Page 39 - WJOLS - World Journal of Laparoscopic Surgery

REVIEW ARTICLE
Natural Orifice Specimen Extraction: An Incisionless

Approach for Colorectal Cancer (Technical Report)

Islam H Metwally

AbstrAct
Background: Natural orifice surgery represents a greatstep to the future. Difficulties arose on our current practice. Reviewing the literature
does not solve all the debates.
Report: The author suggests a simple algorithm for transanal natural orifice specimen extraction (NOSE).
Conclusion: Transanal extraction of colectomy and/or proctectomy specimen is a readdily feasible technique.
Keywords: Colon, Natural orifice, Rectum, Specimen extraction, Transanal.
World Journal of Laparoscopic Surgery (2018): 10.5005/jp-journals-10033-1351

bAckground Department of Surgical Oncology, Oncology Center Mansoura
Natural orifice specimen extraction (NOSE) for colon and rectal University, Mansoura, Dakahlia, Egypt
cancer is still taking its first steps in oncology practice. Several safety Corresponding Author: Islam H Metwally, Department of Surgical
questions, as well as, technical difficulties arose with practizing Oncology, Oncology Center Mansoura University, Mansoura,
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this technique. As a part of Oncology Center Mansoura University Dakahlia, Egypt, Phone: +20 1002985865, e-mail: drislamhany@mans.
(OCMU) center current clinical trial on natural orifice transluminal edu.eg
endoscopic surgery (NOTES) for colorectal cancer with ClinicalTrials. How to cite this article: Metwally IH. Natural Orifice Specimen
gov Identifier: NCT02549456, transanal NOSE is practiced. Different Extraction: An Incisionless Approach for Colorectal Cancer (Technical
technical steps in our practice, as well as, in published series are Report). World J Lap Surg 2018;11(3):147–148.

displayed in an algorithm with videos when possible. Source of support: Nil

Conflict of interest: None
technique
Excluding cases of intersphincteric resection and some cases B2: If you are planning for a side-to-end anastomosis, then do
of ultralow anterior resection where specimen extraction is colotomy and insert the anvil with its auxiliary trocar and push
straight forward and anastomosis is done on the anal verge, against wall to make a new narrow colotomy (with/without
the classic transanal NOSE technique is depicted in Flowchart 1 purse string reinforcement), or use a guide tube to facilitate
and below: the anvil exteriorization.
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Step I: Laparoscopic sigmoidectomy, anterior, low, or ultralow B3: If you are planning for a pouch reconstruction, then do the
resection is done. pouch with a linear stapler, then insert the anvil through the
Step II: Cut the distal end by advanced bipolar for the mesentry or resultant opening.
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mesorectum, then use scissors to cut the lumen (to avoid sealing Step IV: Only applies for technique IIIB, extract the specimen either
of the wall that may hinder specimen extraction). by an Endobag® (Covidien, MA, USA) (Video 3), or a camera sleeve,
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Step III: Either.
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or aCai tube, or a rigid platform; transanal endoscopic microsurgery
• A: Use a long instrument to grip the colon and retrieve it through (TEM) (Richard Wolf, IL, USA) or transanal endoscopic operation (TEO)
the anal canal. Cut the proximal end and insert the anvil extra- (Karl Storz, Tuttilingen, Germany).
corporeal (preferred method if feasible). Here you can close the Step V: Close the distal stump (as in step IIIA), but here you are
distal end with V-Loc® suture (Covidien, MA, USA) transanally mostly implementing either a double- or triple-stapling technique.
or laparoscopically, so implementing a one-stapling technique
(much reducing the cost) (Video 1). Otherwise, you may choose conclusion
to close the stump by a linear stapler, implementing a double- Transanal NOSE is a feasible and flexible method that can minimize
stapling technique. the complications associated with rectal and sigmoid resection. To
• B: Insert the anvil transanally, then choose. our opinion, any surgeon experienced in colorectal laparoscopy can
B1: If you are planning for an end-to-end anastomosis, then cut easily apply this technique with a short learning curve.
the proximal end, insert the anvil, then take a manual purse supplementAry mAteriAls
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string suture, or do a colotomyto insert the anvil through and
use a linear stapler to close just around the anvil’s tip (author’s Video 1: Closing the rectal stump after transanal NOSE after
technique) (Video 2). low anterior resection using the direct exteriorization and

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