Laparoscopic versus open total mesorectal excision for middle and low rectal cancer: a meta-analysis of results of randomized controlled trials

Laparoscopic natural orifice specimen extraction, a minimally invasive surgical technique for mid-rectal cancers: Retrospective single-center analysis and single-surgeon experience of selected patients

OBJECTIVE

To evaluate the feasibility, safety, and short-term outcomes of middle rectal resection followed by transanal specimen extraction.

METHODS

Forty-four patients with small mid-rectal tumors underwent laparoscopic rectal resection followed by transanal specimen extraction.

RESULTS

The procedure was successful in all patients without intraoperative conversion or additional access. The mean operation time was 182.7 minutes (range, 130-255 minutes), the mean blood loss was 26.5 mL (range, 5-120 mL), the mean postoperative exhaust time was 31.3 hours (range, 16-60 hours), and the mean length of hospital stay was 9.5 days (range, 8-19 days). One patient developed anastomotic leakage, which was treated by intravenous antibiotics and daily pelvic cavity flushes through the abdominal drainage tube. No infection-related complications or anal incontinence were observed. The mean tumor size was 2.1 cm (range, 1.6-3.2 cm), the mean number of harvested lymph nodes was 16.5 (range, 6-31), and the mean follow-up time was 8.5 months (range, 2-16 months). By the last follow-up, no signs of recurrence had been found in any patient.

CONCLUSION

The combination of standard laparoscopic proctectomy and transanal specimen extraction could become a well-established strategy for selected patients.

Comparison of Short-Term and Long-Term outcomes of Laparoscopy Versus Laparotomy in Rectal Cancer: Systematic Review and Meta-analysis of Randomized Controlled Trials

Background and objective: The last randomized controlled trials ,the ACOSOG Z6051 1,2 and the ALaCaRT trial3, 4 could not show the non-inferiority of the laparoscopy in comparison to laparotomy for rectal cancer. In fact, the ten first years of practicing laparoscopy were years when surgeons developed their learning curve. Therefore, by excluding this learning bias, it is possible to end up with a more fair and correct comparison between the two techniques. It is henceforth relevant to pursue a new meta-analysis that compares the two techniques and excludes studies done during the earlier periods of laparoscopic rectal surgery. Results: Six randomized controlled trials met the eligibility criteria, involving a total of 1556 patients in the laparoscopy group and 1188 patients in the laparotomy group. Our meta-analysis was in favor of laparoscopy in a significant way for blood loss, first bowel movement and the number of harvested lymph nodes. It was non-significantly in favour of laparoscopy for 30-days mortality after surgery and length of hospital stay. It was significantly in favor of laparotomy for operative duration. No significant difference was found in anastomotic leakage) , reoperation within 30 days, number of positive CRMs and completeness of mesorectal excision between the two groups. No difference was found in recurrence, disease-free survival and overall survival between laparoscopy group and laparotomy group. Conclusion: The comparison of the randomized controlled trials published before and after 2010, showed no significant difference in outcomes between the learning period and after. Keywords: Laparoscopy, laparotomy, long-term outcomes, meta-analysis, short-term outcomes, rectal cancer

Operative outcome of laparoscopic colorectal cancer surgery in a regional hospital in a developing country: A propensity score-matched comparative analysis

OBJECTIVE

Laparoscopic surgery is an alternative procedure for colorectal cancers. However, high-level supporting evidence has been derived from high-volume centers in developed countries. During the early phase of applying the laparoscopic approach, we evaluated the procedure's short-term outcomes in our regional middle-volume hospital in a developing country.

METHODS

We retrospectively analyzed data for a cohort of 223 colorectal cancer patients who underwent elective surgery from October 2017 to September 2019. We compared 165 patients undergoing open surgery (OS group) with 58 undergoing laparoscopic surgery (LS group) using a propensity score-matched analysis.

RESULTS

After matching, each group contained 58 patients for evaluating outcomes. The LS group had more harvested mesenteric lymph nodes (5.0 nodes, 95% confidence interval (CI): 1.8-8.1; p-value: <0.01) with comparable blood loss (p-value: 0.54) and margin status (p-value: 0.66). However, LS was more time-consuming (68.8 min longer; 95% CI: 53.0-84.7; p-value: <0.01). Morbidity and mortality rates were equivalent (odds ratio (OR): 1.3, 95% CI: 0.25-2.73, p-value: 0.74, and OR: 2, 95% CI: 0.18-22.1, p-value: 0.57, respectively). The LS group experienced fewer days to begin normal eating (-0.5 days, 95% CI: -0.9 to -0.1, p-value: 0.04) and shorter hospital stay (-1.5 days, 95% CI: -2.7 to -0.4, p-value: <0.01). The conversion rate was 3.5%.

CONCLUSION

The laparoscopic approach was applicable even in a regional middle-volume hospital in a developing country. However, longer surgical time was a drawback.

Laparoscopic vs. open mesorectal excision for rectal cancer: Are these approaches still comparable? A systematic review and meta-analysis

BACKGROUND

To analyze pathologic and perioperative outcomes of laparoscopic vs. open resections for rectal cancer performed over the last 10 years.

METHODS

A systematic literature search of the following databases was conducted: Cochrane Central Register of Controlled Trials, MEDLINE (through PubMed), EMBASE, and Scopus. Only articles published in English from January 1, 2008 to December 31, 2018 (i.e. the last 10 years), which met inclusion criteria were considered. The review only included articles which compared Laparoscopic rectal resection (LRR) and Open Rectal Resection (ORR) for rectal cancer and reported at least one of the outcomes of interest. The analyses followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement checklist. Only prospective randomized studies were considered. The body of evidence emerging from this study was evaluated using the Grading of Recommendations Assessment Development and Evaluation (GRADE) system. Outcome measures (mean and median values, standard deviations, and interquartile ranges) were extracted for each surgical treatment. Pooled estimates of the mean differences were calculated using random effects models to consider potential inter-study heterogeneity and to adopt a more conservative approach. The pooled effect was considered significant if p <0.05.

RESULTS

Five clinical trials were found eligible for the analyses. A positive involvement of CRM was found in 49 LRRs (8.5%) out of 574 patients and in 30 ORRs out of 557 patients (5.4%) RR was 1.55 (95% CI, 0.99-2.41; p = 0.05) with no heterogeneity (I2 = 0%). Incorrect mesorectal excision was observed in 56 out of 507 (11%) patients who underwent LRR and in 41 (8.4%) out of 484 patients who underwent ORR; RR was 1.30 (95% CI, 0.89-1.91; p = 0.18) with no heterogeneity (I2 = 0%). Regarding other pathologic outcomes, no significant difference between LRR and ORR was observed in the number of lymph nodes harvested or concerning the distance to the distal margin. As expected, a significant difference was found in the operating time for ORR with a mean difference of 41.99 (95% CI, 24.18, 59.81; p <0.00001; heterogeneity: I2 = 25%). However, no difference was found for blood loss. Additionally, no significant differences were found in postoperative outcomes such as postoperative hospital stay and postoperative complications. The overall quality of the evidence was rated as high.

CONCLUSION

Despite the spread of laparoscopy with dedicated surgeons and the development of even more precise surgical tools and technologies, the pathological results of laparoscopic surgery are still comparable to those of open ones. Additionally, concerning the pathological data (and particularly CRM), open surgery guarantees better results as compared to laparoscopic surgery. These results must be a starting point for future evaluations which consider the association between ''successful resection" and long-term oncologic outcomes. The introduction of other minimally invasive techniques for rectal cancer surgery, such as robotic resection or transanal TME (taTME), has revealed new scenarios and made open and even laparoscopic surgery obsolete.

Robotic Colorectal Surgery

The role of robotics in colon and rectal surgery has been established as an important and effective tool for the surgeon. Its inherent technologies have provided for increased visualization and ease of dissection in the minimally invasive approach to surgery. The value of the robot is apparent in the more challenging aspects of colon and rectal procedures, including the intracorporeal anastomosis for right colectomies and the low pelvic dissection for benign and malignant diseases.

Clinical practice guidelines for the surgical treatment of rectal cancer: a consensus statement of the Hellenic Society of Medical Oncologists (HeSMO)

In rectal cancer management, accurate staging by magnetic resonance imaging, neo-adjuvant treatment with the use of radiotherapy, and total mesorectal excision have resulted in remarkable improvement in the oncological outcomes. However, there is substantial discrepancy in the therapeutic approach and failure to adhere to international guidelines among different Greek-Cypriot hospitals. The present guidelines aim to aid the multidisciplinary management of rectal cancer, considering both the local special characteristics of our healthcare system and the international relevant agreements (ESMO, EURECCA). Following background discussion and online communication sessions for feedback among the members of an executive team, a consensus rectal cancer management was obtained. Statements were subjected to the Delphi methodology voting system on two rounds to achieve further consensus by invited multidisciplinary international experts on colorectal cancer. Statements were considered of high, moderate or low consensus if they were voted by ≥80%, 60-80%, or <60%, respectively; those obtaining a low consensus level after both voting rounds were rejected. One hundred and two statements were developed and voted by 100 experts. The mean rate of abstention per statement was 12.5% (range: 2-45%). In the end of the process, all statements achieved a high consensus. Guidelines and algorithms of diagnosis and treatment were proposed. The importance of centralization, care by a multidisciplinary team, adherence to guidelines, and personalization is emphasized.

Efficacy of laparoscopic surgery for rectal cancer and impact of surgeon's degree of specialization: A single center clinical study

AIM: To evaluate the clinical effects of laparoscopic surgery for rectal cancer and the impact of surgeon's degree of specialization.

METHODS: Clinical data for 210 patients who underwent treatment for rectal cancer at Shengjing Hospital Affiliated to China Medical University from January 2010 to march 2012 were reviewed. The patients were divided into a laparoscopic surgery group and an open surgery group, and surgical outcome and postoperative outcome were compared between the two groups. According to the doctor's professional degree, the patients were divided into a professional laparoscopic surgery group and a non-professional laparoscopic surgery group, a professional open surgery group and a non-professional open surgery group. Surgical outcome and postoperative outcome were compared between these groups.

RESULTS: The laparoscopic surgery group had less intraoperative blood loss, shorter time to first postoperative exhaust, shorter time to intake of liquid diets, and shorter hospital stay than the open surgery group (P < 0.01). In addition, the laparoscopic surgery group had a higher number of resected lymph nodes, earlier ambulation, shorter time to urethral catheter removal, and lower incision infection rate than the open surgery group (P < 0.05). The operation time were longer, resected specimen length was shorter, and the total cost was higher in the laparoscopic surgery group than in the open surgery group (P < 0.01). Time to intake of liquid diets was significantly shorter in the two professional groups than the two non-professional groups (P < 0.01). The professional open surgery group had a significantly lower incidence of intestinal fistula than the non-professional open surgery group (P < 0.05).

CONCLUSION: Laparoscopic surgery for rectal cancer has the advantages of less intraoperative bleeding, resecting more lymph nodes, faster postoperative recovery, shorter hospitalization time, and lower postoperative incision infection rate. The degree of doctor's degree of specialization has an impact on postoperative recovery of patients undergoing radical rectal operation.

Laparoscopic colorectal surgery: Current status and implementation of the latest technological innovations

The introduction of laparoscopy is an example of surgical innovation with a rapid implementation in many areas of surgery. A large number of controlled studies and meta-analyses have shown that laparoscopic colorectal surgery is associated with the same benefits than other minimally invasive procedures, including lesser pain, earlier recovery of bowel transit and shorter hospital stay. On the other hand, despite initial concerns about oncological safety, well-designed prospective randomized multicentre trials have demonstrated that oncological outcomes of laparoscopy and open surgery are similar. Although the use of laparoscopy in colorectal surgery has increased in recent years, the percentages of patients treated with surgery using minimally invasive techniques are still reduced and there are also substantial differences among centres. It has been argued that the limiting factor for the use of laparoscopic procedures is the number of surgeons with adequate skills to perform a laparoscopic colectomy rather than the tumour of patients’ characteristics. In this regard, future efforts to increase the use of laparoscopic techniques in colorectal surgery will necessarily require more efforts in teaching surgeons. We here present a review of recent controversies of the use of laparoscopy in colorectal surgery, such as in rectal cancer operations, the possibility of reproducing complete mesocolon excision, and the benefits of intra-corporeal anastomosis after right hemicolectomy. We also describe the results of latest innovations such as single incision laparoscopic surgery, robotic surgery and natural orifice transluminal endoscopic surgery for colon and rectal diseases.

Transanal total mesorectal excision: Towards standardization of technique

AIM: To describe the role of Transanal total mesorectal excision (TaTME) in minimally invasive rectal cancer surgery, to examine the differences in patient selection and in reported surgical techniques and their impacts on postoperative outcomes and to discuss the future of TaTME.

METHODS: MEDLINE (PubMed), EMBASE, and The Cochrane Library were systematically searched through the 1^st of March 2015 using a predefined search strategy.

RESULTS: A total of 20 studies with 323 patients were included. Most studies were single-arm prospective studies with fewer than 100 patients. Multiple transanal access platforms were used, and the laparoscopic approach was either multi- or single port. The procedure was initiated transanally or transabdominally. If a simultaneous approach with 2 operating surgeons was chosen, the operative time was significantly reduced.

CONCLUSION: TaTME was also associated with better TME specimens and a longer distal resection margin. TaTME is thus feasible in expert hands, but the learning curve and safety profile are not well defined. Long-term follow-up regarding anal function and oncological outcomes should be performed in the future.

Laparoscopic versus open surgery for rectal cancer: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND AND AIM

Laparoscopic and open rectum surgery for rectal cancer remains controversial. This systematic review compared the short-term and long-term efficiency and complications associated with laparoscopic and open resection for rectal cancer.

MATERIALS AND METHODS

We searched PubMed, Embase, Cochrane Library, ISI Web of Knowledge and the China Biology Medicine Database to identify potential randomized controlled trials from their inception to March 31, 2014 without language restriction. Additional articles were identified from searching bibliographies of retrieved articles. Two reviewers independently assessed the full-text articles according to the pre-specified inclusion and exclusion criteria as well as the methodological quality of included trials. The meta-analysis was performed using RevMan 5.2.

RESULTS

A total of 16 randomized controlled trials involving 3,045 participants (laparoscopic group, 1,804 cases; open group, 1,241 cases) were reviewed. Laparoscopic surgery was associated with significantly lower intraoperative blood loss, earlier return of bowel movement and reduced length of hospital stay as compared to open surgery, although with increased operative time. It also showed an obvious advantage for minimizing late complications of adhesion-related bowel obstruction. Importantly, there were no significant differences in other postoperative complications, oncological clearance, 3-year and 5-year or 10 year recurrence and survival rates between two procedures.

CONCLUSIONS

On the basis of this meta-analysis we conclude that laparoscopic surgery has advantages of earlier postoperative recovery, less blood loss and lower rates of adhesion-related bowel obstruction. In addition, oncological outcome is comparable after laparoscopic and open resection for rectal cancer.

Robotic versus laparoscopic total mesorectal excision for rectal cancer: a meta-analysis of eight studies

BACKGROUND

Robotic surgery has been used successfully in many branches of surgery, but there is little evidence in the literature on its use in rectal cancer (RC). We conducted this meta-analysis of randomized controlled trials (RCTs) and non-randomized controlled trials (NRCTs) to evaluate whether the safety and efficacy of robotic total mesorectal excision (RTME) in patients with RC are equivalent to those of laparoscopic TME (LTME).

METHODS

Pubmed, Embase, Cochrane Library, Ovid, and Web of Science databases were searched. Studies clearly documenting a comparison of RTME with LTME for RC were selected. Operative and recovery outcomes, early postoperative morbidity, and oncological parameters were evaluated.

RESULTS

Eight studies were identified that included 1229 patients in total, 554 (45.08 %) in the RTME group and 675 (54.92 %) in the LTME group. Compared with LTME, RTME was associated with lower conversion rate (OR 0.23, 95 % CI [0.10, 0.52]; P = 0.0004), lower positive rate of circumferential resection margins (CRM) (2.74 % vs 5.78 %, OR 0.44, 95 % CI [0.20, 0.96], P = 0.04), and lesser incidence of erectile dysfunction (ED) (OR 0.09, 95 % CI [0.02, 0.41]; P = 0.002). Operation time, estimated blood loss, recovery outcome, postoperative morbidity and mortality, length of hospital stay, number of lymph nodes harvested, distal resection margin (DRM), proximal resection margin (PRM), and local recurrence had no significant differences between the two groups.

CONCLUSIONS

RTME is safe and feasible and may be an alternative treatment for RC. More international multicenter prospective large sample RCTs investigating the long-term oncological and functional outcomes are needed to determine the advantages of RTME over LTME in RC.

Challenge or opportunity: outcomes of laparoscopic resection for rectal cancer in patients with high operative risk

This study investigated the impact of laparoscopic rectal cancer resection for patients with high operative risk, which was defined as American Society of Anesthesiology (ASA) grades III and IV. This study was conducted at a single center on patients undergoing rectal resection from 2006 to 2010. After screening by ASA grade III or IV, 248 patients who met the inclusion criteria were identified, involving 104 open and 144 laparoscopic rectal resections. The distribution of the Charlson Comorbidity Index was similar between the two groups. Compared with open rectal resection, laparoscopic resection had a significantly lower total complication rate (P<.0001), lower pain rate (P=.0002), and lower blood loss (P<.0001). It is notable that the two groups of patients had no significant difference in cardiac and pulmonary complication rates. Thus, these data showed that the laparoscopic group for rectal cancer could provide short-term outcomes similar to those of their open resection counterparts with high operative risk. The 5-year actuarial survival rates were 0.8361 and 0.8119 in the laparoscopic and open groups for stage I/II (difference not significant), as was the 5-year overall survival rate in stage III/IV (P=.0548). In patients with preoperative cardiovascular or pulmonary disease, the 5-year survival curves were significantly different (P=.0165 and P=.0210), respectively. The cost per patient did not differ between the two procedures. The results of this analysis demonstrate the potential advantages of laparoscopic rectal cancer resection for high-risk patients, although a randomized controlled trial should be conducted to confirm the findings of the present study.

Laparoscopic natural orifice specimen extraction-colectomy: A systematic review

Over the last 20 years, laparoscopic colorectal surgery has shown equal efficacy for benign and malignant colorectal diseases when compared to open surgery. However, a laparoscopic approach reduces postoperative morbidity and shortens hospital stay. In the quest to optimize outcomes after laparoscopic colorectal surgery, reduction of access trauma could be a way to improve recovery. To date, one method to reduce access trauma is natural orifice specimen extraction (NOSE). NOSE aims to reduce access trauma in laparoscopic colorectal surgery. The specimen is delivered via a natural orifice and the anastomosis is created intracorporeally. Different methods are used to extract the specimen and to create a bowel anastomosis. Currently, specimens are delivered transcolonically, transrectally, transanally, or transvaginally. Each of these NOSE-procedures raises specific issues with regard to operative technique and application. The presumed benefits of NOSE-procedures are less pain, lower analgesia requirements, faster recovery, shorter hospital stay, better cosmetic results, and lower incisional hernia rates. Avoidance of extraction site laparotomy is the most important characteristic of NOSE. Concerns associated with the NOSE-technique include bacterial contamination of the peritoneal cavity, inflammatory response, and postoperative outcomes, including postoperative pain and the functional and oncologic outcomes. These issues need to be studied in prospective randomized controlled trials. The aim of this systematic review is to describe the role of NOSE in minimally invasive colorectal surgery.

Laparoscopic total mesorectal excision for extraperitoneal rectal cancer: long-term results of a 18-year single-centre experience

BACKGROUND AND OBJECTIVES

The oncologic efficacy of laparoscopic total mesorectal excision (TME) for middle-low rectal cancer is still under discussion because of the few long-term data. This study reports the results arising from a single-institution experience during a 18-year period.

METHODS

Data about 132 consecutive laparoscopic TME performed between January 1994 and January 2012 were analysed with Kaplan-Meier method and a uni- and multi-variate analysis was conducted to define independent survival predictors.

RESULTS

A total of 116 sphincter-preserving operations and 16 abdominoperineal resections were performed. Postoperative mortality and morbidity were 0.8 and 18.2%, with a rate of anastomotic leakage of 13.8%. Average follow-up was 85.9 months (range 13-210). Actuarial local recurrence rate was 4.13% at 5 years (any pelvic recurrence developed after 3 years from surgery). Overall and disease-free survival was respectively 83 and 79.8% at 5 years, 71 and 73% at 10 years and then remained constant until 18 years. Survival was correlated only to tumour stage and the type of surgery.

CONCLUSIONS

Laparoscopic TME for extraperitoneal rectal cancer shows long-term oncologic outcomes similar to open rectal resections.

Robotic versus laparoscopic total mesorectal excision for rectal cancer: a meta-analysis

BACKGROUND

Robotic surgery has been used successfully in many branches of surgery; but there is little evidence in the literature on its use in rectal cancer (RC). We conducted this meta-analysis that included randomized controlled trials and nonrandomized controlled trials of robotic total mesorectal excision (RTME) versus laparoscopic total mesorectal excision (LTME) to evaluate whether the safety and efficacy of RTME in patients with RC are equivalent to those of LTME.

MATERIALS AND METHODS

Pubmed, Embase, Cochrane Library, Ovid, and Web of Science databases were searched. Studies clearly documenting a comparison of RTME with LTME for RC were selected. Operative and recovery outcomes, early postoperative morbidity, and oncological parameters were evaluated.

RESULTS

Eight studies were identified that included 1229 patients in total, 554 (45.08%) in the RTME and 675 (54.92%) in the LTME. Meta-analysis suggested that the conversion rate to open surgery in RTME was significantly lower than in LTME (P = 0.0004). There were no significant differences in operation time, estimated blood loss, recovery outcome, postoperative morbidity and mortality, length of hospital stay, and the oncological accuracy of resection and local recurrence between the two groups. The positive rate of circumferential resection margins (P = 0.04) and the incidence of erectile dysfunction (P = 0.002) were lower in RTME compared with LTME.

CONCLUSIONS

RTME for RC is safe and feasible, and the short- and medium-term oncological and functional outcomes are equivalent or preferable to LTME. It may be an alternative treatment for RC. More multicenter randomized controlled trials investigating the long-term oncological and functional outcomes are required to determine the advantages of RTME over LTME in RC.

Simultaneous laparoscopic resection of primary colorectal cancer and associated liver metastases: a systematic review

As many as 25 % of colorectal cancer (CRC) patients have liver metastases at presentation. However, the optimal strategy for resectable synchronous colorectal liver metastasis remains controversial. Despite the increasing use of laparoscopy in colorectal and liver resections, combined laparoscopic resection of the primary CRC and synchronous liver metastasis is rarely performed. The potential benefits of this approach are the possibility to perform a radical operation with small incisions, earlier recovery, and reduction in costs. The aim of this study was to review the literature on feasibility and short-term results of simultaneous laparoscopic resection. We conducted a systematic search of all articles published until February 2013. Search terms included: hepatectomy [Mesh], "liver resection," laparoscopy [Mesh], hand-assisted laparoscopy [Mesh], surgical procedures, minimally invasive [Mesh], colectomy [Mesh], colorectal neoplasms [Mesh], and "colorectal resections." No randomized trials are available. All data have been reported as case reports, case series, or case-control studies. Thirty-nine minimally invasive simultaneous resections were identified in 14 different articles. There were 9 (23 %) major hepatic resections. The most performed liver resection was left lateral sectionectomy in 26 (67 %) patients. Colorectal resections included low rectal resections with total mesorectal excision, right and left hemicolectomies, and anterior resections. Despite the lack of high-quality evidence, the laparoscopic combined procedure appeared to be feasible and safe, even with major hepatectomies. Good patient selection and refined surgical technique are the keys to successful simultaneous resection. Simultaneous left lateral sectionectomy associated with colorectal resection should be routinely proposed.

Minimally invasive surgery for rectal cancer

Rectal cancer remains a common and complex surgical problem. There is growing evidence that minimally invasive surgery (MIS) can provide ideal care for patients with rectal cancer. This review examines the short- and long-term benefits to MIS for rectal cancer, as well as the current techniques available, and how wider adoption of these techniques may be performed.

Laparoscopic total mesorectal excision with natural orifice specimen extraction

AIM: To introduce transvaginal or transanal specimen extraction in laparoscopic total mesorectal excision surgery to avoid an abdominal incision.

METHODS: Between January 2009 and December 2011, 21 patients with rectal cancer underwent laparoscopic radical resection and the specimen was retrieved by two different ways: transvaginal or transanal rectal removal. Transvaginal specimen extraction approach was strictly limited to elderly post-menopausal women who need hysterectomy. Patients aged between 30 and 80 years, with a body mass index of less than 30 kg/m², underwent elective surgery. The surgical technique and the outcomes related to the specimen extraction, such as duration of surgery, length of hospital stay, and the complications were retrospectively reviewed.

RESULTS: Laparoscopic resection using a natural orifice removal approach was successful in all of the 21 patients. Median operating time was 185 min (range, 122-260 min) and the estimated blood loss was 48 mL. The mean length of hospital stay was 7.5 d (range, 2-11 d). One patient developed postoperative ileus and had an extended hospital stay. The patient complained of minimal pain. There were no postoperative complications or surgery-associated death. The mean size of the lesion was 2.8 cm (range, 1.8-6.0 cm), and the mean number of lymph nodes harvested was 18.7 (range, 8-27). At a mean follow-up of 20.6 mo (range, 10-37 mo), there were no functional disorders associated with the transvaginal and transanal specimen extraction.

CONCLUSION: Transvaginal or transanal extraction in L-TME is a safe and effective procedure. Natural orifice specimen extraction can avoid the abdominal wall incision and its potential complications.