Needlescopic and Endoscopic Cooperative Surgery for Colonic Tumors.

Laparoscopic and endoscopic cooperative surgery (LECS) enables local full-thickness resection using a combination of endoscopic submucosal dissection (ESD) and laparoscopic surgery.1-3 Indications of LECS for colorectal tumors were as follows: 1) intramucosal cancer and adenoma accompanied by wide and severe fibrosis; 2) intramucosal cancer and adenoma involving the diverticulum or appendix; and 3) submucosal tumors.1 Needlescopic surgery is a minimally invasive technique using thin forceps (≤3 mm) while maintaining the surgical quality compared with conventional laparoscopic surgery.4-6 We developed a needlescopic and endoscopic cooperative surgery (NECS) technique combining LECS and needlescopic surgery as a new minimally invasive technique. We herein present a video http://links.lww.com/DCR/B436 of NECS being performed for a benign adenoma at the ascending colon. The tumor was endoscopically unresectable because it was involved with a diverticulum next to the tumor. In brief, the procedure was conducted as follows: 1) A Laparoscopic procedure was performed with a total of 4 ports, including two 3-mm ports. The ascending colon was mobilized from the retroperitoneum, preserving the right ureter and gonadal vessels. After mobilization of the ascending colon, we placed laparoscopic anchoring sutures to lift the colonic wall around the tumor. 2) Endoscopically, a circumferential mucosal incision and seromuscular layer cutting around the tumor and diverticulum were conducted using the ESD technique. 3) Laparoscopically again, the remaining part of the colonic wall was cut, and the tumor was removed. The colonic wall was then closed with a laparoscopic linear stapler while lifting the sutures that had been temporarily placed at a site near the incision line. 4) Endoscopy confirmed the closing line and good passage through the ascending colon. In this NECS technique, postoperative wounds are small and barely noticed. NECS is a viable alternative surgical approach for endoscopically unresectable colonic tumors.