A Comparison of Natural Orifice Versus Transabdominal Specimen Extraction Following Laparoscopic Total Colectomy

Abstract

Introduction:

Natural orifice surgery has been increasingly used in colon surgery since the early 2000s. However, it is rarely used for total colectomy. In this study, we aimed to retrospectively compare natural orifice specimen extraction (NOSE) with transabdominal specimen extraction in patients undergoing laparoscopic total colectomy.

Materials and Methods:

Twenty-six patients who underwent laparoscopic total colectomy between 2013 and 2017 were enrolled and the patients were divided into two groups: NOSE (n = 13) and transabdominal group (n = 13). The patients' demographic characteristics, perioperative and postoperative outcomes, pathology results, visual analog scale scores, and cosmetic scores were compared.

Results:

There was no significant difference between the two groups in terms of demographic characteristics as well as perioperative and postoperative outcomes, including complications. Benign pathologies were more common in the NOSE group (85% versus 15%, P = .001). The pain scores of the postoperative first, second, and third days were significantly lower in the NOSE group 4.1 ± 2.1 versus 7.1 ± 1.3 (P = .005), 3.7 ± 2.2 versus 6.0 ± 1.5 (P = .003), and 2.2 ± 2.0 versus 4.1 ± 0.9 (P = .03), respectively. As expected, the mean cosmetic score was significantly better in the NOSE group (8.3 ± 1.5 versus 6.7 ± 1.8, P = .02).

Conclusion:

NOSE combined with laparoscopic total colectomy provided better patient comfort in benign diseases and small-sized malignant diseases.

Introduction

Laparoscopic techniques are increasingly used in colorectal disease. Although the surgical procedure is completed laparoscopically, an abdominal incision is absolutely required for specimen extraction. Despite the general advantages of laparoscopy such as shorter length of hospital stay, low use of analgesics, rapid recovery process, low incision-related complications, and better cosmesis, an abdominal incision for specimen extraction can disrupt these advantages. To minimize this disadvantage, natural orifice surgery that is a technique having fewer potential early and late complications associated with the wound has begun to be implemented.^1,2 Despite the fact that natural orifice specimen extraction (NOSE)-assisted laparoscopic surgery has been reported in segmental colon resections, it appears to be rarely used in total colon resection in the literature.³

In this article, we aimed to present comparative results of patients in whom we performed specimen extraction by NOSE and abdominal incision after laparoscopic total colectomy.

Materials and Methods

This study was approved by Inonu University Ethical Community (2018/3-3) and registered by www.clinicaltrials.gov (NCT03499769). We reached a total of 26 patients who were referred to our clinic between March 2013 and October 2017 for total colectomy. The patients were divided into two groups: NOSE group (n = 13) and transabdominal group (n = 13). The following conditions were taken into account in patient selection for NOSE: (1) those who gave approval for this method and (2) those who had no technical contraindications for transanal and transvaginal surgical techniques (virginity, pelvic anomaly, anal stricture, and so on). The transanal route was first preferred,³ and the transvaginal route was selected in the patients with large tumors whose transanal extraction was not possible.⁴ The transabdominal route was preferred when the transanal and transvaginal routes could not be used. The suprapubic incision was frequently used in the transabdominal group for specimen extraction, but the median incision was rarely used. The details of the surgical techniques were described in detail previously.⁴

The age, gender, body mass index (BMI), comorbid diseases, operative history, incision length, operating time, amount of bleeding, perioperative and postoperative complications, duration of hospitalization, specimen pathology, tumor size, number of removed lymph nodes, number of positive lymph nodes, tumor stage, visual analog scale (VAS) score, cosmetic score, long-term complications, presence of recurrence, disease-free survival, and overall survival were examined. The largest size specified in pathology reports was accepted as tumor size. Pain scores were recorded by using the 10 cm VAS, with 0 being “no pain” and 10 being “extremely painful.” It was measured without receiving analgesics on the mornings of postoperative days 1 to 3. Cosmetic scores were rated from 1 (worst) to 10 (best). The patients were called by telephone during the follow-up period. Information was obtained about their latest status, hernia, and cosmetic scores.

Descriptive statistics are used for all data and were expressed as mean, percentage, or median and range values. Continuous variables were analyzed by the unpaired t-test or Mann–Whitney U test. Categorical variables were analyzed by the Chi-square test or Fisher's exact test. A P value of <.05 was considered statistically significant. The data were analyzed using SPSS version 16.0 and Microsoft Excel 2013.

Results

This retrospective study included 18 men and 8 women, and the mean age was 42.5 ± 14.7 years. The mean BMI value was 24.9 ± 5.3 kg/m². Preoperative diagnoses of the patients were as follows: 11 (42%) familial adenomatous polyposis, 7 (27%) colon tumor and adenomatous polyposis coli, 4 (15%) attenuated familial adenomatous polyposis, 2 (7%) synchronous colon tumor, and 2 (7%) recurrent colon tumor. The surgical procedures were as follows: 9 (34%) total proctocolectomy and ileal J-pouch and 17 (66%) total colectomy with ileorectal anastomosis. In a patient who was operated due to recurrent colon tumor required conversion to an open procedure due to severe adhesions of the previous surgery. In the NOSE group, 1 patient had synchronous gastric and colon cancer, and this patient underwent a combined laparoscopic total colectomy and subtotal gastrectomy for palliative care.⁵

The average operation time was 370 ± 150 minutes (median 360, range 150–660). The mean perioperative blood loss was 141 ± 197 mL (median 50, range 5–800). In the transabdominal group, the specimen extraction site was suprapubic incision for 11 (84%) patients, lower median incision for 1 patient, and upper-lower median incision (converted case) for 1 patient. In the patient undergoing a lower median incision, this incision was used to release the proximal ileal loop by considering anastomotic tension. In the transabdominal group, the mean incision length was 6.7 ± 1.4 cm (median 6.5, range 5–9). The mean duration of hospital stay was 8.1 ± 3.5 days (median 7, range 3–17).

The mean VAS scores on postoperative days 1 to 3 were, respectively, 5.7 ± 2.3 (median 6, range 1–10), 4.9 ± 2.2 (median 5, range 1–8), and 3.2 ± 1.8 (median 3, range 1–7). The mean VAS scores on postoperative first, second, and third days were significantly lower in the NOSE group than in the transabdominal group (Table 2). No complications were observed in the NOSE group. In the transabdominal group, 2 patients had wound infections, and 1 patient had late incisional hernia. The pathology results were reported as malignant in 11 patients in the transabdominal group and in 2 patients in the NOSE group (85% versus 15%, P = .001). The mean cosmetic score was 7.4 ± 1.8 (median 7.5, range 4–10). The mean cosmetic score was significantly higher in the NOSE group than in the transabdominal group (Table 2).

Three patients, including two in the NOSE group and one in the transabdominal group, had anal incontinence. The tumor was distally placed and ileal J-pouch-anal anastomosis performed in the patient of the transabdominal group. In these patients of the NOSE group, the diagnoses were recurrent colon tumor and familial adenomatous polyposis. The patient with synchronous gastric and colon cancer died due to cancer cachexia at the second postoperative month. The average follow-up time was 16.7 ± 15.6 months (median 10, range 2–59). All the remaining patients were alive and live without any pathology during the follow-up period. The comparative results of the two groups are given in Tables 1 –3.

Table 1.

Preoperative Parameters and the Outcomes

	NOSE (n = 13)	Transabdominal (n = 13)
Parameters	Mean ± SD Median (range)	Mean ± SD Median (range)	P
Gender (female/male)	6/7	2/11	.20
Age	41.9 ± 17.4	43.0 ± 12.0	.85
Age	39 (16–67)	46 (25–67)	.85
BMI (kg/m²)	24.0 ± 5.9	25.7 ± 4.7	.42
BMI (kg/m²)	22.4 (16.9–35.5)	25.6 (20.7–32.8)	.42
Patients with comorbidity	2 (15%)	3 (23%)	1.00
Diabetes mellitus	1^a (7%)	1^b (7%)
Hypertension	1 (7%)	2 (15%)
Chronic obstructive pulmonary disease	1^a (7%)	0 (0%)
Goiter	0 (0%)	1^b (7%)
Patients with previous abdominal surgery	4 (30%)	4 (30%)	1.00
Gynecologic operation	1	0
Open umbilical hernia repair	1	0
Open colectomy	1	2
Open prostatectomy	1	1
Open appendectomy	0	1
Diagnosis
Familial adenomatous polyposis	7 (53%)	4 (30%)	.42
Attenuated familial adenomatous polyposis	3 (23%)	1 (7%)	.59
Synchronous colonic tumor	1 (7%)	1 (7%)	1.00
Methachronic colonic tumor	1 (7%)	1 (7%)	1.00
Colonic tumor and Polyposis	1 (7%)	6 (46%)	.07

Diabetes mellitus and chronic obstructive pulmonary disease in the same 2 patients.

Diabetes mellitus and goiter in the same 2 patients.

BMI, body mass index; SD, standard deviation.

Table 2.

Preoperative–Postoperative Parameters and the Outcomes

	NOSE (n = 13)		Transabdominal (n = 13)
Parameters	Mean ± SD Median (range)		Mean ± SD Median (range)		P
Duration of surgery (min)	336 ± 121		432 ± 145		.08
Duration of surgery (min)	360 (150–500)		480 (180–660)		.08
Intraoperative bleeding (mL)	126 ± 138		187 ± 237		.53
Intraoperative bleeding (mL)	50 (5–400)		100 (5–800)		.53
Incision length (cm)	0		6.7 ± 1.4		<.001
Incision length (cm)	0		6.5 (5–9)		<.001
Anastomosis
J-pouch	2 (15%)		7 (53%)		.09
Ileorectal	11 (85%)		6 (47%)		.09
End-to-end	10 (77%)		11 (84%)		1.00
Side-to-side	3 (23%)		2 (16%)		1.00
Intraoperative complications	0 (0%)		1 (7%)		1.00
Bladder rupture during the incision	0		1
Conversion to open	0		1 (7%)		1.00
Specimen extraction	Transanal	12 (92%)	Suprapubic	11 (84%)
Specimen extraction	Transvaginal	1 (8%)	Median	2 (16%)
Postoperative complications	6 (46%)		6 (46%)		1.00
Abdominal hemorrhage	1 (IIIb)		0
Peripheral neuropathy	0		1 (II)
Abdominal abscess^a	2 (II)		2 (II–IIIb)
Pouchitis	1 (II)		1 (II)
Gastrointestinal fistula^b	2 (IIIb)		0
Ileus^a,b	1 (II)		3 (II)
Wound complications	0 (0%)		3 (23%)		.22
Infection	0 (0%)		2 (15%)		.48
Hernia	0 (0%)		1 (7%)		1.00
VAS score on day 1	4.1 ± 2.1		7.1 ± 1.3		.005
VAS score on day 1	5 (1–7)		7 (5–10)		.005
VAS score on day 2	3.7 ± 2.2		6.0 ± 1.5		.003
VAS score on day 2	3 (1–7)		6.5 (3–7)		.003
VAS score on day 3	2.2 ± 2.0		4.1 ± 0.9		.03
VAS score on day 3	1 (1–7)		4 (3–6)		.03
Length of hospital stay (day)	7.5 ± 3.4		8.7 ± 3.7		.39
Length of hospital stay (day)	7 (3–14)		8 (5–17)		.39
Blood replacement (Unıt)	0.7 ± 1.0		0.9 ± 1.2		.64
Blood replacement (Unıt)	0 (0–3)		0 (0–4)		.64
Cosmetic score	8.3 ± 1.5		6.7 ± 1.8		.02
Cosmetic score	8 (6–10)		6 (4–10)		.02

Values shown in bold are significant.

Abdominal abscess and Ileus in same patient.

Gastrointestinal fistula and Ileus in same patient.

NOSE, natural orifice specimen extraction; SD, standard deviation; VAS, visual analog scale.

Table 3.

Results of the Specimens

	NOSE (n = 13)	Transabdominal (n = 13)
Parameters	Median (range)	Median (range)	P
T
T (benign)	11	2	.001
T1	0	1	1.00
T2	0	2	1.00
T3	2	8	.04
T4 (a-b)	0	0	1.00
N
N (benign)	11	2
0	0	6	.46
1 (a-b)	1 (0-1)	3 (2-1)	1.00
2 (a-b)	1 (0-1)	2 (2-0)	.42
Stage
0	11	2
1	0	3	1.00
2 (a-b-c)	0	3 (2-0-0)	1.00
3 (a-b-c)	2 (0-1-1)	5 (0-5-0)	.46
Length of specimen	90 (77–140)	94 (29–167)	.50
Tumor size (cm)	0 (0–10)	3.5 (0–8.5)	.44
Removed lymph node (total)	0 (0–113)	57 (0–168)	.50
Positive lymph node	0 (0–19)	0 (0–5)	.77

Values shown in bold are significant.

NOSE, natural orifice specimen extraction.

Discussion

Surgical resection is the only radical treatment for colon cancer and colonic premalignant diseases, and laparoscopic colectomy is used more frequently today.⁶ It is well known that laparoscopic surgery reduces both general complications and wound-related complications compared to open surgery.⁷ One of the most important causes of this trend is to minimize incision length.⁸ NOSE-assisted laparoscopic techniques are considered to provide less and less incision-related risks. In NOSE-assisted laparoscopic total colectomy, while the transanal specimen extraction route is used for benign tumors and small-sized malign tumors, the transvaginal route can be used for larger tumors.³ In our study, most of malignant tumors were removed via the suprapubic route, while the transanal and transvaginal routes were used only in 2 patients.

NOSE-assisted surgical techniques are predicted to extend the operation time.⁹ In our study, the operation time did not show significant difference between the two groups, but a bit longer in the transabdominal group. This was attributed to the higher rate of malignant patients in the transabdominal group and to two complicated cases (distal anastomotic tension) in the transabdominal group. The amount of bleeding did not show significant differences between the two groups. In a review involving patients who underwent NOSE-assisted laparoscopic total colectomy,³ it was observed that the operation time was between 210 and 455 minutes and the amount of bleeding was between 10 and 400 mL. The operation time (median 360, range 150–500 minutes) and the amount of bleeding (median 50, range 5–400 mL) in our study were found to be consistent with the literature.

Postoperative pain closely affects patient comfort and recovery process. The pain score increases with increasing length of incision. In our study, it was found that the VAS scores on postoperative days 1 to 3 were significantly lower in the NOSE group. Similarly, a study comparing right colon resection with NOSE or transabdominal extraction determined that the pain scores on postoperative days 1 and 3 were significantly lower in the NOSE group.¹⁰ In a meta-analysis, including 837 cases, comparing the results of laparoscopic colorectal surgery with or without NOSE, the pain scores were found to be significantly lower in the NOSE group.¹ Laparoscopic total colectomy is an extensive laparoscopic colorectal surgery involving the four quadrants of the abdomen, and this study could show that the postoperative pain was significantly reduced by NOSE in laparoscopic total colectomy.

One of the major advantages of minimal invasive surgery is the reduced incision-related complications. The incidence of incisional hernia and wound infection is known to be significantly lower in laparoscopic colon surgery.^11,12 These rates are expected to decrease further with NOSE-assisted laparoscopic surgery. When the complication rates in our study were examined, no wound complications were observed in the NOSE group as expected. In the transabdominal group, 2 patients had wound infections, and 1 patient had late incisional hernia.

The greatest concern on NOSE-assisted laparoscopic surgery consists of anal sphincter damage, sexual dysfunction, and pelvic organ damage. However, the incidence of these complications is very low.¹³ In our study, there was no significant difference between the two groups in terms of changes in anal incontinence, and also, no patients had pelvic organ damage.

Techniques that will lead to better cosmetic results without compromising the main outcomes of the surgical procedure implemented to patients are an indisputable advantage for satisfaction. In our study, the cosmetic score was significantly higher in the NOSE group as expected. In the two meta-analyses examining laparoscopic colorectal cancers, it was found that the cosmetic score was significantly higher in the NOSE group.^1,14

Conclusion

NOSE-assisted laparoscopic total colectomy seems to be compatible for benign diseases and small-sized malignant diseases, and it improves postoperative patient comfort and provides better cosmesis.

Ethical Approval Statement

All procedures performed in studies involving human participants were in accordance with the ethical standards of the Institutional and/or National Research Committee and with the Declaration of Helsinki 1964 and its later amendments or comparable ethical standards.

Footnotes

Disclosure Statement

No competing financial interests exist.

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