Transvaginal specimen extraction in colorectal surgery: current state of the art

The vaginal route for minimally invasive surgery: a practical guide for general surgeons

INTRODUCTION

Vaginal approaches have become routine in the field of gynecologic surgery, whereas in general surgery vaginal wall transection is an infrequent practice typically reserved for extensive tumor resections. Approximately two decades ago, natural orifice transluminal endoscopic surgery (NOTES) revolutionized conventional boundaries by accessing the peritoneal cavity transorally, transrectally, or transvaginally, enabling general surgery without visible scars. Although transvaginal approaches have been successfully used for various abdominal procedures by general surgeons, a gap remains in comprehensive training to fully exploit the potential of this route.

MATERIAL AND METHODS

PubMed, Google Scholar, and Scopus databases were searched to retrieve relevant articles illustrating how general surgeons can adeptly manage vaginal approaches.

RESULTS

The article presents a practical framework for general surgeons to execute a complete vaginal approach, addressing the management of vaginal specimen extraction and vaginal cuff closure, even in the absence of an experienced gynecologist.

CONCLUSION

The evolution of abdominal surgery is moving towards less invasive techniques, emphasizing the importance of understanding the nuances and challenges associated with the vaginal route. This approach is linked to minimal oncological, sexual, and infective complications, and to the absence of pregnancy-related complications. Such knowledge becomes increasingly crucial, particularly with the renewed demand for transvaginal access in robot-assisted NOTES procedures.

Totally intracorporeal colorectal anastomosis (TICA) versus classical mini-laparotomy for specimen extraction, after segmental bowel resection for deep endometriosis: a single-center experience

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.

Natural orifice specimen extraction surgery versus small-incision assisted laparoscopic radical right hemicolectomy

Conventional laparoscopic-assisted right hemicolectomy requires a small abdominal incision to extract the specimen, which becomes an important source of postoperative complications and impairs perioperative experience. Transvaginal natural orifice specimen extraction surgery (NOSES VIIIA) avoids this small incision by extracting the specimen through the vagina. Here we describe the design of a multicenter, open-label, parallel, noninferior, phase III randomized controlled trial (NCT05495048). The aim of this study is to confirm that the NOSES VIIIA procedure is not inferior to small-incision assisted right hemicolectomy in long-term oncological efficacy. A total of 352 female patients with right colon adenocarcinoma/high-grade intraepithelial neoplasia will be randomly assigned to the NOSES VIIIA arm and the small-incision arm in a 1:1 ratio. The primary end point of this trial is 3 year disease-free survival. Clinical Trial Registration: NCT05495048 (ClinicalTrials.gov).

Transvaginal Natural Orifice Specimen Extraction (NOSE) in Laparoscopic Colorectal Cancer Surgery With New Insights on Technique and Patient Selection

BACKGROUND

Following laparoscopic colorectal surgery, transabdominal specimen extraction requires a mini-laparotomy or Pfannenstiel incision, associated with increased postoperative pain and wound complications. The vagina has several unique properties that make natural orifice specimen extraction (NOSE) ideal. We report our experience with transvaginal NOSE for colorectal cancer surgery.

MATERIALS AND METHODS

A transvaginal sizer allows the posterior vagina to be incised under tension. A transverse or cruciate incision is made, followed by the insertion of a double-ring wound protector. The external ring is opened against the perineum to shorten the length of the conduit for specimen delivery. Vaginotomy closure is performed via laparoscopy using a barbed suture.

RESULTS

Seventeen consecutive female patients underwent elective colorectal cancer surgery with attempted transvaginal NOSE. Median age and body mass index was 67 (range: 50 to 82) years and 26.5 (range: 19.7 to 35.8) kg/m 2 , respectively. Fourteen patients (82%) underwent left-sided resections and 3 (18%) underwent right-sided resections. Median operating time, blood loss, and length of hospital stay was 245 (range: 155 to 360) minutes, 30 (range: 10 to 500) mL, and 3 (range: 2 to 9) days, respectively. Transvaginal extraction was unsuccessful in 1 (6%) patient. Two (12%) patients experienced early postoperative morbidity, neither attributable to the extraction procedure. Median tumor circumferential diameter was 3.3 (range: 2.2 to 7.0) cm. Median follow-up duration was 17 (range: 8 to 27) months. There was no instance of sexual dysfunction.

CONCLUSIONS

Transvaginal NOSE for colorectal cancer surgery is feasible and safe in selected patients. Overall specimen diameter, inclusive of tumor and mesentery, relative to pelvic outlet and conduit diameter is the most important consideration for transvaginal NOSE.

Transvaginal natural orifice specimen extraction surgery for 3D laparoscopic radical cystectomy: A cohort study

Objective

Transvaginal natural orifice specimen extraction surgery (NOSES) has been widely used in laparoscopic surgery due to its benefits. However, laparoscopic radical cystectomy (LRC) with NOSES has rarely been reported.

Materials and Methods

A retrospective analysis of 25 patients who underwent 3D LRC with NOSES from November 2014 to November 2019 was performed. The clinical and perioperative related data, peri and postoperative complications, and oncologic outcomes were recorded.

Results

Surgery was successfully completed in 25 patients, and none were converted to open surgery. Mean total operative time was 294.1 ± 48.80 min. Mean NOSES time was12 ± 6.48 min. The median post-op hospital stay was 10.5 d (range 6-27 d). The median visual analog pain score on post-op day 1, 2, and 3 was 2, 2, and 1, respectively. Thirteen patients had 30-day complications (3 had Clavien grade I and 11 had Clavien grade II). Pelvic floor distress inventory-short form 20 (PFDI-20) was 9.8 ± 1.9 after three months (compared with pre-PFDI-20, P = 0.06) and 9.3 ± 1.2 after six months (compared with pre-PFDI-20, P = 0.15). At the mean follow-up of 24.7 ± 12.05 months (range 11-60 months), one patient (4%) had recurrence, two (8%) had metastasis, and one (4%) died.

Conclusion

Transvaginal NOSES in 3D LRC is safe and feasible. Understanding the female vagina anatomy and comprehending the techniques is conducive to avoid incision-related complications. NOSES is minimally invasive with good cosmetic outcomes with few surgical complications or affecting pelvic floor function.

Case study of colorectal endometriosis treated with endoscopic submucosal excavation

Colorectal endometriosis (CEM) is a rare and complicated form of deep invasive endometriosis. Its treatment methods include drug therapy and surgery. However, it is often difficult to alleviate symptoms and address problems, such as infertility, using drug treatment alone. Surgical intervention provides a histologic diagnosis, allows assessment of pelvic cysts or masses with features concerning for malignancy, and reduces pain by destroying the endometriotic implants. We consider surgery in women with the following: Persistent pain despite medical therapy; Contraindications to or refusal of medical therapy; Need for a tissue diagnosis of endometriosis; Exclusion of malignancy in an adnexal mass; Obstruction of the bowel or urinary tract. But there is no consensus about the surgical methods. With the rapid development of gastroenteroscopy technology in recent years, many local gastrointestinal tumors that previously required surgical resection can now be removed by endoscopic surgery. Herein, we report one case of CEM treated by endoscopic submucosal excavation (ESE) to provide a new treatment option for the radical resection of single CEM.

Comparison of laparoscopic adnexal mass extraction via the transumbilical and transvaginal routes

This study was performed to compare the transumbilical (TU) and transvaginal (TV) routes for adnexal mass removal from the abdominal cavity. Data from 93 women who underwent laparoscopic (LS) surgery for the removal of benign adnexal masses at three centres between January 2016 and December 2020 were examined retrospectively. The specimen retrieval times in the TU and TV groups were 9.0 ± 2.0 and 9.8 ± 2.5 min, respectively (p = .373). Additional analgesic was required in 13.8% and 14.3% of cases in the TU and TV groups, respectively. The mean 3-month (2-4 months) postoperative visual analogue scale (VAS) score was lower in the TV group than in the TU group. The postoperative vaginal length did not differ between the TU and TV groups (8.9 (8.7-9.1) vs. 8.7 (8.4-9.1) cm; p = .465). Oophorectomy and the TU route were found to be independent risk factors for the worsening of the VAS score. Sexual function index scores were similar in the two groups. The TV method for specimen removal in LS surgery may cause less pain in the early postoperative period and less dyspareunia in the later period without shortening the length of the vagina.Impact StatementWhat is already known on this subject? Compared with open procedures, minimally invasive surgery (MIS) is associated with faster recovery times, better patient quality of life and lower postoperative complication rates. The removal of an adnexal mass from the abdominal cavity is performed most commonly using the suprapubic, transumbilical (TU) or transvaginal (TV) route.What do the results of this study add? The specimen retrieval times in the TU and TV groups were 9.0 ± 2.0 and 9.8 ± 2.5 min, respectively (p = .373). The mean 3-month (2-4 months) postoperative visual analogue scale (VAS) score was lower in the TV group than in the TU group. Oophorectomy and the TU route were found to be independent risk factors for the worsening of the VAS score. Sexual function index scores were similar in the two groups.What are the implications of these findings for clinical practice and/or further research? In conclusion, specimen removal via the TV route in LS surgery may cause less pain in the early postoperative period and less dyspareunia in the later period without reducing the length of the vagina.

Feasibility and safety of transvaginal specimen extraction in deep endometriosis colorectal resectional surgery and analysis of risk factors for postoperative complications

BACKGROUND

The aim of the present study was to demonstrate that transvaginal specimen extraction is a feasible and safe approach in colorectal resection for deep endometriosis (DE) and to assess the risk factors for postoperative complications.

METHODS

This retrospective cohort study included all the consecutive patients undergoing segmental bowel resection for symptomatic endometriosis at "La Paz" University Hospital (Madrid, Spain) and at "Hospital General Universitario de Valencia" (Valencia, Spain) from January 2014 to December to 2017. Patients were grouped according to specimen extraction approach into those who had transvaginal extraction (Group I) and those who had suprapubic extraction (Group II). Clinic-demographical, surgical and post-surgical data were recorded. Intra- and postoperative complications were classified according to Clavien-Dindo criteria. Postoperative data were compared between groups. Risk factors associated with surgery were investigated.

RESULTS

Out of 99 female patients included (average age 36.91 ± 5.36 years), 23 patients (23.2%) had transvaginal and 76 (76.8%) had suprapubic specimen extraction. The groups were comparable regarding operative time, nodule size, level of anastomosis, hospital stay and intraoperative complications. We observed no statistically significant differences in postoperative complications and rectovaginal fistula rate between the groups. Binary logistic regression analyses determined that vaginal endometriosis is an independent risk factor for postoperative complications (OR: 2.63, 95% CI [1.10-6.48], p = 0.03).

CONCLUSIONS

Transvaginal specimen extraction is a safe and feasible technique in DE colorectal surgery and should be taken into consideration whenever vaginal endometriosis exists. Nevertheless, vaginal endometriosis can be an independent risk factor for postoperative complications in DE surgery.

Nomogram for predicting the feasibility of natural orifice specimen extraction after laparoscopic rectal resection

BACKGROUND AND AIM

The goal of this study was to develop a preoperative nomogram for predicting the feasibility of trans-anal natural orifice specimen extraction (NOSE) for rectal cancer.

METHODS

The analysis included 201 patients who underwent trans-anal NOSE and 457 patients who failed to undergo trans-anal NOSE in Shanghai East Hospital. The data collected included age, gender, body mass index, presence of tumor obstruction, distance from anal verge; maximum tumor diameter and anteroposterior thickness of mesorectum (AP) measured by magnetic resonance imaging; interspinous diameter, intertuberous diameter (IT), anteroposterior diameter of the inlet (API), anteroposterior diameter of the midplane, anteroposterior diameter of the outlet (APO), sacral length and pelvic depth (PD) measured by computed tomography.

RESULTS

The multivariate analysis suggested that a lower body mass index (P < 0.001), no tumor obstruction (P = 0.005), a shorter distance from anal verge (P < 0.001), a smaller tumor size (P < 0.001), a thinner AP (P < 0.001), a wider and shallower bony pelvis (API/PD, P < 0.001), and a wider and shorter pelvic outlet (IT/APO, P < 0.001) were significantly associated with an increased probability of trans-anal NOSE. Successful NOSE patients had a decreased time to liquid intake (P < 0.001), a shorter postoperative hospital stay (P < 0.001), and fewer wound infections (P = 0.045). No significant difference in the rate of mortality or recurrence was observed. The nomogram model presented an area under the receiver operating characteristic curve of 0.81 (95% CI, 0.78 to 0.85) and good calibration.

CONCLUSION

We developed a nomogram model that has some predicative value for the feasibility of laparoscopic rectal resection with trans-anal NOSE, utilizing clinical and radiologic parameters, available in most institutions.

Laparoscopic specimen extraction in vitro: preliminary experience

BACKGROUND

The last procedure performed by the surgeon in laparoscopic surgery is to extract the specimen through the smallest incision possible. This experiment aimed to explore the maximum diameter of specimens that can be extracted through auxiliary incisions of different lengths and shapes by in vitro physical experiments.

MATERIALS AND METHODS

We used the abdominal wall with the muscle layer, fixed on a square wooden frame, to simulate the human abdominal wall. Then, specimen extraction ports were made with circular, inverted Y-shaped and straight-line incisions of different sizes and lengths, and specimens of different sizes were made from tissues of different species. These specimens were extracted from different incisions with a force gauge. The tension value (N) was measured, and records were made of the length or diameter of the smallest auxiliary incision through which a given specimen could pass, as well as the largest specimen diameter that could pass through an incision of a given size. This experiment provides us with preliminary experience-based knowledge of how to choose the appropriate auxiliary incision for surgical specimen extraction according to the diameter of the specimen.

RESULTS

The maximum diameters of specimens that could be extracted with circular ostomy diameters of 2.4, 2.7 and 3.3 cm were 4.0, 4.5 and 6.0 cm, respectively. Specimens with diameters of 6.0, 8.0 and 10.0 cm could be extracted through inverted Y-shaped incisions with a length around the umbilicus of 1 cm and an extension length of 1.0, 3.0, and 4.0 cm, respectively. Moreover, these same specimens could be extracted through inverted Y-shaped incisions with a length around the umbilicus of 2 cm and extension lengths of 0.0, 1.0 and 2.0 cm. Tough tissue specimens (made from chicken gizzards) with diameters of 1.0, 2.0, 4.0 and 6.0 cm, respectively, could be removed through straight-line incisions measuring 1.0, 2.0, 3.0 and 4.0 cm in length.

CONCLUSION

Along with preoperative imaging, surgical planning and trocar position, the shape and length of auxiliary incisions can be used to improve the extraction of specimens via laparoscopic surgery.

Minilaparoscopy in gynecology: applications, benefits and limitations

The word "minilaparoscopy" refers to laparoscopic surgical procedures performed using <5-mm trocars, with the exception of the umbilical access. The aim of this review is to explore the feasibility of minilaparoscopy in gynecologic surgery, focusing on instruments, surgical techniques, application and limits of this approach. In this review the authors discussed the positive features and limitation of 3-mm laparoscopy for gynecologic surgery. Using smaller trocars decreases incisional and postoperative pain, and shortens hospitalization, and provides a better cosmetic outcome. Transvaginal specimen extraction can be used to maximize the aesthetic outcomes. A minilaparoscopic surgical procedure is accomplished with lower carbon dioxide pressures, reducing pneumoperitoneum related complications. Accurate patient selection is critical in order to offer the best laparoscopic approach, considering that obesity and endometriosis may represent a challenge for 3-mm surgical tools, which are more flexible and have lower grasping ability. Minilaparoscopy has been shown as a valid alternative to conventional laparoscopy both for diagnostic purpose, major surgical procedures and oncological surgery. Minilaparoscopy in gynecologic surgery represents an option for selected patients, for both benign and malignant indications. The aesthetic outcome represents the main benefit of this approach. Surgeons must be aware of few limitations of this technique such as severe obesity and endometriosis.

Short- and long-term outcomes for transvaginal specimen extraction versus minilaparotomy after robotic anterior resection for colorectal cancer: a mono-institution retrospective study

BACKGROUND

Colorectal cancer resection surgery with transvaginal specimen extraction is becoming increasingly accepted and used by surgeons. However, few publications on robotic anterior sigmoid colon and rectal cancer resection with transvaginal specimen extraction (TVSE) have been reported, and a clinical outcome comparison between conventional robotic minilaparotomy (LAP) and transvaginal specimen extraction in anterior sigmoid colon and rectal cancer resection has not been performed. The current study compared the short- and long-term outcomes of TVSE and LAP for sigmoid colon cancer and rectal cancer in a mono-institution.

METHODS

From December 2014 to October 2018, 45 patients who underwent TVSE and 45 patients who underwent LAP matched by tumor location, tumor stage, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, gender, and age at the same period were included in the current study. The short- and long-term outcomes of TVSE and LAP were discussed.

RESULTS

No significant differences were found in patient characteristics. For the short-term outcomes, the operative time in the TVSE group was longer than that in the LAP group, and the postoperative pain and additional analgesia were lower in the TVSE group. Patients in the TVSE group required slightly less time to pass first flatus. There were no significant differences in overall complications, time to regular diet, length of hospital stay after surgery, estimated blood loss, or pathological outcomes. For long-term outcomes, the 3-year overall survival (94.9% vs. 91.7%, p = 0.702) and 3-year disease-free survival (88.4% vs. 86.2%, p = 0.758) were comparable between the two groups.

CONCLUSION

The robotic TVSE is safe and feasible in selected sigmoid/upper rectal cancer patients with tumor diameter < 5 cm. This approach has slightly better short-term outcomes in terms of less postoperative pain and less analgesic requirements without any significant difference in long-term outcomes.

Prospective multicenter study of reduced port surgery combined with transvaginal specimen extraction for colorectal cancer resection

PURPOSE

The relevance of transvaginal specimen extraction (TVSE) combined with reduced port surgery (RPS) remains unknown. This study investigated the feasibility of TVSE with RPS according to short-term outcomes and cosmesis.

METHODS

This prospective multicenter study enrolled ten patients at three institutions. For the semi-quantification of each parameter, we administered questionnaires to assess pain (visual analogue scale), subjective/objective wound healing esthetics [photo series questionnaires (PSQ)], and quality of life (QOL).

RESULTS

No operative complications occurred, except one case of urinary tract infection, which was promptly cured with antibiotics. On day 0, pain was rated at 2.3 ± 0.67 at rest and 4.9 ± 0.82 during sneezing; these ratings gradually declined over time. The PSQ showed that the patient ratings of wound esthetics after TVSE were not inferior to ratings from patients after conventional laparoscopy or single incision laparoscopic surgery, and they were significantly higher than the patient ratings of wounds after laparotomy (P < 0.05). The QOL scores showed that, in comparison to before surgery, after surgery, patients reported significant deterioration of their physical function (96.67 ± 1.49 vs. 87.33 ± 2.71), emotional function (93.33 ± 2.72 vs. 86.67 ± 2.22), fatigue (7.78 ± 3.72 vs. 26.67 ± 8.31), and pain (6.67 ± 3.69 vs. 18.33 ± 4.61).

CONCLUSION

TVSE with RPS for colorectal cancer was feasible and was associated with a low degree of postoperative pain.

Transabdominal versus transvaginal specimen extraction in mini-laparoscopic surgery

AIM

The objective of this study was to present our experiences of tissue extraction via the transvaginal (TV) route after a mini-laparoscopic gynecological surgery and compare them with our transabdominal (TA) specimen extraction experiences.

METHODS

This prospective randomized controlled study was conducted in a tertiary care center between July 2014 and February 2016. Fifty-eight women who were undergoing mini-laparoscopy for adnexal mass removal were randomized into two groups according to the surgical specimen removal by the TV route (n = 28) or the TA route (n = 30). The main outcome measures were the postoperative incisional pain, cosmetic outcomes and overall satisfaction rate. The secondary outcome measures were additional blood loss, additional operation duration and the need for morcellation.

RESULTS

The TV group had significantly lower visual analog scale scores than the TA group at 6 and 24 h postoperatively. The morcellation needs were lower in the TV group than in the TA group. Three months after the surgery, the participants scored a higher rate of overall satisfaction in the cosmetic outcomes in the TV group than in the TA group.

CONCLUSION

Tissue extraction through a posterior colpotomy after mini-laparoscopic surgery may be a feasible technique for improving cosmetic results, decreasing postoperative pain and decreasing the need for morcellation when compared to TA specimen retrieval.

Laparoscopy-Assisted Natural Orifice Specimen Extraction to Treat Tumors of the Sigmoid Colon and Rectum: The Short- and Long-Term Outcomes of a Retrospective Study

Background: Few studies have assessed the short- and long-term outcomes of laparoscopically assisted natural orifice specimen extraction (NOSE) in patients with sigmoid colon and rectal tumors. We investigated the short- and long-term outcomes of patients undergoing laparoscopic-assisted NOSE for tumors of the sigmoid colon and rectum. Methods: Ninety-eight patients with sigmoid colon and rectal tumors undergoing laparoscopic-assisted NOSE were included. The tumor was classified according to its distance from the anal verge: Group 1 (15-30 cm), Group 2 (5-15 cm), and Group 3 (≤5 cm). In Group 1 patients, a laparoscopic surgical specimen collection bag was used as a special transrectal device. In Group 2 patients, transanal endoscopic microsurgery device and specimen collection bag were used. In Group 3 patients, a Lone-Star retractor was used. The demographic characteristics and intra- and postoperative outcomes were measured. Results: In Group 1, 1 patient had respiratory disease and 1 had enterocolitis as short-term postoperative complications. One patient showed intestinal obstruction as a long-term postoperative complication. In Group 2, 2 patients had an ileus, 1 had an anastomotic leak, 2 had urinary retention, and 1 had respiratory disease as short-term complications. Only one patient had a long-term complication: anastomotic stenosis. In Group 3, short-term complications were present in 3 patients: 1 had hemorrhage, 1 had urinary retention, and 1 had respiratory disease. Long-term complications included one case of anastomotic stenosis and one of intestinal obstruction. Conclusions: NOSE is safe and cosmetically and theoretically superior to conventional laparoscopy when different devices are used according to the tumor's location.

A case of vaginal recurrence following laparoscopic left-sided colon cancer resection combined with transvaginal specimen extraction

Here, we presented a case of laparoscopic colon cancer resection who developed vaginal recurrence after transvaginal specimen extraction. To our knowledge, this is the first case report on natural orifice specimen extraction-site cancer recurrence. A 59-year-old female underwent laparoscopic left hemicolectomy due to left-sided colon adenocarcinoma, and the specimen was removed through the vagina. She was admitted to the hospital with the complaint of vaginal discharge after 1 year. Tumoural infiltration on the posterior vaginal wall was diagnosed, and biopsy was reported as adenocarcinoma. The patient underwent laparoscopic low anterior resection, total abdominal hysterectomy, bilateral salpingooferectomy and en bloc resection of the posterior vaginal wall due to the local recurrence of colon cancer. She had no recurrence or metastasis within the 3^rd year after primary tumour surgery. Recurrence at the specimen extraction site after natural orifice surgery should be considered among the complications. For this reason, incision-preserving methods should not be neglected.

A Specimen Extraction Instrument Based on Braided Fiber Tube for Natural Orifice Translumenal Endoscopic Surgery

Natural orifice translumenal endoscopic surgery (NOTES) has offered significant advantages of less pain, reduced recovery time, and minimized scar after operation, demonstrating a promising development prospect. However, the large-size specimen extraction remains challenging for NOTES, due to the narrow space of the human natural orifices. To address such difficulties, a specimen extraction method that utilizes the braided fiber tube (BFT) structure with excellent retractility to accommodate and bind the bulky specimen has been proposed. Based on the theory of helical spring, the geometric model and the mechanical model of the BFT are established, and experiments have been performed to verify the accuracy of the derived mechanical model. In addition, a tensile test of using the BFT to extract large specimens via a small channel is carried out, which verifies the stable extraction performance of the proposed design. The BFT will not be damaged when extracting the specimen with a diameter less than 1.75 times of the channel diameter. A NOTES-specific specimen extraction instrument is designed according to the characteristics of NOTES, and it has three degrees-of-freedom and is able to actively capture different specimen by using a suction cup. Finally, specimen extraction experiments on NOTES multitasking platform phantom have been conducted using the prototyped instrument to validate its feasibility and effectiveness.

Left colon resection with transrectal specimen extraction: current status

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Totally Laparoscopic Resection for Low Sigmoid and Rectal Cancer Using Natural Orifice Specimen Extraction Techniques

BACKGROUND

A minilaparotomy for specimen extraction during laparoscopy occasionally results in postoperative wound complications. We have performed a totally laparoscopic resection for early colorectal cancer using the natural orifice specimen extraction technique.

METHODS

From 2008 to 2013, we have performed a totally laparoscopic resection for clinical stage I and IIA low sigmoid colon and rectal cancers. A prospectively maintained database was reviewed to assess the outcomes after surgery.

RESULTS

In total, 40 patients had high anterior resections using transanal specimen extraction, and 32 patients had low anterior resections with transanal pull-through. Eight patients (11%) reported conversion to conventional laparoscopic colorectal resections; anastomotic leakages occurred in 4 patients (5.6%). No mortality or cancer recurrence was observed during 42.5±16.2 months of follow-up.

CONCLUSIONS

One natural orifice specimen extraction technique, known as transanal specimen extraction, has emerged as a promising form of totally laparoscopic surgical intervention for early-stage cancers of the low sigmoid colon and rectum.

Laparoscopic-Assisted Natural Orifice Specimen Extraction Radical Descending Colectomy Using a Cai Tube

AIM

To overcome the technical difficulty of exteriorizing a specimen through the descending colon stump, we applied laparoscopic-assisted natural orifice specimen extraction (LA-NOSE) using a Cai tube.

METHODS

From April 2014 to February 2015, we successfully performed total laparoscopic radical surgery with LA-NOSE in six patients with descending colon lesions. The time of operation, blood loss amount, lymph nodes harvested, postoperative recovery, postoperative complications and follow-up were observed.

RESULTS

Total laparoscopic dissection and anastomosis with natural orifice removal using a Cai tube was successful in all 6 patients; no deaths, anastomotic bleeding, fistulas, infections, or any other complications were recorded. The median operating time was 327.7 ± 73.4 min, and the estimated blood loss was 66.7 ± 69.2 mL. The mean number of lymph nodes harvested was 15.7 ± 4.4. Recovery of gastrointestinal function ranged from 2 to 4 days after the operation. The mean length of postoperative hospital stay was 12.3 ± 3.2 days. The six cases were followed up for 6-16 (12.5 ± 3.6) months, and all patients avoided auxiliary incision which demonstrated potential cosmetic advantages and uneventful recovery with no additional complications or cancer recurrence.

CONCLUSION

In this pilot study of six patients, LA-NOSE radical descending colectomy using a Cai tube was feasible and safe.

Feasibility and Technique for Transvaginal Natural Orifice Transluminal Endoscopic Surgery Liver Resection: A Porcine Model

INTRODUCTION

Natural orifice transluminal endoscopic surgery (NOTES) is a challenging minimally invasive procedure. Although laparoscopic techniques for liver resection are gaining acceptance worldwide, few studies have investigated NOTES liver resection. We used a porcine model to assess the feasibility and safety of transvaginal NOTES liver resection (TV NOTES LR).

MATERIALS AND METHODS

Nine female pigs underwent TV NOTES LR. A nonsurvival acute porcine model with general anesthesia was used in all cases. Using hybrid NOTES technique, we placed only 1 umbilical 12-mm umbilical trocar in the abdominal wall, which was used to create pneumoperitoneum. A laparoscope was then advanced to obtain intra-abdominal visualization. A 15-mm vaginal trocar was inserted under direct laparoscopic vision, and a flexible endoscope was introduced through the vaginal trocar. A long, flexible grasper and endocavity retractor were used to stably retract the liver. The liver edge was partially transected using energy devices inserted through the umbilical trocar. To transect the left lateral lobe, a flexible linear stapler was inserted alongside the vaginal trocar. A specimen extraction bag was deployed and extracted transvaginally. Blood loss, bile leakage, operative time, and specimen size were evaluated. Necropsy studies were performed after the procedures.

RESULTS

Eighteen transvaginal NOTES partial liver resections and 4 transvaginal NOTES left lateral lobectomies were successfully performed on 9 pigs. Mean operative time was 165.8 minutes, and mean estimated blood loss was 76.6 mL. All TV NOTES LRs were performed without complications or deaths. Necropsy showed no bile leakage from remnant liver.

CONCLUSIONS

Our porcine model suggests that TV NOTES LR is technically feasible and safe and has the potential for clinical use as a minimally invasive alternative to conventional laparoscopic liver resection.

Robotic Surgery for Colon and Rectal Cancer

Robotic surgery, used generally for colorectal cancer, has the advantages of a three-dimensional surgical view, steadiness, and seven degrees of robotic arms. However, there are disadvantages, such as a decreased sense of touch, extra time needed to dock the robotic cart, and high cost. Robotic surgery is performed using various techniques, with or without laparoscopic surgery. Because the results of this approach are reported to be similar to or less favorable than those of laparoscopic surgery, the learning curve for robotic colorectal surgery remains controversial. However, according to short- and long-term oncologic outcomes, robotic colorectal surgery is feasible and safe compared with conventional surgery. Advanced technologies in robotic surgery have resulted in favorable intraoperative and perioperative clinical outcomes as well as functional outcomes. As the technical advances in robotic surgery improve surgical performance as well as outcomes, it increasingly is being regarded as a treatment option for colorectal surgery. However, a multicenter, randomized clinical trial is needed to validate this approach.

Laparoscopic Anterior Resection with Transvaginal Specimen Extraction (TVSE) for Colorectal Cancer and Concomitant Total Hysterectomy and Bilateral Salpingo-Oophrectomy (THBSO): A Technical Description

BACKGROUND

Natural orifice specimen extraction (NOSE) has evolved to circumvent the need for a specimen extraction site. Transvaginal specimen extraction (TVSE) for colorectal disease has been shown to be safe and feasible in selected cases.1 ^, 2 We describe our technique of TVSE in a case of laparoscopic ultra-low anterior resection (ULAR) with defunctioning ileostomy (DI) with a concomitant total hysterectomy and bilateral salpingo-oophrectomy (THBSO).

METHODS AND RESULTS

A 74-year-old Chinese female was diagnosed with a mid-rectal cancer following colonoscopic evaluation for a change in bowel habits. Preoperative magnetic resonance imaging (MRI) suggested T2N0 disease and the patient was recommended for upfront surgery following multidisciplinary discussion. Computed tomography (CT) scan confirmed a 4.3 × 3.4 cm right adnexal cystic lesion, without enhancing septations or soft tissue component. No metastatic disease was identified. The patient underwent a laparoscopic ULAR with DI and THBSO with TVSE; operative time was 469 min. The specimen showed a 2.5 cm mid-rectal tumour. Histology revealed a pT3N1a moderately differentiated adenocarcinoma of the mid rectum, with 1 of 20 lymph nodes involved by metastatic carcinoma. The quality of the total mesorectal excision (TME) was good, with no breach in the mesorectal fascia. The distal and radial margins were 1.5 and 3.0 cm, respectively. The patient recovered well postoperatively, with minimal wound site pain, and was discharged well on postoperative day 5.

CONCLUSION

TVSE is oncologically safe and feasible in certain malignant colorectal pathologies. It is an option to consider in selected cases that require a concomitant gynecological procedure.

Laparoscopic Right Colon Resection With Transvaginal Extraction: A Systematic Review of 90 Cases

BACKGROUND

Natural orifice specimen extraction is a laparoscopic technique that reduces the procedure's invasiveness.

OBJECTIVE

We aimed to examine all the available data for the transvaginal extraction of laparoscopic right-sided colonic resections.

DATA SOURCES

A systematic search was conducted using PubMed/MEDLINE, Cochrane, Google Scholar, EBSCO, clinicaltrials.gov, and congress abstract databases.

STUDY SELECTION

All case-control series, case series, and case reports were included, irrespective of age, region, race, obesity, comorbidities, or history of previous surgery. No restrictions were made in terms of language, country, or journal.

MAIN OUTCOME MEASURES

Patient selection criteria and results of the cumulative data.

RESULTS

The search identified 10 studies including 90 cases. Most patients were elderly (mean, 65.9; range, 29 to 87 y) and had comorbid diseases (96%). 33.8% had a history of abdominopelvic surgery. The mean body mass index was 25.7 kg/m (range, 18 to 50 kg/m). Most patients (83%) had malign or premalign (14%) diseases and required regular or extended right hemicolectomies (99%). The mean operating time and blood loss ranges were 193 (140 to 471) minutes and 62.4 (0 to 300) mL, respectively. Overall, morbidities were seen in 18 patients (20%), and 3 of them were related to the transvaginal extraction. There were no abdominal wound related early or late complications. When compared with laparoscopic colon resections with transabdominal extraction, the procedure seems to result in decreased postoperative pain and length of hospital stay.

LIMITATIONS

There are a limited number of comparative studies and an absence of randomized studies.

CONCLUSIONS

Laparoscopic resection and transvaginal specimen extraction is a promising technique for some right-sided colon pathologies. For patient selection, an accessible vaginal port (patient acceptance and a vagina that is not narrow) and an en-mass lesion of ≤8 cm were necessary. Malignancy, previous abdominopelvic surgery, obesity, and old age were not considered as contraindications.

Transvaginal Hybrid NOTES Procedure for Treatment of Gallstone Ileus

Gallstone ileus is a rare mechanical bowel obstruction, and previously reported cases have been treated laparoscopically with good results. Although transvaginal hybrid NOTES without a minilaparotomy has been reported to decrease the incidence of surgical wound complications, to our knowledge, this procedure has not been used previously to treat gallstone ileus. We present a case of a 63-year-old woman who underwent transvaginal hybrid NOTES procedure for treatment of gallstone ileus. This case was admitted to our hospital following acute-onset abdominal pain and vomiting. We diagnosed gallstone ileus with cholecystoduodenal fistula by computed tomography and performed totally laparoscopic surgery using only three 5 mm abdominal ports with transvaginal specimen extraction and enterectomy. The patient's postoperative course was uneventful, and laparoscopic cholecystectomy and fistula repair were performed 8 months after the initial surgery. The patient experienced additional pain relief and good cosmetic outcomes. In conclusion, using transvaginal hybrid NOTES may become a future option to minimize the invasiveness of other laparoscopic procedures.

A case of splenic metastasis of ovarian cancer treated with complete laparoscopic splenectomy and transvaginal specimen extraction

A 61-year-old woman was diagnosed with right inguinal lymph node and splenic metastasis of ovarian serous cystadenocarcinoma. We performed right inguinal lymph node dissection and total laparoscopic splenectomy in the supine position followed by transvaginal specimen extraction (TVSE). First, using three ports, we extracted the right inguinal lymph node. We repaired the posterior wall of the inguinal canal using a mesh plug. We added two ports and displaced the spleen from the retroperitoneum and lifted it using a snake retractor, disconnecting the hilum using an automatic suturing device. Next, the posterior wall of the vagina was intraperitoneally incised. And an Alexis® laparoscopic system was inserted into the vagina. The cap maintained aeroperitoneum, a collection bag was inserted in the abdominal cavity via the vagina, and the spleen was collected. When the spleen was removed from the body, partial fragmentation of the organ was required in the bag. Organ fragmentation was performed only within the bag, and we made sure not to tear the bag. The vaginal wound was laparoscopically sutured. The patient had no operative complications and was able to actively ambulate at the first day after surgery due to a slight postoperative pain. Total laparoscopic splenectomy with TVSE in the supine position may be a safe and feasible method for selected female patients. This technique enables minimally invasive surgery for female patients with splenic disease.

Robotic gastrectomy with transvaginal specimen extraction for female gastric cancer patients

AIM: To describe the application of complete robotic gastrectomy with transvaginal specimen extraction (TVSE) for gastric cancer patients.

METHODS: Between July and November 2014, eight female patients who were diagnosed with gastric adenocarcinoma underwent a TVSE following a full robot-sewn gastrectomy. According to the tumor location, the patients were allocated to two different groups; two patients received robotic total gastrectomy with TVSE and the other six received robotic distal gastrectomy with TVSE.

RESULTS: Surgical procedures were successfully performed in all eight cases without conversion. The mean age was 55.3 (range, 42-69) years, and the mean body mass index was 23.2 (range, 21.6-26.0) kg/m². The mean total operative time and blood loss were 224 (range, 200-298) min and 62.5 (range, 50-150) mL, respectively. The mean postoperative hospital stay was 3.6 (range, 3-5) d. The mean number of lymph nodes resected was 23.6 (range, 17-27). None was readmitted within 30 d of postoperation. During the follow-up, no stricture developed nor was any anastomotic leakage detected.

CONCLUSION: It is possible to perform a TVSE following a full robot-sewn gastrectomy with standard D2 lymph node resection for female gastric cancer patients.

Laparoscopic colon and rectal resections with intracorporeal anastomosis and trans-vaginal specimen extraction for colorectal cancer. A case series and systematic literature review

PURPOSE

Intracorporeal anastomosis associated to trans-vaginal specimen extraction decreases the extent of colon mobilisation and the number and size of abdominal incisions, improving the benefits of minimally invasive surgery in female patients. The aim of this study was to evaluate the safety and effectiveness of this procedure for colorectal cancer.

METHODS

Between 2009 and 2013, 13 female patients underwent laparoscopic colon and rectal resection for colorectal cancer with intracorporeal anastomosis and trans-vaginal specimen extraction: 2 right colectomies, 1 transverse colon resection, 4 left colectomies and 6 anterior resections were performed. A MEDLINE search of publications on the presented procedure for colon neoplasms was carried out.

RESULTS

There were no intraoperative complications and no conversions. Postoperative visual analogue scale (VAS) score in the pelvis, abdomen and shoulder was moderate. In the postoperative period, we observed two colorectal anastomotic strictures, successfully treated with pneumatic endoscopic dilation. Median length of the specimen was 18.5 cm, with a median tumour size of 5.5 cm in diameter. Median number of retrieved lymph nodes was 12. All circumferential resection margins were negative. During a mean follow-up of 31 months (range, 6-62), there was neither evidence of recurrent disease nor disorders related to the genitourinary system. The aesthetic outcome was considered satisfactory in all patients. Nine studies were identified in the systematic review.

CONCLUSIONS

Our case series, according to the results of the literature, showed that intracorporeal anastomosis associated to trans-vaginal specimen extraction is feasible and safe in selected female patients.

Inflammatory bowel disease meta-evidence and its challenges: is it time to restructure surgical research?

AIM

The aim of this study was to compare the methodological quality and input paper characteristics of systematic reviews and meta-analyses reported in the medical and surgical literature by performing a systematic 'overview of reviews'. Ulcerative colitis (UC) and Crohn's disease (CD) were used as the framework for this comparison as they are relatively common serious conditions, with both medical and surgical options for therapy.

METHOD

Medline, Embase, CINHAL and the Cochrane Database were searched to November 2013. Eligible papers were systematic reviews or meta-analyses that considered a question of therapy in CD or UC. Two independent reviewers selected the papers, extracted the data and scored their methodology using the AMSTAR scoring system. The papers were categorized into medical therapy (M), surgical therapy (S) or medical and surgical therapy (MS) groups. Following retrieval of the sample of meta-evidence papers, the original input studies used in their creation were identified and a search of Medline, Embase, CINHAL and the Cochrane Database was performed. A team of researchers then examined the collection of papers for bibliographic and financial information.

RESULTS

Five hundred papers were identified in the meta-evidence search, of which 118 were deemed eligible. There was a difference in the AMSTAR-rated average quality of the papers between the S and M group (S 7.36 vs M 8.75, P = 0.01). On average S papers were published in journals with a lower impact factor (S 3.26, M 5.04, MS 5.30, P < 0.001). S papers also showed more heterogeneity (I(2) ; S 37%, M 24%, MS 10%, P < 0.001). Some 25% of S meta-analyses used data-sets with significant heterogeneity (I(2) > 75%), compared with 8% of M meta-analyses and 3% of the MS meta-analyses. Some 5% of S papers were done on data sets that had I(2) values > 90%. There was no difference in the average number of papers assessed in each group, the average number of patients per meta-paper, the average time covered by the reviews, the average number of papers considered within each meta-analysis, or the average number of patients considered within each meta-analysis. Considering the conclusions of each meta-analysis, S meta-evidence was 50% more likely than M meta-evidence to be unable to make recommendations for practice. A total of 1499 original input papers were identified, of which 283 were used in more than one review. Within the non-repeated papers (n = 1023) the average impact factor within the S group was lower than that of the M and the MS groups (3.720 vs 11.230 vs 7.563, respectively; ANOVAP < 0.001). M papers had higher rates of pharmaceutical sponsorship than S papers (M 56% vs S 1%) and twice the level of government support (M 16% vs S 8%). Of note, 21% of M papers had corporate sponsorship but did not list any conflict of interest.

CONCLUSION

Compared with M meta-analyses, S meta-analyses in the UC and CD domain are more likely to be of poorer methodological quality, are of a greater degree of heterogeneity and less often offer a positive conclusion. The papers used to generate meta-evidence in M papers have a greater degree of corporate and government sponsorship, and are more likely to come from journals with higher impact factors.

Scarless hepatectomy: natural orifice specimen extraction after left lateral sectionectomy

BACKGROUND

The use of laparoscopy in liver surgery is well established and considered as the gold standard for small resections. The laparoscopic resections have lower morbidity and better cosmetic results, but still require an incision to remove the surgical specimen. The possibility of remove the specimen through natural orifices and avoid an abdominal incision may further improve the benefits offered by minimally invasive procedures.

AIM

To describe the technique of transvaginal extraction of the specimen after laparoscopic liver left lateral sectionectomy.

METHOD

The laparoscopic liver resection is performed in a standard fashion. After completing the resection, the specimen is placed into a retrieval plastic bag. To perform de extraction, a vaginal colpotomy is performed, guided by a 12 mm trocar introduced through the vagina. Then the extraction bag is removed pulling the bag through the extended incision in the posterior wall of the vagina. After the extraction, the colpotomy incision is closed laparoscopically.

RESULTS

This technique was performed in a 74-year-old woman with a 3 cm lesion between liver segments 2 and 3. She had a fast and uneventful recovery.

CONCLUSION

This technique appears to be feasible, safe and avoid the complications of an abdominal incision.

Next step in minimally invasive surgery: hybrid image-guided surgery

Surgery, interventional radiology, and advanced endoscopy have all developed minimally invasive techniques to effectively treat a variety of diseases with positive impact on patients' postoperative outcomes. However, those techniques are challenging and require extensive training. Robotics and computer sciences can help facilitate minimally invasive approaches. Furthermore, surgery, advanced endoscopy, and interventional radiology could converge towards a new hybrid specialty, hybrid image-guided minimally invasive therapies, in which the three fundamental disciplines could complement one another to maximize the positive effects and reduce the iatrogenic footprint on patients. The present manuscript describes the fundamental steps of this new paradigm shift in surgical therapies that, in our opinion, will be the next revolutionary step in minimally invasive approaches.

Improving outcomes and cost-effectiveness of colorectal surgery

In order to truly make an impact on improving the cost effectiveness, and most importantly, the outcomes of patients undergoing colorectal surgery, all aspects of care need to be scrutinized, re-evaluated, and refined. To accomplish this, everything from the way we train surgeons to the adoption of a minimally invasive approach for colorectal disease, along with the use of adjunct intraoperative measures to decrease morbidity and mortality, may all need to be incorporated within an ERAS program. Only then will this approach lead the provider to a patient-centric care plan which can successfully reduce metrics such as morbidity, mortality, and length of stay (even with the obligatory readmission rate) and provide it all at a lower cost of care.

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.

Evaluation of technical feasibility and safety of Single-Site™ robotic right colectomy: three case reports

BACKGROUND

Robotic Single-Site™ surgery overcomes the technical constraints of single-access laparoscopy. After performing over 130 Single-Site robotic cholecystectomies and stabilizing operative times, we applied this technology to right colon surgery.

METHODS

We successfully completed three Single-Site robotic right colectomies (SSRRCs) using the da Vinci Si Surgical System(®) with a Single-Site kit (© Intuitive Surgical™) inserted through a suprapubic incision.

RESULTS

Overall SSRRC operative time was 218.3 ± 75.9 min. A side-to-side anisoperistaltic anastomosis was fashioned intracorporeally (two cases) or extracorporeally (one case). All patients were discharged within 5 days. There were no complications and oncological principles were satisfied. There were no recurrences up to 12 months.

CONCLUSIONS

This is the first report of SSRRC with intracorporeal anastomosis using the da Vinci(®) Single-Site™ port inserted through a suprapubic incision. This approach is feasible and safe, with oncological outcomes potentially equivalent to those of robotic or laparoscopic multiport surgery.

Prospective randomized trial of hybrid NOTES colectomy versus conventional laparoscopic colectomy for left-sided colonic tumors

BACKGROUND

We conducted a randomized study of a laparoscopic technique for removing left-sided colon tumors that can reduce postoperative pain and other wound-related complications compared to the conventional technique. It is a novel technique of hybrid natural orifice translumenal endoscopic surgery (NOTES) colectomy (HNC) whereby laparoscopic colonic mobilization, transection, and anastomosis are performed intracorporeally. The specimen is then delivered through the anus using the transanal endoscopic operation (TEO) device, precluding the need for mini-laparotomy. We compared the short-term outcomes of patients who underwent HNC with those who underwent conventional laparoscopic colectomy (CL).

METHODS

Patients suffering left-sided colonic tumor were recruited and were randomized into two groups: HNC and CL. Operative data and complications were prospectively recorded and analyzed.

RESULTS

During a 3-year period, we recruited 70 patients (35 per group). No significant difference was observed between the two groups with respect to operating time (105 vs. 100 min, p = 0.851), blood loss (30 vs. 30 ml, p = 0.954), or length of hospital stay (5 vs. 5 days, p = 0.990). The maximum pain score during the first week was significantly lower in the HNC group (1 vs. 2, p = 0.017). No patients in the HNC group developed wound infection, whereas four patients in the CL group did so (p = 0.005).

CONCLUSIONS

With this hybrid NOTES technique, selected patients with left-sided colonic tumors can enjoy the full benefits of minimally invasive surgery with significantly less wound pain and a lower wound infection rate than are observed with CL.

Totally laparoscopic intracorporeal anastomosis with natural orifice specimen extraction (NOSE) techniques, particularly suitable for bowel endometriosis

The objective of this retrospective study was to evaluate the feasibility of natural orifice specimen extraction (NOSE) techniques in 41 patients undergoing bowel resection for treatment of deep infiltrating endometriosis. In all patients laparoscopic treatment of rectovaginal endometriosis with bowel resection had been performed. In 32 patients the classic approach was adopted (group 1), and in 9 a NOSE technique was performed (group 2). Demographic, operative, and postoperative data were compared. Statistical analyses were performed using SPSS software, version 16.0. When needed, qualitative variables were compared using the χ(2) test or the Fisher exact test. Quantitative variables using the t-test were used. The threshold of statistical significance was set at p = .05. No statistically significant difference was observed between the 2 groups. Eight complications (19.5%) were observed, 2 minor (4.8%) and 6 major (14.6%). Of major complications, 2 were observed in the NOSE group (n = 2; 22.2%). It was concluded that the NOSE technique is a feasible approach in patients undergoing bowel resection for treatment of deep infiltrating endometriosis.

Future directions in surgery for colorectal cancer: the evolving role of transanal endoscopic surgery

SUMMARY 

The morbidity associated with radical surgery for rectal cancer has launched a revolution in increasingly less-invasive methods of resection, including a recent resurgence in transanal endoscopic surgical approaches. The next evolution in transanal surgery for rectal cancer is natural orifice translumenal endoscopic surgery (NOTES). To date, 14 series of transanal NOTES total mesorectal excision (TME) for rectal cancer have been published (n = 76). Overall, the intraoperative and postoperative complication rates of 8 and 28%, respectively, compare favorably to those expected from laparoscopic and open TME. Short-term follow-up after NOTES TME has yielded no cancer recurrence in average-risk patients. High-risk patients have cancer recurrence rates similar to those after laparoscopic TME. Overall, these early data support transanal NOTES TME as a safe and viable alternative to conventional TME. Advances in instrumentation, surgical expertise and neoadjuvant treatment may expand current indications for NOTES even further.

Mini-invasive surgery for colorectal cancer

Laparoscopic techniques have been extensively used for the surgical management of colorectal cancer during the last two decades. Accumulating data have demonstrated that laparoscopic colectomy is associated with better short-term outcomes and equivalent oncologic outcomes when compared with open surgery. However, some controversies regarding the oncologic quality of mini-invasive surgery for rectal cancer exist. Meanwhile, some progresses in colorectal surgery, such as robotic technology, single-incision laparoscopic surgery, natural orifice specimen extraction, and natural orifice transluminal endoscopic surgery, have been made in recent years. In this article, we review the published data and mainly focus on the current status and latest advances of mini-invasive surgery for colorectal cancer.

Systematic Review and Meta-analysis of Complications in Transvaginal Approach in Laparoscopic Surgery

Transvaginal access is the most popular natural orifice translumenal technique in the minimally invasive surgery. Reviews on non-gynecological transvaginal approach morbidities reveal that rates vary greatly. A systematic review of transvaginal approach in non-gynecological intraabdominal procedures was carried out to assess the risk of complications. A systematic search was conducted using MEDLINE, EMBASE, PubMed, and the Cochrane Library from the inception of these databases to March 2012. The following keywords were searched: "transvaginal", "NOTES", "single incision", and "single port". From the total of 231 potentially eligible abstracts, 87 papers were retrieved and evaluated as fulfilling the eligibility criteria. The final analysis included 32 articles. The overall complications rate was 4.4 %, and complications related to the transvaginal port reached 2.4 %. Conversion rate to open surgery was 3.4 %. The incidence of postoperative urinary tract infection was 0.8 %. The mean operative time was 119 min. The mean hospital stay was 3.1 days (range 6 h-12 days). The technique of transvaginal access can offer several advantages for a patient and is associated with an acceptable rate of complications.

Advanced laparoscopic surgery for colorectal disease: NOTES/NOSE or single port?

Laparoscopic surgery for colorectal disease is an evolving, dynamic subject undergoing constant adaptation. Hence there are significant ongoing advances in technique and technology as has been seen with the emergence of single port and Natural Orifice Transluminal Endoscopic operations with already considerable ramifications for many aspects of minimal access surgery. Most recently single port technologies and expertise have synergized with Transanal Endoscopic (TEM/TEO) experience to allow their convergence out of their respective niches so that pelvic surgery can be laparoendoscopically performed from both its abdominal and perineal aspects. Distinct from wound-related benefits, such capacity for high resolution and multi-dimensional imaging relates significant benefit to the operating team and patient. This state of the art review demonstrates the crucial perspective that advanced practices and performance capabilities are intrinsically complimentary rather than competitive. All surgeons need therefore to participate in adapting their practice styles to allow technical step-advance across the discipline.