Recently, minimally invasive surgery (MIS) become almost the gold standard surgical approach in many centers due to its benefits compared to open surgery (1). Especially in colorectal surgery (CRS), it is stated that minimally invasive approach is associated with less postoperative pain, earlier bowel function recovery and shorter hospital stay (2). However, the approach requires an abdominal incision approximately 3–8 cm long for specimen extraction. Natural orifice specimen extraction (NOSE) is the technique in which the intra-abdominally resected specimen is extracted by opening a hollow organ that communicates with the outside of the body, including anus, vagina, mouth or ureter, and it aims to reduce postoperative pain, incisional hernia, wound infection and cosmetic concerns, due to abdominal incision (3,4). The indications of NOSE are similar to conventional minimally invasive colorectal resections (3). Although this technique reaches a high number of cases especially for CRS; recently, it has started to be used as a minimally invasive alternative for other organ resections, such as stomach, liver, and adrenal gland (4-6).
Since 1991, when it was first performed (7,8), CRS combined with NOSE has been successfully performed with increasing numbers in many centers (3). The studies have shown that while general complication rates are similar, NOSE is superior to transabdominal specimen extraction, especially in terms of postoperative pain, length of hospital stay and cosmesis, and this result have been very effective in these increasing numbers (9). In addition to the benefits of the technique, rare complications such as perioperative organ injury, anastomotic leakage, fecal incontinence, intra-abdominal contamination, dyspareunia and recurrence in the specimen extraction area can be seen (10). In order to minimize these complications, recommendations such as preoperative rectal and vaginal cleaning, selection of a natural orifice compatible with the specimen diameter, or extraction of the specimen in a protective sheath, were presented in the ‘CRS combined with NOSE consensus report’ in 2019 (3).
In some of the cases, in addition to CRS, combined resections may be required for metastases, secondary primary malignancies, or benign diseases, and it is controversial. PubMed and Google Scholar database were scanned in April 2022 and 812 potential articles were selected for research. After exclusions (non-English articles, Natural Orifice Transluminal Endoscopic Surgery (NOTES), and only colorectal resections with NOSE articles) and reference cross check, we collected 19 eligible studies including 42 case reports who included the study. These data were summarized in Table 1. In the present study, we aimed to review the literature of NOSE for combined resections with CRSs, from the perspective of choice of the natural orifice, technical feasibility, and postoperative results.
|Patients||Author||Year||Country/region||Gender||Age (years)||Operation||Specimen extraction||Colorectal pathology malignant/benign||Indication of combined resection malignant/benign||Protection sheath||Combined organ||Duration of surgery (min)||Blood loss (mL)||Complication||Length of hospital stay (d)|
|P1||Breitenstein et al. (11)||2006||Switzerland||F||59||Sigmoidectomy/hysterectomy||Transvaginal||Benign||Benign||0||Uterus||NA||NA||Colitis||15|
|P2||Breitenstein et al. (11)||2006||Switzerland||F||39||Sigmoidectomy/hysterectomy||Transvaginal||Benign||Benign||0||Uterus||NA||NA||0||9|
|P3||Lakshman et al. (12)||2006||Australia||F||42||Anterior resection/hysterectomy/bilateral salphingo-ooferectomy||Transvaginal||Benign||Benign||1||Uterus/ovary/salpings||240||200||0||3|
|P4||Lakshman et al. (12)||2006||Australia||F||46||Anterior resection/hysterectomy/bilateral salphingo-ooferectomy||Transvaginal||Malignant||Benign||1||Uterus/ovary/salpings||270||200||0||4|
|P5||Lakshman et al. (12)||2006||Australia||F||55||Anterior resection/hysterectomy/bilateral salphingo-ooferectomy||Transvaginal||Malignant||Malignant||1||Uterus/ovary/salpings||180||100||0||NA|
|P6||Dozois et al. (13)||2008||USA||F||53||Total colectomy/hysterectomy||Transvaginal||Malignant||Benign||0||Uterus||455||400||0||7|
|P7||Pickron et al. (14)||2009||USA||F||40||Ileocecal resection/hysterectomy/bilateral salphingo-ooferectomy||Transvaginal||Benign||Benign||0||Uterus/ovary/salpings||NA||NA||NA||NA|
|P8||García Flórez et al. (15)||2010||Spain||F||86||Anterior resection/right salphingo-ooferectomy||Transvaginal||Malignant||Malignant||1||Right salping/ovary||225||180||0||6|
|P9||Tan et al. (16)||2017||Singapore||F||74||Low anterior resection/hysterectomy/bilateral salphingo-ooferectomy||Transvaginal||Malignant||Benign||NA||Uterus/ovary/salpings||469||NA||0||5|
|P10||Karagul et al. (17)||2017||Turkey||NA||NA||NA||NA||NA||Benign||NA||Gallbladder||NA||NA||NA||NA|
|P11||Sumer et al. (18)||2018||Turkey||M||66||Subtotal colectomy/gastrectomy||Transanal||Malignant||Malignant||0||Stomach||520||250||0||17|
|P12||Wang et al. (19)||2020||China||M||68||Anterior resection/gastrectomy||Transanal||Malignant||Malignant||1||Stomach||355||50||0||NA|
|P13||Gundogan et al. (9)||2021||Turkey||NA||NA||Right hemicolectomy/cholesystectomy||Transanal||Malignant||Benign||NA||Gallbladder||NA||NA||NA||NA|
|P14||Gundogan et al. (9)||2021||Turkey||NA||NA||Right hemicolectomy/liver metastatectomy||Transanal||Malignant||Malignant||NA||Liver||NA||NA||NA||NA|
|P15||Cheng et al. (20)||2020||Taiwan||NA||NA||Right hemicolectomy/NA||Transanal||NA||NA||NA||NA||NA||NA||NA||NA|
|P16||Cheng et al. (20)||2020||Taiwan||NA||NA||Right hemicolectomy/NA||Transanal||NA||NA||NA||NA||NA||NA||NA||NA|
|P17||Efetov et al. (21)||2021||Russia||F||NA||Anterior resection/right salphingo-ooferectomy||Transanal||Malignant||Benign||NA||Right salping/ovary||NA||NA||NA||NA|
|P18||Wang et al. (22)||2021||China||M||65||Anterior resection/gastrectomy||Transanal||Malignant||Malignant||NA||Stomach||NA||NA||NA||NA|
|P19||Meng et al. (23)||2021||China||F||37||Right hemicolectomy/pancreaticoduodenectomy||Transvaginal||Malignant||Malignant||1||Pancreas-duodenum||470||130||0||7|
|P20||Lendzion and Gilmore (24)||2021||Australia||F||74||Right hemicolectomy/hysterectomy||Transvaginal||Malignant||Benign||1||Uterus||240||NA||0||5|
|P21||Lendzion and Gilmore (24)||2021||Australia||F||45||Right hemicolectomy/hysterectomy||Transvaginal||Malignant||NA||1||Uterus||270||NA||0||3|
|P22||Lendzion and Gilmore (24)||2021||Australia||F||75||Anterior resection/right hemicolectomy/bilateral salphingo-ooferectomy||Transvaginal||Malignant||Malignant||1||Peritoneum/omentum/bilateral ovaries/salpings||510||NA||0||4|
|P23–34||Chen et al. (25)||2021||Australia||NA||NA||Colorectal resections/cholecystectomy/appendectomy/hysterectomy/salphingo-oofrectomy||Transanal/Transvaginal||Benign||NA||1||4 gallbladders; 2 appendix; 5 ovaries/salphings; 1 uterus||NA||NA||NA||NA|
|P35||Aydin et al. (5)||2022||Turkey||F||70||Anterior resection/liver metastasectomy||Transvaginal||Malignant||Malignant||1||Liver||540||0||0||5|
|P36||Aydin et al. (5)||2022||Turkey||F||45||Anterior resection/liver metastasectomy||Transanal||Malignant||Malignant||1||Liver||420||0||Pleural effusion||8|
|P37||Aydin et al. (5)||2022||Turkey||M||58||Anterior resection/liver metastasectomy||Transanal||Malignant||Malignant||1||Liver||390||50||Anastomosis leak||39|
|P38||Aydin et al. (5)||2022||Turkey||F||73||Anterior resection/liver metastasectomy||Transvaginal||Malignant||Malignant||1||Liver||390||60||0||8|
|P39||Aydin et al. (5)||2022||Turkey||F||44||Anterior resection/liver metastasectomy||Transanal||Malignant||Malignant||1||Liver||300||0||0||9|
|P40||Gonçalves et al. (26)||2022||Portugal||F||45||Sigmoidectomy/hysterectomy||Transanal||Benign||Benign||0||Uterus||NA||NA||0||NA|
|P41||Drestadt et al. (27)||2020||Germany||NA||NA||Anterior resection/cholecystectomy||Transvaginal||Benign||Benign||0||Gallbladder||NA||NA||NA||NA|
|P42||Drestadt et al. (27)||2020||Germany||NA||NA||Anterior resection/liver resection||Transvaginal||Benign||NA||0||Liver||NA||NA||NA||NA|
F, female; NA, not available; M, male.
Colorectal carcinoma liver metastasis
Colorectal cancer is frequently seen in the world and it is also the leading cause of cancer-related deaths. The liver is the most common organ of colorectal cancer metastasis with a rate of 15–25%, and if possible, the only potentially curative treatment is surgical resection. Synchronous resections can be performed with comparable short and long term results as an alternative to ‘‘liver first approach’’ and ‘‘tumor first approach’’ (28). Currently, MIS is used effectively and safely for both colorectal and liver resections. MIS, which is the gold standard for CRS, has become a promising alternative for liver resections with the increasing number of cases. As a result, it has become inevitable to perform combined resections in colorectal carcinoma liver metastases that require technical challenges. Synchronous resections of colorectal cancer and liver metastases combined with NOSE are few in the literature and are limited to case reports (5,9,17,29). When all of these cases were examined, we saw that it is possible to use NOSE in relation to tumor diameter in combined resections that include minor hepatectomies (up to 2 segments of the liver) or metastasectomies. Due to the larger specimen diameters in major hepatectomies, it is unlikely to perform NOSE. In the colorectal cancer NOSE consensus, it is stated that the transanal route is the ideal orifice for extraction and the transvaginal route is the second alternative especially for more bulky specimens due to its elasticity (3). Additionally, the transvaginal route has a considerable limitation it can be performed only for females. It has been suggested that the orifice selection should be based on the maximum circumferential diameter of the specimen in the consensus report (the transanal route for tumor <3 cm and the transvaginal route for tumor 3–5 cm). In conclusion, we think that using similar specimen extraction route principles for combined resections in colorectal cancer liver metastasis, if both of the specimens’ circumferential diameters are suitable, would be better in terms of technical feasibility and postoperative results.
Secondary primary gastrointestinal malignancies or locally advanced colorectal tumors
Multiple primary carcinomas are defined as more than one cancer in the same individual, these may be either synchronous or metachronous (22). The localization of these tumors can be in organs such as colon, rectum, small intestine, stomach, and pancreas. Sometimes a synchronous tumor may also be present in different parts of the colon (24). Although secondary primary gastrointestinal cancers are extremely rare, the potentially curative treatment is surgical resection. Conventional surgery of synchronous gastrointestinal tumors requires large incisions and so, the first choice is to perform both organ resections with a minimally invasive approach. Today, the MIS comes to the fore in all kinds of gastrointestinal resections. There are also case reports showing that NOSE can be used for multivisceral resections in locally advanced colorectal tumors that have invaded other organs, although it is not recommended in the NOSE consensus for colorectal cancers (23). It is clear that combining MIS with NOSE will further improve postoperative outcomes. When the literature is reviewed, MIS combined with NOSE for synchronous gastrointestinal tumors is limited to a few case reports (18,19,22-24). The majority of cases had secondary primary gastric cancers. When these cases were examined, we saw that NOSE can be used effectively and safely in synchronous tumor resections or multivisceral resections of locally advanced tumors. It is noteworthy that large samples such as combined gastrectomy can also be obtained using the transanal route. In addition, there is a study showing the feasibility of NOSE in combined resections for additional organ diseases in the surgical treatment of benign colorectal diseases (25). In conclusion, the absence of any major complications in the early or late postoperative period is highly positive and promising that this type of multivisceral resections and NOSE can be combined in experienced hands.
The minimally invasive approach in gynecological surgery has recently come to the fore. The vagina, as an access to the abdominal cavity, has been used by gynecologists for a very long time. Especially after hysterectomy, the open vaginal cuff, which is large enough, has encouraged surgeons to perform the main specimen extraction transvaginally over time. So as a result, NOSE has almost become the standard approach in minimally invasive gynecological surgery. With the exception of patient disapproval, virginity, or pelvic anomalies, transvaginal specimen extraction has become almost routine (9). The transvaginal route is more suitable for the extraction of larger specimens, due to its elasticity, than the transanal route. Although rectovaginal fistula, pelvic abscess, and bladder dysfunction are major complications associated with transvaginal route usage, these are quite rare (30). In the literature, gynecological resections combined with CRSs are limited to case reports (11-16,21,26). The most common gynecological indications for combined CRSs are benign or malignant gynecological tumors (ovaries, endometrium and cervix) and endometriosis. Especially colorectal implants of endometriosis are one of the most important reasons for the need for combined resections. Perhaps the point that should be emphasized here is; since resection of other system organs will be required in these operations, multidisciplinary teamwork (gynecologist and gastrointestinal surgeon) may be required. In conclusion, when the cases in the literature were examined, transvaginal specimen extraction has become the standard approach for gynecologists interested in MIS, and this method has been used effectively and safely, when additional CRSs are required.
There are case reports of other organ resections combined with CRSs in the literature, such as cholecystectomy, appendectomy, lymphadenectomy (9,17,20,25,27). When the perioperative findings and postoperative results were examined, it was seen that the resected specimens of these organs were mostly benign, and NOSE was quite practical and effective for such cases.
NOSE in CRSs is a new and effective approach in current surgery. In cases requiring additional organ resection combined with colorectal diseases, NOSE is technically feasible in selected patients by experienced surgeons. To minimize the complications, we think consensus recommendations should be followed as similar to single organ resections. It is certain that new studies on this subject are needed in order to obtain clearer results.
Provenance and Peer Review: This article was commissioned by the Guest Editor (Cuneyt Kayaalp) for the series “Natural Orifice Specimen Extraction in Colorectal Surgery” published in Annals of Laparoscopic and Endoscopic Surgery. The article has undergone external peer review.
Peer Review File: Available at https://ales.amegroups.com/article/view/10.21037/ales-22-23/prf
Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://ales.amegroups.com/article/view/10.21037/ales-22-23/coif). The series “Natural Orifice Specimen Extraction in Colorectal Surgery” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
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Cite this article as: Aydin MC, Saglam K. Combined resections with colorectal surgeries and their combined natural orifice specimen extractions (NOSE): a clinical practice review. Ann Laparosc Endosc Surg 2023;8:5.