New trends in colorectal surgery: Single port and natural orifice techniques

Abstract

Single-incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) have rapidly gained pace worldwide, potentially replacing conventional laparoscopic surgery (CLS) as the preferred colorectal surgery technique. Currently available data mainly consist of retrospective series analyzed in four meta-analyses. Despite conflicting results and lack of an objective comparison, SILS appears to offer cosmetic advantages over CLS. However, due to conflicting results and marked heterogeneity, present data fail to show significant differences in terms of operative time, postoperative morbidity profiles, port-site complications rates, oncological appropriateness, duration of hospitalization or cost when comparing SILS with conventional laparoscopy for colorectal procedures. The application of “pure” NOTES in humans remains limited to case reports because of unresolved issues concerning the ideal access site, distant organ reach, spatial orientation and viscera closure. Alternatively, minilaparoscopy-assisted natural orifice surgery techniques are being developed. The transanal “down-to-up” total mesorectum excision has been derived for transanal endoscopic microsurgery (TEM) and represents the most encouraging NOTES-derived technique. Preliminary experiences demonstrate good oncological and functional short-term outcomes. Large-scale randomized controlled trials are now mandatory to confirm the long-term SILS results and validate transanal TEM for the application of NOTES in humans.

Keywords: Surgery, Colon, Rectum, Cancer, Laparoscopy, Single-port, Natural orifice transluminal endoscopic surgery

Core tip: Despite lack of irrevocable proofs and unresolved technical issues, single-incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) became inevitable options in today’s colorectal surgery armamentarium. In comparison to conventional laparoscopic surgery, colorectal SILS offers a cosmetic advantage with no compromise of surgical morbidity, oncological appropriateness or increased cost. The “down-to-up” total mesorectum excision appears as the most encouraging NOTES-related technique for clinical application in humans. It further offers potential benefits in functional and oncological outcomes. Well-designed randomised studies are now essential to validate the long-term results of these novel techniques.