theoretically reducing the incidence of anastomotic stricture, and being easily reproducible, can be widely applied for better cosmetic and functional outcome.