Robotic natural orifice specimen extraction surgery I-type F method vs conventional robotic resection for lower rectal cancer

BACKGROUND Robotic resection using the natural orifice specimen extraction surgery I-type F method(R-NOSES I-F)is a novel minimally invasive surgical strategy for the treatment of lower rectal cancer.However,the current literature on this method is limited to case reports,and further investigation into its safety and feasibility is warranted.AIM To evaluate the safety and feasibility of R-NOSES I-F for the treatment of low rectal cancer.METHODS From September 2018 to February 2022,206 patients diagnosed with low rectal cancer at First Affiliated Hospital of Nanchang University were included in this retrospective analysis.Of these patients,22 underwent R-NOSES I-F surgery(RNOSES I-F group)and 76 underwent conventional robotic-assisted low rectal cancer resection(RLRC group).Clinicopathological data of all patients were collected and analyzed.Postoperative outcomes and prognoses were compared between the two groups.Statistical analysis was performed using SPSS software.RESULTS Patients in the R-NOSES I-F group had a significantly lower visual analog score for pain on postoperative day 1(1.7±0.7 vs 2.2±0.6,P=0.003)and shorter postoperative anal venting time(2.7±0.6 vs 3.5±0.7,P<0.001)than those in the RLRC group.There were no significant differences between the two groups in terms of sex,age,body mass index,tumor size,TNM stage,operative time,intrao-perative bleeding,postoperative complications,or inflammatory response(P>0.05).Postoperative anal and urinary functions,as assessed by Wexner,low anterior resection syndrome,and International Prostate Symptom Scale scores,were similar in both groups(P>0.05).Long-term follow-up revealed no significant differences in the rates of local recurrence and distant metastasis between the two groups(P>0.05).CONCLUSION R-NOSES I-F is a safe and effective minimally invasive procedure for the treatment of lower rectal cancer.It improves pain relief,promotes gastrointestinal function recovery,and helps avoid incision-related complications.

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 NOSEprocedures 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.

Complete laparoscopic resection of the rectum using natural orifice specimen extraction

AIM: To investigate how complete laparoscopic anterior resection with natural orifice specimen extraction (NOSE), as a novel minimally invasive surgery, compares to conventional laparoscopic surgery.

Transanal natural orifice specimen extraction for laparoscopic anterior resection in rectal cancer

AIM: To investigate whether transanal natural orifice specimen extraction (NOSE) is a better technique for rectal cancer resection.METHODS: A prospectively designed database of a consecutive series of patients undergoing laparoscopic low anterior resection for rectal cancer with various tumor-node-metastasis classi?cations from March 2011 to February 2012 at the First Affiliated Hospital of Sun Yat-Sen University was analyzed. Patient selection for transanal specimen extraction and intracorporeal anastomosis was made on the basis of tumor size and distance of rectal lesions from the anal verge. Demographic data, operative parameters, and postoperative outcomes were assessed.RESULTS: None of the patients was converted to laparotomy. Respectively, there were 16 cases in the low anastomosis and five in the ultralow anastomosis groups. Mean age of the patients was 45.4 years, and mean body mass index was 23.1 kg/m2. Mean distance of the lower edge of the lesion from the anal verge was 8.3 cm. Mean operating time was 132 min, and mean intraoperative blood loss was 84 mL. According to the principle of rectal cancer surgery, we performed D2 lymph node dissection in 13 cases and D3 in eight. Mean lymph nodes harvest was 17.8, and the number of positive lymph nodes was 3.4. Median hospital stay was 6.7 d. No serious postoperative complication occurred except for one anastomotic leakage. All patients remained disease free. Mean Wexner score was 3.7 at 11 mo after the operation.CONCLUSION: Transanal NOSE for total laparoscopic low/ultralow anterior resection is feasible, safe and oncologically sound. Further studies with long-term outcomes are needed to explore its potential advantages.

Safety and survival outcomes of transanal natural orifice specimen extraction using prolapsing technique for patients with middle-to low-rectal cancer

Objective:The transanal approach to specimen collection,combined with the prolapsing technique,is a wellestablished and minimally invasive surgery for treating rectal cancer.However,reports on outcomes for this approach are sparse.We compared short-and long-term outcomes of conventional laparoscopic surgery(CLS)vs.transanal natural orifice specimen extraction(NOSE)using the prolapsing technique for patients with middle-to low-rectal cancer.Methods:From January 2013 to December 2017,we enrolled consecutive patients with middle-to low-rectal cancer undergoing laparoscopic anterior resection.Totally,50 patients who underwent transanal NOSE using the prolapsing technique were matched with 50 patients who received CLS.Clinical parameters and survival outcomes between the two groups were compared.Results:Estimated blood loss(29.70±29.28 vs.52.80±45.09 mL,P=0.003),time to first flatus(2.50±0.79 vs.2.86±0.76,P=0.022),time to liquid diet(3.62±0.64 vs.4.20±0.76 d,P<0.001),and the need for analgesics(22%vs.48%,P=0.006)were significantly lower for the NOSE group compared to the CLS group.The incidences of overall complications and fecal incontinence were comparable in both groups.After a median follow-up of 44.52 months,the overall local recurrence rate(6%vs.5%,P=0.670),3-year disease-free survival(86.7%vs.88.0%,P=0.945)and 3-year overall survival(95.6%vs.96.0%,P=0.708),were not significantly different.Conclusions:For total laparoscopic rectal resection,transanal NOSE using the prolapsing technique is effective and safe,and associated with less trauma and pain,a faster recovery,and similar survival outcomes compared to CLS.

Natural orifice specimen extraction with laparoscopic radical gastrectomy for distal gastric cancer: A case report

BACKGROUND This article introduces the surgical method and early experience in performing totally laparoscopic radical gastrectomy with transrectal specimen extraction for gastric cancer, and we evaluate the short-term effects and feasibility of this new procedure for gastric cancer in a 64-year-old male patient. This approach may provide new possibilities for gastric natural orifice specimen extraction(NOSE)surgery. In addition, we believe that this new procedure may further relieve pain,speed up recovery, and cause minimal physiological and psychological impact.CASE SUMMARY We performed NOSE gastrectomy in a male patient. Tumor resection, digestive tract reconstruction, and lymph node dissection were performed totally laparoscopically;the specimen was extracted from the natural orifice of the rectum-anus. This procedure reduced damage to the abdominal wall and decreased postoperative pain. We successfully performed radical gastrectomy without conversion and complications. Total operative time and blood loss were 176 min and 50 m L, respectively. The patient resumed normal activities of daily living on day 1 without pain, and passed flatus within 48 h. Postoperative hospital stay was 10 d. The number of resected lymph nodes was 0/43. During the follow-up, no stricture or anastomotic leakage was detected. Three months postoperatively, colonoscopy showed full recovery of the rectum without stricture or scar contracture. Computed tomography and laboratory test results showed no signs of tumor recurrence. There was no visible scar on the abdominal wall.CONCLUSION It is safe and reliable to perform totally laparoscopic radical gastrectomy with transrectal specimen extraction for distal gastric cancer patients.

Development and future perspectives of natural orifice specimen extraction surgery for gastric cancer

In recent years,natural orifice specimen extraction surgery(NOSES),a novel minimally invasive surgical technique,has become a focus in the surgical field,and has been initially applied in gastric surgery in many national medical centers worldwide.In addition,this new surgical technique was launched in major hospitals in China.With an increasing number of patients who have accepted this new surgical technique,NOSES has provided new prospects for the treatment of gastric cancer(GC),which may achieve a better outcome for both patients and surgeons.More and more experts and scholars from different countries and regions are currently paying close attention to NOSES for the treatment of GC.However,there are only a few reports of its use in GC.This review focuses on the research progress in NOSES for radical gastrectomy in recent years.We also discuss the challenges and prospects of NOSES in clinical practice.

Analysis of the Results of Rectal Cancer Treatment via 3D Laparoscopic Natural Orifice Specimen Extraction Surgery (NOSES IV)

Objective:To investigate the effect of 3D laparoscopic natural orifice specimen extraction surgery as rectal cancer treatment.Methods:The study was carried out in Shaanxi Provincial People’s Hospital from July 2021 to July 2022.80 rectal cancer patients were selected and divided into two groups which are the experimental group and control group.The experimental group was given 3D laparoscopic surgery while the control group was given 2D laparoscopic surgery.The results were compared and analysed.Results:The patients in the experimental group had shorter operative and evacuation times,less intraoperative bleeding,and a lower rate of complications.Conclusion:The clinical application of 3D laparoscopic radical surgery for rectal cancer via natural lumen extraction is more effective,which can promote patients'recovery and reduce the incidence of adverse events.

International guideline on natural orifice specimen extraction surgery(NOSES)for colorectal cancer(2023 version)

Purpose In recent years,natural orifice specimen extraction surgery(NOSES)has gained widespread attention as an alternative approach.Although the safety and feasibility of NOSES have been well documented,many questions remain open for discussion.The aim of this guideline is to provide more evidence for the promotion of NOSES.Methods This guideline has been prepared by the CACA Committee of Colorectal Cancer Society and the International NOSES Alliance,based on the latest evidence.Results The guideline on NOSES for colorectal cancer include the definition,classification,technology requirement,indications,technical difficulties and clinical research.Conclusion The guideline provides a full introduction of the theoretical and technical aspects of NOSES for colorectal cancer which will beneficial to development of NOSES.

Perioperative outcomes of transvaginal specimen extraction laparoscopic total gastrectomy and conventional laparoscopicassisted total gastrectomy

BACKGROUND Natural orifice specimen extraction surgery(NOSES)has emerged as a promising alternative compared to conventional laparoscopic-assisted total gastrectomy(LATG)for treating gastric cancer(GC).However,evidence regarding the efficacy and safety of NOSES for GC surgery is limited.This study aimed to compare the safety and feasibility,in addition to postoperative complications of NOSES and LATG.METHODS Dual circular staplers were used in Roux-en-Y digestive tract reconstruction for transvaginal specimen extraction LATG,and its outcomes were compared with LATG in a cohort of 51 GC patients with tumor size≤5 cm.The study was conducted from May 2018 to September 2020,and patients were categorized into the NOSES group(n=22)and LATG group(n=29).Perioperative parameters were compared and analyzed,including patient and tumor characteristics,postoperative outcomes,and anastomosis-related complications,postoperative hospital stay,the length of abdominal incision,difference in tumor type,postoperative complications,and postoperative survival.RESULTS Postoperative exhaust time,operation duration,mean postoperative hospital stay,length of abdominal incision,number of specific staplers used,and Brief Illness Perception Questionnaire score were significant in both groups(P<0.01).In the NOSES group,the postoperative time to first flatus,mean postoperative hospital stay,and length of abdominal incision were significantly shorter than those in the LATG group.Patients in the NOSES group had faster postoperative recovery,and achieved abdominal minimally invasive incision that met aesthetic requirements.There were no significant differences in gender,age,tumor type,postoperative complications,and postoperative survival between the two groups.CONCLUSION The application of dual circular staplers in Roux-en-Y digestive tract reconstruction combined with NOSES gastrectomy is safe and convenient.This approach offers better short-term outcomes compared to LATG,while long-term survival rates are comparable to those of conventional laparoscopic surgery.

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

In recent years,natural orifice specimen extraction surgery(NOSES)in the treatment of colorectal cancer has attracted widespread attention.The potential benefits of NOSES including reduction in postoperative pain and wound complications,less use of postoperative analgesic,faster recovery of bowel function,shorter length of hospital stay,better cosmetic and psychological effect have been described in colorectal surgery.Despite significant decrease in surgical trauma of NOSES have been observed,the potential pitfalls of this technique have been demonstrated.Particularly,several issues including bacteriological concerns,oncological outcomes and patient selection are raised with this new technique.Therefore,it is urgent and necessary to reach a consensus as an industry guideline to standardize the implementation of NOSES in colorectal surgery.After three rounds of discussion by all members of the International Alliance of NOSES,the consensus is finally completed,which is also of great significance to the long-term progress of NOSES worldwide.

International consensus on natural orifice specimen extraction surgery(NOSES)for gastric cancer(2019)

At present,natural orifice specimen extraction surgery(NOSES)has attracted more and more attention worldwide,because of its great advantages including minimal cutaneous trauma and post-operative pain,fast post-operative recovery,short hospital stay,and positive psychological impact.However,NOSES for the treatment of gastric cancer(GC)is still in its infancy,and there is great potential to improve its theoretical system and clinical practice.Especially,several key points including oncological outcomes,bacteriological concerns,indication selection,and standardized surgical procedures are raised with this innovative technique.Therefore,it is necessary to achieve an international consensus to regulate the implementation of GC-NOSES,which is of great significance for healthy and orderly development of NOSES worldwide.

Outcomes after natural orifice extraction vs conventional specimen extraction surgery for colorectal cancer: A propensity scorematched analysis

BACKGROUND Natural orifice specimen extraction(NOSE)via the anus or vagina replaces conventional transabdominal specimen retrieval via the transabdominal route through a limited mid-line laparotomy or Pfannenstiel incision.Reducing the number of laparoscopic ports further decreases operative abdominal wall trauma.These techniques reduce the surgical wound size as well as the risk of incisionrelated morbidity.AIM To compare short-term outcomes following 3-port NOSE surgery with a matched cohort of conventional non-NOSE colorectal cancer surgery.METHODS Patients who underwent elective 3-port laparoscopic colorectal NOSE surgery between February to October 2021 were identified.Selection criteria for NOSE surgery was adapted from the 2019 International Consensus on Natural Orifice Specimen Extraction Surgery for colorectal cancer.Patients with clinical T4 or N2 tumors on staging computed tomography were also excluded.The propensity score-matched cohort was identified amongst patients who underwent conventional laparoscopic colorectal surgery from January 2019 to December 2020.Matching was performed in the ratio of 1:4 based on age,gender,type of resection,and p-tumor node metastasis staging.RESULTS Over the eight-month study duration,14 consecutive cases(nine female,five male)of elective 3-port laparoscopic surgery with NOSE were performed for colorectal cancer.Median age and body mass index were 70(range 43-82)years and 24.1(range 20.0-31.7)kg/m2 respectively.Six patients underwent transanal NOSE and eight had transvaginal NOSE.Median operative time,intraoperative blood loss and postoperative length of stay were 208(range 165-365)min,30(range 10-150)mL and 3(range 2-6)d respectively.Two(14%)suffered minor postoperative compilations not attributable to the NOSE procedure.Median follow-up duration was 12(range 8-15)mo.No instances of mortality,local or distant disease recurrence were recorded in this cohort.Compared to the conventional surgery cohort of 56 patients,the 3-port NOSE cohort had significantly quicker mean return of bowel function(2.6 vs 1.2 d,P<0.001),reduced postoperative pain and patientcontrolled analgesia use,and decreased length of hospital stay(6.4 vs 3.4 d,P<0.001).There were no statistical differences in surgical duration and perioperative complication rates between the NOSE and non-NOSE cohorts.CONCLUSION 3-port laparoscopic colorectal surgery with NOSE is a feasible technique,augmenting the minimally invasive nature of surgery and producing good outcomes.Appropriate patient selection and expertise in conventional laparoscopy are required.

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

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

机器人辅助下经自然腔道取标本手术应用于乙状结肠癌和直肠癌患者的近期疗效分析

目的 探讨机器人辅助下经自然腔道取标本手术(NOSES)应用于乙状结肠癌和直肠癌患者的近期疗效。方法 回顾性分析2021年7月至2021年10月于中国医学科学院肿瘤医院接受机器人辅助的结直肠癌患者31例,包括直肠肿瘤18例,乙状结肠肿瘤13例。所有患者根据术中情况决定手术方式,观察手术和术后恢复情况、术后病理学结果,了解患者术后生存、肿瘤进展情况。结果 31例患者顺利完成手术,17例患者接受NOSES手术,剩余14例采取常规手术方式取标本。NOSES组患者的BMI更低[(22.59±2.70)cm比(25.48±2.34)cm,t=1.142,P=0.004];N分期淋巴结转移率更低(χ^(2)=7.343,P=0.025);术中出血量更少[(24.12±14.17)cm比(35.71±11.58)cm,t=0.896,P=0.020],并且术后首次离床活动时间更早[(27.41±10.95)cm比(40.00±9.51)cm,t=1.227,P=0.002]。31名患者在围手术期内均未发生手术相关并发症。术后随访时间3~6个月,所有患者均未发生肿瘤复发、进展和死亡。结论 机器人辅助下NOSES应用于乙状结肠癌和直肠癌患者安全可行,近期疗效满意。