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A novel single-port laparoscopic operation for colorectal cancer with transanal specimen extraction: a comparative study
© Kim et al.; licensee BioMed Central. 2015
Received: 6 August 2014
Accepted: 28 November 2014
Published: 30 January 2015
Extension of a single incision for the purpose of specimen extraction in single-port laparoscopic surgery (SPLS) can undermine the merits of SPLS, either by hurting cosmesis or by increasing wound morbidity.
We retrospectively analyzed the clinical outcomes of patients undergoing SPLS sigmoidectomy, either with transanal specimen extraction (TASE, n = 15) or transumbilical specimen extraction (TUSE, n = 68), for colorectal cancer between March 2009 and March 2013. The inclusion criterion was a tumor diameter of ≤ 5 cm. The median follow-up was 93 months (range 13 – 149).
Most of intraoperative and postoperative variables were comparable between the two groups, except for lengthening of operation time in TASE (287 ± 87 min vs. 226 ± 78 min, P = 0.011). TUSE did not lengthen the duration of postoperative recovery, hospital stay, or pain, or increase the incidence of postoperative complications. Whereas TUSE showed 8.8% (6/68) of wound-related complications, TASE did not show wound-related complications during follow-up period (P = 0.586).
With the exception of a prolonged operation time, TASE showed equivalent surgical outcomes as TUSE in SPLS sigmoidectomy. Thus, the implement of TASE is expected to provide one way of reducing wound-related complications in SPLS in patients with a tumor diameter of ≤5 cm.
In the era of laparoscopy, pioneering surgeons continue to attempt to reduce the size and number of incision(s) in order to maximize the benefits of minimally invasive surgery. The size and number of incision(s) is important because these parameters are closely related to the risk of various postoperative sequelae, such as pain, infection, injury to the vessels and nerves of the abdominal wall, and incisional hernia [1–3]. In this respect, the introduction of single-port laparoscopic surgery (SPLS) has raised the possibility of overcoming, or at least effectively reducing, wound-related morbidity. SPLS does dramatically reduce the number of surgical wounds. However, when it is necessary to extract a bulky specimen, such as the liver, spleen, or an intestinal segment, a corresponding incision size is still required, which simultaneously compromises the benefits of SPLS and increases wound morbidity. Therefore, it is essential to find a method for reducing the incision size required for specimen extraction.
The pursuit of a surgical technique that involves no external wound has led to the development of natural orifice transluminal endoscopic surgery (NOTES) [4–6]. The fundamental concept of NOTES is to reach the operative field through a natural orifice, such as the oral cavity, vagina, or anal canal, thereby circumventing the abdominal wall. Until now, most attempts at NOTES are still in the preclinical trial stage because of technical difficulties [7–9]. However, this method has inspired laparoscopic surgeons to borrow the basic concept of NOTES and adapt it for laparoscopic surgery [8, 10]; consequently, hybrid laparoscopic techniques, combining laparoscopic surgical techniques with natural orifice specimen extraction (NOSE), have been developed [11–13].
NOSE can be performed via the stomach, colorectum, anus, and vagina. In colectomies, the preferred specimen extraction site is the anus because the colectomy procedure naturally makes way for specimen extraction without an additional intraorgan incision [14–16]. However, the feasibility and safety of transanal NOSE in SPLS has not yet been determined, and to the best of our knowledge, no comparative studies have been performed thus far. Therefore, we attempted to determine the role of transanal specimen extraction (TASE) by comparing its surgical outcomes with those of transumbilical specimen extraction (TUSE) in single-port anterior resection (AR) or low anterior resection (LAR) for colorectal cancer.
Study design and data collection
A complication was defined as the occurrence of any adverse event before discharge. Postoperative complications were classified as described by Clavien and colleagues . Delayed gastric emptying was defined as when a nasogastric tube was required for ≥ 4 postoperative days or if its reinsertion was required, or when the patient remained intolerant to solid diet by postoperative day 7. Urinary retention was defined as when the patient could not pass urine within 12 h after removal of the urinary catheter. Operative time was measured from the time of initial skin incision to completion of wound closure, based on documentation by the anesthesiologist. Pathological margins were determined by two pathologists (Kim JO, Lee JU) based on formalin-fixed specimens. Staging was based on the 6th edition of the American Joint Committee on Cancer manual .
Total mesorectal excision (TME) was performed in all cases of rectal cancer. Before TME, we ensured the visual field by elevating the peritoneal fold (male) or the uterus (female) with an intracorporeal stitch. Anterior dissection of TME widened the gap between the anterior rectal wall and the Denonvillier’s fascia in men or the posterior vaginal wall in women. In addition, posterior and lateral dissection of TME reached the level of the puborectalis muscle. Thereafter, the proximal and distal ends of the lesion were completely enclosed with nylon tape to prevent cancer dissemination. The following steps differed according to the method of specimen extraction (TUSE or TASE).
Regardless of the method of specimen extraction, a Jackson-Pratt drain was inserted through the single-port incision site, as needed.
Postoperative diet was initiated and advanced as previously described . Postoperative pain was first managed by patient-controlled administration of intravenous fentanyl citrate, and additional intravenous medications for pain control were given as needed. The urinary catheter was typically removed on postoperative day 1.
The results are presented as the mean ± standard deviation and/or median (range). Continuous variables were compared with the Mann–Whitney U-test or independent t-test, depending on the normality of the quantitative variables. Categorical and ordinal variables were compared with the chi-square test. Statistical analysis was performed with SPSS version 15.0 (SPSS Inc., Chicago, IL, USA). A p value < 0.05 was considered statistically significant.
Basal characteristics and pathological comparisons
Patient demographics and baseline characteristics
Total patients (n = 83)
TUSE (n = 68)
TASE (n = 15)
Mean ± SD
63.9 ± 10.3
64.3 ± 11.0
62.0 ± 8.3
Sex, n (%)
Body-mass index, kg/m2 (%)
Mean ± SD
23.0 ± 2.9
23.2 ± 3.0
22.3 ± 2.4
Charlson comorbidity index, n (%)
Charlson index = 0
Charlson index > 0
The location of lesion
Sigmoid colon (including the rectosigmoid junction)
Low anterior resection
Comparison of intraoperative and pathological variables
Data related to operative details and tumor pathology
Total patients (n = 83)
TUSE (n = 68)
TASE (n = 15)
Overall operative time (min)
Mean ± SD
237 ± 82
226 ± 78
287 ± 87
Estimated blood loss, mL
Mean ± SD
282 ± 191
279 ± 196
287 ± 171
PRC transfused patients, n (%)
Intraoperative complications, n (%)
Major serosal tearing
Duration of drain installation, days
Mean ± SD
4.1 ± 2.5
4.4 ± 2.9
3.6 ± 1.9
Tumor differentiation, n (%)
Tumor depth (T classification), n (%)
Lymph node metastasis, n (%)
Tumor stage, n (%)
Largest tumor diameter (cm)
Mean ± SD
3.3 ± 1.4
3.4 ± 1.3
3.0 ± 1.8
Lymph nodes in resected specimen
Mean ± SD
17.1 ± 9.3
17.0 ± 9.4
17.7 ± 9.6
Proximal margin (cm)
Mean ± SD
10.0 ± 12.2
9.4 ± 13.2
9.5 ± 4.6
Distal margin (cm)
Mean ± SD
7.0 ± 5.0
7.2 ± 5.2
6.2 ± 2.7
Perineural invasion, n (%)
Lymphovascular invasion, n (%)
The estimated blood losses and the amount of packed red cell transfusion was not significantly different between the two groups. The incidence of intraoperative complications was also not significantly different. The median largest tumor diameters in the TUSE and TASE groups were 4.0 (0.3–5.0) cm and 3.0 (2.0–5.0) cm, respectively (p = 0.220).
Next, pathological outcomes were compared. Several parameters seemed to include more advanced pathologies in the TUSE group than in the TASE group, such as tumor depth (T1, T2, and T3 stages; 16.2%, 22.0%, and 61.8% in the TUSE group, respectively; 33.3%, 46.7%, and 20.0% in the TASE group, respectively; p = 0.013) and lymphovascular invasion (86.8% in the TUSE group vs. 53.3% in the TASE group; p = 0.007).
The other parameters, including tumor cell differentiation, lymph node metastasis, tumor stage, and perineural invasion, were comparable between the two groups. In addition, the two groups showed similar oncologic results, such as sufficient attainment of surgical margins and lymph nodes.
Comparison of postoperative variables
TUSE (n = 68)
TASE (n = 15)
Duration prior to first flatus, day(s)
Mean ± SD
1.9 ± 1.1
2.2 ± 1.0
Durations prior to free oral fluids
Mean ± SD
2.2 ± 1.8
2.8 ± 2.4
Duration prior to solid diet, day(s)
Mean ± SD
3.4 ± 3.2
4.2 ± 3.2
Frequency of narcotic analgesics
Mean ± SD
3.0 ± 4.6
2.1 ± 3.1
Frequency of total analgesics
Mean ± SD
4.0 ± 6.7
3.1 ± 3.9
Postoperative length of stay, day(s)
Mean ± SD
10.3 ± 9.6
7.5 ± 3.6
Overall postoperative complications, %
Delayed gastric emptying
Delayed gastric emptying
Anastomotic site leakage
Wound-related complications during FU period, %
In this study, we attempted to determine the utility of TASE by comparing it with TUSE. The process of TASE prolonged the overall operation time because of the additional detailed procedures. However, the TASE group showed similar results as the TUSE group in other parameters, such as the incidence of intraoperative and postoperative complications, postoperative gastrointestinal functional recovery, the frequency of postoperative analgesics usage, and the length of hospital stay; this reflects the safety and feasibility of the procedure. Notably, though it did not reach statistical significance, wound-related complications were lower in TASE than TUSE (0.0% vs. 8.8%, P = 0.586). Although the sample size was too small for definitive conclusions, these preliminary results suggest the safety and feasibility of TASE.
The NOSE technique involves specimen extraction through a natural orifice, such as the anus or vagina. There are several benefits of NOSE. Most of all, NOSE can improve cosmesis dramatically by negating wound extension for specimen extraction. In addition, NOSE can reduce wound morbidities, such as wound infection, injury to the vessels and nerves of the abdominal wall, and incisional hernia [1–3]. Moreover, NOSE theoretically reduces postoperative somatic pain at the incision site. Postoperative pain after laparoscopic surgery is determined by a combination of numerous factors, including wound size, distension-induced neuropraxia of the phrenic nerves, residual intra-abdominal gas after laparoscopy, the humidity and volume of the insufflated gas, anesthetic drugs, and sociocultural and individual factors . Of these, wound size constitutes a substantial portion. In this study, the TASE group required lower doses of both narcotic analgesics and total analgesics, though the difference did not reach statistical significance. Further studies with an adequately larger patient population are necessary to determine the effects of TASE on postoperative pain.
The natural orifices commonly used for specimen extraction during colectomies are the anus (TASE) and vagina (TVSE, transvaginal specimen extraction). TASE has several advantages over TVSE, especially in colorectal surgery ; it can be used regardless of sex, does not require additional intraorgan incision, and is technically more feasible. In contrast, the process of TVSE is more complicated due to the anatomy of Douglas’s pouch. It was reported that protective ileostomy was required more frequently in TVSE than in TASE because of accidental intraoperative damage to the sigmoid colon and rectum .
There are several qualifications for the ideal method of specimen extraction. First, it should ensure patient safety from the beginning of the process throughout the postoperative period. In addition, it should not be so technically difficult as to significantly prolong the operation time. Finally, the process of specimen extraction should not offset the advantages of minimally invasive surgery. Taken together, TASE may be considered a preferred method of specimen extraction after single-port AR or LAR. TASE resulted in equivalent surgical outcomes as TUSE in terms of postoperative complications, while leaving a NOTES-like scar (≤ 2 cm). The major demerit of TASE was a longer operation time; however, considering the benefits of TASE and the trends in shortening operation times, this demerit may be easily overcome.
In our study, there was a lengthening of operation time in TASE group (260 min vs. 215 min, P < 0.011). So far, there have been no reports comparing the operation time between TUSE and TASE in SPLS. Meantime, applications of TASE into the conventional laparoscopic surgery have been sporadically reported. Wolthuis et al.  reported in a systematic analysis that TASE did not lengthen the operation time in the procedures involving left-sided laparoscopic colectomy compared with TUSE. Fuchs et al. also concluded after the earlier experience of TASE in the laparoscopic surgery that the application of TASE to laparoscopic surgery was quite easy and is not a major problem for an experienced laparoscopic surgeon, indicating that TASE procedure does not require a long learning curve or the acquisition of new, specialized skills. Interestingly, in a paper comparing TUSE and TVSE, TVSE required longer operation time, possibly due to the necessity of intracorporeal suturing and anastomosis took longer . Further study with a larger population is warranted to investigate the effects of TASE in the overall operation time in SPLS.
A drawback to TASE is its limited application; it can be applied to the patients with a small tumor, i.e. a tumor diameter of 5 cm or less in this study. We have designed anal trocars in various sizes up to 6 cm (3-, 4-, 5-, and 6-cm) for the restoration of rectal sphincter muscle tone. The median tumor diameter in the TASE group was 3.0 cm (2.0–5.0 cm) in this study. However, we think as surveillance system enables the early detection of colorectal cancer, the inclusion of patients who would benefit from TASE would be wider.
In our series, we did not observe fecal incontinence or any complications related to anorectal function. Excessive pressure during TASE can induce fecal incontinence, possibly due to the loss of anal sphincter muscle tone . Therefore, in every surgery, we attempted to avoid excessive rectal dilatation. We gently retrieved the specimen by way of the metallic anal trocar made of stainless steel, which gradually dilated the anus and rectal wall within very limited time span. Multiple reports on the anorectal function after trananal endoscopic microsurgery (TEM) has shown that TEM, even repeated TEMs, does not affect anal sphincter pressure, rectoanal reflexes, rectal sensation or compliance [22–26]. Thus we think TASE is safe, in terms of anorectal function, in patients with a tumor diameter of ≤5 cm.
The limitations of this study are those common to all database research. As a retrospective review of prospectively collective data, our results should be confirmed by a prospective trial. Next, the limitations of this pilot study also include the small patient population, especially TASE patients (n = 15). In addition, TUSE and TASE groups seemed to be not completely balanced; TUSE patients showed higher incidences of T3 tumor (61.8% vs. 20.0%, P = 0.013) and lymphovascular invasion (86.8% vs. 53.3%, P = 0.007), suggesting advanced histology.
This pilot study shows that with the exception of operation time, surgical outcomes of TASE were comparable to those of TUSE. Even though TASE prolonged operation time, it appeared to decrease over time, suggesting an adequate learning curve. In addition, TASE procedure did not affect anorectal function. In the SPLS, extension of a single incision for the purpose of specimen extraction can undermine the merits of SPLS either by hurting cosmesis or by increasing wound morbidity, such as umbilical hernia. Though the establishment of the safety and feasibility of TASE requires further study, the implement of TASE in SPLS is expected to provide one way of reducing wound-related complications in patients with a tumor diameter of ≤5 cm.
This study did not involve any funding body.
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