For colorectal surgery, NOSE approach means that the rectum can be used for the placement of trocars, surgical tools or for the extraction of the specimen.
This video is focused on the main steps to achieve a total colectomy with a transanal NOSE and ileo-rectal anastomosis.
A total of five trocars are used. One of 12mm in supra-umbilical position for a 30º scope, another of 12mm at the right iliac fossa, three of 5mm, one at the right flank, another at the left flank and the last one at the epigastrium.
The patient is placed in a Trendelenburg position slightly to the right. The bowel is accommodated to expose the mesosigma, the inferior mesenteric vessels are identified and dissected with the hook. It is important that the assistant surgeon maintains the traction of the vessels to improve the visualization of the avascular planes. The vascular transection is accomplished with a firing of a vascular cartridge.
The sigma is dissected reaching the peritoneal reflection and leaving free the colon from the surrounding fat tissue. The colon is sectioned with a mechanical suture, taking care of leaving a large rectal stump because it will be re-sectioned later on during the surgery.
The descending colon is mobilized, first from medial to lateral, it is important to remember the retroperitoneal structures such as the kidney and pancreas must be respected.
Reverse-Trendelenburg positioning of the patient is adopted for splenic flexure mobilization, a medial dissection approach is used to set free the posterior wall of the colon, then the Told´s fascia is sectioned.
The gastrocolic ligament is sectioned to enter into the lesser sac and complete the lateral mobilization. The transverse colon is anatomized and the middle colic vessels sectioned with the LigaSure™
Next, the patient is placed to his or her right side to dissect the right colic vessels following an avascular plane and taking care of leaving the duodenum below. The section was also performed with a LigaSure™, this allows a medial mobilization.
Between the pneumoperitoneum and traction maneuvers, the Told´s fascia of the ascending colon and the cecum is sectioned. At this phase the colon is completely detached.
The rectal stump is used as an access route for a mechanical suture and transect the ileum, this avoids an incision at the abdominal wall. In cases of bulky mesentery, big surgical specimens and morbid obese patients, the rectal stump can be damaged during the NOSE, it is important to recognize these situations and perform the extraction in a classic manner.
Symmetric traction from the sides of the rectal stump must be maintained. The anvil shaft is placed into the abdominal cavity and the rectum is closed with an EndoGIA™.
The anvil is set for an ileo-rectal side-to-end anastomosis, always check for correct orientation and avoid tension. Good quality donuts are obtained with this EEATM Stapler Device.