A Novel Hybrid Retroperitoneal Approach and Natural Orifice Specimen Extraction Surgery II for Surgical Treatment of Rectosigmoid Cancer.

Abstract

The retroperitoneal approach and natural orifice specimen extraction surgery are emerging minimally invasive techniques in colorectal surgery. Each technique independently aims to reduce operative trauma and enhance postoperative recovery. This report presents the first known case combining these 2 minimally invasive strategies for the surgical treatment of rectosigmoid cancer. This combined approach has the potential to minimize both peritoneal and abdominal wall trauma. By performing key surgical steps (mobilization, devascularization, lymphadenectomy) through the retroperitoneal space and eliminating the need for an abdominal incision for specimen extraction, it may reduce postoperative pain and surgical site complications. A 68-year-old woman with rectosigmoid adenocarcinoma clinical stage T3N1M0 disease underwent the procedure. Trocar placement included a 10-millimeter umbilical port, three ports in the left flank for retroperitoneal access and an additional port for the transperitoneal phase of the procedure. Key steps performed retroperitoneally included sigmoid colon mobilization, D3 lymph node dissection, and vessel-sparing ligation of the inferior mesenteric artery (preserving the left colic artery) and inferior mesenteric vein. The retroperitoneal space was then connected to the abdominal cavity. The rectum was transected, and the specimen was extracted transrectally (natural orifice specimen extraction surgery type II). An end-to-end anastomosis was created with a circular stapler. The operation lasted 190 minutes with an estimated blood loss of 20 milliliters. The final histology confirmed a pathologic stage T3N1a adenocarcinoma with 1 positive lymph node out of 26 retrieved. There were no intraoperative or postoperative complications. The patient had an uneventful recovery and was discharged on postoperative day 7. This approach represents a novel advancement in minimally invasive colorectal surgery, providing direct vascular access without entering the abdominal cavity and eliminating visible scars. It offers potential advantages for complex cases with adhesions or elevated body mass index and warrants further validation in larger prospective series. See New Technology Report Video.