New Method of Modified NOSES I

The proximal sigmoid mesentery is fully dissected while protecting the peri-intestinal vascular arch. The bowel is isolated at the site 2–3 cm distal to the lower edge of the tumor and 10 cm proximal to the tumor. The bowel is divided in the intended resection line proximal to the tumor (Fig. 45.1a). The sponge forceps is inserted through the anus to grasp the distal rectum, which is then pulled and everted out of the abdominal cavity through the anus (Fig. 45.1b). Dilute iodine solution is used for the repeated irrigation of the everted rectum (Fig. 45.1c); then purse-string forceps is used to clamp the rectum at 1–2 cm distal to the tumor under direct vision (Fig. 45.1d). After the rectum is transected and the specimen is removed, the sponge forceps is inserted into the abdominal cavity through the anus to pull the distal end of the sigmoid colon out of the abdominal cavity (Fig. 45.1e). Following this, the purse-string forceps is used to clamp the distal end of the sigmoid colon, the sigmoid wall is incised, and the blood supply to the distal end of the sigmoid colon is verified (Fig. 45.1f). Subsequently, the anvil is inserted into the distal sigmoid colon, and the purse-string suture is tightened (Fig. 45.1g).The distal sigmoid colon with the anvil is returned to the abdominal cavity; then the sigmoid rectal end-to-end anastomosis is performed after tightening the purse-string suture at the rectal stump (Fig. 45.1h). No auxiliary incision is made in the abdominal wall (Fig. 45.1i) (Hu et al. 2019).