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Page 6 of 11 Jeong et al. Mini-invasive Surg 2019;3:38 I http://dx.doi.org/10.20517/2574-1225.2019.42

Figure 3. Three steps of pure NOTES. Pure NOTES consist of three steps: anal (anorectal), intracorporeal, and second anal step.
According to each step, TaTME, CME + CVL, and anal completion are performed, respectively. Anal completion can be done by finishing
of pull through, transection of specimen, and anastomosis. NOTES: natural orifice transluminal endoscopic surgery; TaTME: transanal
total mesorectal excision; CME: complete mesocolic excision; CVL: central vascular ligation

In addition, NOTES-style surgery may be difficult under conditions such as redundancy of the colon
length, anatomical variation, and surgical history including urological gynecology, and it is difficult to
predict the future, such as severe natural adhesion of the colon to the left low quadrant (LLQ) area or
excessive extension. Care should be taken to prevent or reduce the possibility of soiling or spillage. The
author’s method is to use a Lap-bag (Endo-catch bag). With sufficient TME in the pelvic cavity, entry into
the abdominal cavity is necessary for further dissection and progression. At this time, an incision is made
in the anterior peritoneal reflexion through the abdominal cavity and pushed into the abdominal cavity