Specimen Extraction Research Articles

Comment on: Intracorporeal Versus Extracorporeal Anastomosis in Robotic Right Colectomy: A Multicenter, Triple-Blind, Randomized Clinical Trial.

We would like to thank Dohrn et al1 for their randomized controlled trial comparing intracorporeal anastomosis (ICA) with specimen extraction through a Pfannenstiel incision with extracorporeal anastomosis (ECA) with specimen extraction through a transverse right upper quadrant incision in patients undergoing robotic right hemicolectomy (rRHC). The authors state that the main advantage of ICA during rRHC is that it allows for specimen extraction through a Pfannenstiel incision with, as a corollary, reduced postoperative pain and therefore improved postoperative recovery. To this end, they performed a sample size calculation based on the “Quality of Recovery-15” (QoR-15) questionnaire, which is a patient-reported composite outcome. Unfortunately, the trial was not powered on the semiquantitative assessment of postoperative pain or on any objective measurement of postoperative recovery. Second, the main advantage of the robotic approach for RHC is the improved possibility of performing ICA and choosing a Pfannenstiel incision as the extraction site when compared to laparoscopy. Performing ECA during rRHC offers, to our opinion, absolutely no advantage over ICA, and we therefore question the pertinence of the comparison chosen by the authors, especially when considering the increased cost of the robotic approach. A Pfannenstiel incision is more discreet that a right upper quadrant incision, and is esthetically preferred by patients. On this aspect, we note that the esthetical scoring of the extraction site was not considered in the outcomes and was not included in the QoR-15 questionnaire. Moreover, Pfannenstiel incisions have lower incidence of incisional hernia than transverse right upper quadrant incisions (0.9% vs 3.7%),2 which may support ICA over ECA from both a medical point of view but also an economical point of view. This outcome was not assessed in the trial. Finally, we note that a significant proportion of eligible patients were not randomized and that recruitment was paused during 1 year due to the unavailability of qualified surgeons. However, no threshold of experience was set. We believe it would have been preferable to set a threshold in terms of experience, or to audit the surgical procedures as performed for example in the robotic versus laparoscopic surgery for middle and low rectal cancer trial.3 For instance, it was shown that the results of the Robotic-Assisted versus conventional Laparoscopic surgery on risk of conversion to open laparotomy Among patients undergoing Resection for Rectal cancer trial4 were potentially biased by the experience of participating surgeons.5,6 To conclude, we believe that, despite the results of this randomized controlled trial, ICA should be preferred over ECA during rRHC. ACKNOWLEDGMENTS J.M. conceived and designed the study. All authors interpreted the data and contributed to the writing of the draft manuscript. All authors approved the final version of the manuscript.

Technique for efficient tissue containment and extraction of large specimens

Technique for efficient tissue containment and extraction of large specimens

Comment on "Early results of novel robotic surgery-assisted low anterior resection for rectal cancer and transvaginal specimen extraction by using Da Vinci XI: initial clinical experience".

Comment on "Early results of novel robotic surgery-assisted low anterior resection for rectal cancer and transvaginal specimen extraction by using Da Vinci XI: initial clinical experience".

Three-Port Laparoscopic Splenic Flexure Colectomy for Descending Colon Cancer with Intracorporeal Colocolic Anastomosis and Transvaginal Natural Orifice Specimen Extraction

Introduction: Transanal and transvaginal natural orifice specimen extraction (NOSE) are viable alternatives to transabdominal specimen retrieval after laparoscopic colorectal surgery in selected patients without increasing morbidity or compromising oncologic outcomes.1 Conventional laparoscopic colorectal surgery is performed using one camera port, two operator ports, and one or two assistant ports. Three-port surgery is feasible2 and complementary to NOSE for laparoscopic colorectal cancer surgery to reduce surgical trauma to the abdominal wall.3 Transanal NOSE avoids an additional vaginal incision, however, the transvaginal route is preferable for larger tumors because of the elasticity of the vagina.3 Although dyspareunia and rectovaginal fistulae are theoretical concerns following transvaginal NOSE, these fears are thus far unfounded.1,3 Placement of a transvaginal wound protector protects against the risk of tumor seeding. Transvaginal NOSE following three-port laparoscopic D3 right hemicolectomy4 and three-port laparoscopic anterior resection5 have been previously demonstrated. Compared with other locations within the large bowel, cancers of the splenic flexure are relatively uncommon.6 Splenic flexure colectomy preserves bowel and is safe and oncologically comparable with a subtotal colectomy or formal left hemicolectomy.7,8 However, segmental resection and anastomosis for tumors in this area can be technically challenging. Methods: A 69-year-old patient with a descending colon cancer and body mass index of 29.2 kg/m2 presented for resection. Preoperative bowel preparation with 2 L polyethylene glycol was administered. A 12-mm transumbilical camera port was used, with a 12- and 5-mm right iliac fossa and right flank working ports, respectively. The splenic flexure was mobilized from medial to lateral. The inferior mesenteric artery was identified, and the left colic artery was ligated at its origin, with adequate distal mesenteric division to ensure satisfactory lymph node harvest. Proximal and distal bowel transection were performed intracorporeally with a linear stapler. An isoperistaltic side-to-side colocolic anastomosis was fashioned, with a two-layer closure of the colonic defect. The uterus was hitched to the anterior abdominal wall with a transabdominal suture. The vagina was cleansed before a posterior vaginotomy was created with the help of a transvaginal sizer. A double ring wound protector was inserted transvaginally with one ring completely within the abdominal cavity and the other ring opened against the perineum to shorten the channel for specimen delivery. The wound protector was removed and the vaginotomy was closed using a barbed suture. Results: Operative time was 3 hours 15 minutes, with 20 mL intraoperative blood loss. There was minimal postoperative pain with return of gastrointestinal function on the first postoperative day. The patient was discharged uneventfully on postoperative day 2. Histology was pT4N1 and 27 lymph nodes were harvested. Adjuvant chemotherapy was administered, with no evidence of disease recurrence at 6 months follow-up. Conclusion: The reduced port technique is feasible and synergistic with NOSE for splenic flexure colectomy in selected patients, augmenting the minimally invasive nature of laparoscopy. No competing financial interests exist. Runtime of video: 5 mins 49 secs Patient Consent: The authors have received and archived patient consent for video recording/publication in advance of video recording of procedure.

Laparoscopic Low Anterior Resection for Severe Deep Pelvic Endometriosis (Stage IV) With Hybrid Notes Technique for Specimen Extraction and Anvil Insertion.

Saeidi, Sara M.D.1,2; Meroni, Paola M.D.3; Di Saverio, Salomone M.D.2,4,5 Author Information

Evaluating short-term and survival outcomes of natural orifice specimen extraction surgery for colorectal cancer: A single-centre retrospective study.

Natural orifice specimen extraction surgery (NOSES) has been confirmed as an alternative approach without auxiliary incisions. The purpose of this study was to investigate the short-term and survival outcomes of NOSES versus conventional laparoscopic surgery (LAP) in treatment of sigmoid and high rectal cancer. The retrospective study was conducted at single centers between January 2017 to December 2021. Relevant data included clinical demographics, pathological features, operative parameters, postoperative complications and survival outcomes were collected and analyzed. All procedures were performed using either a NOSES or a conventional LAP approach. Propensity score matching (PSM) was conducted to balance clinical and pathological features between the two groups. After PSM, a total of 288 patients were eventually included in this study, 144 in each group. Patients in the NOSES group experienced faster recovery of gastrointestinal function (2.6 ± 0.8 vs. 3.6 ± 0.9 day, P = 0.037), less pain and less analgesia required (12.5% vs. 33.3%, P < 0.001). In addition, the incidence of surgical site infection in the LAP group was significantly higher than that in the NOSES group (12.5% vs. 4.2%, P = 0.011), especially incision-related complications (8.3% vs. 2.1%, P = 0.017). After a median follow-up of 32 (range, 3-75) months, the two groups had similar 3-year overall survival rates (88.4% vs. 88.6%; P = 0.850) and disease-free survival rates (82.9% vs. 77.2%; P = 0.494). The transrectal NOSES procedure is a well-established strategy with advantages in reducing postoperative pain, faster recovery of gastrointestinal function, and less incision-related complications. In addition, the long-term survival is similar between NOSES and conventional laparoscopic surgery.

Thoracolaparoscopic radical resection of esophagogastric junction cancers with a NOSE-like approach to extract large specimens.

To investigate the efficacy and safety of combined thoracoscopic and laparoscopic radical resection of esophagogastric junction cancers using a natural orifice specimen extraction-like approach for extraction of large surgical specimens. Patients who had esophagogastric junction cancers treated with thoracolaparoscopic resection using the natural orifice specimen extraction-like approach for specimen extraction were retrospectively enrolled. A 5-cm transverse incision on the abdominal wall at the middle of the superior pubic symphysis was made for surgical specimen extraction. The clinical, surgical, complications, and follow-up data were analyzed. A total of 162 patients were enrolled, and the surgery was successful in all patients (100%). The total surgical duration ranged 165 to 270 minutes, with blood loss 20 to 150 mL, hospital stay 8 to 22 days, first flatus time 2 to 7 days, extubation time of drainage tubes 1 to 26 days, first oral feeding time 5 to 10 days, number of lymph nodes resected 15 to 39, postoperative ambulation time 1 to 2 days, and postoperative residual rate of cancerous cells at the surgical margins 0. Postoperative complications occurred in 14 (8.6%), including anastomotic leakage in 4 (2.5%), anastomotic stenosis in 3 (1.9%), hydrothorax in 4 (2.5%), and incision infection in 3 (1.9%). At follow-up (mean 12 months), all patients were alive, and the transverse incision was a linear scar concealed in the suprapubic pubic hair area. The combined laparoscopic and thoracoscopic surgery for radical resection of carcinomas at the esophagogastric junction is safe and effective, and a transverse incision at the suprapubic symphysis for specimen extraction results in improved minimal invasiveness and cosmesis.

Comparison of transabdominal wall specimen retrieval and natural orifice specimen extraction robotic surgery in the outcome of colorectal cancer treatment.

Natural orifice specimen extraction surgery (NOSES), as a new star of minimally invasive techniques, has been increasingly favored and promoted in the field of surgery around the world. Most previous studies were comparative studies of laparoscopic NOSES and conventional laparoscopic surgery. However, there is little research on comparing robotic colorectal cancer NOSES with conventional robotic-assisted colorectal cancer resection surgery. This study is a retrospective study of propensity score matching (PSM). This study included Ninety-one propensity score-matched pairs of the participant who had undergone robotic colorectal cancer resection surgery at our center between January 2017 and December 2020. The covariates used in the propensity score included gender, age, BMI, ASA score, maximum tumor diameter, the tumor's height from the anal verge, histological differentiation, AJCC stage, T stage, N stage, and history of previous abdominal surgery. The outcome measurement criteria included postoperative complications, inflammatory response, pelvic floor function, anal function, cosmetic outcome, quality of life, disease-free survival (DFS), and overall survival (OS). The robotic NOSES group had faster recovery time from gastrointestinal function (P = 0.014), shorter abdominal incision length (P < 0.001), less pain (P < 0.001), less additional analgesia required (P < 0.001), and lower postoperative indicators of white blood cell count (P < 0.001) and C-reactive protein content compared to the robotic-assisted resection surgery (RARS) group (P = 0.035). Additionally, the robotic NOSES group had significantly better body imagery (P < 0.001), cosmetic scores (P < 0.001), somatic function (P = 0.003), role function (P = 0.039), emotional function (P = 0.001), social function (P = 0.004), and overall function (P < 0.001) than the RARS group. The two groups demonstrated no significant difference between DFS and OS. Robotic colorectal cancer NOSES is a safe and feasible minimally invasive procedure and offers shorter abdominal incisions, less pain, less surgical stress response, and better postoperative quality of life. Therefore, this technique can be further promoted for colorectal cancer patients eligible for NOSES.

HPLC-MS/MS determination and the postmortem distribution or postmortem redistribution of paraquat and its metabolites in four fatal intoxication cases

HPLC-MS/MS analysis and postmortem distribution or postmortem redistribution of paraquat and its two metabolites in poisoning death cases were reported. Paraquat, monoquat, and paraquat monopyridone were extracted from the sample with acetonitrile or methanol, respectively, detected by ZORBAX HILIC Plus (4.6 × 100 mm, 3.5 μm) chromatographic column, with 0.1 % formic acid aqueous solution - 0.1 % formic acid acetonitrile solution (v/v) as mobile phase. Paraquat, monoquat, and paraquat monopyridone had a good linear relationship within the range of 10–1000, 1–400, and 1–1000 ng/mL (or g), the correlation coefficient (r) were all ≥ 0.9996. Their detection limits were lower than 1 ng/mL (or g). The detection accuracy was 91.25∼113.44 %. The intra-day and inter-day precision were 1.51–3.99 % and 1.92–4.93 %, respectively. This method was used to detect and analyze four rare paraquat poisoning cases. The distribution of paraquat, monoquat, and paraquat monopyridone is uneven, which is relatively high in the heart, blood, lung, and kidney. Heart blood/Peripheral blood ratio of paraquat, monoquat, paraquat monopyridone concentration in two poisoned cases were 1.4, 2.0, 1.5 and 1.9, 1.3, 1.2, which showed a location dependent postmortem redistribution. This is the first time that HPLC-MS/MS and the postmortem distribution or postmortem redistribution of paraquat metabolites in poisoned death cases have been reported. This research provides scientific basis for forensic identification of paraquat poisoning cases and extraction of biological specimen.

Estudio comparativo de la extracción de la pieza de nefrectomía laparoscópica mediante una incisión de tipo Pfannenstiel

ObjectivesThe aim of our study is to demonstrate that the Pfannenstiel incision is a reliable option in terms of postoperative complications compared to other types of incisions usually performed for kidney extraction after laparoscopic nephrectomy. Materials and methodsRetrospective and comparative study of 256 patients who underwent laparoscopic nephrectomy or nephroureterectomy. Patients were divided into two groups: specimen extraction by Pfannenstiel incision (group 1) and specimen extraction by way of other incisions (group 2). Incisional hernia, surgical site infection, pain score, seroma, haematoma/bleeding, wound dehiscence and muscle paralysis were analyzed in each patient. ResultsPatients in Pfannenstiel group presented a rate of wound complications of 11.72% vs 27.34% with other incisions, p = 0.002, it was significantly inferior the rate of wound dehiscence (5.5% vs 12.5%, p = 0.047) and seroma (3.1% vs 7.8%, p = 0.022). Using multivariate logistic regression, Pfannenstiel incision was a significant protective predictor factor for wound complications (OR = 0.34, p = 0.005). ConclusionsThe Pfannenstiel incision allowed the extraction of bigger kidney masses with less incidence of dehiscence, seroma and in general wound complications. The hospital stay was lower in Pfannenstiel extraction group. These results present this incision as a reliable and safe option in the decision of which incision to select.

Laparoscopic subtotal hysterectomy followed by in-bag transvaginal corpus uteri morcellation and extraction: A case series

ObjectivesLaparoscopic subtotal hysterectomy (LSH) is a possible treatment for patients with benign uterine disease. Once the hysterectomy has been completed, morcellation and extraction of the corpus uteri is a crucial step of the procedure. We here present a case series to evaluate the feasibility of the in-bag transvaginal specimen retrieval following LSH. Study designWe report a case series of consecutive patients who underwent LSH followed by in-bag transvaginal specimen retrieval. LSH was accomplished in a standard fashion. Once the uterus was detached from the cervix, a 2 cm posterior colpotomy was performed laparoscopically with a monopolar hook under direct view to insert a specimen retrieval bag into the abdomen. The corpus uteri was placed into the bag and transvaginal contained manual morcellation was performed. The colpotomy was then sutured transvaginally. Baseline patients’ characteristics and surgical data were collected. Postoperative complications, same-hospital readmissions, and reoperations were registered if occurred within 30 days from surgery. ResultsPatients’ median age and BMI were 45,5 and 22,7, respectively. Median operative time was 71.5 min (range 34–143) and uterus weight ranged from 60 g to 470 g (median 210 g). The estimated blood loss was 100 mL (median) and no blood transfusion was required. No conversions to open surgery, nor intraoperative complications occurred. Median hospital stay was 2 days (1–3) and no postoperative complications within 30 days from surgery were recorded. ConclusionsLSH followed by in-bag transvaginal specimen extraction is a promising technique and might be considered a reliable and safe option to further reduce the invasiveness of the procedure.

Development of a machine learning algorithm to predict complications of total laparoscopic anterior resection and natural orifice specimen extraction surgery in rectal cancer

BackgroundTotal laparoscopic anterior resection (tLAR) and natural orifice specimen extraction surgery (NOSES) has been widely adopted in the treatment of rectal cancer (RC). However, no study has been performed to predict the short-term outcomes of tLAR using machine learning algorithms to analyze a national cohort. MethodsData from consecutive RC patients who underwent tLAR were collected from the China NOSES Database (CNDB). The random forest (RF), extreme gradient boosting (XGBoost), support vector machine (SVM), deep neural network (DNN), logistic regression (LR) and K-nearest neighbor (KNN) algorithms were used to develop risk models to predict short-term complications of tLAR. The area under the receiver operating characteristic curve (AUROC), Gini coefficient, specificity and sensitivity were calculated to assess the performance of each risk model. The selected factors from the models were evaluated by relative importance. ResultsA total of 4313 RC patients were identified, and 667 patients (15.5%) developed postoperative complications. The machine learning model of XGBoost showed more promising results in the prediction of complication than other models (AUROC 0.90, P < 0.001). The performance was similar when internal and external validation was used. In the XGBoost model, the top four influential factors were the distance from the lower edge of the tumor to the anus, age at diagnosis, surgical time and comorbidities. In risk stratification analysis, the rate of postoperative complications in the high-risk group was significantly higher than in the medium- and low-risk groups (P < 0.001). ConclusionThe machine learning model shows potential benefits in predicting the risk of complications in RC patients after tLAR. This novel approach can provide reliable individual information for surgical treatment recommendations.

Tips and Tricks in Laparoscopic Adrenalectomy for Pheochromocytoma. How We Do It

"Pheochromocytomas are rare neuroendocrine tumors that frequently have genetic involvement and can present a particular risk in terms of the anesthetic-surgical procedure. Current worldwide medical recommendations state that laparoscopic adrenalectomy is the conventional treatment for pheochromocytoma, however, the ideal surgical strategy is still being developed as specialized surgeons gain experience with these rare tumors. The study's purpose was to thoroughly evaluate our film library and identify the best surgical steps that represent our standardized procedure. We developed a comprehensive set of surgical critical strategies for either a left or right adrenalectomy, providing helpful advice on patient positioning, port placement, the adrenal gland approach, as well as other surgical methods specifically designed for tumor mobilization and dissection. The current paper aims to synthesize our clinical experience in terms of preoperative preparation, patient positioning, intraoperative complications, causes of conversion, and specimen extraction. The main conclusions concern both the best surgical approach and the importance of surgical experience in the clinical management of these rare tumor types. "

The incidence of extraction site incisional hernia after minimally invasive colorectal surgery: a systematic review and meta-analysis.

Minimally invasive colorectal surgery reduces surgical trauma with better preservation of abdominal wall integrity, but the extraction site is still at risk of incisional hernia (IH). The aim of this study was to determine pooled incidence of IH for each type of extraction site and to compare rates of IH after midline, nonmidline and Pfannenstiel extraction. A systematic review and meta-analysis was conducted using the PRISMA guidelines. Single-armed and multiple-armed cohort studies and randomized controlled trials regarding minimally invasive colorectal surgery were searched from five databases. Outcomes were pooled and compared with random-effects, inverse-variance models. Risk of bias within the studies was assessed using the Cochrane ROBINS-I and RoB 2 tool. Thirty six studies were included, with a total 11,788 patients. The pooled extraction site IH rate was 16.0% for midline (n=4081), 9.3% for umbilical (n=2425), 5.2% for transverse (n=3213), 9.4% for paramedian (n=134) and 2.1% for Pfannenstiel (n=1449). Nonmidline extraction (transverse and paramedian) showed significantly lower odds ratios (ORs) for IH when compared with midline extraction (including umbilical). Pfannenstiel extraction resulted in a significantly lower OR for IH compared with midline [OR 0.12 (0.50-0.30)], transverse [OR 0.25 (0.13-0.50)] and umbilical (OR 0.072 [0.033-0.16]) extraction sites. The risks of surgical site infection, seroma/haematoma or wound dehiscence were not significantly different in any of the analyses. Pfannenstiel extraction is the preferred method in minimally invasive colorectal surgery. In cases where Pfannenstiel extraction is not possible, surgeons should avoid specimen extraction in the midline.

Comparison of Midline and Off-midline specimen extraction following laparoscopic left-sided colorectal resections: A systematic review and meta-analysis.

This study aims to evaluate comparative outcomes following midline versus off-midline specimen extractions following laparoscopic left-sided colorectal resections. A systematic search of electronic information sources was conducted. Studies comparing 'midline' versus 'off midline' specimen extraction following laparoscopic left-sided colorectal resections performed for malignancies were included. The rate of incisional hernia formation, surgical site infection (SSI), total operative time and blood loss, anastomotic leak (AL) and length of hospital stay (LOS) was the evaluated outcome parameters. Five comparative observational studies reporting a total of 1187 patients comparing midline (n = 701) and off-midline (n = 486) approaches for specimen extraction were identified. Specimen extraction performed through an off-midline incision was not associated with a significantly reduced rate of SSI (odds ratio [OR]: 0.71; P = 0.68), the occurrence of AL (OR: 0.76; P = 0.66) and future development of incisional hernias (OR: 0.65; P = 0.64) compared to the conventional midline approach. No statistically significant difference was observed in total operative time (mean difference [MD]: 0.13; P = 0.99), intraoperative blood loss (MD: 2.31; P = 0.91) and LOS (MD: 0.78; P = 0.18) between the two groups. Off-midline specimen extraction following minimally invasive left-sided colorectal cancer surgery is associated with similar rates of SSI and incisional hernia formation compared to the vertical midline incision. Furthermore, there were no statistically significant differences observed between the two groups for evaluated outcomes such as total operative time, intra-operative blood loss, AL rate and LOS. As such, we did not find any advantage of one approach over the other. Future high-quality well-designed trials are required to make robust conclusions.

Transanal specimen extraction after left-sided laparoscopic colectomy: a systematic review and meta-analysis

To compare the short-term results after left-sided laparoscopic colectomy with transanal and transabdominal specimen extraction. We selected 998 appropriate manuscripts and subsequently excluded 995 ones due to exclusion criteria. Thus, the meta-analysis was based on 3 randomized trials in accordance with PRISMA recommendations. A total of 353 patients were enrolled in meta-analysis including 169 resections with transanal specimen extraction and 184 surgeries with transabdominal extraction. Overall risk of postoperative complications (OR=0.60; 95% CI 0.31-1.14; p=0.12) including anastomotic leakage (OR=1.83; 95% CI 0.43-7.89; p=0.42) was similar in both groups. At the same time, severity of pain syndrome (mean difference = -2.35; 95% CI -2.51-2.19), time to the first flatus discharge (mean difference = -0.92; 95% CI -0.99-0.85) and postoperative hospital stay (mean difference = -1.5; 95% CI -2.03-0.98) were significantly lower in the group of transanal extraction (p<0.00001). Transanal specimen extraction in left-sided laparoscopic colectomy does not increase overall risk of postoperative complications. In addition, the NOSE technique has some advantages in short-term results compared to procedures with transabdominal specimen extraction.

Combined resections with colorectal surgeries and their combined natural orifice specimen extractions (NOSE): a clinical practice review

: Compared to conventional ones, minimally invasive surgical techniques have come to the fore in many fields, especially in colorectal surgery (CRS), due to their benefits. These benefits are better postoperative outcomes, particularly due to less abdominal trauma and smaller incisions. However, postoperative pain, incisional hernia or infection, and poor cosmesis, due to abdominal incisions made for specimen extraction, reduce the positive results that can be achieved. The basic starting point of natural orifice specimen extraction (NOSE) surgery is to eliminate these incisions and their negative effects. NOSE has been performed more frequently, especially in CRS, with the increase in experience. In some of the patients, in addition to CRS, combined resections may be required for metastases, secondary primary malignancies, or benign diseases. However, in the literature, NOSE in combined resections with CRS is limited to case reports and it is controversial. We aimed to review the literature in terms of NOSE for combined resections with CRS, including preoperative details, technical feasibility, perioperative findings and postoperative results. When a total of 42 cases in the literature were examined; it was observed that organs such as liver, stomach, pancreas, gallbladder, endometrium and ovaries were removed synchronously in CRS combined with NOSE. No major complication due to NOSE was observed perioperatively. According to these available data, NOSE in combined organ resections with CRS may be a safe and effective alternative surgical technique. It is obvious that there is a need for studies on this subject in order to obtain more reliable results.

Laparoscopic radical transverse colectomy with transrectal specimen extraction: A novel natural orifice specimen extraction procedure: A case report.

Transverse colon cancer accounts for about 10% of all colonic cancers. The resection of cancers in the transverse colon is technically more challenging, compared with other cancer locations in the colon because the variable anatomy of the middle colic vessels demands excellent surgical skills and the anatomical location of the transverse colon is related to major organs. We report a novel laparoscopic technique for the first time used in surgery of transverse colon cancer which combines a total intracorporeal anastomosis with natural orifice specimen extraction to solve the problems of traditional laparoscopic surgery. A 48-year-old male patient, whose diagnosis was transverse colon adenocarcinoma, was admitted to the hospital. The surgery was performed in accordance with the procedure of totally laparoscopic right hemicolectomy and the specimen was extracted by opening the rectum. Natural orifice specimen extraction surgery has many advantages, including less pain, better cosmesis and minimising risks of complications and also has comparable long-term outcomes compared to conventional laparoscopic surgery.

The safety of Pfannenstiel incision for specimen extraction in laparoscopic colorectal surgery for colorectal cancer: a systematic review and meta-analysis.

The Pfannenstiel incision is often used in gynecological Cesarean section; however, there is limited research on the use of the Pfannenstiel incision for specimen extraction in laparoscopic surgery for the treatment of colorectal cancer. To evaluate the safety of using the Pfannenstiel incision for specimen extraction in laparoscopic surgery for colorectal cancer patients. PubMed, Embase, Web of Science, Cochrane Library, CNKI, VIP and WanFangData were searched for studies published up to March 10, 2023; a random-effects model (RCT) and a fixed-effect model were used to evaluate the safety. Operative time, length of extraction skin incision, overall complications, superficial wound infection, organ/space surgical site infection and incisional hernia were evaluated. A total of 5 studies were included in this research. There were no significant advantages in operation time, length of the incision, overall complications, superficial wound infection and organ/space surgical site in the Pfannenstiel group compared to the no Pfannenstiel group. However, the Pfannenstiel incision has a tendency to increase the length of the incision (SMD = 0.05; 95% CI = -0.22 to 0.33; p = 0.71) and the results of the remaining five (operative time,overall complications,incisional hernia, incisional infection and organ/space surgical site infection) are slightly skewed toward the Pfannenstiel incision. It is worth mentioning that incisional hernia (IH) may have an advantage in the Pfannenstiel group compared to the no Pfannenstiel group. Four studies were not at clear risk of bias and two studies were at risk of bias. Our study concludes that the Pfannenstiel incision has a good safety record and it is a good option for extracting specimens during laparoscopic surgery for colon cancer. The Pfannenstiel incision used for laparoscopic surgical specimen extraction has a significantly lower incidence of incisional hernia over no Pfannenstiel.

Short-term and long-term survival outcomes for transrectal specimen extraction after laparoscopic right hemicolectomy: a propensity-score matching study.

Natural orifice specimen extraction surgery (NOSES) has been widely applied to the treatment of colorectal cancer. This study aim to investigate the short-term and survival outcomes of transrectal specimen extraction after laparoscopic right hemicolectomy. From January 2016 to December 2021, a total of 166 consecutive patients with right colon cancer who underwent laparoscopic right hemicolectomy in Cancer Hospital of Chinese Academy of Medical Sciences and Beijing Hospital were identified. Baseline data, perioperative parameters, anal function, inflammatory indicators and survival outcomes were collected and compared. Totally, 24 patients who underwent transrectal NOSE were matched with 24 patients who received conventional laparoscopic surgery (LAP). Patients in NOSES group had a significantly lower incidence of incision infection (0 vs 20.8%, P=0.048), faster recovery of gastrointestinal function (2.1 vs 3,1 days, P=0.032) compared with those in LAP group. In addition, patients in the NOSE group experienced significantly less postoperative pain on POD1 (2.3 vs 4.4, P<0.001), POD3 (2.1 vs 3.9, P<0.001), and POD5 (1.7 vs 2.8, P=0.011). Regarding to anal function 6 months after surgery, no significant difference was observed in Wexner incontinence scale (9.8 vs 9.5, P=0.559) between the two groups. In terms of indicators of the inflammatory response, there were no significant differences in body temperature, neutrophils, and PCT levels between the two groups. However, CRP levels in the NOSES group on POD 3 (6.9 vs 5.1 mg/L, P=0.016) and POD 5 (3.8 vs 2.6 mg/L, P=0.027) were significantly higher than in the LAP group. With regarded to survival outcomes, patients in the NOSES group were similar to those in the LAP group for 3-year OS (100% vs 91.2%, P=0.949), 3-year DFS (86.2% vs 84.8%, P=0.949), and 3-year LRFS (94.2% vs 88.7%, P=0.549). For total laparoscopic right hemicolectomy, transrectal NOSE is effective and safe, and associated with lower incidence of wound infection, less pain, faster recovery, and similar survival outcomes compared to conventional laparoscopic surgery.