Transrectal endoscopic retrorectal access (TERA): A novel NOTES approach to the peritoneal cavity

Background: As the field of natural orifice translumenal endoscopic surgery (NOTES) expands, new access sites are being investigated. One access site to the peritoneal cavity, which has not been the subject of much investigation, is transrectal access. The aim of this article is to describe a new method to peritoneal access: transrectal endoscopic retrorectal access (TERA). Materials and Methods: Three pigs were placed in the supine position under general anesthesia, and an umbilical port was placed for the pneumoperitoneum, as well as visualization of the pelvic dissection and access. A rectotomy was made under direct vision above the dentate line posteriorly. The flexible endoscope was introduced into the retrorectal space, balloon dilation was used to open and dissect the retrorectal plane, and the peritoneal cavity was entered with a needle knife. After peritoneal exploration, the endoscope was withdrawn and the rectotomy was closed under direct vision. Results: Each of the 3 cases was successful with entry into the peritoneal cavity to the right of the sacral promontory. Direct visualization allowed the avoidance of injury to the ureter, vessels, and nervous structures of the pelvis. The flexible endoscope allowed an easy direct visualization of the upper abdominal organs. In addition, retroflexion allowed a view of the pelvic organs. Mean operative time was 40 minutes. Conclusions: TERA is a novel access route to the peritoneal cavity that can be performed by using readily available instrumentation. When performed under direct view, injury to the adjacent structures can be avoided while obtaining access. Unresolved issues include sterility of the procedure and reproducibility, and future survival studies will delineate long-term safety.