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Transanal endoscopic microsurgery (TEM) is a type of natural orifice transluminal endoscopic surgery, developed for rectal tumors and used also to treat other rectal diseases. Anastomotic complications after colorectal surgery, including stenosis, represent a challenging problem. We present the case of a 36-year-old woman with a diagnosis of Hirschsprung disease that was submitted to a modified Duhamel operation. A postoperative barium enema showed a complete stricture of the anastomosis that was impossible to resolve by flexible endoscopic approach. Then an intraoperative endoscopic approach to facilitate the localization of preanastomotic colon (proximal colon from the anastomosis) was performed by a small colotomy and the colonic recanalization was obtained by the creation of a neo-anastomosis by TEM, under fluoroscopic-endoscopic control. The patient underwent a control barium enema showing regular retrograde transit of contrast medium without evidence of stenosis. In our experience, transanal approach by TEM-colonoscopy assisted is safe and feasible and represents a model of combined minimally invasive technique.

Lipomas are the most common non-epithelial tumours of the colon. Nevertheless, symptomatic colonic lipomas are a rare entity in adults. Intussusception is the commonest complication of submucosal lipomas and often presents with absent, non-specific or intermittent symptoms, hence the diagnosis is challenging. In non-emergency situations, most patients undergo computed tomography scan as well as endoscopic evaluation of the colon prior to any surgical intervention. While successful endoscopic excision of lipomas has been reported, segmental resection of the colon is most commonly practiced. To the best of our knowledge, this is the first report of laparoscopic assisted submucosal excision of an intussuscepting colonic lipoma through a colotomy. We present the case of a young female patient with few weeks history of intermittent abdominal pain associated with nausea. She had previously undergone various investigations including colonoscopy and was awaiting an elective left hemicolectomy. She presented to our Emergency department with subacute large bowel obstruction. A CT scan confirmed the diagnosis of colo-colic intussusception due to a large descending colon lipoma. The patient underwent a laparoscopic assisted procedure - following laparoscopic colonic mobilisation, submucosal excision of the large lipoma was performed through a colotomy placed through the taenia on the opposite wall. The mucosal defect and colotomy were closed following the excision. The patient recovery was uneventful and histopathology of the specimen confirmed the diagnosis.

Despite careful and meticulous technique, unfortunately injuries can occur to the bowel. Understanding how to avoid them, recognize them when they do occur, and manage them is crucial to minimizing further complications.

A 46 years old male presented with a history of assault and insertion of a long wooden object through his anus. Examination and radiological investigations of the patient revealed a 34x4.0 cm long wooden object in the rectosigmoid colon. The foreign body was delivered by colotomy under general anesthesia.

We studied natural orifice transcolonic drainage of intra-abdominal abscesses in a canine survival model to evaluate the difficulty of peritonoscopy and abscess drainage and the reliability of endoluminal colotomy closure.We placed a 7 cm nonsterile saline-filled latex balloon intra-abdominally to mimic or induce an abscess or inflammatory mass. Seven days later, we advanced a single-channel endoscope transanally into the sigmoid colon of the animal, made a colotomy and then advanced the endoscope intraperitoneally. We evacuated the identified abscess and placed a drain transabdominally. We closed the colotomy endoluminally with a tissue approximation system using 2 polypropylene sutures attached to metal T-bars. Two weeks later, we evaluated the colotomy closure at laparotomy.We studied 12 dogs: 8 had subphrenic balloon implants and 4 had interbowel loop implants. Eleven survived and underwent transcolonic peritonoscopy; we identified the "abscess" in 9. The colotomy was successfully closed in 10 of 11 dogs. Although abscesses were easily identified, the overall difficulty of the peritonoscopy was moderate to severe. One dog required colotomy closure via laparotomy, while 9 had successful endoluminal closure. After colotomy closure, 8 animals survived for 2 weeks (study end point) without surgical complications, sepsis or localized abdominal infections. On postmortem examination, all closures were intact without any adjacent organ damage or procedure-related complications.Natural orifice transluminal endoscopic surgery provides a novel alternative to treating intra-abdominal pathology. It is technically feasible to perform endoscopic transcolonic peritonoscopy and drainage of an intra-abdominal abscess with reliable closure of the colotomy in a canine experimental model.Nous avons étudié le drainage transcolique par voie naturelle d’abcès intraabdominaux dans un modèle canin de survie afin d’évaluer la difficulté de la péritonoscopie et du drainage des abcès, ainsi que la fiabilité de la fermeture endoluminale de la colotomie.Nous avons inséré un ballonnet de latex de 7 cm non stérile empli de solution physiologique par voie intra-abdominale pour simuler ou induire un abcès ou une masse inflammatoire. Sept jours plus tard, nous avons introduit un endoscopeà simple canal par voie transanale jusqu’au sigmoïde de l’animal, procédé à une colotomie et ensuite poussé l’endoscope dans le péritoine. Nous avons vidé l’abcès observé et placé un drain par voie transabdominale. Nous avons ensuite procédé à une fermeture endoluminale de la colotomie avec un système de rapprochement tissulaire utilisant 2 sutures de polypropylène fixées à des pièces métalliques en T. Deux semaines plus tard, nous avons évalué la fermeture de la colotomie par laparotomie.Notre étude a porté sur 12 chiens : 8 avaient un ballonnet implanté au niveau sous-phrénique et 4, entre les anses intestinales. Onze ont survécu et ont subi la péritonoscopie transcolique; nous avons retracé « l’abcès » chez 9 d'entre eux. La colotomie a été refermée avec succès chez 10 chiens sur 11. Même s’il a été facile de retracer les abcès, la difficulté globale de la péritonoscopie a été jugée de modéréeà marquée. Un chien a eu besoin d’une fermeture de colotomie par laparotomie, tandis que la fermeture endoluminale a réussi chez 9 animaux. Après la fermeture de la colotomie, 8 chiens ont survécu 2 semaines (fin de l’étude) sans complications chirurgicales, sepsis ni infections abdominales localisées. À l’autopsie, toutes les fermeturesétaient intactes, sans atteinte aux organes adjacents ni complications des suites de l’intervention.La chirurgie endoscopique transluminale par voie naturelle offre une solution de rechange pour le traitement des pathologies intra-abdominales. Il est possible au plan technique de réaliser une péritonoscopie transcolique endoscopique et de drainer un abcès intra-abdominal avec fermeture fiable de la colotomie dans un modèle expérimental chez le chien.

This nonsystematic review was performed to evaluate the literature that pertains to laparoscopic right colectomy, focusing on extracorporeal versus intracorporeal ileocolic anastomosis. The literature search was performed using PubMed to investigate the current status of research on 3 topics: (1) laparoscopic right colectomy with extracorporeal anastomosis, (2) laparoscopic right colectomy with intracorporeal anastomosis, and (3) comparisons of the 2 techniques. Each topic was reviewed, and the most relevant articles were selected for each subheading. Current literature is bringing to the forefront new evidence that laparoscopic right colectomy with intracorporeal anastomosis can be performed within a comparable time frame as extracorporeal anastomosis and with similar complication rates. Recent reports have presented evidence in which the entire operation is performed intracorporeally by a medial-to-lateral approach with comparable results to those observed in the surgery performed with extracorporeal anastomosis. The advantages of intracorporeal anastomosis are that mobilization of the transverse colon is not necessary, the anastomosis is performed away from the abdominal wall, and there is decreased potential for adhesion formation and a smaller extraction site. Potential disadvantages include intra-abdominal colotomy, requirement of laparoscopic suturing skills, and longer operative time.

BACKGROUND AND STUDY AIMS: Perforation of the colon is considered to be one of the most serious complications of flexible endoscopy. The over-the-scope clip system (OTSC) has previously been shown to close small colonic perforations effectively. The aim of this randomized controlled porcine study was to compare acute closure strengths between the novel 11-mm over-the-scope-clip and surgical closure for large colonic perforations. MATERIAL AND METHODS: In 24 anesthetized domestic pigs, an 18-mm sigmoid perforation was created endoscopically using a needle knife and dilating balloon. The animals were randomly assigned to undergo either open surgical repair (n = 12) or endoscopic closure using the OTSC system (n = 12). Pressurized leak tests were performed during necropsy. RESULTS: Mean time to perform the incision in the sigmoid colon and obtain peritoneal access was 5.5 minutes (range 3 - 12; SD ± 2.5). Mean time for endoscopic closure was 6.8 minutes (range 3 - 14; SD ± 3). At necropsy, all OTSC and surgical closures demonstrated complete sealing of colotomy sites. In one case peritoneum and in a second case adjacent small intestine were found incorporated into the OTSC closure. No other complications occurred. Pressurized leak tests revealed a mean burst pressure of 62.8 mmHg (range 18 - 112; SD 35.7) for OTSC closures and 67.4 mmHg (range 30 - 90; SD 19) for sutured closure. No significant differences in burst pressures were noted between the OTSC closures and surgical repair. CONCLUSION: Closure of acute perforations using the OTSC system is comparable to surgical closure in a nonsurvival porcine model.

Current techniques of laparoscopic colectomy require an abdominal incision for extraction of the specimen. Although this incision is smaller than that for open laparotomy incision, it may reduce the advantages of laparoscopic surgery. In totally laparoscopic sigmoid colectomy, intracorporeal anastomosis is technically difficult. A safe and simple technique for circularly stapled intracorporeal anastomosis is described. After mobilization of the colon and division of the mesentery, a semicircumferential colotomy is made at the anterior colonic wall just proximal to the transection site. The anvil of a circular stapling device, secured with a Prolene suture, is introduced via the colotomy. The suture is advanced anteriorly so that the center rod of the circular stapling device penetrates the colonic wall. The colon is staple-transected at this point to secure the anvil on the proximal colon. A grasping forceps is brought through the rectum, and the specimen is extracted through the colotomy made at the distal staple line. After the colotomy is reclosed with a linear stapler, anastomosis is established using a hemidouble stapling technique. Totally laparoscopic sigmoid colectomies were performed for 16 patients with colon cancers. All the patients were treated laparoscopically without any complications. The average operation time was 180 min. Although one patient experienced wound infection, no major complications occurred. There was no mortality in this series. The procedure of totally intracorporeal anastomosis combined with transanal extraction of the specimen can be performed easily, enabling surgeons to achieve minimal invasiveness comparable with that of hybrid natural orifice translumenal endoscopic surgery (NOTES).

This study aimed to evaluate the effect of two different sterilization protocols on the bacterial counts in the swine colon as preparation for natural orifice translumenal endoscopic surgery (NOTES) surgery.In this study, 16 swine were randomized to two different colonic sterilization protocols: low colonic irrigation using 300 ml of a 1:1 dilution of 10% povidone-iodine (Betadine) with sterile saline, followed by 1 g of cefoxitin dissolved in 300 ml of saline or two consecutive 300-ml irrigations using a quaternary ammonium antimicrobial agent (Onamer M). Colonic cultures were taken before colonic cleansing after a decontamination protocol and after completion of the NOTES procedure. The Invitrogen live/dead bacterial viability kit was used to assess for change in the bacterial load. A qualitative culture of peritoneal fluid was obtained at the end of the NOTES procedure. Colon mucosal biopsies obtained immediately after the sterilization procedure and at the 2-week necropsy point were evaluated for mucosal changes.Protocol 1 resulted in an average 93% decrease in live colonic bacteria versus 90% with protocol 2 (nonsignificant difference). After a NOTES procedure, group 1 had a 62% increase in live bacteria and group 2 had a 31% increase (nonsignificant difference). Peritoneal cultures also were obtained. Bacteria were isolated from the peritoneal fluid of all the animals, and two or more species were isolated from 75% of the animals. There was no evidence of peritoneal infection at necropsy. Reactive epithelial changes and mild inflammation were the only pathologic abnormalities. No changes were noted at histologic evaluation of colonic mucosa after 2 weeks, demonstrating that these were temporary changes.Colonic irrigation with Betadine and antibiotics are as effective for bacterial decontamination of the swine colon as a quaternary ammonium compound. The results of this study support the use of either protocol. Despite thorough decontamination, peritoneal contamination occurs. The significance of this for humans is unknown.

Background Transgastric and transvaginal approaches in natural orifice transluminal endoscopic surgery (NOTES) are the most commonly used, although the transcolonic approach may have some advantages. Objective To develop a workable technique for transcolonic NOTES. Design A nonsurvival study followed by a survival study in a porcine model. Transcolonic peritoneoscopy was performed with the use of a novel intracolonic occlusion balloon. The colotomy was closed with endoclips. A necropsy and histologic evaluation were performed 2 weeks after surgery. Setting Academic hospital, health science research center. Subjects Fifteen female Yorkshire pigs (5 nonsurvival, 10 survival). Interventions A balloon-tipped catheter was placed proximal to the colotomy site. The balloon was inflated to occlude the colonic lumen. An endoscope was inserted through the anus. Colonic incision was created with an endoscopic needle-knife at 15 to 20 cm from the anal verge. Peritoneoscopy was performed. The colotomy was closed with endoclips. Main Outcome Measurements Rates of complications, survival, healing, and adhesions. Results Two initial experiments were complicated by bowel distension and contamination of the incision area by colonic content. In the remaining 13 pigs, the experiments were performed with the use of the intracolonic occlusion balloon. No complications were documented. Necropsies were performed 2 weeks after surgery. Gross and histologic evaluations demonstrated near complete healing. Minimal adhesions were identified in 4 of 10 pigs. Limitation Imperfection of the prototype balloon. Conclusions Excessive bowel distension and fecal contamination because of spillage from the proximal bowel may be barriers to performing transcolonic NOTES. Isolation of the operative area by splitting the bowel and sealing the colonic lumen with the balloon above the colonic incision may overcome these problems and optimize the technique.

BACKGROUND AND STUDY AIMS: Safe, reliable, and efficient endoscopic closure of a colotomy is paramount for endoscopic full thickness excision of the colon. Two newly developed devices, the Tissue Apposition System (TAS) and the InScope Multi-Clip Applier (IMCA), may help to achieve this. The aim of this study was to determine the feasibility of using each device to close colotomies after full thickness wall excisions. MATERIAL AND METHODS: 12 pigs were used in the study. After laparoscopic full thickness excision of the colonic wall, the defect was closed using either the TAS or the IMCA. Closure was performed under laparoscopic vision. Success of colotomy closure, time taken for colotomy closure, postoperative infections, and complication rates were recorded. RESULTS: Complete closure was achieved in 6/6 pigs in the TAS group. In 5/6 pigs in the IMCA group closure was successful; in one pig laparoscopic assistance was used. Median closure time (range) was significantly lower in the TAS group at 48 minutes (15 - 51) vs. 76 minutes (43 - 145) in the IMCA group. There were no postoperative infections or complications. CONCLUSIONS: Endoscopic closure after full thickness colonic wall excision is feasible with both the TAS and the IMCA. Closure times are significantly shorter and handling is easier with the TAS. Combined use of both systems might be beneficial.

BACKGROUND AND STUDY AIMS: Natural orifice transluminal endoscopic surgery (NOTES) is a potentially less invasive alternative to laparoscopic surgery that may be applicable to distal pancreatectomy. We aimed to demonstrate the technical feasibility of a NOTES distal pancreatectomy in an in vivo porcine model via a combined transvaginal-transcolonic approach. MATERIAL AND METHODS: The procedure was performed in five female Yorkshire pigs weighing approximately 30 kg each. A prototype endoscope (”R-scope”), advanced into the peritoneal cavity through an anterior colotomy, and a computer-assisted linear stapler, introduced transvaginally, were used in dissection and resection of the distal pancreas. Prone positioning was used to enhance retroperitoneal exposure. Pneumodissection was used for blunt dissection. The colotomies were closed with endoloops. Necropsies were done immediately after the procedure in the first three animals, and after 2 weeks’ survival in the final two animals. RESULTS: Distal pancreatectomy was successful in all five animals. Prone positioning was critically important for proper exposure of retroperitoneal and pelvic structures. Pneumodissection was effective for blunt dissection, and both the linear stapler and R-scope functioned smoothly. Transvaginal and transcolonic access provided similar intraperitoneal views, and the dual-lumen approach enhanced triangulation. Both survival animals thrived postoperatively. Necropsies revealed clean staple lines; closed transcolonic and transvaginal incisions; and absence of infection, hemorrhage, or fluid collections. CONCLUSIONS: NOTES distal pancreatectomy is technically feasible in the porcine model. The transvaginal approach provides a vantage point very similar to that of the transcolonic route and holds promise as a NOTES access site, either singly or as part of a dual-lumen approach. The endoscopic linear stapler and R-scope both advance NOTES capabilities. The novel concepts of fully prone positioning, pneumodissection, and endoloop colotomy closures are introduced. Considering anatomical differences and that healthy animals were used, transferring this technique to patients with pancreatic disease might be difficult and further modifications would likely be needed.

Differentiation of large bowel disease from small intestinal disorders is based on history and clinical examination. The clinical signs are a result of disruption of the functions of the large bowel – namely, absorption of water and electrolytes from luminal contents, and storage and periodic expulsion of faecal material. This chapter addresses anatomy, diagnosis and treatment of many different conditions. Operative techniques: Colotomy; Colectomy; Typhlectomy (caecal resection); Incision colopexy; Anal ‘pull-out’ procedure for lesions requiring full-thickness resection; Rectal ‘pull-through’ procedure; Dorsal rectal approach; Ventral approach to the rectum; Perineal herniorrhaphy in a male dog; Anal sacculectomy; Anoplasty.

Benign lesions of the colon are infrequent and with a low percentage of appearance. Colon lipomas are in the third place of benign tumors after adenomas and smooth muscle [1,5]. Colonic lipomas are benign non epithelial tumors of soft texture and mesenchymal origin; generally they grow from mature adipocytes. Lipomas can appear in the entire gastrointestinal tract. They are generally asymptomatic, but when symptomatically, bleeding and obstruction can appear [2,4]. Its clinical diagnosis is difficult, signs and symptoms include abdominal pain, obstruction, lower gastrointestinal bleeding, diarrhea, constipation, and intussusception [5]. These tumors are found in endoscopies, radiological exams, surgical interventions, and autopsies. We present 2 cases of colon lipoma.

Colorectal foreign bodies are infrequently encounteredand present a dilemma for management. The diagnosis may be confirmedby plain abdominal radiographs and rectal examination, butabdominal computerized tomography with 3-D reconstruction can be decisive in thefurther management and must be advised without reconsideration. Transanal removal is only possible for very low-lying objects, while patients with high-lying foreign bodiesusually require anoperative intervention. An early decision of laparotomy should only be madeafter subjecting the patient to suitable investigations to determineexactly the localization of the object, in order toavoid any inadvertent damage to the adjoining vasculatureas well as anal incontinence. We report the case of a youngadult male who presented in the emergency department with a Hand Held Bidet Shower inserted per rectum. Transanal removal was unsuccessful and Emergent laparotomy with colotomy and primary repair was necessary for safe removal of the same.

The millennium provides an opportunity to contemplate and review the recent past and to plan for the future. The last half century, in particular, has been the golden age of gastroenterology, wherein rigorous, scientifically based medicine has revolutionized gastrointestinal diagnosis and therapy. The technologic fantasy and science fiction of 50 years ago has become the real and commonplace. The peptic ulcer that was treated by the Sippy meal, gastric freezing, or gastric radiation 50 years ago is now treated by scientifically based pharmacotherapy, including potent proton-pump inhibitors and antimicrobial therapy. The cecal adenoma that required inpatient laparotomy and colotomy for polypectomy 30 years ago is now simply removed by ambulatory colonoscopic polypectomy. The surgical gastrostomy for long-term enteral feeding of 20 years ago is replaced by percutaneous endoscopic gastrostomy. The awkward, painful, and sometimes dangerous semiflexible endoscope of 42 years ago has been replaced by the simple, convenient, and safe flexible endoscope. The word abdomen is derived from the Latin abdere , meaning hidden or concealed. 62 The flexible endoscope, the computed tomography (CT) scan, and the abdominal ultrasound study have opened this previously inaccessible organ to observation and inspection by the gastroenterologist, radiologist, and surgeon without surgery. The surgeon's knife has become the endoscopist's papillotome, and the laparotomy has become a laparoscopy. The diagnostic laparotomy has become nearly obsolete. The excitement at novel discoveries yields to complacency with time as the inconceivable becomes ubiquitous. Yet what human endeavor has contributed more to the betterment of humanity than medicine? For example, one simple gastroenterologic therapy—oral rehydration with glucose and electrolyte solution—has saved millions of lives per year worldwide from cholera. This revolution was accomplished not by the sword but by the pencil, not by rhetoric but by statistics, and not by climbing the ramparts but by toiling in the laboratory and clinic. This revolution is largely undocumented, unrecognized, and unpraised. The furious pace of magnificent discovery and invention and the preoccupation of the discoverers and inventors with discovery and invention have left little time for writing a history. A gastroenterologic history provides manifold salutary effects. First, individuals who toiled, created, and invented receive overdue and well-deserved recognition. Second, a history provides role models to the initiate or student in gastroenterology. Third, a historical perspective provides the discipline an identity, purpose, and mission. Fourth, a history collates, categorizes, and clarifies the important issues in gastroenterology. An historical perspective helps outline important ongoing areas of controversy and research interest and suggests strategies, approaches, and techniques for further research. Fifth, a history that celebrates great past gastroenterologic achievements may cause legislators to reconsider draconian cutbacks in funding future worthy projects. A contemporaneous history is most meaningful because a contemporary can evaluate the impact of changes, with knowledge of past and present. Immediacy provides impact. This article is included in this issue of the Gastroenterology Clinics in honor of the millennium. To provide a proper perspective, Cappell asked several senior luminaries to vote as a committee on the 50 great landmarks during the past 50 years. The vote revealed surprising concordance, with the largest discrepancy being a difference in six of the selected landmarks. The importance and history of each landmark discovery is discussed to provide an appropriate vehicle for a brief modern history of gastroenterology. The first part of this historical essay, which discussed endoscopic, radiologic, and surgical techniques and upper gastrointestinal disorders, was presented in the March 2000 issue of the Gastroenterology Clinics . This second part completes the historical essay.

Background Benign colonic polyps that are impossible to remove with the aid of the flexible colonoscope because of their size or location must be removed surgically. Methods Twenty patients with colonic adenomatous polyps that could not be resected by colonoscopy because of size or difficult location (n = 18) or polyps in combination with diverticulitis (n = 2) underwent polyp removal through a small ‘assisted’ incision in the abdominal wall using a standard ‘dissection-facilitated’ laparoscopic approach to the affected colonic segment. Results In six patients the polyp was removed through a colotomy, in three through a limited resection (two ileocaecal and one limited sigmoid resection) and in 11 through a standard colectomy (four right hemicolectomy, one left hemicolectomy, four sigmoid and two anterior resections) because of suspicion of cancer. In only one patient could the polyp not be found during laparoscopy, resulting in a second conventional surgical intervention. In four patients carcinoma was diagnosed in the specimen. Conclusion Precise preoperative localization of the polyp and the use of dissection-facilitated laparoscopic colonic surgery make laparoscopic removal of benign colonic polyps an alternative to an open procedure.

Objective. To assess outcomes of a hand-assisted laparoscopic approach (HALS) for the management of difficult colorectal polyps. Methods. In 2007–2013 at the Institute of Oncology, Vilnius University, 25 HALS colorectal procedures for polyps which could not be treated by endoscopy were performed. Demographic data, histology of the biopsy, type of surgery, length of postoperative stay, complications and final pathology were reviewed prospectively. Results. 25 patients with a mean age of 65.88±13.3 years underwent HALS polypectomy. Preoperative morphology was: 20 (80%) patients with adenomas and 5 (20%) – Ca in situ. Laparoscopic mobilization of colonic segment, and colotomy with removal of polyp was performed for 5 (20%) polyps. Laparoscopic segmental bowel resection was performed in 20 (80%): anterior rectal resection with partial total mesorectal excision – 10 (40%), left hemicolectomy – 6 (24%), sigmoid resection – 3 (12%) and resection of transverse colon in 1 (4%). Mean postoperative hospital stay was 6.4±2.5 days. Two patients (8%) had complications – urinary tract infection. Both recovered after conservative treatment. Mean polyp size was 3.8±2.2 cm. Final pathology revealed polyp (n = 1), tubular adenoma (n = 3), tubulovillous adenoma (n = 12), Carcinoma in situ (n = 7) and invasive cancer (n = 2). Both patients underwent laparoscopic left hemicolectomies (HALS) in 14 and 10 days after laparoscopic colotomy and polypectomy. Conclusions. For the management of endoscopically unresectable polyps, laparoscopic polypectomy is currently the technique of choice.

to present the results of treatment of rectal foreign bodies.15-year outcomes of 112 patients with rectal foreign bodies were analyzed.Outpatient and hospital care were applied in 52 (46%) and 60 (54%) of cases respectively. Transanal removal was made in 97 (87%) patients including 28 (25%) cases of general anaesthesia. 14 (13%) patients underwent surgery. Colostomy was performed in 7 (6%) cases. We presented cases of foreign bodies removal through laparotomy, colotomy and SILS-assisted transanal approach.From clinical point of view foreign bodies should be first of all classified by their dimensions. Anamnesis and physical examination are very important. Abdominal X-ray survey is obligatory. Transanal removal under general anaesthesia is advisable if perforation is absent. If such procedure is impossible laparotomy is indicated.Algorithm of survey and treatment is presented.В последние годы число больных с инородными телами прямой кишки имеет тенденцию к росту, особенно среди городского населения, а в некоторых наблюдениях отмечаются тяжелые осложнения, поэтому проблема требует внимания не только специалистов-колопроктологов, но и хирургов амбулаторий и стационаров, оказывающих экстренную хирургическую помощь. Материал и методы. Проведен анализ результатов лечения 112 пациентов с инородными телами прямой кишки за 15 лет. Результаты. Амбулаторная помощь была оказана 52 (46%) больным, стационарное лечение получали 60 (54%) пациентов. Трансанальное удаление инородного тела произведено в 97 (87%) наблюдениях, из них в 28 (25%) процедуру выполняли под общей анестезией. Оперированы 14 (13%) пациентов. В 7 (6%) наблюдениях произвели колостомию. Представлены клинические примеры удаления инородных тел из лапаротомного доступа, с помощью колотомии, а также трансанально с использованием SILS-порта. Обсуждение. С клинической точки зрения, инородные тела следует классифицировать прежде всего по размеру. В диагностике большое внимание уделяется анамнезу и физикальному обследованию. Считаем обязательным проведение рентгенологического исследования органов брюшной полости. При отсутствии признаков перфорации следует осуществить трансанальное удаление под общим обезболиванием. При невозможности манипуляции показана лапаротомия. Вывод. Приведен алгоритм обследования и лечения в случае инородного тела прямой кишки.В последние годы число больных с инородными телами прямой кишки имеет тенденцию к росту, особенно среди городского населения, а в некоторых наблюдениях отмечаются тяжелые осложнения, поэтому проблема требует внимания не только специалистов-колопроктологов, но и хирургов амбулаторий и стационаров, оказывающих экстренную хирургическую помощь. Материал и методы. Проведен анализ результатов лечения 112 пациентов с инородными телами прямой кишки за 15 лет. Результаты. Амбулаторная помощь была оказана 52 (46%) больным, стационарное лечение получали 60 (54%) пациентов. Трансанальное удаление инородного тела произведено в 97 (87%) наблюдениях, из них в 28 (25%) процедуру выполняли под общей анестезией. Оперированы 14 (13%) пациентов. В 7 (6%) наблюдениях произвели колостомию. Представлены клинические примеры удаления инородных тел из лапаротомного доступа, с помощью колотомии, а также трансанально с использованием SILS-порта. Обсуждение. С клинической точки зрения, инородные тела следует классифицировать прежде всего по размеру. В диагностике большое внимание уделяется анамнезу и физикальному обследованию. Считаем обязательным проведение рентгенологического исследования органов брюшной полости. При отсутствии признаков перфорации следует осуществить трансанальное удаление под общим обезболиванием. При невозможности манипуляции показана лапаротомия. Вывод. Приведен алгоритм обследования и лечения в случае инородного тела прямой кишки.

A transrectal (TR) approach for natural orifice translumenal endoscopic surgery (NOTES) makes sense for colorectal surgery because the colotomy can be incorporated into subsequent anastomosis. Because cancer is a primary indication for left-sided colon resection, oncologic standards will have to be met by a NOTES procedure. This study aimed to assess whether pure TR rectosigmoidectomy can be performed with strict adherence to oncologic principles compared with a conventional laparoscopically assisted approach (LAP).Human male cadavers were allocated to either TR (n = 4) or LAP (n = 2). A simulated sigmoid lesion was created at 25 cm. Transrectal retrograde mobilization of the rectosigmoid was performed using conventional transanal endoscopic microsurgery (TEM) instrumentation. After ligation of the superior hemorrhoidal artery and further mobilization, the specimen was delivered transanally and divided extracorporeally. Using a circular stapler, NOTES colorectal anastomosis was performed. Lymph node yield, adequate resection margins, and operative time were compared with LAP.Transrectal retrograde rectosigmoid dissection was achieved in all attempts (4/4) and showed numbers of lymph nodes (median, 5; range, 3-6) similar to the LAP group (median, 4.5; range, 2-7). One pure TR approach failed to resect the lesion. Three TR procedures required additional mobilization via an abdominal approach to provide adequate margins. The mean length of TR specimens was 16 ± 4 cm compared with 31 ± 9 cm achieved by LAP (p0.01). The TR operative time was significantly longer (247 ± 15 vs 110 ± 14 min).Lymph node yield during TR rectosigmoidectomy was similar to that achieved by the LAP approach. However, conventional TEM instrumentation alone did not permit adequate colon mobilization. This indicates a need for flexible instrumentation or other technical solutions to perform true NOTES colectomies.

OBJECTIVE To determine the technical feasibility and clinical outcomes of laparoscopic anterior resection using combined single-port and endoluminal technique. METHODS A single port was placed at the umbilicus. Sigmoid colon was retracted using transabdominal sutures. After adequate mobilization, the colon was stapled distal to the lesion using noncutting endostapler, and the rectum was opened distal to the staple line. The transanal endoscopic operation device was placed transanally and the anvil of a circular stapler was then delivered through the device into the peritoneal cavity. The anvil was placed intraluminally through a colotomy made proximal to the lesion; after this, the colon was transected above the colotomy site. The specimen was next delivered transanally through the transanal endoscopic operation device. Finally, the rectum was closed with endostapler and intracorporeal side-to-end colorectal anastomosis was constructed using the circular stapler. RESULTS This technique was attempted in an 80-year-old woman with a 3 cm sessile polyp in the distal sigmoid. Laparoscopic anterior resection was arranged as the polyp was not amenable to endoscopic removal. The operative time was 150 minutes. There was no intraoperative complication. The patient was discharged on postoperative day 6, with a maximum pain score of 3. CONCLUSIONS Laparoscopic anterior resection using this combined single-port and endoluminal technique is feasible for small lesions in the sigmoid colon or upper rectum. The technique avoids multiple trocar incisions and a minilaparotomy for specimen retrieval.

As surgeons become more familiar with laparoscopic instrumentation, innova.the minimally invasive procedures are replacing traditional surgical approaches. The limitations of minimal access surgical procedures are unknown, but it is likely that this technique will continue to be the forerunner in general surgery. Laparoscopic colotomy and polypectomy is an example of new innovative minimal access procedures. gy. polyps may be removed by a colonoscope or sigmoidoscope using a snare with cautery capability.? If a polyp is too large to remove by endoscopy, or if angulation and looping of the colon inhibit safe passage of the endoscope, the polyp is removed via exploratory laparotomy and a colon resection or colotomy and polypectomy. Laparoscopic removal of colon polyps provides an alternative to laparotomy for patients with colonic polyps not amenable to colonoscopic removal. Etiology, Treatment

Background and study aims Transluminal closure is fundamental to the safe introduction of natural orifice transluminal endoscopic surgery (NOTES) into humans. Suture, staples, and clips have been used. We aimed to evaluate the acute strength of various gastrotomy and colotomy closure techniques in an ex vivo porcine model by assessing air leak pressures. Patients and methods The following closure modalities were assessed with at least five samples per arm: conventional open/laparoscopic suturing techniques including full-thickness interrupted sutures, double-layer sutures, and purse-string sutures, as well as endoscopic clips and endoscopic staples. Historical values for transgastric closures with hand-sewn interrupted sutures, endoscopic clips, and a prototype endoscopic suture device were used from our laboratory's prior study. Results Using Kruskal-Wallis analysis, the overall comparisons were significant ( P = 0.0038 for gastrotomy closure; P = 0.0018 for colotomy closure). Post hoc paired comparisons revealed that the difference between all closure arms versus negative control were significant. Significance could not be established among the various closure arms. However, trends suggested hand-sewn double-layer sutures, endoscopic staples, and both hand-sewn and endoscopically-placed purse-string sutures produced the strongest closures. Furthermore, endoscopic clips appeared sufficient for colotomy closure when ideally placed. Conclusions Suture (both hand-sewn and endoscopically deployed) appears to produce the strongest closures in both stomach and colon, with the important caveats that (1) a continuous through-thickness suture track be avoided, such as in the full-thickness closure, or (2) suture holes be buried, such as in the purse-string configuration. When suture tracks are full-thickness, they can serve as leak sites. Staples and clips can produce comparable closures, but only under ideal conditions.

Background Safe and efficient endoscopic closure of a colotomy is essential for transcolonic peritoneal access or endoscopic full-thickness resection of the colon, if open or laparoscopic surgery is to be avoided. Objective To compare the feasibility and safety of colotomy closure with the newly developed Tissue Approximation System (TAS, Ethicon Endo-Surgery, Inc.) to conventional laparoscopic suture closure. Design Prospective randomized survival animal study involving 16 pigs. Setting University hospital. Interventions Pigs were randomized for closure of a 2- to 3-cm full-thickness colotomy with the TAS or with a conventional laparoscopic running suture. Main Outcome Measurements Success of colotomy closure, time of colotomy closure, postoperative infection, and complication rates. Results Colotomies were successfully closed in all animals. Median closure time (range) was 39.5 minutes (25-95 min) in the TAS group and 23 minutes (16-40 min) in the laparoscopic group ( P = .0134). There were no postoperative infections or complications. Limitations Closure with the TAS was performed under laparoscopic vision. There was no control group without closure of the colotomy site. Conclusions Colotomies are safely closed with the TAS with comparable results to laparoscopic closure. The TAS may serve as a useful tool to close full-thickness colon defects or colotomy sites made for transluminal endoscopic procedures.

A pictorial review of colorectal foreign bodies and their extraction.A prospective data-base and photographic record of patients who presented with retained colorectal foreign bodies at our institution has been maintained since 1995. Information regarding the foreign body, clinical presentation and extraction technique were documented.All 13 patients were male: age range 2-66 years. Seven were Caucasian, 4 African and 1 Asian. The foreign bodies included a penknife, an aerosol deodorant spray can, a blue plastic tumbler, a plastic bag containing two bank-notes and some marijuana, a plastic packet containing fish hooks, a penlight torch, a broomstick, a battery powered vibrator, a primus stove, a cap of an aerosol can, a piece of wire, a piece of hosepipe wrapped with wire and an iron bar. They entered the alimentary tract for a variety of reasons; anal autoeroticism (3), concealment (2), attention seeking behaviour (3), accidental (1), assault (2) and to alleviate constipation (2). Plain radiographs accurately demonstrated the site of the foreign body in 8 patients. Extraction was at laparotomy in 2 patients with peritonitis and in 3 who required extraction by colotomy. In 7 patients who had transanal extraction, four required general anaesthesia to facilitate extraction and extraction was possible under conscious sedation in the emergency room in three. The remaining patient extracted the foreign body himself and presented to hospital with a rectal perforation.The emergency room physician must confirm the presence of a rectal foreign body. Extraction in the emergency room is usually not possible and patient's with retained rectal foreign bodies should be referred to a colorectal surgeon.

Anastomotic stricture is an increasingly common clinical finding. It is thought to arise because of ischemia, disruption, or leakage at an anastomosis site. Its management can be difficult and strictures often are resistant to standard dilation therapy. Major corrective surgery is possible; however, it is technically challenging and not without risk. We have used a circular stapler to excise colorectal strictures, introducing the anvil of the stapler via a proximal stoma or colotomy, drawing the anvil through the stricture with a snare via a colonoscope and affixing it to the body of a circular staple gun and excising the stricture. We have with found this to be an effective treatment in appropriately selected patients.

PURPOSE: Patients with colorectal polyps often display a large kink or distinct mucosal fold in the area where the polypectomy is to take place. As a result, there is a higher risk of perforation or partial ablation during an endoscopic polypectomy. Is it safer to perform an endoscopic polypectomy using the control and assistance of a laparoscope? Can a segment resection of the colon that would otherwise be necessary be avoided? METHODS: An endoscopic polypectomy using a laparoscope was conducted on six patients whose colorectal polyps were in an anatomically unfavorable location. The need for an open or laparoscopic segment resection or colotomy was indicated in all cases. The growth was located in the rectosigmoidal transition in five patients and in the region of the left flexure in one patient. We decided that an endoscopic polypectomy using the assistance of a laparoscope would be the most comfortable and technically elegant method, as well as easy. Except the well-known risks of laparoscopy and endoscopic polypectomy, no other risks have been seen in our patients. The affected area of the colon, the sigma, and the left flexure were mobilized and stretched as much as possible to enable a simultaneous and low-risk endoscopic polypectomy. In one case, we had to conduct a fractionated ablation because of a very wide-based finding. RESULTS: The operation averaged 57 minutes, and no operation-specific complications were observed. Postoperative recovery in the hospital was very short and averaged 2.5 days. The histopathologic findings were benign in all cases, but a serious dysplasia was diagnosed in one patient. CONCLUSIONS: The laparoscopic-assisted polypectomy is a safe method to remove even complicated polyps in anatomically unfavorable locations.

This article tries to answer the question about the feasibility of laparoscopically assisted resection of difficult ‘‘benign’’ polyps. It would have been useful if the data presented had been contextualized with regard to the number of patients who underwent alternative or open procedures? Primarily, open resection of benign, even difficult polyps, is no longer the therapy of choice and almost dispensable since the introduction of combined procedures to our department in the early 1990s. Thus, all patients received the combined approach at first. Seven patients (5%) underwent conversion to open surgery due to suspicion of malignant disease (n = 3, according to institutional policy), bowel perforation during colonoscopy (n = 1), difficult closure of the colotomy (n = 2), and incomplete resection of a rectal lesion (n = 1). This was clearly stated in the article. If the polyps were classified as endoscopically resectable in a routine preoperative endoscopic examination, this was the preferred therapy. The definition of polyps deemed unresectable by colonoscopy was accepted as subjective. However, was there any screening or repeat colonoscopy by an experienced colonoscopist? All the patients had received a colonoscopy by an experienced endoscopist before presenting to our institution. However, preoperative recolonoscopy routinely performed could preserve about 5% of patients from surgical treatment. Concrete endoscopic snare resection had even been attempted for 27 of the patients but was unsuccessful. Moreover, we note that with laparoscopic assistance, only eight polyps were endoscopically approachable, as displayed in Table 2. Voloyiannis et al. [1] found that selective colonoscopy for 171 of 252 patients referred led to avoidance of resection for 101 patients. As a result, 58% of these were rescoped, and 40% of all the patients referred avoided resection. This resection rate may improve with the relatively new technique of colonoscopic (endoscopic) mucosal resection described by Saito et al. [2]. The percentage of resections avoided by recolonoscopy was comparably low in our series, as already mentioned. However, all referring practitioners are highly experienced endoscopists, and the low avoidance rate may be due to the fact that the classification of polyps as unresectable is justified to a great extent. The technique of endoscopic submucosal dissection for large colonic adenomas, as described by Saito et al. [2], is very demanding but attracting initial interest in Japan. In the Western world, endoscopic submucosal resection still is in its infancy and not a standard procedure. Additionally, it is associated with a much higher complication rate. The authors are to be complimented for their honest appraisal of complications at 25%. D. Wilhelm (&) H. Feussner Department of Surgery, Technische Universitat Munchen, Klinikum rechts der Isar, Ismaninger Strasse 22, 81675 Munich, Germany e-mail: wilhelm@chir.med.tu-muenchen.de

A modified technique of an intracolonic bypass procedure after an anastomosis has already been completed is described. Its use would be in place of those situations where the surgeon is contemplating protecting the completed anastomosis with a temporary colostomy/ileostomy.