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This technique continues to be implemented, particularly for right-sided colon pathology, given the difficulty of using the distal colon for specimen extraction. A more recent series of right colectomies with NOSE via the vagina was described by Franklin et al 15 in In this series that included 26 transvaginal specimen extractions, feasibility of this method is demonstrated with a complication rate of 7. Karagul et al 14 found that specimens that were too large for transrectal and transanal extraction were successfully removed via the vagina.

The obvious restriction of this technique is that it is only an option for female patients. A greater volume of literature focuses on NOSE for left-sided colon pathology 10 and is typically performed through a proctotomy. The distal transection point for specimens in the left colon can serve as the viscerotomy in these cases. The distensible rectum lends itself well to passage of specimens for extraction, and anal dilation for retrieval is a relatively simple task.

A step-wise description of this technique is described by Wolthuis et al. The long-term implications of this, particularly in removing malignant tumors, remain to be seen. In the treatment of rectal cancer, the transanal total mesorectal excision taTME has been well described with promising oncologic results. NOSE, in these cases, is the most practical route of specimen extraction as the rectum or anus serves as the viscerotomy site and needs to be transected as a mandatory step in the operation. We now routinely perform NOSE as part of any laparoscopic or robotic transanal-abdominal transanal proctosigmoidectomy and have reported perioperative morbidity and mortality of Quality of studies that report on colorectal NOSE outcomes has substantially increased in recent years.

Larger series and randomized controlled trials now demonstrate some benefits with NOSE as compared to conventional specimen extraction, particularly in regard to postoperative analgesic use, time to first bowel function, cosmesis, and length of hospital stay. More recently, literature about NOSE in colorectal surgery has begun to focus on patient selection and the specific factors that may prevent successful NOSE. Technical feasibility of this technique relies upon careful patient selection, which will be subsequently discussed in greater detail.

Several studies suggest some benefit to NOSE over laparoscopy with conventional abdominal wall specimen extraction. Superior outcomes in terms of postoperative pain control, time to first bowel function, hospital length of stay, reduced incisional complications, and improved cosmesis have been demonstrated. Careful examination of patient characteristics in these studies can be used to extrapolate themes that can aid in selecting patients who can most benefit from NOSE in colorectal surgery.

Improved postoperative analgesia in colorectal surgery patients undergoing NOSE is demonstrated by large case series and randomized controlled trials. Several larger case series report lower analgesic use and better pain scores after NOSE. The study was powered to show differences in analgesic use after surgery. The NOSE group used significantly less acetaminophen and patient-controlled epidural analgesia. Pain scores remained significantly lower after 1 week. Quicker return of bowel function, measured by time to first passage of flatus or first bowel movement following surgery, has been described when comparing NOSE to conventional specimen extraction.

Dr. Matthew Schultzel - Encinitas, La Jolla - Surgery (General Surgery), Colon and Rectal Surgery

Earlier bowel function may contribute to shorter length of hospital stay. Shorter hospital stays have been reported in case-matched studies. Some discrepancy exists, however, as several other studies in the literature show no difference in length of hospital stay compared to conventional specimen extraction. A properly powered randomized controlled trial has yet to report on the length of hospital stay in colorectal NOSE. Incisional-related complications in colorectal surgery have similar rates when comparing open and conventional laparoscopic surgery. Kuhry et al 25 showed in a meta-analysis that incisional hernia rates in colorectal cancer operations are These incision-related complications are thought to be linked to the mini-laparotomy.

NOSE addresses this by eliminating the need for mini-laparotomy.

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In a study that compared postoperative complications between NOSE and conventional specimen extraction in sigmoid or rectal cancer, patients having NOSE had significantly lower perioperative complication rates. This was attributed to a significant reduction in incisional wound infection.

Incisional hernias associated with mini-laparotomies may be avoided by NOSE as well. Improved cosmesis has been assumed to be superior in patients undergoing NOSE compared to conventional specimen extraction; however, Wolthuis et al 22 investigated this more objectively in a case-matched series. They found that cosmesis was significantly better in the NOSE group as evaluated by a body image questionnaire and the Patient Scar Assessment Questionnaire.

This cosmetic advantage can be factored into selecting patients who could benefit from NOSE in colorectal surgery.

In this ideal population, superior outcomes are described without significant increases in morbidity. Wolthuis published a randomized controlled trial that demonstrates significantly reduced pain with NOSE compared to conventional specimen extraction, 20 but higher-quality studies looking at time to first bowel function, hospital length of stay, and morbidity are lacking. Randomized controlled trials should assess these outcome measures, as initial results in large series of carefully selected populations are encouraging.

It is important to note that even in these carefully selected patient cohorts, there are several reports in the literature in which NOSE attempts failed and required extraction of the specimen by conventional means. This highlights the importance of patient selection in utilizing this technique. As with any new technique, several concerns are raised with NOSE.

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Particularly, these issues include infection associated with viscerotomy, breakdown in the closure of the organ used for specimen extraction, pain or functional consequences of disturbing an otherwise healthy organ for specimen extraction, and the potential for seeding unaffected organs in the extraction of malignancy. Contamination associated with opening a hollow viscus for NOSE, particularly the colon or rectum, has been investigated.

It should be noted that bacterial contamination of the operative field is common in laparoscopic surgery, even when specimens are removed by a mini-laparotomy. However, the study reports no statistical differences in clinical infectious outcomes. The NOSE group of 17 patients reported one patient who developed a 2 cm pelvic abscess and another who had an anastomotic leak. Fever of unknown source was reported in two other patients. The matched conventional specimen extraction group of nine patients had no infectious complications. While conclusions about clinically significant infectious risk are difficult to make based on this study, it is worth noting that this study, and several other series, report infectious complication rates that are similar to those reported for laparoscopic colorectal surgery with conventional specimen extraction.

In each of these experiences, bowel preparations were performed preoperatively. In transvaginal NOSE, some have raised concern about the effects of a posterior colpotomy. No complications related to the colpotomy incision have been reported in colorectal surgery.

The vagina has many properties that are ideal for specimen extraction, including elasticity, redundant vascular supply lending to excellent healing, clean nature, and relatively easy access. Palanivelu et al 29 found no dyspareunia in any of the 11 patients in their series after nearly 1 year of follow-up.

Kim et al 30 demonstrated no rectovaginal fistulas and no dyspareunia at 3-months follow-up in 58 patients who underwent transvaginal specimen extraction. In transanal NOSE, concerns have been raised about incontinence and anal dysfunction; however, both Zhang 41 and Wolthuis et al 20 , 31 found no anal dysfunction or fecal incontinence associated with this. Evaluating oncologic outcomes when implementing new surgical techniques is of paramount importance.

Short-term outcomes have been favorable. Margin status has been reported to be similar to conventional specimen extraction. Long-term oncologic outcomes in our series are encouraging with 7. Tumor implantation upon specimen removal via natural orifice is another concern that has been raised. Reports of laparoscopic port site metastasis in the past raise concerns of removing malignant specimens through healthy viscera such as the rectum, anus, or vagina. Variants in wound protection including laparoscopic bags, duel-ring wound protectors, and TEO ports have all been used for this purpose.

It has been reported that use of these devices can reduce the chance of successful NOSE. Karagul et al 14 describe washing the anus and rectum with povidone-iodine before and after specimen removal without using a wound protector. With a mean follow-up of Concerns about infection, pain, or functional consequences of the organ used for specimen extraction, and oncologic outcomes in NOSE have been addressed in the literature.

While no clear disadvantages have been demonstrated in using organs for specimen extraction, infection rates and oncologic outcomes seem to be similar to conventional specimen extraction. In the literature, the two prevailing themes that seem to be associated with feasibility of NOSE are patient characteristics, particularly BMI and male sex, and specimen bulk, measured by maximum diameter and size of tumor. Patient characteristics including BMI, sex, and comorbidity may influence the feasibility and potential benefit of NOSE in colorectal surgery. Failure of NOSE and the reason for failure are reported in many of these studies; yet, patient characteristics in this subset are not commonly provided by authors.

Table 2 lists the available patient characteristics in cases of failed NOSE from the literature. Bulky specimens are the most commonly cited reason for NOSE failure in colorectal surgery. It has been well established that the elastic properties of the vagina allow removal of more bulky specimens when compared to proctotomies. In this series, there was a statistically significant difference in the mean size of extracted specimens via vagina and anus 5.

Independent of specimen size, transvaginal specimen extraction is more technically feasible for removing right colectomy specimens compared to the alternative of moving the right-sided specimen endoscopically through the entire length of the colon. The question of pelvic shape and anatomy differences between men and women is worth mentioning.

Some studies compare transanal NOSE between men and women. When transanal NOSE for laparoscopic colorectal resections is compared between men and women, the success rates are similar NOSE in colorectal surgery for the obese patient poses unique technical challenges. Increased BMI is associated with increased visceral fat, 33 which may be associated with specimen bulk.

It is well recognized that one of the advantages of minimally invasive surgery is the improved visualization and postoperative outcomes in patients with higher BMI, but as we discussed earlier, the benefit of minimally invasive surgery is diminished by mini-laparotomies made for specimen extraction. They report a failure in a patient with BMI The postoperative outcomes for these patients were not discussed separately. As the literature is highly selective in terms of BMI, this should be considered a significant factor in assessing whether or not NOSE will be technically feasible when planning an operation.

Complication rates for this specific population are not reported. In a randomized clinical trial by Wolthuis et al, 20 inflammatory response between conventional specimen extraction and NOSE was compared using postoperative C-reactive protein.

Transanal total mesorectal excision with single incision laparoscopic surgery

C-reactive protein levels were found to be higher in the NOSE group, but ultimately, this was not associated with an increased length of hospital stay. The implications of this are unclear, but it could be suggested that patients with more comorbidities are less likely to tolerate a more robust inflammatory response. Conversely, use of pain scores in the same study was significantly lower in the NOSE group. In more frail patients with comorbidities, the advantage of decreased narcotic use is obvious.

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Coagulopathy was set as the exclusion criterion in some NOSE colorectal studies. This should be considered as there is a reported rate of postoperative intraluminal hemorrhage of 4.

The role of transanal total mesorectal excision in rectal surgery

History of prior operations and radiation exposure may influence the feasibility of any operation. While such history can make operations more challenging, there are no reported NOSE failures that cite this as the reason for failure. In the context of rectal cancer treatment and taTME, neoadjuvant radiation is the standard of care.