Vol.2, No.7, 386-389 (2013) Case Reports in Clinical Medicine
http://dx.doi.org/10.4236/crcm.2013.27103
3-Port incisionless laparoscopic surgery for rectal
cancer with a transrectal assistance
Lin Zhang, Guohu Zhang, Peihong Wang, Yonghua Wang, Yaning Song, Hong Zou,
Lijun Tang*
Center of General Surgery, Chengdu General Hospital of Chengdu Military Area Command, Chengdu, China;
*Corresponding Author: [e-mail]
Received 25 July 2013; revised 26 August 2013; accepted 8 September 2013
Copyright © 2013 Lin Zhang et al. This is an open access article distributed under the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Introduction: To present the initial experience of
3-port incisionless laparoscopic surgery for rec-
tal cancer with a transrectal assistance by using
a toothed oval clamp. Case Presentation: One
p atient re ceiv ed 3-port incis ionless laparoscopic
surgery for rectal cancer with a transrectal as-
sistance by using a toothed oval clamp. Better
direct visi on and exposur e could be ac quired for
performing lap aroscopic surgical procedure, avoid-
ing additional port inserted. Using this proce-
dure, with strictly adhering to the principles of
laparoscopic colectomy and oncological proce-
dure, along with the specimen exteriorized via
recta, transacted and a stapled anastomosis
performed, no incision can be achieved at the
end of an operation. The operative time was 180
minutes. The estimated blood loss in the course
of an operation was 80 ml. The p atient recov ered
quickly after surgery, with no post-operative pain
and no incision. The patient was dischanged
home on the 6th postoperative day. Conclusions:
With a transrectal assistance by using a toothed
oval clamp, 3-port laparoscopic surgery for rec-
tal cancer could be achieved w ithout no incision
at the end of the operation, the same as NOTES.
It is enormously advantageous to the p atient and
suitable for application in developing countries,
especially in a rural area.
Keyw ords: Laparoscopic Su rge ry; Incisionle ss;
Rectal Cancer; Transrect a l; Assistanc e
1. INTRODUCTION
In recent years, laparoscopic surgeries have been
widely accepted as a treatment of colon diseases, includ-
ing colon cancer [1-3]. The short term benefit of the
laparoscopic approach in colorectal surgery is obvious,
namely, faster postoperative recovery, improved postop-
erative pain control, reduced pulmonary dysfunction, and
shorter hospitalization [4-6].
In order to further improve upon the results of multi-
port laparoscopic colectomies (LACs), efforts have been
made to further reduce the trauma caused by incisions,
even in a minimum number of port sites inserted with
trocars used. Now natural orifice transluminal endo-
scopic surgery (NOTES) provides the potential for per-
formance of scarless operations. In 2007, Whiteford et al.
described the first transanal NOTES radical sigmoidec-
tomy in human cadavers [7]. However, the progress con-
tinues to be hampered by always needing for expensive
specialized equipment as well as safety concerns regard-
ing NOTES translumenal access, particularly regarding
access closure [8]. To some extent, it has hindered the
widespread acceptance of this approach.
Since 2008, when single-incision laparoscopic colec-
tomy (SILC) was first introduced, the number of relevant
publications has been increasin g yearly. In comparison to
multiport laparoscopic colectomy, the potential advan-
tages of SILS are thought to be improved cosmesis as
well as incisional and/or parietal pain and avoidance of
port site-related complications [9]. But expensive pro-
prietary equipment and additional incisions are needed
for retrieval of the specimen.
In this paper, we introduce a new surgical procedure of
3-port incisionless laparoscopic surgery for rectal cancer
with a t ransrect al assi stance by us ing a to othed oval cl amp.
2. CASE REPORT
A 38-year-old married female presented to her local
doctor with bloody stools. Than the patient was referred
to our hospital for the reason that a crater lesion of ~30
mm in diameter and 8 cm from the anal verge had been

L. Zhang et al. / Case Reports in Clinical Medicine 2 (201 3) 386-389 387
found in the middle rectum by colonoscopy. The biopsy
outcome confirmed rectal adenocarcinoma. The patient’s
past history and laboratory test results were not con-
tributory.
The potential risks and benefits of the operation were
discussed with the patient, who gave informed consent.
All of the principles of laparoscopic colectomy and on-
cological procedure were strictly adhered to.
The patient was placed in the lithotomy position. three
ports (Johnson & Johnson, USA) were used, with place-
ment in the left upper for 5 mm trocar, right upper for 12
mm trocar which was later used as a drain site, umbili-
cum upper for 12 mm trocar and for 30˚-angled scopes
(Olympus, Japan). At the beginning of procedure, the
operator was located in the two legs of the patient, in
order to visualize abdominal organs in line with the 30˚-
angled scopes without the need for retroflexion. En-bloc
resection and mobilization of the sigmoid colon and its
mesentery proceeded cephalad along the avascular plane.
The inferior mesenteric artery (IMA) was highly dis-
sected and staple divided (Clips, Johnson & Johnson
MEDICAL GmbH, USA) (Figure 1). After the adequate
length of the sigmoid colon was carefully preserved for
anastomosis, the colon was subsequently obtained to
introduce an endoscopic linear stapler (Johnson & John-
son, USA) into the peritoneal cavity and divided fol-
lowed by introducing the anvil of the circular stapler
(Johnson & Johnson, USA) into the proximal colon via
transrectum.
Following this, the operator changed to located in the
left position of the patient, in order to perform procedure
in line with the field of vision of the 30˚-angled scopes.
The left and right ureter were identified, and the
presacral plane was carefully caudally developed with
preservation of the autonomic nerve fibers using the
technique of sharp total mesor ectal excition with a trans-
rectal assistance by using toothed oval clamp (Figure 2).
Once the peritoneal reflection was reached, the colon
was then pulled out through the rectum, transected and a
intracorporeally stapled colorectal anastomosis perform-
ed with the circular stapler (Johnson & Johnson, USA)
used (Figure 3). A drainage tube was posited upper an-
astomotic line via transrectum, avoiding temporary di-
verting loop ileostomy and anastomotic leakage (Figure
4).
The operative time was 180 minutes. The estimated
blood loss in the course of operation was 80 ml. The pa-
tient recovered quickly after surgery, with no postopera-
tive pain and no insicion. On postoperative day 3 the
patient had completely resumed total gastrointestinal
function and had her first flatus. The blood loss of
drainage tube was about 30 - 50 ml per day and was
pulled out on postoperative day 4. The patient was dis-
changed home on postoperative day 6. Pathology re-
Figure 1. The inferior mesenteric artery
(IMA) was highly dissected and staple di-
vided.
Figure 2. Excision of mesorectum along
the prescaral plane with exposure by using
transrectal toothed oval clamp.
Figure 3. View of intracorporeally coloanal
anastomosis performed between the proxi-
mal sigmoid colon and distal anorectal
cuff.
Figure 4. 3-port used after incisionless
laparoscopic rectal operation, one of which
was used as a drain site.
vealed an intact mesorectum with 3 out of 12 retrieved
lymph nodes positiv e for aden oc arcinoma (pT3 N1 ). Mar-

L. Zhang et al. / Case Reports in Clinical Medicine 2 (201 3) 386-389
388
gins were free of tumor.
3. DISCUSSION
Although many large randomized trials with the la-
paroscopic approach in colon cancer had demonstrated
equivalent oncologic efficacy with similar overall sur-
vival, disease-free survival and local and distant recur-
rences [10-12], the relevant data of large randomized
trials with the laparoscopic approach in rectal cohort is
scarce, hampering its widely accepted.
Overall laparoscopic rectal resection for malign ancy is
technically more demanding in that concerns about nerve
preservation, complete total mesorectal excision, and
adequate lymph node yield are still unsettled in this set-
ting. But the remarkable magnified view provided by the
monitor of laparoscopic operation system has become
more advantageous and fascinating and enables safe and
accurate manipulation at sites such as the deep pelvic
floor, lower bladder, posterior surface of the prostate and
anal region, where visualization is difficult to achieve
during open surgery and manipulation is usually carried
out under nearly blind conditions [13].
In order to further improve upon the results of LACs,
efforts have been made to further reduce the trauma
caused by incisions, even in a minimum number of port
site inserted with trocars used. This results in a paradox.
on one hand, both operator and patient persue scarless or
minor insicions; on the other hand, with reduction num-
ber of port site, exposure of operating site should be
more difficult for performing adequately surgical proce-
dure. So we put forward a useful laparoscopic assisting
approach with a transrectal assistance by using toothed
oval clamp.
In our opinion, a new transrectal laparoscopic assisting
approach offers multiple advantages: 1) with respect to
laparoscopic surgery for rectal cancer，the sharp angle of
the sacral promontory and narrow pelvis hindered the
proximal dissection of rectal wall and its attached mes-
entery. To overcome those anatomic constraints, expo-
sure turned out to be more important. Based on our early
experience, with a transrectal assistance by using toothed
oval clamp performed by second assistant, operator
could acquire better direct vision and exposure for per-
forming laparoscopic surgical procedure, avoiding addi-
tional port inserted; 2) Patients, both male and female,
independent of age and body shape, usually dislike scars,
not only for cosmetic reasons but because scars indicate
they have undergone treatment before. This resulted in
NOTES, eliminating the incision through the abdominal
wall and using natural orifices，meeting the aspirations of
the patients and su rgeons [14]. But in the level of LACs,
minor incision always needed. Using our above-men-
tioned procedure, along with the specimen exteriorized
via transrectal, transacted and a stapled anastomosis per-
formed, incisionless can be achieved at the end of opera-
tion, same as NOTES; 3) Our new transrectal laparo-
scopic assisting device is much cheaper than instrument
of other minimally invasive surgeries in that it is a sim-
ple device whose cost is approximately 50 USD. So it is
suitable for application in developing countries, espe-
cially in a rural area.
Nevertheless，we have to refer some caveats emerged
in our initially experience with this technique. Firstly,
strict selection of patients for this approach include tho se
with biopsy proven resectable rectal malignancy located
4 - 12 cm from anal verge who are otherwise eligible to
undergo standard open or laparoscopic low anterior re-
section with temporary diverting stoma. Meanwhile tu-
mors must be preoperatively staged as node negative, T1,
T2 or T3 based on pelvic MRI with no evidence of me-
tastasis on staging CT scans. Secondly, lesions of eligi-
ble patients which causing no more than 50% stenosis of
the lumen, as well as better mechanical bowel prepara-
tion, could ensure a satisfied operation outcome, avoid-
ing temporary diverting loop ileostomy and anastomotic
leakage.
4. CONCLUSION
On the basis of our preliminary experience, we believe
that with a transrectal assistance by using a toothed oval
clamp, 3-port laparoscopic surgery for rectal cancer can
be done without an incision at the end of the operation,
same as NOTES. With this useful technique, made from
commonly used and relatively inexpensive surgical equip-
ment, avoiding long and complex learning curves, op-
erator could acquire much more exposure, assistance
during performing surgical procedure. Above all, it is
suitable for application in developing countries, espe-
cially in a rural area.
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