探讨应用腹腔镜技术经人体自然通路对直肠癌患者行全直肠系膜切除术的可行性。

对2011年3至7月，中山大学附属第一医院12例经病理活检确诊的直肠癌患者，在腹腔镜下进行根治性全直肠系膜切除，低位直肠癌8例，高位直肠癌4例；男5例，女7例，平均年龄(61.18±7.5)岁。操作如下：肠系膜下动静脉根部切断，夹闭，切断左结肠和乙状结肠动静脉Ⅰ～Ⅲ分支，保留边缘动脉弓，用腔镜下切割缝合器在肿瘤近端预切断处切断、闭合肠管，经肛门在肿瘤远端预切断处缝闭直肠，在缝闭处下缘切断肠管。扩肛到5～6 cm直径大小，用标本袋保护，经肛门取出标本。近端结肠经肛门拖出并行荷包缝合，置入抵钉座、结扎。远端直肠(肛管)用肛门直肠扩张器显露，经肛门荷包缝合直肠残端，腹腔镜下完成经肛的结肠直肠(肛管)吻合。

无一例中转开腹，手术时间平均(123±85)min，平均失血量为87 ml。下切缘为2～5 cm；术后平均住院时间为8 d ；吻合口漏1例，无盆腔感染、肠梗阻、腹腔以及盆腔出血、吻合口出血以及吻合口狭窄等并发症。术后标本评估：全直肠系膜完全切除12例，环周切缘阴性12例，下切缘均为阴性，R0切除12例；平均淋巴结个数为(16.7±4.6)个，阳性淋巴结数为(4.6±1.8)个；高分化腺癌8例，低分化及黏液腺癌4例；TNM分期：Ⅱ期5例，Ⅲ期7例。

对直肠癌患者行腹腔镜辅助下根治性全直肠系膜切除术，经自然腔道取出标本，完成低位(超低位)前切除术，不违背肿瘤根治原则，同时在技术上是安全和可行的，可避免另加腹部小切口取出标本。

To discuss the feasibility of the laparoscopic radical colorectal cancer resection combined with natural orifice surgery extraction (NOSE).

From March 2011 to July 2011, the NOSE operations were performed on 12 patients with primary cancer of the low rectum, including 8 cases in low rectal cancer group and 4 cases in high rectal cancer group. Seven women and 5 men were enrolled. The mean age was 61.18±7.5 years. In the low rectal cancer group, the inferior mesenteric vessels were high ligated and clipped. Then, the Ⅰ-Ⅲ branches of left colon vessel and sigmoid vessels were cut and the Edge aortic arch was reserved. The marginal arteries were cut at the superior margin of tumor. The proximal and distal colon were closed with Endo.CIA. The distal rectum was closed at the low margin of tumor via anus. In high rectal cancer group, the rectum was cut at the low margin via abdomen. In low rectal cancer group, the distal rectum and anus canal were isolated circumferentially. The rectum was cut off at the proxiral end pulled out through and canal. After that, the specimen was dragged out through the anus with the protection of specimen bag, while the anal was dilated to 5-6 cm. The proximal rectum was implanted with the stapler head and closed with purse-string suture. While the distal rectum was exposed with an anorectal dilator, we did another purse-string suture to close the stump of distal rectum. Finally, the colorectal anastomosis was completed by the laparoscopy via abdomen and anus.

The mean blood loss was 81ml. No patient was converted to open surgery. The average length of hospital stay was 8 days. One case occurred anastomotic leakage, and no complications were occured, such as pelvic infection, intestinal obstruction, abdominal and pelvic bleeding, anastomotic obstruction and bleeding. Postoperative specimen evaluation showed that all the cases were TME with negative circumferential resection margin and R0 dissection. The average lymph nodes number was 16.7±4.6, while the positive lymph nodes number was 4.6±1.8. In all the cases, 8 were high-differentiated adenocarcinoma. 4 were low-differentiated adenocarcinoma or mucious adenocarcinoma. At the same time, 5 cases were stageⅡ and 7 cases were stage Ⅲ in TNM stage.

This technique is a safe and effective procedure for successfully performing laparoscopic TME of lower (or ultra-low) rectal cancer. It is not against the cancer radical dissection principle. The procedure was smoothly completed without any extra abdominal incision.