Surgical Innovation 18(3) 193–200 © The Author(s) 2011 Reprints and permission: http://www. sagepub.com/journalsPermissions.nav DOI: 10.1177/1553350611411490 http://sri.sagepub.com Introduction The concept of natural orifice transluminal endoscopic surgery (NOTES) in digestive surgery involves the use of the transgastric, transvaginal, transanal, or transvesical routes to access the peritoneal cavity avoiding incisions in the abdominal wall. 1 Although some authors have reported experimental tran- srectal NOTES procedures such as cholecystectomies 2 and ventral hernia repair, 3 the natural field of application of this access is colorectal surgery since it is more justifiable to create a viscerotomy in the organ to be resected. We have previously demonstrated the feasibility of a double access (transgastric and transrectal) pure NOTES sigmoidectomy in a survival swine model. 4 Mesentery dis- section, anvil placement, and proximal sigmoid division were achieved transrectally whereas anastomosis con- struction and specimen retrieval were done after a “pull through” technique. In more proximal colonic resections higher than the level of transrectal viscerotomy, the access is not included in the specimen and its closure must be addressed. There is a lack of secure closure methods of the transrectal incision. Different solutions have been proposed to address the rectal viscerotomy such as the placement of endoloops and/ or endoclips, 2 manual suture with transanal endoscopic microsurgery (TEM) instruments, and linear stapler. 5 411490SRI 18 3 10.1177/155335061 1411490Leroy et alSurgical Innovation 1 IRCAD/EITS, Hôpitaux Universitaires, Strasbourg, France Corresponding Author: Joël Leroy, Department of Surgery, IRCAD/EITS, Hôpitaux Universitaires, 1 Place de l’Hôpital, 67091 Strasbourg Cedex, France Email: joel.leroy@ircad.u-strasbg.fr Original Technique to Close the Transrectal Viscerotomy Access in a NOTES Transrectal and Transgastric Segmental Colectomy Joël Leroy, MD, FRCS 1 , Michele Diana, MD 1 , Silvana Perretta, MD 1 , James Wall, MD 1 ,Vivian De Ruijter, MD 1 , and Jacques Marescaux, MD, (Hon) FRCS, (Hon) FACS, (Hon) JSES 1 Abstract Segmental colectomy is an ideal procedure for natural orifice transluminal endoscopic surgery (NOTES). Transanal endoscopic approaches have enabled rectosigmoid colectomy through a viscerotomy that is resected with the specimen. To extend NOTES segmental colectomy to the entire colon and beyond, a rectal viscerotomy will have to be safely and effectively closed at the end of the procedure. A new technique for rectal viscerotomy closure using a circular EEA Hemorrhoid and Prolapse Stapler with DST Series Technology (Covidien) is described. Keywords colorectal surgery, NOTES, viscerotomy closure technique The aim of this study is to assess the feasibility of full- thickness transrectal viscerotomy closure using a circular stapler (EEA Hemorrhoid and Prolapse Stapler with DST Series Technology, Covidien, Mansfield, MA) in a totally NOTES transgastric and transrectal segmental colectomy using transanal endoscopic operation (TEO) as surgical platform. Materials and Methods Equipment TEO (Karl Storz, Tuttlingen, Germany) is a modification of TEM 6-8 with a dedicated instrumentation composed of a special endoscope (8 or 15 cm in length and 4 cm in diam- eter) equipped with high-definition video laparoscopic imaging system that allows precise manipulation of tis- sue, full-thickness resection, and suturing of the defect. 9 EEA Hemorrhoid and Prolapse Stapler with DST Series Technology (Covidien) is designed for use in circumferential Editorial