intersphincteric resection ( isr ) is a procedure that aims to preserve anal function in patients with very low rectal cancer . since the introduction of laparoscopic rectal surgery for rectal cancer
first described laparoscopic isr ( lap isr ) in 2000 , and a number of cases have since been reported .
we present our clinical experience with lap isr performed using needlescopic instruments in two patients with very low rectal cancer .
the first port for the camera is placed at the umbilicus using the open technique .
two 5-mm ports for the operator are inserted through the right upper and lower quadrants , and the upper port is placed where a diverting stoma would be created .
two needlescopic forceps ( endo - relief hope denshi co. , chiba , japan ) for the assistant are inserted into the left upper , and lower quadrants , such that a total of 5 ports are placed [ figure 1 ] .
the port placement ( schema and external view ) the endo - relief is a new type of needlescopic forceps .
the tip of this new forceps has the same shape and size as that of the conventional 5-mm forceps ; however , the new forceps type has a shaft measuring 2.4 mm in diameter . during the operation ,
this needlescopic forceps is assembled from five parts , including the tip which has the same size and shape as the conventional 5-mm forceps and a shaft measuring 2.4 mm in diameter assembling and use this forceps as follows . 

the shaft guide plus ( hope denshi co. , chiba , japan ) is directly inserted into the abdominal cavity through the abdominal wall.the top of the guide is passed through a 5-mm port extra - corporeally , and the inner needle is removed.the forceps end is connected to the shaft guide outer sheath.the handle parts are finally assembled , and the forceps top is then intra - corporeally pulled through a 5-mm port [ figure 3 ] . 
 
the shaft guide plus ( hope denshi co. , chiba , japan ) is directly inserted into the abdominal cavity through the abdominal wall .
the top of the guide is passed through a 5-mm port extra - corporeally , and the inner needle is removed .
the handle parts are finally assembled , and the forceps top is then intra - corporeally pulled through a 5-mm port [ figure 3 ] .
the shaft guide plus ( hope denshi co. , chiba , japan ) is directly inserted into the abdominal cavity through the abdominal wall ( a ) .
the top of the guide is passed through a 5-mm port extra - corporeally , and the inner needle is removed ( b ) .
the forceps end ( arrow ) is connected to the shaft guide outer sheath ( c ) .
the handle parts are finally assembled , and the forceps top is intra - corporeally pulled through a 5-mm port ( d ) after dissection of the rectosigmoid mesentery at the level of the sacral promontory [ figure 4 ] , the lymph nodes around the inferior mesenteric artery ( i m a ) are dissected using the electrocautery device and laparoscopic coagulating shears .
the i m a is divided above the left colic artery , after ligation with the clip , and the inferior mesenteric vein is divided at the same level .
colonic mobilisation is performed using a medial to lateral approach , to preserve the ureter and the gonadal vessels . the mesorectum is carefully mobilized into the pelvis to preserve the hypogastric nerves and pelvic plexus .
the needlescopic forceps inserted at the left upper quadrant is pulled cranially with the band or the gauze tied around the rectum circumferentially , and total mesorectal excision is carried down to the levator ani muscles .
the puborectalis and the hiatal ligament are dissected to the intersphincteric plane , which is about 2 cm distal from the top of the hiatal ligament .
the rectosigmoid mesentery is grasped with the end - relief , and then dissected using the electrocautery device ( a ) .
the puborectalis and the anococcygeal ligaments ( hiatal ligament ) are dissected to the intersphincteric plane , which is about 2 cm distal from the top of the anococcygeal ligament ( arrow ) ( b ) in the transanal dissection , the application of a self - holding retractor ( lone star retractor cooper surgical inc . ,
a circular incision of the mucosa and the internal anal sphincter is performed at the dentate line .
a loop ileostomy is created at the right upper port site , and the drainage tube is inserted into the pelvis . after the operation , the only abdominal incisions are limited to the stoma site and the port sites [ figure 5 ] .
one patient was a 60-year - old woman with a body mass index ( bmi ) of 22.5 .
colonoscopy revealed a rectal tumour and the distal border was located 3.5 cm distal from the anal verge [ figure 6 ] .
colonoscopy revealed a rectal tumour and the distal border was located 4.5 cm distal from the anal verge [ figure 6 ] .
operative times were 384 min and 406 min , and blood losses were 10 ml and 55 ml , respectively .
there were no intraoperative complications , and we were able to perform this procedure without the need for insertion of an additional port or changing the needlescopic forceps to conventional 5-mm forceps .
the postoperative hospital stays were 14 days and 20 days , respectively , because both patients needed to acquire sufficient knowledge of stoma management .
numbers of harvested lymph nodes were 7 and 16 , respectively . however , there was no lymph node metastasis in either case .
colonoscopy reveals a rectal tumour located 3.5 cm distal from the anal verge in a 60-year - old woman ( a ) .
a rectal tumour is located 4.5 cm distal from the anal verge in a 61-year - old man ( b )
intersphincteric resection is a sphincter - preserving procedure developed with the aim of avoiding the need for a permanent stoma in cases with very low rectal cancer , and was introduced by schiessel et al . with the spread of laparoscopic surgery to colon cancer
lap isr was first described by watanabe et al . in 2000 . since then , the feasibility of lap isr , in terms of complications , outcomes and anal functions , has been reported .
however , the sample sizes in these reports are relatively small , and only three reports collected > 100 cases having undergone lap isr .
first , this technique is often performed for low rectal cancer at stage 0/1 or clinical t1/t2 .
second , the lap isr procedure requires greater skill than laparoscopic low anterior resection . with lap isr procedures , it is not necessary to create an extraction site , because the resected specimen is extracted through the anus . furthermore , in many cases , a diverting ileostomy is created to avoid any potential risk for anastomotic leakage . in the recent literature ,
a diverting stoma was created in 88 - 100% of cases , the exception being the 11% described by park et al .
the stoma site can be used for single - incision laparoscopic surgery ( sils ) placement to reduce the number of ports .
reported that they created the sils port in the right lower abdomen , where a diverting stoma would be created , and the other two ports ( 10 mm port just above the umbilicus , 5 mm port at the left side of the abdomen ) .
two ports were inserted through the sils port , such that 4 ports in total were placed .
the concept of reduced port surgery includes not only sils , but also needlescopic surgery ( ns ) .
ns has been introduced for benign abdominal diseases , such as cholecystitis with gallbladder stones and appendicitis . in colorectal cancer surgery , ns is more advantageous as the natural orifice , that is , the rectum or the vagina , can be used for specimen extraction .
however , ns is adapted for isr procedures in order to avoid the creation of an extraction site , because the surgical specimen is extracted through the anus .
moreover , ns does not require expert techniques , as compared with the sils procedure .
therefore , we apply needlescopic instruments with the end relief when performing lap isr . during the operation , there is no tissue damage due to grasping the mesorectum or rectum with the end relief . because the needlescopic forceps tip has the same shape and size as those of a conventional 5-mm forceps , the risk of tissue injury with grasping and lifting
the end relief may have a particular advantage for laparoscopic colorectal surgery , because this procedure involves lifting tissues to maintain the operating field and grasping the large intestine .
furthermore , ns can more easily and safely be applied to laparoscopic colorectal surgery than needlescopic forceps in which both the needle shaft and tip are small .
the skin damage is only 2.4 mm in diameter , with the passage of the 2.4 mm shaft through the abdominal wall , because it can be used without a trocar .
although the end relief is strong enough for grasping tissues , the shaft can easily be slightly bent , when heavy tissues such as the mesorectum are lifted up .
therefore , we remain mindful of the direction of forceps implementation , in order to avoid bending the shaft .
laparoscopic isr is suitable for reduced port surgery , particularly ns , single port surgery , or mixed surgery , because the surgical specimen is extracted through the anus without creating a new extraction site .
our lap isr procedure using needlescopic instruments is a feasible procedure for minimally invasive surgery .
 intersphincteric resection ( isr ) is a procedure designed to preserve anal function in cases with very low rectal cancer . 
 we report our clinical experience with laparoscopic isr ( lap isr ) performed using needlescopic instruments . 
 first , a camera port is created at the umbilicus . 
 two 5-mm ports are then inserted at the right upper and lower quadrants . 
 two needlescopic forceps ( endo - relief hope denshi co. , chiba , japan ) are inserted at the left upper and lower quadrants . 
 we then perform the following procedures ; ligation of the inferior mesenteric artery and vein , total mesorectal excision and dissection of the intersphincteric space . after the transanal intersphincteric dissection 
 , the specimen is extracted through the anus and a hand sewn coloanal anastomosis is performed . 
 the covering ileostomy is finally created at the right upper port . 
 we performed lap isr using needlescopic forceps in two patients with very low rectal cancer . in both cases 
 , we were able to perform this procedure without insertion of an additional port or to change the needlescopic forceps to conventional 5-mm forceps . 
 lap isr with needlescopic instruments is a feasible procedure for minimally invasive surgery . 
INTRODUCTION
SURGICAL TECHNIQUE
RESULTS
DISCUSSION
CONCLUSIONS