CHAPTER 01.pdf · surgery generated an increased interest among surgical and gastroenterological...
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CHAPTER GENERAL INTRODUCTION AND OUTLINE OF THIS THESIS S. Velthuis
Transcript of CHAPTER 01.pdf · surgery generated an increased interest among surgical and gastroenterological...
CHAPTERGENERAL INTRODUCTION
AND OUTLINE OF THIS THESIS
S. Velthuis
EVOLUTION OF MINIMALLY INVASIVE COLORECTAL SURGERY
Laparoscopic surgery was introduced in the 1990s in order to improve patient outcomes. As with
all new procedures, surgeons started with relatively simple procedures like appendectomies and
hysterectomies. Extensive research showed many benefits of laparoscopic surgery for the patient
with respect to time to recovery, duration of hospital stay, perioperative pain and morbidity and
cosmetic results.
Consequently, the range of abdominal surgical procedures performed by laparoscopy has grown
enormously. For certain procedures such as cholecystectomy, laparoscopy has already replaced
open surgery as the standard of care.1-‐5
The clear advantages of laparoscopic surgery generated an increased interest among surgical and
gastroenterological communities to further reduce surgical trauma through ‘scarless’ surgery.
These advances in minimally invasive surgery include the development of natural orifice
translumenal endoscopic surgery, laparoendoscopic single-‐site surgery and the recent
development of transanal minimally invasive surgery.
NATURAL ORIFICE TRANSLUMENAL ENDOSCOPIC SURGERY
Although the first colpotomy to perform a hysterectomy was already described in 18136, most
research on NOTES took place in recent years since Kalloo et al. described diagnostic and
therapeutic flexible transgastric peritoneoscopy in porcine models in 2004.7-‐9 In NOTES the
surgeon accesses the peritoneal cavity through a hollow viscus, instead of the abdominal wall, to
perform diagnostic and therapeutic procedures.
Initially the transgastric route was evaluated, first in porcine models, later in human. More
recently, other orifices such as the vagina, urethra and anus are used as an entrance to incise
respectively the posterior vaginal wall, the bladder and the rectum or colon.10
1
11
INTR
OD
UCT
ION
AN
D T
HES
IS O
UTL
INE
EVOLUTION OF MINIMALLY INVASIVE COLORECTAL SURGERY
Laparoscopic surgery was introduced in the 1990s in order to improve patient outcomes. As with
all new procedures, surgeons started with relatively simple procedures like appendectomies and
hysterectomies. Extensive research showed many benefits of laparoscopic surgery for the patient
with respect to time to recovery, duration of hospital stay, perioperative pain and morbidity and
cosmetic results.
Consequently, the range of abdominal surgical procedures performed by laparoscopy has grown
enormously. For certain procedures such as cholecystectomy, laparoscopy has already replaced
open surgery as the standard of care.1-‐5
The clear advantages of laparoscopic surgery generated an increased interest among surgical and
gastroenterological communities to further reduce surgical trauma through ‘scarless’ surgery.
These advances in minimally invasive surgery include the development of natural orifice
translumenal endoscopic surgery, laparoendoscopic single-‐site surgery and the recent
development of transanal minimally invasive surgery.
NATURAL ORIFICE TRANSLUMENAL ENDOSCOPIC SURGERY
Although the first colpotomy to perform a hysterectomy was already described in 18136, most
research on NOTES took place in recent years since Kalloo et al. described diagnostic and
therapeutic flexible transgastric peritoneoscopy in porcine models in 2004.7-‐9 In NOTES the
surgeon accesses the peritoneal cavity through a hollow viscus, instead of the abdominal wall, to
perform diagnostic and therapeutic procedures.
Initially the transgastric route was evaluated, first in porcine models, later in human. More
recently, other orifices such as the vagina, urethra and anus are used as an entrance to incise
respectively the posterior vaginal wall, the bladder and the rectum or colon.10
12
Advantages
NOTES avoids the need for abdominal incisions which may reduce postoperative pain, may
facilitate a shorter hospital stay, may limit postoperative complications such as wound infections
and incisional hernias, and improves cosmetic results. Therefore, NOTES could be the next major
paradigm shift in surgery.10
Challenges in clinical practice
Despite the potential advantages of NOTES, critics expressed concerns about its safety and
implementation in clinical care. As a result, a working group consisting of expert laparoscopic
surgeons from the SAGES (Society of American Gastrointestinal Endoscopic Surgeons) and
members of the ASGE (American Society for Gastrointestinal Endoscopy) came together for a
meeting in 2005. This meeting led to the development of the Natural Orifice Surgery Consortium
for Assessment and Research (NOSCAR). With ‘The White Paper’ they published a document that
would serve as a guide for the responsible development of NOTES and they identified ten
potential barriers that will impact the safety of NOTES (table 1).11
The amount of publications on NOTES has shown a significant growth since 2005. However,
widespread implementation of NOTES has still not occurred due to the mentioned potential
barriers.
Table 1. Potential barriers to clinical practice11
Access to peritoneal cavity
Gastric (intestinal) closure
Prevention of infection
Development of suturing device
Spatial orientation
Development of a multitasking platform
Control of intraperitoneal haemorrhage
Compression syndromes
Training other providers
Management of iatrogenic intraperitoneal complications
Physiologic untoward events
LAPAROENDOSCOPIC SINGLE-‐SITE SURGERY
During extensive research on NOTES new ideas emerged. The design of a single, multichannel port
led to a sidetrack of NOTES: laparoendoscopic single-‐site surgery (LESS). LESS is known by many
different names and refers to a laparoscopic access technique that uses a single incision, usually
the umbilicus, but also a future ileo-‐ or colostomy site or transanally in case of transanal minimally
invasive surgery (TAMIS).
The indications for LESS are similar to those for multiport laparoscopic surgery. Frequently
performed procedures are cholecystectomy12, appendectomy13, inguinal hernia repair14,
salpingectomy15, tubal ligation16, nephrectomy17, and colon resection18.
Compared to conventional laparoscopy, the laparoscopic single-‐site approach is considered more
challenging due to several technical factors. These technical factors include loss of triangulation
and loss of depth perception, reduced range of motion of the instruments, limited extracorpeal
working space with ‘clashing’ of the instruments, and a suboptimal view as the result of difficult
instrument and camera position.19
Laparoendoscopic single-‐site techniques are still in development in many abdominal and pelvic
surgery fields, sometimes in combination with other novel devices, like robotic surgery. In 2008,
1
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INTR
OD
UCT
ION
AN
D T
HES
IS O
UTL
INE
Advantages
NOTES avoids the need for abdominal incisions which may reduce postoperative pain, may
facilitate a shorter hospital stay, may limit postoperative complications such as wound infections
and incisional hernias, and improves cosmetic results. Therefore, NOTES could be the next major
paradigm shift in surgery.10
Challenges in clinical practice
Despite the potential advantages of NOTES, critics expressed concerns about its safety and
implementation in clinical care. As a result, a working group consisting of expert laparoscopic
surgeons from the SAGES (Society of American Gastrointestinal Endoscopic Surgeons) and
members of the ASGE (American Society for Gastrointestinal Endoscopy) came together for a
meeting in 2005. This meeting led to the development of the Natural Orifice Surgery Consortium
for Assessment and Research (NOSCAR). With ‘The White Paper’ they published a document that
would serve as a guide for the responsible development of NOTES and they identified ten
potential barriers that will impact the safety of NOTES (table 1).11
The amount of publications on NOTES has shown a significant growth since 2005. However,
widespread implementation of NOTES has still not occurred due to the mentioned potential
barriers.
Table 1. Potential barriers to clinical practice11
Access to peritoneal cavity
Gastric (intestinal) closure
Prevention of infection
Development of suturing device
Spatial orientation
Development of a multitasking platform
Control of intraperitoneal haemorrhage
Compression syndromes
Training other providers
Management of iatrogenic intraperitoneal complications
Physiologic untoward events
LAPAROENDOSCOPIC SINGLE-‐SITE SURGERY
During extensive research on NOTES new ideas emerged. The design of a single, multichannel port
led to a sidetrack of NOTES: laparoendoscopic single-‐site surgery (LESS). LESS is known by many
different names and refers to a laparoscopic access technique that uses a single incision, usually
the umbilicus, but also a future ileo-‐ or colostomy site or transanally in case of transanal minimally
invasive surgery (TAMIS).
The indications for LESS are similar to those for multiport laparoscopic surgery. Frequently
performed procedures are cholecystectomy12, appendectomy13, inguinal hernia repair14,
salpingectomy15, tubal ligation16, nephrectomy17, and colon resection18.
Compared to conventional laparoscopy, the laparoscopic single-‐site approach is considered more
challenging due to several technical factors. These technical factors include loss of triangulation
and loss of depth perception, reduced range of motion of the instruments, limited extracorpeal
working space with ‘clashing’ of the instruments, and a suboptimal view as the result of difficult
instrument and camera position.19
Laparoendoscopic single-‐site techniques are still in development in many abdominal and pelvic
surgery fields, sometimes in combination with other novel devices, like robotic surgery. In 2008,
14
the Laparoendoscopic Single-‐Site Surgery Consortium for Assessment and Research (LESSCAR) was
formed to coordinate and advance the technique of LESS in a cohensive and safe manner.19
TAMIS / taTME
Transanal endoscopic microsurgery (TEM) was successfully introduced in 1983 by Buess et al.20 to
resect rectal adenomas and selected early stage rectum carcinomas. This technique initially
required a large rigid proctoscope and was regarded as relatively technically challenging and
expensive. Atallah et al.21 demonstrated the possibility to use a single-‐port to gain endoscopic
access for the resection of rectal tumours. The endoscopic access of the rectum by using a single-‐
port and laparoscopic instruments is termed transanal minimally invasive surgery (TAMIS) and
created new possibilities in the minimally invasive treatment of rectum carcinomas.
The introduction of the total mesorectal excision (TME) for rectum carcinomas by Heald in 1982
and its subsequent worldwide standardisation has led to significant improvements in oncological
outcomes.22-‐24 The cornerstone of TME is dissection of the presacral plane, also known as the ‘holy
plane’ and removal of an intact mesorectum.25 Especially in case of low rectal cancer (about 0-‐5
centimetres from anal verge) it is often challenging to achieve a complete mesorectal excision,
regardless of the use of an open or laparoscopic technique.26
To potentially improve oncological outcomes, transanal TME (taTME) or TAMIS TME has been
developed, which is still practically a combination of single-‐ or multiport laparoscopy and NOTES.
In 2013, Heald stated that transanal TME would revolutionise the practice of rectal cancer
surgery.26 In taTME, rectal cancer is approached from distal through the anus instead of proximal
through the abdomen as in traditional TME. Small patient series have demonstrated feasibility of
this technique and showed the ability to perform complete mesorectal excisions with adequate
circumferential resection margins (CRM).27-‐36
OUTLINE OF THIS THESIS
This thesis focuses on the advances in minimally invasive surgery and its implementation in clinical
practice. It represents the growth in surgical techniques from a ‘simple’ cholecystectomy towards
complex rectal cancer surgery.
In chapter 2 we evaluate our experience with single-‐incision laparoscopic (SILS) right colectomy
for colon cancer in a two-‐centre study. In a prospective case-‐controlled study of 100 patients, SILS
right colectomy is compared to the conventional multiport laparoscopic right colectomy. During
this study, some of the surgeons experienced an increased physical burden with SILS when
compared to multiport laparoscopy, mainly due to clashing of the instruments. This observation
resulted in chapter 3, an ergonomic study in which the differences in physical workload between
SILS and multiport laparoscopy was evaluated in surgeons and surgical residents.
From single-‐incision laparoscopy we progressed to our first hybrid-‐NOTES procedures. In The
Netherlands, we were the first to perform a hybrid-‐transvaginal cholecystectomy on a regular
basis. Chapter 4 shows the clinical and cosmetic outcomes after one year of performing
transvaginal cholecystectomy. In chapter 5 we demonstrate the clinical and cosmetic results of a
case-‐controlled study comparing single-‐incision, transvaginal and multiport laparoscopic
techniques for cholecystectomy.
In chapter 6 we describe the use of a single-‐port platform for the endoscopic excision of rectum
tumours as an initial step towards the development of transanal TME. Chapter 7 describes the
surgical technique and the short-‐term and pathological results of the first five consecutive patients
who underwent a transanal TME for rectal cancer. Chapter 8 is a descriptive article about taTME,
which was published in a well-‐read Dutch medical journal to obtain more awareness about this
new technique among Dutch physicians. To further investigate the oncological quality of taTME, a
matched case-‐controlled study comparing the specimens after taTME and multiport TME was
performed (chapter 9). In chapter 10 we focussed on the presence and clinical significance of
peritoneal bacterial contamination after taTME. The transition to NOTES has been a slow process,
partly because of concerns about bacterial translocation. In case of taTME this would be
translocation from the rectum to the intraperitoneal space during the procedure. In chapter 11
1
15
INTR
OD
UCT
ION
AN
D T
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UTL
INE
the Laparoendoscopic Single-‐Site Surgery Consortium for Assessment and Research (LESSCAR) was
formed to coordinate and advance the technique of LESS in a cohensive and safe manner.19
TAMIS / taTME
Transanal endoscopic microsurgery (TEM) was successfully introduced in 1983 by Buess et al.20 to
resect rectal adenomas and selected early stage rectum carcinomas. This technique initially
required a large rigid proctoscope and was regarded as relatively technically challenging and
expensive. Atallah et al.21 demonstrated the possibility to use a single-‐port to gain endoscopic
access for the resection of rectal tumours. The endoscopic access of the rectum by using a single-‐
port and laparoscopic instruments is termed transanal minimally invasive surgery (TAMIS) and
created new possibilities in the minimally invasive treatment of rectum carcinomas.
The introduction of the total mesorectal excision (TME) for rectum carcinomas by Heald in 1982
and its subsequent worldwide standardisation has led to significant improvements in oncological
outcomes.22-‐24 The cornerstone of TME is dissection of the presacral plane, also known as the ‘holy
plane’ and removal of an intact mesorectum.25 Especially in case of low rectal cancer (about 0-‐5
centimetres from anal verge) it is often challenging to achieve a complete mesorectal excision,
regardless of the use of an open or laparoscopic technique.26
To potentially improve oncological outcomes, transanal TME (taTME) or TAMIS TME has been
developed, which is still practically a combination of single-‐ or multiport laparoscopy and NOTES.
In 2013, Heald stated that transanal TME would revolutionise the practice of rectal cancer
surgery.26 In taTME, rectal cancer is approached from distal through the anus instead of proximal
through the abdomen as in traditional TME. Small patient series have demonstrated feasibility of
this technique and showed the ability to perform complete mesorectal excisions with adequate
circumferential resection margins (CRM).27-‐36
OUTLINE OF THIS THESIS
This thesis focuses on the advances in minimally invasive surgery and its implementation in clinical
practice. It represents the growth in surgical techniques from a ‘simple’ cholecystectomy towards
complex rectal cancer surgery.
In chapter 2 we evaluate our experience with single-‐incision laparoscopic (SILS) right colectomy
for colon cancer in a two-‐centre study. In a prospective case-‐controlled study of 100 patients, SILS
right colectomy is compared to the conventional multiport laparoscopic right colectomy. During
this study, some of the surgeons experienced an increased physical burden with SILS when
compared to multiport laparoscopy, mainly due to clashing of the instruments. This observation
resulted in chapter 3, an ergonomic study in which the differences in physical workload between
SILS and multiport laparoscopy was evaluated in surgeons and surgical residents.
From single-‐incision laparoscopy we progressed to our first hybrid-‐NOTES procedures. In The
Netherlands, we were the first to perform a hybrid-‐transvaginal cholecystectomy on a regular
basis. Chapter 4 shows the clinical and cosmetic outcomes after one year of performing
transvaginal cholecystectomy. In chapter 5 we demonstrate the clinical and cosmetic results of a
case-‐controlled study comparing single-‐incision, transvaginal and multiport laparoscopic
techniques for cholecystectomy.
In chapter 6 we describe the use of a single-‐port platform for the endoscopic excision of rectum
tumours as an initial step towards the development of transanal TME. Chapter 7 describes the
surgical technique and the short-‐term and pathological results of the first five consecutive patients
who underwent a transanal TME for rectal cancer. Chapter 8 is a descriptive article about taTME,
which was published in a well-‐read Dutch medical journal to obtain more awareness about this
new technique among Dutch physicians. To further investigate the oncological quality of taTME, a
matched case-‐controlled study comparing the specimens after taTME and multiport TME was
performed (chapter 9). In chapter 10 we focussed on the presence and clinical significance of
peritoneal bacterial contamination after taTME. The transition to NOTES has been a slow process,
partly because of concerns about bacterial translocation. In case of taTME this would be
translocation from the rectum to the intraperitoneal space during the procedure. In chapter 11
16
we demonstrate our short-‐term clinical and oncological results regarding the first 80 performed
taTME procedures for rectum carcinomas.
To date, no randomised controlled trial has been designed to compare the clinical and oncological
outcomes of taTME with multiport laparoscopic TME.
Chapter 12 comprises a description of the study protocol for a future multicentre randomised
clinical trial comparing transanal TME and traditional laparoscopic TME for mid and low rectal
cancer on behalf of the COLOR III study group.
The general discussion (chapter 13) summarizes the main results of this thesis and discusses
future perspectives on personalised surgery.
REFERENCES
1. Jayne DG, Guillou PJ,Thorpe H, et al. Randomized trial of laparoscopic-‐assisted resection of colorectal carcinoma: 3-‐year results of the UK MRC CLASICC Trial Group. J Clin Oncol. Jul 20 2007;25(21):3061-‐3068.
2. Veldkamp R, Kuhry E, Hop WC, et al. Laparoscopic surgery versus open surgery for colon cancer: short-‐term outcomes of a randomized trial. Colon cancer Laparoscopic or Open Resection Study Group (COLOR). Lancet Oncol. 2005 Jul;6(7):477-‐84.
3. Van der Pas MH, Haglind E, Cuesta MA, et al. Laparoscopic versus open surgery for rectal cancer (COLOR II): short-‐term ouctomes of a randomized, phase 3 trial. Colorectal cancer Laparoscopic or Open Resection II (COLOR II) Study Group. Lancet Oncol. 2013 Mar;14(3):210-‐8.
4. Keus F, Gooszen HG, van Laarhoven CJ. Open, small-‐incision, or laparoscopic cholecystectomy for patients with symptomatic cholecystolithiasis. An overview of Cochrane Hepato-‐Biliary Group reviews. Cochrane Database Syst Rev. 2010(1):CD008318
5. Clinical Outcomes of Surgical Therapy Study G. A Comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med. May 13 2004;350(20):2050-‐2069.
6. Nau P, Ellison EC, Muscarella P et al. A review of 130 human enrolled in transgastric NOTES procotols at a single institution. Surg Endosc. 2011(25):4;1004-‐1011.
7. Kalloo AN, Singh VK, Jagannath SB, et al. Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity. Gastrointest End. 2004(60);1:114-‐117.
8. Moreira-‐Pinto J, Lima E, Correia-‐Pinto J, et al. Natural orifice transluminal endoscopy surgery: a review. World J of Gastroent. 2011(17);33:3795-‐3801.
9. Merrifield BF, Wagh MS, Thompson CC. Peroral transgastric organ resection: a feasibility study in pigs. Gastroint End. 2006(63);4:693-‐697.
10. Mohan HM, O’Riordan JM, Winter DC. Natural-‐orifice translumenal endoscopic surgery (NOTES): minimally invasive evolution or revolution? Surg Laparosc Endosc Percut Tech. 2013;23:244-‐250.
11. Deborah EB. ASGE/SAGES Working Group on Natural Orifice Translumenal Endoscopic Surgery: white paper October 2005. Gastroint End. 2006(63);2:199-‐203.
12. Wang D, Wang Y, Ji ZL. Laparoendoscopic single-‐site cholecystectomy versus conventional laparoscopic cholecystectomy: a systematic review of randomized controlled trials. ANZ Journal of Surgery 2012;82(5):303-‐310.
13. Teoh AY, Chiu PW, Wong TC et al. A double-‐blinded randomized controlled trial of laparoendoscopic single-‐site access versus conventional 3-‐port appendectomy. Ann of Surg. 2012;256(6):909-‐916.
14. Siddiqui MR, Kovzel M, Brennan SJ, et al. The role of the laparoendoscopic single site totally extraperitoneal approasch to inguinal hernia repairs: a review and meta-‐analysis of the litereature. Can J Surg. 2014 Apr;57(2):116-‐26.
15. Calcagno M, Pastore M, Montanino M, et al. Laparoendoscopic single-‐site salpingectomy for treatment of ectopic pregnancy. Int J Gynaecolol Obstet 2012 Jan;116(1):81.
16. Gargiulo AR, Nezhat C. Robot-‐assisted laparoscopy, natural orifice transluminal endoscopy, and single-‐site laparoscopy in reproductive surgery. Semin Reprod Med 2011 Mar;29(2):155-‐68.
17. Fan X, Lin T, Xu K et al. Laparoendoscopic single-‐site nephrectomy compared with conventional laparoscopic nephrectomy: a systematic review and meta-‐analysis of comparative studies. Eur Urol 2012 Oct;62(4):601-‐12.
18. Diana M, Dhumane P, Cahili RA, et al. Minimal invasive single-‐site surgery in colorectal procedures: current state of the art. J Minim Access Surg 2011 Jan; 7(1):52-‐60.
19. Gill IS, Advincula AP, Monish A, et al. Consensus statement of the consortium for laparoendoscopic single-‐site surgery. Surg Endosc 2010 24:762-‐768.
20. Buess G, Mentges K, Starlinger M, et al. Technique and results of transanal endoscopic microsurgery in early rectal cancer. Am J Surg. 1992 Jan;163(1):63-‐9.
21. Atallah S, Albert M, Larach S. Transanal minimally invasive surgery: a giant leap forward. Surg Endosc. 2010 Sep;24(9):2200-‐5.
22. Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery. The clue to pelvic recurrence? Br J Surg. 1982 Oct;69(10):613-‐6.
23. Martling AL, Holm T, Rutqvist LE, Moran BJ, Heald RJ, Cedemark B (2000) Effect of a surgical training programme on outcome of rectal cancer in the County of Stockholm. Stockholm Colorectal Cancer Study Group,
1
17
INTR
OD
UCT
ION
AN
D T
HES
IS O
UTL
INE
we demonstrate our short-‐term clinical and oncological results regarding the first 80 performed
taTME procedures for rectum carcinomas.
To date, no randomised controlled trial has been designed to compare the clinical and oncological
outcomes of taTME with multiport laparoscopic TME.
Chapter 12 comprises a description of the study protocol for a future multicentre randomised
clinical trial comparing transanal TME and traditional laparoscopic TME for mid and low rectal
cancer on behalf of the COLOR III study group.
The general discussion (chapter 13) summarizes the main results of this thesis and discusses
future perspectives on personalised surgery.
REFERENCES
1. Jayne DG, Guillou PJ,Thorpe H, et al. Randomized trial of laparoscopic-‐assisted resection of colorectal carcinoma: 3-‐year results of the UK MRC CLASICC Trial Group. J Clin Oncol. Jul 20 2007;25(21):3061-‐3068.
2. Veldkamp R, Kuhry E, Hop WC, et al. Laparoscopic surgery versus open surgery for colon cancer: short-‐term outcomes of a randomized trial. Colon cancer Laparoscopic or Open Resection Study Group (COLOR). Lancet Oncol. 2005 Jul;6(7):477-‐84.
3. Van der Pas MH, Haglind E, Cuesta MA, et al. Laparoscopic versus open surgery for rectal cancer (COLOR II): short-‐term ouctomes of a randomized, phase 3 trial. Colorectal cancer Laparoscopic or Open Resection II (COLOR II) Study Group. Lancet Oncol. 2013 Mar;14(3):210-‐8.
4. Keus F, Gooszen HG, van Laarhoven CJ. Open, small-‐incision, or laparoscopic cholecystectomy for patients with symptomatic cholecystolithiasis. An overview of Cochrane Hepato-‐Biliary Group reviews. Cochrane Database Syst Rev. 2010(1):CD008318
5. Clinical Outcomes of Surgical Therapy Study G. A Comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med. May 13 2004;350(20):2050-‐2069.
6. Nau P, Ellison EC, Muscarella P et al. A review of 130 human enrolled in transgastric NOTES procotols at a single institution. Surg Endosc. 2011(25):4;1004-‐1011.
7. Kalloo AN, Singh VK, Jagannath SB, et al. Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity. Gastrointest End. 2004(60);1:114-‐117.
8. Moreira-‐Pinto J, Lima E, Correia-‐Pinto J, et al. Natural orifice transluminal endoscopy surgery: a review. World J of Gastroent. 2011(17);33:3795-‐3801.
9. Merrifield BF, Wagh MS, Thompson CC. Peroral transgastric organ resection: a feasibility study in pigs. Gastroint End. 2006(63);4:693-‐697.
10. Mohan HM, O’Riordan JM, Winter DC. Natural-‐orifice translumenal endoscopic surgery (NOTES): minimally invasive evolution or revolution? Surg Laparosc Endosc Percut Tech. 2013;23:244-‐250.
11. Deborah EB. ASGE/SAGES Working Group on Natural Orifice Translumenal Endoscopic Surgery: white paper October 2005. Gastroint End. 2006(63);2:199-‐203.
12. Wang D, Wang Y, Ji ZL. Laparoendoscopic single-‐site cholecystectomy versus conventional laparoscopic cholecystectomy: a systematic review of randomized controlled trials. ANZ Journal of Surgery 2012;82(5):303-‐310.
13. Teoh AY, Chiu PW, Wong TC et al. A double-‐blinded randomized controlled trial of laparoendoscopic single-‐site access versus conventional 3-‐port appendectomy. Ann of Surg. 2012;256(6):909-‐916.
14. Siddiqui MR, Kovzel M, Brennan SJ, et al. The role of the laparoendoscopic single site totally extraperitoneal approasch to inguinal hernia repairs: a review and meta-‐analysis of the litereature. Can J Surg. 2014 Apr;57(2):116-‐26.
15. Calcagno M, Pastore M, Montanino M, et al. Laparoendoscopic single-‐site salpingectomy for treatment of ectopic pregnancy. Int J Gynaecolol Obstet 2012 Jan;116(1):81.
16. Gargiulo AR, Nezhat C. Robot-‐assisted laparoscopy, natural orifice transluminal endoscopy, and single-‐site laparoscopy in reproductive surgery. Semin Reprod Med 2011 Mar;29(2):155-‐68.
17. Fan X, Lin T, Xu K et al. Laparoendoscopic single-‐site nephrectomy compared with conventional laparoscopic nephrectomy: a systematic review and meta-‐analysis of comparative studies. Eur Urol 2012 Oct;62(4):601-‐12.
18. Diana M, Dhumane P, Cahili RA, et al. Minimal invasive single-‐site surgery in colorectal procedures: current state of the art. J Minim Access Surg 2011 Jan; 7(1):52-‐60.
19. Gill IS, Advincula AP, Monish A, et al. Consensus statement of the consortium for laparoendoscopic single-‐site surgery. Surg Endosc 2010 24:762-‐768.
20. Buess G, Mentges K, Starlinger M, et al. Technique and results of transanal endoscopic microsurgery in early rectal cancer. Am J Surg. 1992 Jan;163(1):63-‐9.
21. Atallah S, Albert M, Larach S. Transanal minimally invasive surgery: a giant leap forward. Surg Endosc. 2010 Sep;24(9):2200-‐5.
22. Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery. The clue to pelvic recurrence? Br J Surg. 1982 Oct;69(10):613-‐6.
23. Martling AL, Holm T, Rutqvist LE, Moran BJ, Heald RJ, Cedemark B (2000) Effect of a surgical training programme on outcome of rectal cancer in the County of Stockholm. Stockholm Colorectal Cancer Study Group,
Basingstoke Bowel Cancer Research Project. Lancet. 356:93-‐96.
24. Kapiteijn E, Putter H, Van de Velde CJ (2002) Cooperative investigators of the Dutch ColoRectal Cancer Group: impact of the introduction and training of total mesorectal excision on recurrence and survival in rectal cancer in The Netherlands. Br J Surg 89:1142–1149.
25. Heald RJ. The ‘holy plane’ of rectal surgery. J R Soc Med 1988 81:503-‐533.
26. Heald RJ (2013) A new solution to some old problems: transanal TME. Tech Coloproctol 17:257–258.
27. Marks J, Mizrahi B, Dalane S, Nweze I, Marks G (2010) Laparoscopic transanal abdominal transanal resection with sphincter preservation for rectal cancer in the distal 3 cm of the rectum after neoadjuvant therapy. Surg Endosc 24:2700–2707
28. Zorron R, Philips HN, Coelho D, Flach L, Lemos FB, Vassallo RC (2012) Perirectal NOTES access: ‘‘down-‐to-‐up’’ total mesorectal excision for rectal cancer. Surg Innov 19:11–19
29. McLemore EC, Coker AM, Devaraj B et al (2013) TAMIS-‐assisted laparoscopic low anterior resection with total mesorectal excision in a cadaveric series. Surg Endosc 27:3478–3484.
30. Rouanet P, Mourregot A, Azar CC et al (2013) Transanal endoscopic proctectomy: an innovative procedure for difficult resection of rectal tumors in men with narrow pelvis. Dis Colon Rectum 56:408–415
31. Lacy AM, Rattner DW, Adelsdorfer C et al (2013) Transanal natural orifice transluminal endoscopic surgery (NOTES) rectal resection: ‘‘down-‐to-‐up’’ total mesorectal excision (TME)-‐shortterm outcomes in the first 20 cases. Surg Endosc 27:3165–3172.
32. Sylla P, Bordeianou LG, Berger D et al (2013) A pilot study of natural orifice transanal endoscopic total mesorectal excision with laparoscopic assistance for rectal cancer. Surg Endosc 27:3396–3405
33. Cahill RA (2013) Single port surgery for rectal cancer-‐going up or down? Dis Colon Rectum 56:1199–1200
34. Wolthuis AM, van Overstraeten ADB, D’Hoore A (2014) Dynamic article: transanal rectal excision: a pilot study. Dis Colon Rectum 57:105–109
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