Transanal Endoscopic Microsurgery (TEM) allows for full thickness rectal resections and closure. TEM has also been used to perform a NOTES sigmoid colectomy in human cadavers. To test the feasibility of performing advanced NOTES procedures, we present our novel technique for performing a right hemicolectomy in a cadaver using a combined NOTES approach; a transrectal TEM approach augmented by a transgastric flexible endoscopic approach.

In a cadaver model, TEM instruments were used to create an enterotomy in the rectum to gain access to the peritoneal cavity. A dual channel endoscope was placed transrectally through a non-steerable endoscopic trocar which was placed through a modified TEM faceplate. Under direct vision with the transrectal scope (TRS) a gastrotomy was made using an upper-endoscope placed through a steerable endoscopic trocar. The transgastric scope (TGS) was used for observation and providing traction/counter-traction. The TRS was used for dissection with prototype energy devices. Standard TEM instruments were also used parallel to the TRS to aid in retraction. Mobilization of the right colon was started inferiorly. An articulating stapler placed transrectally was used to transect the ileocolic vessels, bowel, and to create the side-to-side ileo-transverse colon anastomosis. The specimen was delivered transanally.

With this technique we were able to successfully resect the right colon and create an anastomosis with the combined efforts of a transrectal and transgastric approach.

We demonstrate that a right colon resection can be performed without skin incisions. Future developments of NOTES platforms will make this procedure more widely applicable.