Natural orifice specimen extraction in colorectal surgery: patient selection and perspectives

Abstract

Over the past 30 years, colorectal surgery has evolved to include minimally invasive surgical techniques. Minimally invasive surgery is associated with reduced postoperative pain, reduced wound complications, earlier return of bowel function, and possibly shorter length of hospital stay. These benefits have been attributed to a reduction in operative trauma compared to open surgery. The need to extract the specimen in colorectal operations through a “mini-laparotomy” can negate many of the advantages of minimally invasive surgery. Natural orifice specimen extraction (NOSE) is the opening of a hollow viscus that already communicates with the outside world, such as the vagina or distal gastrointestinal tract, in order to remove a specimen. The premise of this technique is to reduce the trauma required to remove the specimen with the expectation that this may improve outcomes. Reduction in postoperative analgesic use, quicker return of bowel function, and shorter length of hospital stay have been observed in colorectal operations with NOSE compared to conventional specimen extraction. While the feasibility of NOSE has been demonstrated in colorectal surgery, failures of this technique have also been described. Selection of patients who can successfully undergo NOSE needs further investigation. This review aims to guide surgeons in appropriately selecting patients for NOSE in colorectal surgery. Patient and specimen characteristics are reviewed in order to define patient populations in which NOSE is likely to be successful. Randomized trials comparing NOSE to conventional specimen extraction in colorectal surgery tend to enroll patients with favorable characteristics (body mass index <30, American Society of Anesthesiologists class ≤3, specimen diameter <6.5 cm) and demonstrate improved outcomes. Adopters of NOSE should restrict using this technique to the populations in which feasibility has been defined in the literature. Wider application to other populations, particularly patients with body mass index >30 and those with significant comorbidities, requires further study.

Comparison of NOSES and Conventional Laparoscopic Surgery in Colorectal Cancer: Bacteriological and Oncological Concerns

“…In 1993, Franklin et al (10) were the first to publish a case of patient who underwent sigmoid resection with transrectal specimen extraction. In recent years, more and more people have noticed that NOSES is more minimally invasive than conventional laparoscopic surgery and has accelerated the postoperative recovery of patients (11)(12)(13). It has caused widespread concern in the treatment of colorectal cancer and could be the next step in minimizing minimally invasive surgery (1,5,14).…”

International consensus on natural orifice specimen extraction surgery (NOSES) for colorectal cancer

“…Locally advanced tumor, acute bowel obstruction and perforation from cancer are not recommended to perform laparoscopy. Thirdly, NOSES also has specific indication requirements, including: the depth of tumor invasion should be T2 or T3, the CDmax of specimen should be less than 3 cm for transanal-NOSES and 3–5cm for transvaginal-NOSES, body mass index (BMI) should be less than 30 kg/m 2 for transanal-NOSES and less than 35 kg/m 2 for transvaginal-NOSES [14, 21]. Fourthly, NOSES is also recommended for benign tumors, Tis and T1 tumor when local excision is not indicated for whatever reasons.…”

“…Therefore, the posterior colpotomy incision does not affect the sexual function and not increase the risk of bleeding. Currently, there are no complications related to the colpotomy incision reported in colorectal surgery [21].…”

Transrectal natural orifice specimen extraction after sigmoidectomy with D2 lymph node dissection – a video vignette

“…Several attempts have been described for optimizing outcomes after laparoscopic and robotic approaches. Natural orifice specimen extraction surgery (NOSES) has met with great interest among laparoscopic colorectal surgeons since it reduces trauma and wound infection and also minimizes postoperative pain . Compared with the traditional laparoscopic technique, better cosmetic results and lower rates of incisional hernia have been demonstrated .…”