Transrectal - Natural Orifice Translumenal Endoscopic Surgery (NOTES)

Pre-clinical phase: We conducted the first phase of the study in cadavers to troubleshoot the procedures, and to determine the optimal transrectal approach (anterior versus posterior). We have determined the anterior transrectal approach to be feasible and preferable to a posterior transrectal approach.

Clinical phase: The second phase of the project will be a feasibility study involving 10 human patients. We will recruit patients who are already scheduled to undergo elective laparoscopic total proctocolectomy, total abdominal colectomy, completion proctectomy , or sigmoidectomy from the surgical clinics.

Operative procedure: Patients will undergo a standard preoperative mechanical bowel prep, and will receive standard perioperative antibiotics and deep venous thrombosis (DVT) prophylaxis to reduce the risk of surgical site infection and thromboembolic complications, respectively. The subjects will be placed in lithotomy position, and undergo general anesthesia per usual routine. A laparoscopic team and a NOTES team will carry out the operation. The laparoscopic team will obtain laparoscopic access using standard laparoscopic technique. The NOTES team will perform rigid proctoscopy to assess the suitability of the rectum. The Karl-Storz (Tuttlingen, Germany) operating rectoscope will be used for TEM. After positioning the rectoscope, an intraluminal tissue oximetry measurement will be taken at the intended rectotomy site using an FDA-approved endoscopic tissue oximetry probe (T-Stat®, Spectros, Portola Valley, CA) passed through the TEM device. In human patients, we will collect peritoneal fluid for quantitative cultures at two time-points (immediately after peritoneal access, and after rectotomy closure), using a sterile suction trap attached in-line to a laparoscopic suction irrigator to determine the level of contamination from the procedure. The NOTES appendectomy will be completed using the flexible endoscope with laparoscopic assistance as needed. We will remove the specimen through the anus and close the rectal access site with a standard TEM closure. We will then perform a standard intraoperative insufflation test by submerging the pelvis and rectotomy site under saline, and insufflating the rectum to look for bubbles from the rectal closure site. At the conclusion of the NOTES procedures, we will remove the TEM device, and a laparoscopic team will proceed with laparoscopic proctocolectomy or total abdominal colectomy as originally planned. Once the specimen has been removed, we will use a bench-top test to determine the burst-pressure strength of the rectotomy closures. The specimen will be sent to pathology per standard routine, and postoperative care for the proctocolectomy or total abdominal colectomy patients will proceed per usual routine.

Outcome measurements: We will measure operative times, intraoperative complication rates, tissue oxygen saturation at the closure site, and rectotomy closure strength using an intraoperative insufflation test and an ex-vivo burst-pressure test. In the human cases we will also obtain intraoperative quantitative peritoneal fluid cultures to quantify the amount of peritoneal contamination as a result of the NOTES procedures.

Patients will be followed while in the hospital to assess for complications potentially related to the NOTES procedure. They will then return and be evaluated by their surgeon two weeks following their procedure. At this visit, any additional post-operative complications potentially related to the NOTES procedure will be noted in the patient's medical record.