Natural Orifice Specimen Extraction Surgery Research Articles

Comparison of the mid- and long-term outcomes between natural orifice specimen extraction surgery and conventional laparoscopic surgery with abdominal auxiliary incision in the treatment of rectal cancer based on propensity score matching method

Objective: To compare the mid- and long-term outcomes between natural orifice specimen extraction surgery (NOSES) and conventional laparoscopic surgery with abdominal auxiliary incision in the treatment of rectal cancer. Methods: A propensity score matching study was conducted. Patients with pathological diagnosis of rectal adenocarcinoma, preoperative imaging assessment of T1-3 and body mass index <28 kg/m(2) were included. Those who underwent local resection or abdominoperineal resection, had simultaneous multiple primary cancers, malignant intestinal obstruction or perforation, received neoadjuvant radiotherapy, and were unsuitable for laparoscopic surgery were excluded. From January 2017 to January 2019, 264 patients undergoing laparoscopic rectal cancer surgery at the Department of Colorectal Tumor Surgery, Shengjing Hospital of China Medical University were enrolled in this study, and divided into the NOSES group (52 cases) and the auxiliary incision group (212 cases). Propensity score matching method was used as 1:1 to match the initial data, and 46 pairs were finally obtained. SPSS 26.0 was used for data analysis, and 2-year disease-free survival, intraoperative and perioperative indicators were compared between the two groups. Results: The tumor short diameter in the NOSES group and the auxiliary incision group was (2.9±0.8) cm and (3.1±1.0) cm (t=0.842, P=0.402) respectively. Other baseline data were also comparable between the two groups(all P>0.05). There were no significant differences in operative time, intraoperative blood loss, length of hospital stay and postoperative complication rate between the two groups (all P>0.05). The time to first flatus [2 (1-6) days vs. 3 (1-6) days, Z=-3.035, P=0.002] and to liquid food intake [3 (1-6) days vs. 3 (2-7) days, Z=-2.587, P=0.010] after surgery in the NOSES group were earlier than those that in the auxiliary incision group. Compared with the auxiliary incision group, the postoperative pain score was lower [3 (2-5) vs. 4 (3-7), Z=-5.477, P<0.001], and the aesthetic score was higher [8 (6-9) vs. 7 (5-8), Z=-6.329, P<0.001] in the NOSES group. The distal resection margin in the NOSES group was longer than that in the auxiliary incised group [(3.7±1.2) cm vs. (2.9±1.4) cm, t=3.287, P<0.001]. There were no significant differences in proximal resection margin the number of harvested lymph nodes and positive rate of circumferential resection margin between the two groups (all P>0.05). The 2-year disease-free survival rate in the NOSES group and the auxiliary incision group was 93.5% and 89.1% respectively, and the difference was not statistically significant (P=0.466). Conclusions: NOSES has similar mid- and long-term outcomes to conventional laparoscopic surgery and the advantages of better cosmetic effect, less postoperative pain and faster recovery, which is more in line with the concept of minimally invasive and worthy of clinical promotion.

Natural orifice specimen extraction surgery versus conventional laparoscopic-assisted resection for colorectal cancer in elderly patients: a propensity-score matching study.

Whether natural orifice specimen extraction surgery (NOSES) could provide beneficial effects in treating elderly patients is still under debate. The aim of the study was to compare the clinical outcomes of transanal NOSES with conventional laparoscopic-assisted resection (LA) in elderly colorectal cancer (CRC) patients. A retrospective analysis from the Second Affiliated Hospital of Harbin Medical University between 2013 and 2017 was performed. Outcomes related to surgery, body image, quality of life, anal function and long-term survival were compared between the two groups with the propensity-score matching (PSM) method. After PSM, 78 patients were successfully compared. Patients with NOSES had faster gastrointestinal function recovery (P = 0.028), less postoperative complications (P = 0.025), lower pain scores on days 1, 3 and 5 after surgery (P < 0.001). The body image score (P < 0.001) and cosmetic score (P < 0.001) were significantly higher in the NOSES group than the LA group at 1month after surgery. Patients with NOSES posed better global health status (P < 0.001), role function (P = 0.009), emotional function (P = 0.011) and social function (P = 0.011) at 3months after surgery. Moreover, NOSES showed non inferiority in anal function 6months after surgery. No significant difference could be found regarding to overall survival (OS), disease-free survival (DFS), local recurrence (LR) and distant metastasis (DM). In elderly CRC patients, NOSES harbored favorable postoperative outcomes, excellent cosmetic properties and better quality of life. Besides, anal function and long-term outcomes of NOSES can be sure for elderly patients.

A new and practical surgical technique of transvaginal natural orifice specimen extraction surgery (NOSES) in laparoscopic nephroureterectomy-an initial clinical experience.

To explore the safety, feasibility and clinical effect of transvaginal natural orifice specimen extraction surgery (NOSES) in 3D laparoscopic nephroureterectomy (LNU) for upper tract urothelial carcinoma (UTUC). A retrospective analysis was made of 16 female patients who underwent 3D LNU and NOSES in the Department of Urology, Cancer Hospital, Chinese Academy of Medical Sciences from June 2019 to December 2020. The basic clinical data, perioperative related data, perioperative complications, visual analogue pain score (VAS), postoperative scar assessment questionnaire (PSAQ) at 3 months, female pelvic floor dysfunction questionnaire (PFDI-20) and female sexual function index questionnaire (FSFI) at preoperative and postoperative 3 months were analyzed and evaluated. The surgery was successfully completed in all 16 patients, and none of them was converted to open surgery. No postoperative complications, such as abdominal incision-related infection. No cases of local recurrence and distant metastasis were observed during follow-up of 3 to 21 months. The VAS scores at 24 h and 48 h after operation were 2.9 ± 0.7, 1.3 ± 0.6, respectively. PSAQ scores at 3 months after operation were 34.3 ± 3.3. PFDI-20 scores of women preoperative and postoperative 3 months were 6.25 ± 1.75, 6.3 ± 1.8, respectively, and the difference was not statistically significant (p = 0.924). There was no significant difference in FSFI scores between preoperative and postoperative 3 months (p = 0.892). Transvaginal NOSES in 3D LNU for UTUC is safe, feasible and practical. The successful development of this technique has laid a solid foundation for further clinical application and promotion.

Analysis of the Clinical Effect of Natural Orifice Specimen Extraction Surgery Combined with Transanal Endoscopic Operations.

Background: To explore the clinical efficacy of natural orifice specimen extraction surgery (NOSES) combined with transanal endoscopic operations (TEOs) to remove specimens from the anus for laparoscopic radical resection of colorectal cancer. Methods: From January 2014 to May 2020, 120 colorectal cancer patients were selected as study samples, including 60 cases who underwent NOSES laparoscopic radical resection of colorectal cancer (experimental group) and 60 cases who underwent traditional laparoscopic radical resection of colorectal cancer (control group). The basic preoperative conditions, operative time, intraoperative blood loss, lymph node dissection, postoperative hospitalization time, postoperative exhaust and defecation time, postoperative anal function, and postoperative complications were analyzed retrospectively. Results: Sleep quality score (6.26 ± 1.16), pain score (2.95 ± 0.79), and hospitalization time (11.55 ± 3.79 days) were better than those for the control group (P < .05). There were no positive cases of incisal margin in both groups. Gastrointestinal function recovery time, blood loss, lymph node dissection, and postoperative complications were not statistically significant (P > .05). Conclusion: NOSES combined with TEOs has the advantages of less trauma, quick postoperative recovery, and low psychological pressure, so it is worth popularizing.

Role of robotic natural orifice specimen extraction surgery in colorectal neoplasms

Natural orifice specimen extraction surgery (NOSES) is especially suitable for colorectal surgery. Until now, most of the reports published were about laparoscopic NOSES, the reports about robotic NOSES are extremely rare. This study aims to explore the safety and feasibility of robotic NOSES for colorectal neoplasms. All patients underwent robotic NOSES from March 2016 to October 2019 in our hospital were enrolled for retrospective analysis. Clinicopathological data including patient characteristics, perioperative information and pathological information were collected and analyzed. According to the distance between tumor and anus or whether neoadjuvant chemoradiotherapy (nRCT) is performed, we grouped the cases and studied its influence on robotic NOSES. Also, we compared the previous reports on laparoscopic NOSES with our study and revealed advantages of robotic NOSES in terms of safety and feasibility. A total of 180 patients were enrolled. The average distance from the lower edge of the tumor to the anus was (8.64 ± 3.64) cm and maximum circumferential diameter (CDmax) of specimen was (3.5 ± 1.6) cm. In terms of safety, the average operation time, intraoperative blood loss, and postoperative hospital stay were (187.5 ± 78.3) min, (47.4 ± 34) mL, and (11.3 ± 7.5) days, respectively. In terms of feasibility, the average number of lymph node harvested was (14.8 ± 5). Robotic NOSES shows advantages in terms of safety and feasibility compared with laparoscopic NOSES. This procedure could not only be a safe procedure but also could achieve good oncological outcomes.

Comparison of natural orifice specimen extraction surgery and conventional laparoscopic-assisted resection in the treatment effects of low rectal cancer

Natural orifice specimen extraction surgery (NOSES) is an intra-abdominal procedure that does not require an auxiliary incision to take a surgical sample from the abdominal wall through the natural orifice, but there are few systematic clinical studies on it. The aim of this study was to demonstrate the safety and feasibility of NOSES. We retrospectively analyzed the clinical data and follow-up of 165 patients with low rectal cancer who underwent NOSES or conventional laparoscopic surgery at our center from January 2013 to June 2015. From the perioperative data and postoperative follow-up results of both groups, patients in the NOSES group had less intraoperative bleeding (49.3 ± 55.8 ml vs. 75.1 ± 57.3 ml, p = 0.02), shorter postoperative gastrointestinal recovery (42.3 ± 15.5 h vs. 50.1 ± 17.0 h, p = 0.01), less postoperative analgesic use (35.6% vs. 57.6%, p = 0.02), lower postoperative pain scores, lower rate of postoperative complications (6.8% vs. 25.4%, p = 0.01), better satisfaction of the image and cosmesis of the abdominal wall postoperatively, and higher quality of life. Moreover, there was no significant difference in overall survival (OS) and disease-free survival (DFS) between two groups. Overall, NOSES is a safe and reliable minimally invasive surgical technique for patients with low rectal cancer.

Proctotomy leak following laparoscopic total gastrectomy with transrectal specimen extraction for gastric cancer: a case report

BackgroundDespite increasing acceptance in colorectal surgery, natural orifice specimen extraction (NOSE) surgery for the treatment of gastric cancer is still in its infancy, especially via the transrectal approach, which was barely reported. So little is known about its complications. Here we report the first case of proctotomy leak after transrectal NOSE gastrectomy, and our experience in preventive interventions.Case presentationA 62-year-old male patient complaining of upper abdominal pain who underwent open distal gastrectomy for gastric cancer one year ago was diagnosed with recurrent gastric cancer by gastroscopic biopsy. We performed laparoscopic total gastrectomy with transrectal specimen extraction on the patient. The operation was completed in a total laparoscopic approach and the specimen was extracted through a 3 cm longitudinal incision in the anterior wall of the upper rectum, then interrupted sutures were used for full-thickness closure of the rectal incision. The operative time was 470 min and intra-operative blood loss was 100 mL. The postoperative pathological examination showed pT1bN0M0 gastric adenocarcinoma. The patient developed proctotomy leak on the 10th postoperative day. We analyzed the causes of this rare complication and put forward a series of technical improvements. After failure of conservative treatment, a diverting ileostomy was created and the patient eventually recovered. We successfully prevented proctotomy leak in the subsequent 20 transrectal NOSE gastrectomies using improved techniques.ConclusionsProctotomy leak after transrectal specimen extraction should be considered among the complications of NOSE surgery and can be prevented by technical precautions.

Long-Term Outcome Comparison Between Two Specimen Extraction Approaches for Middle Rectum Cancer: A Retrospective Study.

Objective. There are few studies comparing the long-term results of natural orifice specimen extraction surgery (NOSES) and conventional laparoscopic-assisted resection (LA) in the treatment of middle rectal cancer. This retrospective analysis aimed to evaluate the reliability of NOSES. Method. From January 2013 to December 2017, all patients diagnosed with median rectal cancer in our hospital who underwent NOSES and LA were enrolled. We used propensity-score matching (PSM) to balance baseline data between the NOSES group and the laparoscopic group. The primary endpoint was overall survival (OS) and disease-free survival (DFS). We used the Kaplan-Meier method to estimate OS and DFS. Student's t-test was used to analyze the difference of continuous data. Categorical data were compared using the Kruskal-Wallis test or Fisher's exact test. Results. After PSM, 38 patients were included in each group. We found that surgical bleeding volume in the NOSES group was considerably lower than that in the LA group (49.5 ± 47.5mL vs. 86.3 ± 83.5mL, P = .01). From the short-term results, the first flatus and regular diet time in the NOSES group were shorter than those in the LA group (41.3 ± 25.2 vs. 54.0 ± 19.2hours, P < .01 and 63.9 ± 42.6hours vs. 105.1 ± 66.8hours, P < .01, respectively). Long-term OS and DFS were not different between the groups. Conclusion. Therefore, NOSES is a reliable technique for middle rectal cancer treatment. Short-term outcomes are pointedly better than LA, while the two surgical approaches did not differ in the long-term outcomes or complication rate.

Propensity score–matched comparison between totally laparoscopic right hemicolectomy with transcolonic natural orifice specimen extraction and conventional laparoscopic surgery with mini-laparotomy in the treatment of ascending colon cancer (with video)

Now that the debate about the safety and effectiveness of laparoscopic versus open surgery is over, attention has turned to innovations that can verify whether minimizing the impact of laparoscopy on the abdominal wall can further reduce pain, improve patient comfort, lead to superior cosmesis, and reduce morbidity. The aim of this study was to further explore the application value of totally laparoscopic right hemicolectomy with transcolonic natural orifice specimen extraction (NOSE) and to evaluate the short-term efficacy of transcolonic NOSE surgery for resecting specimens of ascending colon cancer. From January 2016 to May 2017, a retrospective study was conducted in Guangxi. Propensity score matching was used to minimize the bias from nonrandomized treatment assignment. Patients were followed up through May2020. Forty-nine patients underwent totally laparoscopic right hemicolectomy with transcolonic NOSE and 116 patients laparoscopic right hemicolectomy with mini-laparotomy (ML) procedures at our institution. After propensity score matching, each group included 45 patients, and all covariate imbalances were alleviated. The transcolonic NOSE group and the ML group did not differ significantly in terms of baseline clinical characteristics. The transcolonic NOSE group was associated with a shorter time to first flatus (NOSE vs ML: 1.8 ± .5 vs 3.2 ± .8, P= .032), a shorter length of hospital stay (11.3 ± 2.5 days vs 13.0 ± 3.1 days, P= .034), a shorter time to first liquid intake (2.6 ± .8 vs 3.8 ± .9, P= .068), less pain (1.8 ± .8 vs 4.2 ± .7, P= .013), less analgesia requirement (6 [13.3%] vs 21 [46.7%], P= .001), and lower C-reactive protein levels on postoperative day 1 (3.6 ± 1.7 vs 8.2 ± 2.2, P= .001) and postoperative day 3 (NOSE 2.4 ± 1.4 vs M: 4.6 ± 1.7 [P= .013]) than the ML group. The median follow-up was 28.4 months (interquartile range, 18.0-36.0). The 3-year overall survival rates were similar between the transcolonic NOSE group and the ML group. In total, laparoscopic right hemicolectomy with transcolonic specimen extraction appears to be safe for selected patients with ascending colon cancer as a minimally invasive surgery.

Natural Orifice Specimen Extraction Surgery versus Conventional Laparoscopic-Assisted Resection in the Treatment of Colorectal Cancer: A Propensity-Score Matching Study.

BackgroundNatural orifice specimen extraction surgery (NOSES) has been successfully applied to the treatment of gastric, colorectal cancer (CRC). However, the development of NOSES is still in the exploratory stage, and there is still no strong evidence-based medical evidence.Patients and MethodsFrom January 2013 to June 2017, consecutive patients with colorectal cancer who underwent transluminal resection, anastomosis, and specimen extraction and those who underwent conventional laparoscopic resection were enrolled. Propensity score matching was used to align clinicopathological features between the two groups.ResultsA total of 372 patients were eventually included in this study, 186 in each group. According to perioperative information and postoperative follow-up in both groups, the NOSES group had less blood loss (P = 0.011), shorter time to recovery of gastrointestinal function (P < 0.001), shorter postoperative hospital stay (P = 0.037). The NOSES group had fewer postoperative analgesics (P < 0.001), lower postoperative pain scores (P < 0.001), and lower incidence of postoperative complications (P = 0.017). Compared with the LA (laparoscopic) group, the NOSES group had better physical function (P<0.05), role function (P<0.001), emotional function (P<0.001) and global health status than LA group, while symptoms such as pain (P<0.001), insomnia (P<0.001), constipation (P<0.001) and diarrhea (P<0.05) were less severe in the NOSES group. In addition, the NOSES group had higher body image scores. Overall survival (OS) and disease-free survival (DFS) were not significantly different between the two groups.ConclusionFor surgical treatment of colorectal cancer, NOSES has advantages in reducing postoperative pain, recovery of gastrointestinal function, postoperative quality of life, and improving patients’ satisfaction with abdominal wall aesthetics. There was no difference in long-term survival between NOSES and conventional laparoscopic surgery.

Recto-vaginal fistula after laparoscopic rectal cancer resection through natural orifice specimen extraction surgery and transvaginal specimen extraction combined with hysterectomy

Abstract Introduction: Laparoscopic rectal cancer resection is currently the most common surgical procedure for treating colorectal cancer. The surgical technique of natural orifice specimen extraction surgery (NOSES) for colorectal cancer is becoming common but post-operative complications occur. In this article, we present a patient with rectal cancer who underwent trans-vaginal NOSES laparoscopic rectal cancer resection combined with hysterectomy and developed a recto-vaginal fistula after the surgery. Patient Concerns: The patient was a 56-year-old female with complaint of blood in the stool 7 months before without obvious cause, with aggravation in the last one month. Colonoscopy revealed a mass located 6 cm from the anus. Diagnoses: Colonoscopy findings and pathology results suggested mesenchymal ulcerative adenocarcinoma of the rectum. Interventions: Patient underwent trans-vaginal NOSES laparoscopic rectal cancer resection combined with hysterectomy. Outcome s: The patient recovered well but developed anastomotic fistula on postoperative day 11. An enterostomy was performed urgently. The patient was in stable condition at 1 month follow-up. Conclusion: NOSES has the advantage of reduced trauma, quick recovery time, and aesthetics. However, for patients with advanced tumors, especially cancers that invade adjacent organs, expanded resection will increase the risk of postoperative complications. Routine digital rectal examination after ultra-low rectal anastomosis can aid in diagnosing anastomotic leakage early in patients with obscure clinical features.

A modified technique of transanal specimen extraction in the laparoscopic anterior rectal resection for upper rectal or lower sigmoid colon cancer: a retrospective study

BackgroundIn recent years, natural orifice specimen extraction surgery (NOSES) has become a field of special interest for colorectal surgeons. Some researchers have reported transanal specimen extraction in the laparoscopic anterior rectal resection, including intersphincteric resection (ISR) and rectal eversion-resection. However, these surgical procedures have certain limitations. Based on the proven expertise in laparoscopic surgery, our center has developed a modified technique of transanal specimen extraction. The aim of this study was to investigate the safety and feasibility of a modified technique of transanal specimen extraction in the laparoscopic anterior rectal resection.MethodsFrom January 2011 to January 2014, the patients with upper rectal or lower sigmoid colon cancer who had undergone laparoscopic anterior rectal resection with specimen extraction by a modified transanal technique were enrolled in the observation group, and the patients who had undergone laparoscopic anterior rectal resection with specimen extraction via an abdominal incision by the same surgeons during the same period were enrolled in the control group.ResultsA total of 36 patients were included in the observation group and 128 patients were included in the control group. There were no significant differences (P > 0.05) between the two groups in terms of the mean operative time [144 ± 10 min vs. 141 ± 11 min], mean intraoperative blood loss [63 ± 6 ml vs. 61 ± 7 ml], and the mean time to anal exhaust [67 ± 7 h vs. 65 ± 8 h]. However, there were significant differences (P < 0.05) between the two groups in terms of the mean postoperative Visual Analogue Scale (VAS) pain scores [3.4 ± 1.1 vs. 4.5 ± 1.2], mean postoperative hospital stay [6.0 ± 1.1 days ± vs. 7.2 ± 1.2 days], and incidence of postoperative complications (4/36 vs. 15/128). Long-term follow-up results showed that there was no significant difference (P > 0.05) between the two groups in terms of the 3- or 5-year overall survival.ConclusionsThe modified technique of transanal specimen extraction in the laparoscopic anterior rectal resection fulfilled the principle of no-neoplasm touch technique, with advantages, such as minimal trauma, rapid recovery, and fewer complications. Long-term follow-up results also showed satisfactory oncological outcomes.

Robotic natural orifice specimen extraction surgery versus traditional robotic-assisted surgery (NOTR) for patients with colorectal cancer: a study protocol for a randomized controlled trial

BackgroundNatural orifice specimen extraction surgery for colorectal cancer has been introduced in order to reduce the abdominal incision, demonstrating major development potential in minimally invasive surgery. We are conducting this randomized controlled trial to assess whether robotic NOSES is non-inferior to traditional robotic-assisted surgery for patients with colorectal cancer in terms of primary and secondary outcomes.Method/designAccordingly, a prospective, open-label, randomized controlled, parallel-group, multicenter, and non-inferiority trial will be conducted to discuss the safety and efficacy of robotic natural orifice extraction surgery compared to traditional robotic-assisted surgery. Here, 550 estimated participants will be enrolled to have 80% power to detect differences with a one-sided significance level of 0.025 in consideration of the non-inferiority margin of 10%. The primary outcome is the incidence of surgical complications, which will be classified using the Clavien-Dindo system.DiscussionThis trial is expected to reveal whether robotic NOSES is non-inferior to traditional robotic-assisted surgery, which is of great significance in regard to the development of robotic NOSES for patients with colorectal cancer in the minimally invasive era. Furthermore, robotic NOSES is expected to exhibit superiority to traditional robotic-assisted surgery in terms of both primary and secondary outcomes.Trial registrationClinicalTrials.govNCT04230772. Registered on January 15, 2020.

A Novel Method of Natural Orifice Specimen Extraction Surgery (NOSES) during Laparoscopic Anterior Resection for Rectal Cancer.

We propose a modification to the reconstruction method of natural orifice specimen extraction surgery (NOSES) during laparoscopic anterior resection (LAR) for rectal cancer (RC) and evaluated its feasibility and short-term safety by comparing surgical and postoperative outcomes with those of conventional LAR. Twenty patients with RC underwent “double-purse” NOSES-LAR from October 2017 to June 2018. Data of clinicopathological characteristics, surgical and postoperative outcomes, and follow-up findings in NOSES-LAR cases were collected and retrospectively compared with those of conventional LAR to clarify the clinical benefits. The median postoperative hospital stay was lower in the double-purse NOSES group than the conventional group (6.6 vs. 7.1 days, respectively). In the conventional group, anastomotic leakage and incision site infection occurred in one patient each. In contrast, there were no complications in the double-purse group. There were no significant differences in blood loss, surgical duration, and time of the first flatus between the two groups. Additionally, “double-purse” NOSES-LAR was more economical than the conventional LAR. “Double-purse” NOSES-LAR is a safe, feasible, and minimally invasive promising procedure for LAR of RC with faster recovery, while requiring less surgical skills and lower clinical costs.

Uncomplicated Sigmoid Volvulus Is Ideal for Laparoscopic Sigmoidectomy With Transrectal Natural Orifice Specimen Extraction.

Natural orifice specimen extraction is the next step in minimally invasive colorectal surgery but can be technically challenging, with additional risks, especially for oncologic surgery. For several key reasons, sigmoid volvulus is well suited for natural orifice specimen extraction surgery. We describe our method and experience with double-stapled anastomosis transrectal natural orifice specimen extraction for sigmoid volvulus. Using 3- or 4-port laparoscopy, the mesentery is separated from the long sigmoid loop. After the distal bowel is tied off and washed out, the rectum is completely transected and the proximal bowel delivered transrectally through a wound protector. Proximal transection is performed externally, and the circular stapler anvil is set before the bowel is returned into the abdominal cavity. The rectum stump is closed with an endoscopic linear stapler, and a circular-stapled anastomosis is performed. After successful endoscopic decompression, 6 patients underwent elective laparoscopic sigmoidectomy with natural orifice specimen extraction for volvulus at China Medical University Hospital from 2015 to 2020. The median operative time was 179 minutes (range, 151-236 min). No intraoperative complications were encountered. The median postoperative length of stay was 4 days (range, 2-9 d). One patient experienced postoperative small-bowel ileus resulting in readmission. The median follow-up duration was 12 months (range, 2-49 mo). One recurrence of volvulus was recorded 27 months postsurgery. Uncomplicated sigmoid volvulus can be treated effectively with sigmoidectomy and natural orifice specimen extraction. Surgeons who attempt this procedure should be well versed with conventional laparoscopy but do not necessarily need to be experienced with natural orifice specimen extraction for successful surgery.

Total laparoscopic left hemicolectomy with preservation of inferior mesenteric artery and vein combined with natural orifice specimen extraction

Introduction: For left side colon cancer surgery, the roots of the inferior mesenteric artery and vein (IMA/IMV) are generally cut to perform the D3 lymph node dissection. In these cases, the extended resection of the colon would be required owing to the poor blood supply of the colon. In order to reduce the risk of distal bowel ischaemia and anastomosis leakage and preserve more normal sigmoid colon function, we aimed to introduce an innovative method to preserve the IMA/IMV and present its efficacy and safety. Materials and Methods: From January to February in 2019, two advanced colonic splenic flexure cancer (CSFC) patients received total laparoscopic left hemicolectomy with preservation of IMA/IMV combined with natural orifice specimen extraction surgery. The surgery followed the D3 lymph node dissection principle. Results: Two patients underwent a total laparoscopic surgery and no cases were converted to open or laparoscopic-assisted surgery. The mean time of operation was 148 min and mean blood loss was 50 ml. The harvested lymph nodes were 17 and 39 respective and the length of normal bowel both proximal and distal to the tumor more than 10 cm. The mean time of post-operative hospitalisation was 6 days. There were no cases of intra-or post-operative morbidity, or of bleeding owing to vessel injury. Conclusion: It is an efficient and safe technique to treat CSFC in a setting of surgeons experienced in laparoscopic colorectal surgery.

Retrospective Study of Natural Orifice Specimen Extraction Surgery in Resection of Sigmoid and Rectal Tumors.

Background: With the development of surgical technology, surgeons are paying more and more attention to minimally invasive procedures such as injury reduction, pain reduction, and beautiful incisions to ensure the effectiveness of surgical treatment. This article discusses the safety, feasibility, and clinical outcomes of laparoscopic resection of sigmoid colon and rectal tumors via natural orifice specimen extraction surgery (NOSES). Materials and Methods: The clinical data of 39 patients who underwent complete laparoscopic resection of sigmoid colon tumor or rectal tumor at Chengde Medical College Hospital between 2018 and 2020, including general patient data (gender, age, body mass index [BMI], etc.), surgery-related data, general postoperative conditions, and postoperative pathological data, were retrospectively analyzed to explore the feasibility and safety of NOSES. Results: The specimens were all removed through the anorectal resection drag out type. The average age of 39 patients was 61.3 ± 10.2 years, the average BMI was 24.0 ± 3.1 kg/m2, the average postoperative hospital stay was 11.2 ± 4.4 days, 12 patients with sigmoid colon tumors, including 11 malignant tumors and 1 schwannoma, 27 rectal tumors, including 1 rectal villous tubular adenoma, among the 37 patients with malignant tumors, ulcer type 32 cases of adenocarcinoma and 5 cases of mass adenocarcinoma, mean number of lymph nodes detected intraoperatively (11.9 ± 3.9), mean operative time (162.9 ± 43.0 minutes), mean operative bleeding (36.9 ± 13.0 mL), mean time of initial exhaust (4.3 ± 3.0) days, mean time of laparoscopic drainage tube removal (9.8 ± 1.4) days, mean time of postoperative feeding (4.4 ± 3.0) days, the average maximum tumor diameter (3.7 ± 1.4 cm), and the average distance of the tumor from the anal margin (14.1 ± 6.1 cm); after surgery, there were two cases of anastomotic fistula. Conclusion: Laparoscopic resection of sigmoid colon and rectal tumors via natural orifice specimen extraction has the advantages of less pain, reduced incisional complications, good safety, and accurate efficacy in clinical applications.

Correspondence on international consensus on natural-orifice specimen-extraction surgery (NOSES) for colorectal cancer.

Correspondence on international consensus on natural-orifice specimen-extraction surgery (NOSES) for colorectal cancer.

Precision functional sphincter-preserving surgery (PPS) for ultralow rectal cancer: a natural orifice specimen extraction (NOSE) surgery technique.

In patients with ultralow rectal cancer, surgical resection of the tumor without impairing sphincter function remains a technical challenge. The purpose of this study was to describe a new technique of transanal natural orifice specimen extraction (NOSE) surgery using our independently developed devices, aiming to achieve precise cancer resection and preserve sphincter function in patients with ultralow rectal cancer. Precision functional sphincter-preserving surgery (PPS) was performed on nineteen patients with ultralow rectal cancer between June 2019 and April 2020. With the help of our independently developed devices, surgeons directly and accurately removed the lower edge of the tumor and retained healthy rectal tissue on the nontumorous side. Hand-sewn anastomosis with a mattress suture was used to achieve sturdy anastomosis. Preoperative baseline characteristics, operative details, 90-day postoperative complications, costs, and analfunctionscore at 6 months after surgery were documented. Nineteen ultralow rectal cancer patients with a median distance to the dentate line of 2.0 cm successfully underwent PPS without serious postoperative complications. Six out of nineteen patients (31.6%) received a prophylactic stoma. The average cost was 62164.1 yuan. At 6 months after surgery, the average Wexner anal function score and the average Vaizey score were both 3 points. PPS can be employed to precisely resect rectal tumors and preserve sphincter function in ultralow rectal cancer patients. The use of our devices enhanced surgical efficiency, reduced the need for prophylactic stoma, reduced surgery-related costs, and prevented abdominal surgical incisions.

Safety and Feasibility of Robotic Natural Orifice Specimen Extraction Surgery in Colorectal Neoplasms During the Initial Learning Curve.

Aim: To analyze the learning curve (LC) for robotic natural orifice specimen extraction surgery (NOSES) for colorectal neoplasms and evaluate safety and feasibility during the initial LC.Method: Patients who consecutively underwent robotic NOSES performed by two surgeons between March 2016 and October 2019 were analyzed retrospectively. The operation time was evaluated using the cumulative sum method to analyze the LC. The clinicopathological data before and after the completion of LC were extracted and compared to evaluate safety and feasibility.Results: In total, 99 and 66 cases were scheduled for robotic NOSES by Prof. Yao and Prof. Li, respectively. The peak points of LC were observed at the 42nd and 15th cases of Yao and Li, respectively, then operation time began to decrease. Only the operation time for Yao before the completion of LC (213.3 ± 67.0 min) was longer than that after the completion of LC (143.8 ± 33.3 min). For Yao nor for Li, other indices, such as postoperative hospital stay, intraoperative blood loss, conversion to laparotomy, incidence of anastomotic leakage, reoperation rate, and 90-day mortality rate lacked significant statistical differences(P > 0.05). In terms of feasibility, the number of lymph nodes harvested, positive resection margin rate, and total cost before and after the completion of LC had no significant statistical difference (P > 0.05).Conclusion: The cases before the completion of LC for robotic NOSES in colorectal neoplasms varied from 15 cases to 42 cases. Robotic NOSES is safe and feasible during the initial LC.