Transrectal Specimen Extraction Research Articles

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.

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.

Preliminary surgical outcomes of laparoscopic right hemicolectomy with transrectal specimen extraction: a propensity score matching study of 120 cases (with video).

Compared with conventional laparoscopic surgery, natural orifice specimen extraction surgery (NOSES) has many advantages. Laparoscopic right colectomy with transvaginal specimen extraction has been reported, but the safety and feasibility of transrectal specimen extraction in male patients with ascending colon cancer remain to be verified. This study aimed to preliminarily evaluate the feasibility and safety of laparoscopic right hemicolectomy with transrectal specimen extraction. The study was conducted at a single tertiary medical center in China. A total of 494 consecutive patients who underwent laparoscopic right colectomy between September 2018 and September 2020 were included. Transrectal specimen extraction was performed in 40 male patients (the NOSES group). Patients in the NOSES group were matched to the conventional laparoscopic group using propensity score matching at a 1:2 ratio. Short-term and long-term outcomes between the two groups were compared and evaluated. Forty patients in the NOSES group and 80 patients in the conventional laparoscopic group were matched for analysis. Baseline characteristics were balanced after propensity matching. The operative features, including operating time, intraoperative bleeding, and the number of harvested lymph nodes, were statistically comparable in both groups. In terms of post-operative recovery, patients in the NOSES group showed preferable outcomes, as evidenced by less post-operative pain and faster return to flatus, defecation, and discharge. The post-operative complications rate, according to the Clavien-Dindo classification system, was similar in both groups. No differences in overall survival or disease-free survival were observed between the two groups. Laparoscopic right colectomy with transrectal specimen extraction is oncologically safe. Compared with conventional laparoscopic right colectomy, it can reduce post-operative pain, accelerate post-operative recovery, shorten the hospital stay, and achieve better cosmetic effect.

The success rate of robotic natural orifice intracorporeal anastomosis and transrectal extraction (NICE procedure) in a large cohort of consecutive unselected patients

BackgroundThe Robotic NICE procedure is a total intracorporeal natural orifice approach in which specimen extraction and anastomosis is accomplished without an abdominal wall incision other than the port sites themselves. We aim to present the success rate of the NICE procedure in a large cohort of unselected consecutive patients presenting with colorectal disease using a stepwise and reproducible robotic approach.MethodsConsecutive patients who presented with benign or malignant disease requiring left-sided colorectal resection and anastomosis between May 2018 and June 2021 were evaluated. Data abstracted included demographic, clinical data, disease features, intervention data, and outcomes data. The main outcome was success rate of Intracorporeal anastomosis (ICA), transrectal extraction of specimen (TRSE), and conversion rate.ResultsA total of 306 patients underwent NICE procedure. Diverticulitis was the main diagnosis (64%) followed by colorectal neoplasm (27%). Median operative time was 219 min, and the median estimated blood loss was 50 ml. ICA was achieved in all cases (100%). TRSE was successfully achieved in 95.4% of cases. In 14 patients (4.6%), an abdominal incision was required due to inability to extract a bulky specimen through the rectum. There overall postoperative complications rate was 12.4%. Eight patients (2.6%) experienced postoperative ileus. There were no superficial or deep surgical site infection (SSI). Eleven patients (3.6%) developed organ SSI space including 5 patients with intra-abdominal abscess and 4 patients with anastomotic leak. There was one mortality (0.3%) due to toxic megacolon from resistant Clostridium difficile. The 30-day reoperation rate was 2.9% (n = 9) including six patients presenting with organ space SSI and three patients with postoperative obstruction at the diverting loop ileostomy site.ConclusionThe NICE procedure is associated with a very high success rate for both intracorporeal anastomosis and transrectal specimen extraction in a large cohort of unselected patients.

A nomogram for predicting feasibility of laparoscopic anterior resection with trans-rectal specimen extraction (NOSES) in patients with upper rectal cancer

BackgroundLaparoscopic anterior resection with trans-rectal specimen extraction (NOSES) has been demonstrated as a safe and effective technique in appropriate patients with upper rectal cancer (RC). However, improper selection of RC candidates for NOSES may lead to potential surgical and oncological unsafety as well as complications such as bacteria contamination and anastomotic leak. Unfortunately, no tools are available for evaluating the risk and excluding improper cases before surgery. This study aims to estimate its clinical relevancy and to investigate independent clinical-pathological predictors for identifying candidates for NOSES in patients with upper RC and to develop a validated scoring nomogram to facilitate clinical decision making.MethodsThe study was performed at Shanghai East hospital, a tertiary medical center and teaching hospital. 111 eligible patients with upper RC who underwent elective laparoscopic anterior resection between February and October of 2017 were included in the final analysis. Univariate and multivariate analyses were performed to compare characteristics between the two surgical techniques. Odds ratios (OR) were determined by logistic regression analyses to identify and quantify the clinical relevancy and ability of predictors for identifying NOSES candidate. The nomogram was constructed and characterized by c-index, calibration, bootstrapping validation, ROC curve analysis, and decision curve analysis.ResultsUpper RC patients with successful NOSES tended to be featured with female gender, negative preoperative CEA/CA19-9, decreased mesorectum length (MRL), ratio of diameter (ROD) and ratio of area (ROA) values, while no significant statistical correlations were observed with age, body mass index (BMI), tumor location, and tumor-related biological characteristics (ie., vascular invasion, lymph node count, TNM stages). Furthermore, the two techniques exhibited comparably low incidence of perioperative complications and achieved similar functional results under the standard procedures. The nomogram incorporating three independent preoperative predictors including gender, CEA status and ROD showed a high c-index of 0.814 and considerable reliability, accuracy and clinical net benefit.ConclusionsNOSES for patients with upper RC is multifactorial; while it is a safe and efficient technique if used properly. The nomogram is useful for patient evaluation in the future.

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.

Robotic natural-orifice IntraCorporeal anastomosis with Extraction (NICE procedure) for complicated diverticulitis

BackgroundTotally intracorporeal surgery for left-sided resection carries numerous potential advantages by avoiding crossing staple lines and eliminating the need for an abdominal incision. For those with complicated diverticulitis, minimally invasive surgery is known to be technically challenging due to inflamed tissue, distorted pelvic anatomy, and obliterated tissue planes, resulting in high conversion rates. We aim to illustrate the stepwise approach and modifications required to successful complete the robotic Natural-orifice IntraCorporeal anastomosis with transrectal specimen Extraction (NICE) procedure in this cohort.MethodsConsecutive, elective, unselected patients presenting with complicated diverticulitis defined as fistula, abscess and stricture underwent the NICE procedure over a 24-month period. Demographic and intraoperative data were collected, and video recordings were reviewed and edited on encrypted server.ResultsA total of 60 patients (50% female) underwent the NICE procedure for complicated diverticulitis with a mean age of 58.9 years and mean BMI of 30.7 kg/m2. The mean operative time was 231.6 min. All cases (100%) were achieved with intracorporeal anastomosis using a circular stapling device. All but one patient (98.3%) had successful transrectal extraction of the specimen. Forty-four (73%) of the specimens required a specimen-thinning maneuver to successfully extract the specimen and there were no conversions. We identified seven key technical modifications and considerations to facilitate successful completion of the procedure which are illustrated, including early release of the disease, mesentery-sparing dissection, dual instrument control of the mesenteric vasculature, release of the rectal reflection, use of NICE back table, specimen-thinning maneuver, and closure of the rectal cuff.ConclusionWe present a stepwise approach with key modifications to successfully achieve totally robotic intracorporeal resection for those presenting with complicated diverticulitis. This approach may help overcome the technical challenges and provide a foundation for reproducible results.

Laparoscopic radical right hemicolectomy with transrectal-specimen extraction: a novel natural-orifice specimen-extraction procedure.

Laparoscopic radical right hemicolectomy with transrectal-specimen extraction: a novel natural-orifice specimen-extraction procedure.

Analysis on clinical factors affecting transrectal natural orifice specimen extraction in rectal cancer surgery

Objective: To identify the factors associated with successful transrectal specimen extraction after laparoscopic rectal cancer resection. Methods: A retrospective case-control study was conducted. Clinical data of rectal cancer patients who did or did not successfully undergo transrectal specimen extraction in Shanghai East Hospital between January 2017 and December 2017 were retrieved through the rectal cancer database of Shanghai East Hospital. Case inclusion criteria: (1) tumor size ≤7 cm by pelvic MRI; (2) body mass index (BMI)≤ 30 kg/m(2); (3) no history of neoadjuvant chemoradiotherapy; (4) no anal stenosis. Clinical data including age, gender, BMI, tumor obstruction, distance from tumor to anal verge, history of abdominal operation, maximal diameter of tumor and width of mesorectum in the anteroposterior dimension measured by pelvic MRI, etc. were collected. The χ(2) test was used to perform univariate analysis. Multivariate logistic regression was used to identify factors affecting transrectal specimen extraction. Results: A total of 208 patients were included in the analysis. Of 208 patients, 132 were men and 76 were women; mean age was (63±11) years old and median tumor size was 3.8 (IQR, 3.0 to 5.0) cm. Sixty-six (31.7%) patients completed transrectal specimen extraction successfully. Univariate analysis showed that patients who completed transrectal specimen extraction were more likely to have a lower BMI (χ(2)=7.420, P=0.006), be free from malignant obstruction (χ(2)=8.972, P=0.003), have a shorter distance from tumor to the anal verge (<5.0 cm) (χ(2)=14.960, P<0.001), a smaller tumor size (≤5.0 cm) (χ(2)=18.495, P<0.001) and a thinner mesorectum in the anteroposterior dimension (≤6.0 cm) (χ(2)=34.612, P<0.001) than those who failed to perform transrectal specimen extraction. Gender, age or history of abdominal operation were not associated with the successful extraction (all P>0.05). Multivariate analysis revealed that BMI ≤25.0 kg/m(2) (OR=2.32, 95% CI: 1.06 to 5.06, P=0.034), free from malignant obstruction (OR=3.01, 95% CI: 1.82 to 6.69, P<0.001), the distance from tumor to the anal verge <5.0 cm (OR=3.73, 95% CI: 1.22 to 11.43, P=0.021), tumor size ≤ 5.0 cm (OR=4.43, 95% CI: 1.39 to 14.09, P=0.012), and the anteroposterior width of mesorectum ≤ 6.0 cm (OR=4.30, 95% CI: 2.02 to 9.18, P<0.001) were independent protective factors for successful transrectal specimen extraction. Conclusion: Preoperative assessment of BMI, malignant obstruction, distance from tumor to the anal verge, tumor size and anteroposterior width of mesorectum is beneficial to choose appropriate patients with rectal cancer to undergo transrectal specimen extraction.

Surgical resection for diverticulitis using robotic natural orifice intracorporeal anastomosis and transrectal extraction approach: the NICE procedure

Numerous studies have confirmed significant benefits of intracorporeal anastomosis (ICA)following colorectal procedures; however technical challenges have limited this approach following conventional laparoscopic surgery. The robotic Xiplatform serves as an enabling technology and has resulted in a surge of reports for right-sided ICA, however, there are no reports involving more complex left-sided procedures such as diverticulitis.Furthermore, there are no reports of natural orifice-assisted techniques using robotic Xiin which the specimen can be removed and the anvil can be placed transrectally, thereby completely eliminating the need for an abdominal wall incision other than for port sites. We present a pilot study to investigate the safety, feasibility and short-term outcomes of robotic Natural orifice-assisted IntraCorporeal anastomosis with transrectal Extraction of specimen, called the robotic NICE procedure. Consecutive patients presenting for elective resection for diverticulitis with formation of a colorectal anastomosis were entered into an IRB database. All patients underwent the robotic NICE procedure. Demographic data, intraoperative data and outcomes data were assessed and analyzed. Ten patients (five males and five females) underwent resection.The mean age and BMI were 56years (43-66) and 29kg/m2 (21-35). All procedures were successfully completed including transrectal extraction of the specimen and formation of an ICA. The mean operative time was198min (146-338)and mean EBL was35ml (15-50). Mean time to first flatus was 16h (10-22) and mean length of stay was 1.9days (1.6-2.6). There were no intraoperative or postoperative complications. There was no unexpected ICU stay, reoperation or readmission. Colorectal left-sided resections such as for diverticulitis were safely accomplished using natural orifice-assisted extraction of the specimen as well as complete intracorporeal anastomosis in this pilot study. The NICE procedure resulted in early return of bowel function, short length of stay and low complication. The complete elimination of abdominal wall incision likely accounts for these findings and larger cohorts of patients are to be investigated to explore this promising approach afforded by robotic technology.

Left colon resection with transrectal specimen extraction: current status.

Full laparoscopic left colectomy with transrectal specimen extraction is proposed as an improvement of the minimally invasive surgical technique. This paper reviews in detail the current status of left-sided colectomy and upper rectum resection with transrectal specimen extraction. A systematic review was performed of all types of publications on colorectal resection with natural orifice specimen extraction (NOSE). We only included studies reporting on left colectomy, sigmoidectomy, and high anterior resection with transrectal specimen extraction (TRSE), excluding transanal (TASE), transvaginal, or transcolonic specimen extraction. Surgical techniques, patient characteristics, and outcomes were reviewed in detail. Thirty-five papers reported on TRSE (2 randomized clinical trials, 7 case-matched series, 19 case series, 5 case reports, and 2 articles on surgical technique). We found a wide variety of innovative anastomotic and specimen extraction techniques. After excluding duplicates and papers reporting mixed TRSE and TASE results, outcomes in patients undergoing TRSE from 23 publications showed a conversion rate to conventional laparoscopy of 3.7% (21/559), overall morbidity 9.5% (53/559) [major in 2.9% (16/559), intra-abdominal infection in 2.1% (12/559)]. No mortality was reported. Postoperative anal incontinence was rarely reported. Several studies showed a decrease in postoperative pain and some in length of hospital stay. Colectomy with TRSE is feasible and seems safe in selected patients. Reported outcomes seem in general similar to conventional laparoscopic colectomy with a possible benefit in postoperative pain and length of hospital stay. Obvious selection bias and lack of high quality trials do not allow firm conclusions to be drawn.

Protective measures in laparoscopic resection for upper or mid rectal cancer and sigmoid colon cancer with transrectal specimen extraction surgery

To introduce the use of a self-made specimen protective sleeve in laparoscopic resection for upper or mid rectal cancer and sigmoid colon cancer with transrectal specimen extraction surgery and the improvement of implantation method, so as to avoid and reduce bacterial contamination and tumor cell dissemination in abdominal cavity. During June 2015 and May 2017, 48 cases of high located rectal or sigmoid colon cancer were operated laparoscopically with natural orifices specimen extraction surgery (NOSES) using a self-made specimen protecting sleeve. Operation indication: (1) Rectum and sigmoid colon cancer with the distance of more than 6 cm from tumor inferior margin to dentate line. (2) The maximum diameter of intestine together with mesangial and tumor <7 cm by intraoperative judgment. (3) No anal and distal rectal surgery, no anorectal stenosis or lack of expansion capacity caused by trauma. (4) No ulcerative colitis, Crohn's disease or radiation proctitis. After transecting the rectum, the specimen protective sleeve was inserted through the right lower 12 mm main Trocar (This sleeve was tailored from the laparoscopic protective sleeve produced by China 3L Corporation, which was intercepted with 25-35 cm from one end of the sleeve according to the length of distal rectal retention. One end was ligated and the other was open with a ligature band. About 5 ml paraffin oil was used to rinse and lubricate during the operation). The rectal stump retained 7-8 cm in abdominal cavity. The transanal ligation part of the protective sleeve was cut off, then the stapler nail seat was inserted and specimen was pull out through the sleeve and rectum. There were 30 males and 18 females. The average age was (64.5±14.1) years, the BMI was (25.4±3.9) kg/m2, the tumor diameter was (3.3±1.1) cm, the maximum diameter of specimen was (5.4±1.5) cm and the length of specimen was (18.6±4.3) cm. Among these 48 cases, specimens of 36 patients were pulled out through inside of the sleeve easily, while specimens of 12 patients were quite difficult with resistance. Of 12 cases, 7 needed the help of transverse forceps, 4 needed to make 1 cm incision in pull-through bowel and insert a suction to decrease the volume of large specimens with gathering of gas and fluid, and 1 received small abdominal incision to remove specimen and perform intestinal reconstruction due to big specimen (the diameter of tumor and mesentery was 7.5 cm). Specimen tears of 6 patients didn't result in dissemination thanks to the specimen protecting sleeve. The operation time was (113.2±76.1) min, the bleeding amount was (38.5±17.3) ml, the time to first oral intake was (47.9±4.4) h, and the postoperative hospitalization length was (8.5±1.7) d. Anastomotic leakage occurred in 1 case (2.1%). No intra-abdominal and trocar infection, and obstruction were found. The use of protective sleeve and the improvement of the method of intraperitoneal implantation can effectively reduce the abdominal contamination during the specimen extraction. It can be applied to big specimens as well.

Comparison of short-term outcomes of transrectal specimen extraction during laparoscopic sigmoid radical resection versus conventional laparoscopically assisted procedure

To compare the short-term outcomes between transrectal specimen extraction during laparoscopic sigmoid radical resection and conventional laparoscopy-assisted sigmoid radical resection. Sixteen patients(transrectal specimen extraction group,4 females and 12 males), who were planned to undergo laparoscopically assisted sigmoid radical resection with BMI<28 kg/m2 and were evaluated as T1-T3 tumor by iconography without distant metastasis, were selected to undergo transrectal specimen extraction during laparoscopic sigmoid radical resection from December 2015 to April 2016 in the Department of Anorectal Surgery of Changhai Hospital. The procedure of specimen extraction was as follows: Perineal anal expansion was performed. The rectum was cut in rectal distal ligature within the abdominal cavity. Telescope cover was placed through Trocar hole in right low abdomen and rectal stump was pulled out of the body through the anus to form an access tunnel. Planned resected bowel was placed in the tunnel and the specimen was dissociated and removed completely from anus. Each patient in transrectal specimen extraction group was individually matched with two patients who underwent laparoscopically assisted sigmoid radical resection by gender, age, BMI and date of surgery. The perioperative outcomes and pathological evaluation of surgical specimen of two groups were retrospectively collected and compared. The differences of baseline data (gender, age, BMI, distance from tumor to anal verge measured by colonoscopy and clinical tumor category) between two groups were not significant (all P>0.05). Compared to laparoscopy-assisted group, transrectal specimen extraction group presented longer operation time [(140.6±8.3) minutes vs. (122.2±26.2) minutes, t=-3.629, P=0.001], and more blood loss[(43.8±9.2) ml vs. (35.3±10.2) ml, t=-2.795, P=0.008], but shorter time to first flatus [(43.1±8.3) hours vs. (52.0±11.4) hours, t=2.756, P=0.008] and lower pain score at operative day and the first postoperative day (3.8±0.8 vs. 4.8±1.1, t=3.558, P=0.001; 2.6±0.6 vs. 3.8±0.8, t=5.165, P=0.000). The case ratio of additional analgesia [6.3%(1/16) ns. 18.8%(6/32)], postoperative hospital stay [(6.8±3.4) days vs. (5.6±0.8) days] and postoperative morbidity of complication [12.5%(2/16) vs. 9.4%(3/32)] were not significantly different between the two groups (all P>0.05). Within postoperative 30-day follow-up, transrectal specimen extraction group had ileus in one patient and anastomotic leakage in one patient, and laparoscopy-assisted group had fat necrosis of assisted incision in two patients and gastric retention in one patient. There were also no significant differences in specimen length[(18.2±4.8) cm vs. (19.8±5.7) cm, P>0.05], tumor size [(4.0±1.2) cm vs. (4.4±1.5) cm, P>0.05] and number of harvested lymph node (14.6±2.6 vs. 16.0±3.0, P>0.05] between two groups. During follow-up of 7-10(mean 9) months of transrectal specimen extraction group and 2-16 (mean 7) months of laparoscopically assisted group, no tumor local relapse and distant metastasis were found in the both groups. As compared to laparoscopy-assisted sigmoid radical resection, transrectal specimen extraction laparoscopic sigmoid radical resection has better short-term efficacy, meanwhile they have comparable oncologic clearance.

Laparoscopic total colectomy with transrectal specimen extraction and intraabdominal ileorectal anastomosis for slow-transit constipation (with video)

Laparoscopic total colectomy with transrectal specimen extraction and intraabdominal ileorectal anastomosis for slow-transit constipation (with video)

Technical questions of the transrectal specimen extraction

During laparoscopic partial colectomy the specimen can be extracted transrectally. This technique decreases the invasiveness of the surgery, because the abdominal wall incision is avoided. Premises of a new surgical technique are precise technical description as well as a favourable balance of advantages and disadvantages. In this paper the authors review the technique they apply and analyse their first results. 45 laparoscopic bowel resections were performed by a multidisciplinary team between 16th April 2014 and 1st November 2015. Indication of surgery was endometriosis, and the specimen was extracted transrectally in 11 patients. Having ligated both bowel ends proximal and distal to the section infiltrated with endometriosis, and the proximal bowel secured with a laparoscopic bulldog. Then the bowel was resected and the specimen was extracted in a camera bag transrectally. A purse-string suture was placed into the proximal bowel end, and the anvil of the circular stapler--which was introduced transrectally--was inserted into the bowel. After closing the rectal stump, the anastomosis was performed with a circular stapler. We used this technique when the upper third of the rectum or sigmoid colon was infiltrated with endometriosis. The difference between the operation time of the two techniques (transabdominal vs. transrectal specimen extraction: 108 min vs. 118 min) was not significant. There was not difference in the WBC count between the first and second postoperative day, and there was not any anastomosis leakage detected either. By using the above technique, postoperative infections could have been reduced to minimum. Transrectal specimen extraction did not increase postoperative complication The authors believe this is a safe way of specimen extraction after partial colectomy.

Totally Laparoscopic Colectomy with Intracorporeal Side-to-End Colorectal Anastomosis and Transrectal Specimen Extraction for Sigmoid and Rectal Cancers.

The techniques of intracorporeal anastomosis and specimen extraction after laparoscopic colectomy via a natural orifice have gained interest increasingly. We evaluated the feasibility of our unique techniques for colorectal reconstruction and report immediate postoperative outcomes in patients with rectosigmoid cancer. Patients with sigmoid or rectal cancer were selected depending on the size of the tumor and its distance from the anal verge. Demographic data, operative parameters, and postoperative outcomes were assessed. After complete resection of the tumor, all patients underwent an intracorporeal side-to-end colorectal anastomosis following transrectal specimen extraction. Laparoscopic resection with our technique of intracorporeal anastomosis was successful in 32 patients. The average operative time was 192±29min, and mean blood loss was 51±18ml. All patients experienced mild postoperative pain, and bowel function returned before postoperative day 3 in most patients. They had an uneventful postoperative course with a median hospital stay of 6days. Major perioperative complications or anastomotic leak were not encountered in this study. The mean size of the lesion was 3.3±1.8cm, and the mean number of harvested nodes was 14±6. During the follow-up period, there were no functional disorders associated with the intracorporeal anastomosis or transrectal specimen extraction. Intracorporeal side-to-end colorectal anastomosis with transrectal specimen extraction in laparoscopic colorectal surgery is a safe and effective procedure for patients with rectosigmoid malignancy.

Transrectal specimen extraction after laparoscopic left colectomy: a case‐matched study

Avoiding 'mini-laparotomy' to extract a colectomy specimen may decrease wound complications and further improve recovery after laparoscopic surgery. The aim of this study was to develop a new technique for transrectal specimen extraction (TRSE) and to compare it with conventional laparoscopy (CL) for left sided colectomy. Eleven patients with benign disease requiring either sigmoid or left colon resection underwent TRSE. The unfired circular stapler was inserted transanally and used as a guide to suture-close the recto-sigmoid junction laparoscopically and as a handle to pull the sutured sigmoid through the opened rectum inside a laparoscopic camera bag. The anvil was inserted into the lumen of the intussuscepted sigmoid and pushed to the level of the anastomosis. The anastomosis was fashioned end-to-end in the first patients and side-to-end in the following patients to improve safety. Intra-operative and postoperative outcomes of patients undergoing TRSE were compared with those of a group of 20 patients undergoing CL, who were matched for type of resection, body mass index and age. The procedure was successful in all but the first patient who was converted to conventional laparoscopic colectomy without any additional morbidity. Two patients in the end-to-end anastomosis group, but none in the side-to-end group, developed peri-anastomotic sepsis. Compared with CL, patients undergoing TRSE did not show any significant differences in operative time, recovery or morbidity. Transrectal specimen extraction after left colectomy using the circular stapler technique is feasible. A side-to-end anastomosis appears safer than an end-to-end anastomosis. Further studies are needed to explore the potential advantages of this procedure over CL.

Colorectal natural orifice transluminal endoscopic surgery (NOTES) and transvaginal/transrectal specimen extraction

Advancements in minimally invasive surgery have both revolutionized laparoscopy and set the stage for the advancement of endoscopic surgery to the forefront of modern medicine. Natural orifice transluminal endoscopic surgery (NOTES) has now become a subject of great interest to surgeons worldwide who wish to reduce the morbidity associated with abdominal operations. However, the application of NOTES to colorectal surgery has thus far been limited due to the complex dissection, anastomosis and specimen extraction typically required when operating on the large bowel. For this reason, laparoscopic-assisted natural orifice surgery has been the means by which most surgeons have begun to incorporate natural orifice surgery into their established practices. Transanal endoscopic surgery, transvaginal-assisted laparoscopy and transrectal specimen extraction are all emerging techniques that may be currently employed, in a hybrid manner, with traditionally accepted laparoscopic operations in order to transition toward less invasive surgery and even pure NOTES. To this end, the vagina appears to be the most practical and widely used site of specimen extraction and adjunct access site for laparoscopic hybrid operations. An accompanying video demonstrates the authors' preferred technique for transvaginal and transrectal specimen extraction.

Laparoscopic sigmoid resection with transrectal specimen extraction: a systematic review

A systematic review was performed to identify differences in surgical technique, postoperative morbidity, length of hospital stay and safety for procedures involving left-sided laparoscopic colectomy with natural orifice specimen extraction. A PubMed search was performed to retrieve studies reporting on left-sided laparoscopic colorectal resection with transrectal specimen extraction. The quality of the different reports was assessed according to the Newcastle-Ottawa Scale. Six studies were included and all but one were cohort studies. Studies on transanal, transvaginal or transcolonic specimen extraction were excluded, as were reports on paediatric surgery. Six papers (including 94 patients) fulfilled the search criteria. The techniques reported were not standardized and this technical heterogeneity hampered pooled analysis. A meta-analysis could also not be performed because of differences in inter-study methods, study population and results. All studies showed, nevertheless, that the technique is feasible with low morbidity and short postoperative hospital stay. No anal dysfunction was reported. To date, the evidence in favour of left-sided laparoscopic colectomy with transrectal specimen extraction is weak (level IV-V). Future clinical research should focus on standardization of the technique. Randomized controlled trials are necessary to show the superiority of this approach with regard to postoperative pain and morbidity, hospital stay, recovery, function and cosmesis.

Hybrid NOTES colectomy for right‐sided colonic tumors

Given the limitation of surgical access and instrumentation, pure NOTES technique currently appears challenging for colorectal surgery. As such, we would like to determine the technical feasibility and clinical results of hybrid NOTES right hemicolectomy with transrectal extraction of specimen. After the right-sided colon was fully mobilized and vessels ligated, bowel resection and intracorporeal side-to-side ileocolic anastomosis were performed with endostaplers. The Transanal Endoscopic Operations device was inserted transanally. The resected specimen was removed via the Transanal Endoscopic Operations device through an enterotomy made over the anterior wall of the upper rectum. The operation was performed on a 42-year-old woman and lasted 120 minutes; blood loss was 30 mL. The patient had an uneventful recovery and was discharged on postoperative day 5. The median pain score was 2 (range, 2-3). Our preliminary experience shows that hybrid NOTES right hemicolectomy is safe and feasible. The technique eliminates the need for mini-laparotomy in patients undergoing laparoscopic right hemicolectomy, and it offers promise in this era of minimally invasive surgery.