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Technique for full laparoscopic sigmoid resection. (A) The specimen is isolated: the proximal sigmoid colon and proximal rectum are tied off with a non-absorbable suture. (B) The rectum is opened semi-circumferentially using a vessel-sealing device and the anvil is delivered into the abdomen transrectally. The spike from the circular stapler is connected to a mono-filament suture and connected to the anvil. (C) A mono-filament suture is connected to the hole in the spike and the spike is attached to the anvil intracorporeally. (D) The proximal bowel is opened using a vessel-sealing device and the anvil is introduced. The colon is divided with a stapler and the anvil is retrieved by gently pulling on the suture. The sharp spike perforates the colon, so that the anvil can be pulled through and the proximal part of the anastomosis is ready. The spike is disconnected from the anvil and removed.
Source publication
Multidisciplinary laparoscopic treatment is the standard of care for radical treatment of deep infiltrating pelvic endometriosis. If bowel resection is necessary, a muscle-split or Pfannenstiel incision is also required. The avoidance of any laparotomy could decrease surgical stress response, give a faster return to normal bowel function, decrease...
Context in source publication
Context 1
... to a mono-filament suture (Prolene 0, Ethicon Endo-Surgery, Cincinnati, OH, USA), placed intra-abdominally via the 12-mm port and connected to the anvil. A colotomy was made at the level of the transition between descending colon and proximal sigmoid colon using a vessel-sealing device, and the anvil was introduced into the descending colon (Fig. 1). The colon was divided with a 60-mm endoscopic linear stapler (Endo GIA Universal Roticulator TM , Covidien, Autosuture, Norwalk, CT, USA). Surprisingly, the Prolene 0-suture is not cut by the linear stapler and can be easily grasped. The anvil was retrieved by gently pulling on the Prolene suture, so that the proximal part of the ...
Citations
... Other authors had previously demonstrated the feasibility and safety of the NOSE technique for bowel resection in DE using both the transvaginal and transrectal routes, for the extraction of the specimen [10,28,31]. In agreement with these studies, we also observed no statistically significant differences in terms of post-operative complications between the TICA technique and the classical one. ...
... Our study, in particular, indicated that, in the TICA group, leakage of the anastomosis never occurred, in contrast to the CT group, where it occurred in only one case (5%) (patient who had already undergone surgery for DE). The leakage rate is essentially the one indicated in the literature, which ranges between 0 and 3% [10,28,31,33,34]. Obviously, given the small number of patients, we cannot It is interesting to observe that one of the most frequent post-operative complications for both techniques was bladder voiding deficit (10%, 2 patients for TICA vs 6.8%, 3 patients for CT). ...
Purpose
The surgical approach to bowel endometriosis is still unclear. The aim of the study is to compare TICA to conventional specimen extractions and extra-abdominal insertion of the anvil in terms of both complications and functional outcomes.
Methods
This is a single-center, observational, retrospective study conducted enrolling symptomatic women underwent laparoscopic excision of deep endometriosis with segmental bowel resection between September 2019 and June 2022. Women who underwent TICA were compared to classical technique (CT) in terms of intra- and postoperative complications, moreover, functional outcomes relating to the pelvic organs were assessed using validated questionnaires [Knowles-Eccersley-Scott-Symptom (KESS) questionnaire and Gastro-Intestinal Quality of Life Index (GIQLI)] for bowel function. Pain symptoms were assessed using Visual Analogue Scale (VAS) scores.
Results
The sample included 64 women. TICA was performed on 31.2% (n = 20) of the women, whereas CT was used on 68.8% (n = 44). None of the patients experienced rectovaginal, vesicovaginal, ureteral or vesical fistula, or ureteral stenosis and uroperitoneum, and in no cases was it necessary to reoperate. Regarding the two surgical approaches, no significant difference was observed in terms of complications. As concerns pain symptoms at 6-month follow-up evaluations on stratified data, except for dysuria, all VAS scales reported showed significant reductions between median values, for both surgery interventions. As well, significant improvements were further observed in KESS scores and overall GIQLI. Only the GIQLI evaluation was significantly smaller in the TICA group compared to CT after the 6-month follow-up.
Conclusions
We did not find any significant differences in terms of intra- or post-operative complications compared TICA and CT, but only a slight improvement in the Gastro-Intestinal Quality of Life Index in patients who underwent the CT compared to the TICA technique.
... Future studies can continue to evaluate the outcomes of NOSE procedures in a variety of procedures. NOSE colectomies have been successful in treating other conditions, including endometriosis of the bowel [16,17] and colorectal cancers [15]. The treatment of malignant conditions using NOSE procedures is increasingly common though there is the concern for tumor seeding into the peritoneum. ...
Background
Natural orifice specimen extraction (NOSE) involves the removal of specimens through a naturally occurring orifice, such as the anus, rather than trans-abdominal extraction. NOSE procedures have been shown to significantly reduce postoperative complications and improve healing.
Objective
The purpose of this case series is to report the outcomes of 27 patients undergoing sigmoidectomies through natural orifice specimen extraction.
Materials and methods
We carefully recorded demographic data on age and BMI, as well as operative data on surgical indication, and length of stay. We also collected data on postoperative complications, including infection, hernia, wound dehiscence, urinary tract infections (UTIs), or anastomotic leaks.
Results
Our patients were majority female (n = 21, 77.8%) with a median age of 53.5 (range: 25-79) and median BMI of 33.2 kg/m² (range: 16.7 - 48.3 kg/m²). Thirteen patients (48.1%) were obese (BMI > 30.0 kg/m²). The majority of these patients underwent sigmoidectomies for benign conditions such as recurrent diverticulitis (n = 9, 33.3%), rectal prolapse (n = 8, 29.6%), perforated diverticulitis (n = 3, 11.1%), colovesical fistula (n = 3, 11.1%), and abdominal abscess (n = 3, 11.1%) (Table 1). One patient was receiving treatment for sigmoid cancer. The average estimated blood loss was 63.26 mL. The average hospital stay was 3.61 days. Three patients (11.1%) developed a fever postoperatively (temperature >= 100.4 F), which resolved the day after. One patient completed a post-operative hospital stay of 19 days for dialysis and rehab placement. No patients (0.0%) experienced any postoperative complications, including wound infection, hernia, dehiscence, UTIs, or anastomotic leakages. There was no postoperative mortality.
Conclusions
Our study demonstrates the practicality and safety of NOSE procedures for sigmoidectomies as an alternative to transabdominal approaches to treat benign colon diseases.
... In recent years, the number of articles reporting the usefulness of laparoscopic colorectal surgery using NOSE has been gradually increasing. Previous studies reported that laparoscopic colorectal surgery with NOSE required only small incisions, resulting in faster gastrointestinal recovery, less postoperative pain, shorter hospital stay, and good cosmetic outcomes [9,[13][14][15][16]. However, laparoscopic surgery using NOSE is technically complicated and difficult, and it requires an enterotomy within the peritoneal cavity, which can cause bacterial infection and cancer cell transplantation. ...
Introduction
In recent years, natural orifice specimen extraction (NOSE) has been attracting attention as a further minimally invasive operation for colorectal cancer, and not only improvement of appearance, but also reduction of pain and wound-related complications due to abdominal wall destruction has been reported. However, NOSE is technically complicated and difficult, and it has not yet been widely used. The aim of this study was to confirm the feasibility, safety, and short-term outcomes of total laparoscopic colon cancer surgery with NOSE.
Case presentation
From May 2018 to October 2019, eight patients with stage 0 or I colon cancer underwent NOSE surgery in our hospital. Transanal specimen extraction was performed in six cases, and transvaginal specimen extraction was performed in two cases. All operations were successfully accomplished without conversion to open surgery. The anastomosis method was double stapling technique in three cases and overlap method in five cases. The median operative time was 224 minutes. The median blood loss was 10 ml. The median time to first flatus was 1 day, and the median time to first stool was 2 days. The median postoperative observation period was 18 months, but there was no recurrence. There were no postoperative complications in these cases.
Conclusion
Total laparoscopic colon cancer surgery with NOSE appears to be feasible, safe, and show promising efficacy for selected patients.
... outcomes for TAMIS approach needs further prospective evaluation [14][15][16][17][18][19][20]. Compared to the traditional laparoscopic techniques, transanal hybrid colon resection (ta-CR) features a reduction in size and a number of transabdominal ports and the use of the transanal pathway to perform the procedure and remove the specimen. ...
... By reducing the number of trocars and especially reducing the size of trocars to maximum 5 mm, the probability of access complications could be potentially reduced [23,24]. With the advent of hybrid techniques, the therapeutic spectrum has been enlarged by using the transanal approach to access the abdominal cavity for colorectal surgery [1,2,[8][9][10][11][12][13][14][15][16][17][18]. ...
... Regarding the possible advantage of a hybrid technique, our initial experience with ta-CR showed a trend towards improved postoperative convalescence as shown in our previous study [17]. Several authors have shown a possible advantage in postoperative pain, when the transanal access is integrated in the operative technique and an effective reduction of the number and size of trocars occurred [14][15][16][18][19][20]. In our series, with 1 exception after a complication, we did not see any wound infections. ...
Background
Transanal hybrid rectal and colon resection have been introduced in recent years at dedicated surgical centers. The anus is used as a natural orifice for large size access. The use of transanal hybrid colectomy techniques is still in its infancy with outcomes and unique complications being identified. The purpose of this work is the evaluation of outcomes for transanal hybrid colon resections (ta-CR), including intra operative and postoperative complications, results, and advantages.
Methods
A prospectively maintained database was analyzed. Inclusion criteria were any patient who underwent ta-CR for rectal prolapse, slow transit, obstructive defaecation, and chronic sigmoid diverticulitis. Patients were excluded from ta-CR if BMI > 30, major previous abdominal surgery, or presence of a large inflammatory mass in diverticulitis. Transanal access was used for all operative steps requiring access of more than 5 mm, such as staplers, large graspers, and specimen retrieval. Data acquisition and analysis was performed for operative time, complications, and postoperative quality of life.
Results
From 2012 to 2017, 82 patients underwent ta-CR [33 males, 49 females, median age 58 (24–80)]. Transanal-subtotal colectomy and ta-CR for constipation was performed in 12 patients; ta-CR and rectopexy in 31, and ta-CR for diverticulitis was performed in 39 patients. Conversion to traditional approach was required in 3 cases (3.6%). Intraoperative complication included 1 rectal tear requiring intervention. Post-op complications included 3 leaks requiring laparoscopic and 1 open revision, the latter developed wound infection and an incisional hernia. Gastrointestinal Quality of Life Index (GIQLI) improved significantly from preoperative 89 to postoperative 119 (p < 0.001). No patients with ta-CR without open revision developed a hernia post-op with median 18 months follow-up.
Conclusions
ta-CR is a safe and effective NOTES Hybrid technique for colorectal procedures in selected patients with benign colon disorders. GIQLI shows improvement and this technique can have the potential in preventing wound and hernia complications.
... The average tumor size in the NOSE group in our study was 3.4 cm, and it was significantly smaller than that in the conventional group. Some authors have stated that obese patients are not suitable for transrectal specimen extraction and set the BMI cutoff at > 28 kg/m 2 [32], > 30 kg/m 2 [29], or > 35 kg/ m 2 [33]. In our study, although no significant difference in patients' BMI was seen in the two groups, the highest BMI was 32 kg/m 2 in the NOSE group and 40 kg/m 2 in the conventional group. ...
Background:
The transvaginal natural orifice specimen extraction (NOSE) approach for right-side colon surgery has been proven to exhibit favorable short-term outcomes. However, thus far, no study has reported the advantages of transrectal NOSE for right-side colon surgery. The aim of this study was to compare the technical feasibility, safety, and short-term outcomes of minimally invasive right hemicolectomy using the transrectal NOSE method and those of conventional mini-laparotomy specimen extraction.
Methods:
A study was conducted on consecutive patients who had minimally invasive right hemicolectomy either for malignancy or benign disease at Chang Gung Memorial Hospital, Linkou, Taiwan, between January 2017 and December 2018. The patients were divided into two groups: conventional surgery with specimen extraction using mini-laparotomy and NOSE surgery. Surgical outcomes, including complications, postoperative short-term recovery, and pain intensity, were analyzed.
Results:
We enrolled 297 patients (151 males, mean age 64.9 ± 12.8 years) who had minimally invasive right hemicolectomy. Of these 297 patients, 272 patients had conventional surgery with specimen extraction through mini-laparotomy and 25 patients had NOSE surgery (23 transrectal, 2 transvaginal). The diagnosis of colon disease did not differ significantly between the conventional and NOSE groups. Postoperative morbidity and mortality rates were comparable. The postoperative hospital stay was significantly (p = 0.004) shorter in the NOSE group (median 5 days, range 3-17 days) than in the conventional group (median 7 days, range 3-45 days). Postoperative pain was significantly (p = 0.026 on postoperative day 1 and p = 0.002 on postoperative day 2) greater in the conventional group than in the NOSE group.
Conclusions:
NOSE was associated with acceptable short-term surgical outcomes that were comparable to those of conventional surgery. NOSE results in less postoperative wound pain and a shorter hospital stay than conventional surgery. Larger studies are needed.
... A number of series have been reported in which laparoscopic bowel resection with NOSE was used for severe endometriosis, and the results have shown improvements in safety and effectiveness. Recently, Wolthuis et al. 21 showed no major impacts, such as developing pelvic abscesses or postoperative complications related to intraoperative bowel openings and manipulations. Microbiology analysis for assessing peritoneal contamination related to colostomy procedures is still unclear in studies published in the literature. ...
... A newer technique combining a laparoscopic and transanal approach can be applied to remove the full thickness of the infiltrating endometrial nodules of the lower and middle rectum (Wolthuis et al., 2011;Bridoux et al., 2012). This technique may reduce the risk of rectal stenosis and denervation (Pronio et al., 2007;Goncalves et al., 2010;Bridoux et al., 2012;Roman and Tuech, 2014). ...
STUDY QUESTION
How should surgery for endometriosis be performed?
SUMMARY ANSWER
This document provides recommendations covering technical aspects of different methods of surgery for deep endometriosis in women of reproductive age.
WHAT IS KNOWN ALREADY
Endometriosis is highly prevalent and often associated with severe symptoms. Yet compared to equally prevalent conditions, it is poorly understood and a challenge to manage. Previously published guidelines have provided recommendations for (surgical) treatment of deep endometriosis, based on the best available evidence, but without technical information and details on how to best perform such treatment in order to be effective and safe.
STUDY DESIGN, SIZE, DURATION
A working group of the European Society for Gynaecological Endoscopy (ESGE), ESHRE and the World Endometriosis Society (WES) collaborated on writing recommendations on the practical aspects of surgery for treatment of deep endometriosis.
PARTICIPANTS/MATERIALS, SETTING, METHODS
This document focused on surgery for deep endometriosis and is complementary to a previous document in this series focusing on endometrioma surgery.
MAIN RESULTS AND THE ROLE OF CHANCE
The document presents general recommendations for surgery for deep endometriosis, starting from preoperative assessments and first steps of surgery. Different approaches for surgical treatment are discussed and are respective of location and extent of disease; uterosacral ligaments and rectovaginal septum with or without involvement of the rectum, urinary tract or extrapelvic endometriosis. In addition, recommendations are provided on the treatment of frozen pelvis and on hysterectomy as a treatment for deep endometriosis.
LIMITATIONS, REASONS FOR CAUTION
Owing to the limited evidence available, recommendations are mostly based on clinical expertise. Where available, references of relevant studies were added.
WIDER IMPLICATIONS OF THE FINDINGS
These recommendations complement previous guidelines on management of endometriosis and the recommendations for surgical treatment of ovarian endometrioma.
STUDY FUNDING/COMPETING INTEREST(S)
The meetings of the working group were funded by ESGE, ESHRE and WES. Dr Roman reports personal fees from ETHICON, PLASMASURGICAL, OLYMPUS and NORDIC PHARMA, outside the submitted work; Dr Becker reports grants from Bayer AG, Volition Rx, MDNA Life Sciences and Roche Diagnostics Inc. and other relationships or activities from AbbVie Inc., and Myriad Inc, during the conduct of the study; Dr Tomassetti reports non-financial support from ESHRE, during the conduct of the study; and non-financial support and other were from Lumenis, Gedeon-Richter, Ferring Pharmaceuticals and Merck SA, outside the submitted work. The other authors had nothing to disclose.
TRIAL REGISTRATION NUMBER
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... Previous studies have reported faster gastrointestinal recovery, less post-operative pain and shorter hospital stay following laparoscopic colorectal surgery with NOSE (51)(52)(53)(54). The results of our meta-analysis also suggested that the NOSE group had less post-operative pain, shorter hospital stay and shorter time to first flatus. ...
Objective: To evaluate the safety and oncological outcomes of laparoscopic colorectal surgery using natural orifice specimen extraction (NOSE) compared with conventional laparoscopic (CL) colorectal surgery in patients with colorectal diseases.
Methods: We conducted a systematic search of PubMed, EMBASE, and Cochrane databases for randomized controlled trials (RCTs), prospective non-randomized trials and retrospective trials up to September 1, 2018, and used 5-year disease-free survival (DFS), lymph node harvest, surgical site infection (SSI), anastomotic leakage, and intra-abdominal abscess as the main endpoints. Subgroup analyses were conducted according to the different study types [RCT and NRCT (non-randomized controlled trial)]. A sensitivity analysis was carried out to evaluate the reliability of the outcomes. RevMan5.3 software was used for statistical analysis.
Results: Fourteen studies were included (two RCTs, seven retrospective trials and five prospective non-randomized trials) involving a total of 1,435 patients. Compared with CL surgery, the NOSE technique resulted in a shorter hospital stay, shorter time to first flatus, less post-operative pain, and fewer SSIs and total perioperative complications. Anastomotic leakage, blood loss, and intra-abdominal abscess did not differ between the two groups, while operation time was longer in the NOSE group. Oncological outcomes such as proximal margin [weighted mean difference [WMD] = 0.47; 95% confidence interval [CI] −0.49 to 1.42; P = 0.34], distal margin (WMD= −0.11; 95% CI −0.66 to 0.45; P = 0.70), lymph node harvest (WMD = −0.97; 95% CI −1.97 to 0.03; P = 0.06) and 5-year DFS (hazard ratio = 0.84; 95% CI 0.54–1.31; P = 0.45) were not different between the NOSE and CL surgery groups.
Conclusions: Compared with CL surgery, NOSE may be a safe procedure, and can achieve similar oncological outcomes. Large multicenter RCTs are needed to provide high-level, evidence-based results in NOSE-treated patients and to determine the risk of local recurrence.
... In our series, transanal extraction of the specimen was possible in 78% of patients in the taTME group and 30% of patients in the robotic group after matching. NOSE has been reported to be a feasible and promising technique in minimally invasive colorectal surgery and was shown to be associated with less pain, analgesic requirement, and other incision-associated morbidities [26][27][28]. ...
Background:
Robotic surgery and transanal minimally invasive surgery are the two recently developed techniques, which can overcome the difficult pelvic dissection in conventional laparoscopy. This study aimed to compare the early cases of robotic and transanal total mesorectal excision (taTME) using propensity score matching.
Methods:
The first 40 cases of taTME and the first 80 sphincter-saving robotic total mesorectal resection for rectal cancer were selected from the prospectively collected database. Using propensity score matching, the outcomes of 40 matched cases of robotic TME were compared with the 40 cases of taTME.
Results:
Before matching, patients in the taTME group were significantly younger. The tumors were smaller but more distally located. Significantly more patients in the taTME group received preoperative chemoradiation. After matching, the two groups did not show any differences in gender, age, comorbidity, the level of tumors, and incidences of preoperative chemoradiation. The operating time was significantly shorter (254 vs. 170 min, p < 0.05) and the blood loss was less (50 vs. 150 ml, p = 0.002) in the taTME group. Conversion rate was 5% in both groups. There was no difference in the hospital stay, overall morbidity, the anastomotic leakage rate, and the urinary complication rate between the two groups. More patients in the taTME group did not require a separate abdominal incision. The distal margin, the number of lymph nodes examined, and the rate positive circumferential margin (0 vs. 5%, p = 0.494) were also similar between the two groups.
Conclusions:
Both taTME and robotic surgery can achieve favorable outcomes in the rectal cancer resection. Comparison of the early experience of the two procedures with propensity score matching showed the taTME was associated with a shorter operating time, less blood loss, and a higher rate of transanal extraction of the specimen. Further evaluation by randomized trials is warranted.
... The distensible rectum lends itself well to passage of specimens for extraction, and anal dilation for retrieval is a relatively simple task. A step-wise description of this technique is described by Wolthuis et al. 16 Transluminal endoscopic operation (TEO) ports (TEO platform; Storz, Tuttlingen, Germany) have been used in long rectal stumps (>10 cm) with double-ringed wound protectors (Alexis wound retractor; Applied Medical, Rancho Santa Margarita, CA, USA) used for shorter rectal stumps to facilitate the removal of the specimen. 17 Other groups have demonstrated removal of specimens without any wound protection. ...
... Specimens of the rectum require a proctotomy as part of the distal margin transection that is already a required step in the operation. After the specimen is extracted, the proctotomy is then completely resected with another firing of a stapler in preparation for use of an end-to-end anastomosis (EEA) stapler, as demonstrated by Wolthuis et al. 16 In our experience with low rectal cancers, the distal transection point of the specimen is at the dentate line and specimens were removed transanally in 100% of laparoscopic cases. A coloanal anastomosis using this already existing viscerotomy was created after specimen extraction. ...
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.
