Techniques for Specimen Extraction During Laparoscopic Colorectal Surgery

Fig. 40.1

(a, b) Patient positioning: modified Lloyd-Davies position

The surgeon should plan their operative strategy – i.e., site of specimen extraction, site of rectal transection, and creation of a well-perfused and tension-free anastomosis – based on tumor height from the anal verge. If the tumor is low but with enough of an anorectal cuff to create a low-stapled anastomosis, the surgeon should be prepared to suture close the rectal stump with a distal purse string in order to allow single-stapling (please see next section for technical considerations).

Operative Technique: Surgical Steps

Transrectal NOSE

A step-by-step approach of laparoscopic NOSE sigmoid colectomy was published in 2011 [23]. After administration of preoperative intravenous antibiotic prophylaxis (cefuroxime 2 g and metronidazole 1.5 g), general anesthesia is induced. The peritoneal cavity is entered in the left subcostal region with a Veress needle, and pneumoperitoneum is established to a pressure of 15 mmHg. A standardized 4-port laparoscopic technique is used, and a conventional medial-to-lateral approach is performed with straight laparoscopic instruments and a 30° 5-mm laparoscope. The inferior mesenteric artery (IMA) and inferior mesenteric vein (IMV) can be clipped and divided (depending on whether this is an oncologic resection or not), safeguarding the left ureter, the gonadal vessels, and the autonomic hypogastric nerves. The sigmoid colon is mobilized by incising Toldt’s fascia, a partial mesorectal excision (PME) with division of the mesorectum of the upper rectum, allowing the rectal ampulla and reservoir function to be preserved. After the proximal and distal colonic margins have been established, the sigmoid mesentery is divided with a vessel-sealing device. The devascularized specimen is isolated, and both the proximal sigmoid colon and proximal rectum are tied off with a nonabsorbable suture. A rectotomy is then performed to deliver the anvil from a circular stapler into the abdominal cavity (Fig. 40.2a–e). The spike from the circular stapler has a built-in hole through which a suture is attached and used to manipulate the anvil. A colotomy is made at the level of the transition between descending and proximal sigmoid colon, the anvil is introduced into the lumen of the descending colon, and the spike is pulled out along the antimesenteric aspect of the colon above the colotomy. The spike is disconnected from the anvil and extracted. The colon containing the enterotomy is transected with an endoscopic linear stapler. Now, the proximal colon is ready for anastomosis. The rectum is transected with laparoscopic endoshears, and the colonic specimen is placed in a plastic pouch and extracted transrectally. The rectal stump is closed with the endoscopic stapler, and the rim of proximal rectum is extracted through the 12-mm trocar. A functional end-to-end stapled intracorporeal colorectal anastomosis is created using the circular stapler, and an air leak test is routinely performed .

../images/465809_1_En_40_Chapter/465809_1_En_40_Fig2_HTML.png — Fig. 40.2

(a) Anvil insertion into the descending colon. (b, c) Anvil retrieval by pulling on the suture placed along the antimesenteric colon, with division of the proximal bowel with a 60-mm endoscopic linear stapler. (d, e) Transrectal NOSE via a protected rectum. (Used with permission of Springer Nature from Wolthuis [42])

Transanal NOSE

Transanal NOSE could be a step during taTME. First, taTME is performed with a one- or two-team approach as described elsewhere [24–26]. If the rectosigmoid specimen and left colon are mobilized completely, a commercially available wound protector should be inserted into the anal canal for protection and to facilitate of specimen extraction (Fig. 40.3a, b). The procedure continues with specimen and colon that will be used for reconstruction being brought out through the anus. It should be stressed that this is not feasible in every patient, because of specimen size, tumor measurements, and pelvic dimensions. As such, it is left to the surgeon to decide whether specimen extraction should be done transanally or transabdominally. In general, large tumors (>3 cm), higher BMI (>35 kg/m²), and a narrow pelvis are suboptimal conditions for transanal NOSE. Procedures are usually technically easier to perform in female patients, given a wider pelvis. Adequate colon length should be obtained via mobilization of the splenic flexure. It is essential that the IMV be transected proximally, and this is best achieved by dividing it immediately inferior to the inferior border of the pancreas. Care should be taken not to damage the marginal artery by tearing and putting too much traction on the specimen.

../images/465809_1_En_40_Chapter/465809_1_En_40_Fig3_HTML.png — Fig. 40.3

(a) After laparoscopic-assisted taTME, a wound protector is inserted into the anal canal, and the specimen can be extracted transanally with a laparoscopic grasper. (b) Transanal NOSE. Exteriorized TME specimen with its vascular pedicle (white arrow) and proximal colon used for the reconstruction (black arrow)

Following specimen extraction, the colon is transected transanally, and the anvil is inserted in the proximal colon. Either hand-sewn or low single stapled, anastomosis can be performed. For a hand-sewn anastomosis, after transection of the specimen, the colon should be gently pushed into the anal canal, and laparoscopy can be performed to confirm that there is no twisting of the colon or its mesentery. If oncologically safe, a low stapled anastomosis should be performed, because it tends to result in better functional outcomes. For a stapled anastomosis, a double purse-string technique is necessary. The open rectal stump should be closed with a carefully placed purse-string suture. It is necessary to take full-thickness bites but to avoid taking the vaginal wall. Moreover, gaps should be avoided, because this will potentially lead to an anastomotic leak. When the anvil is sutured in place and the distal purse string is completed, three different stapling techniques can be used to create a stapled coloanal anastomosis [27].

Pitfalls and Troubleshooting

Technically, the leap from conventional laparoscopic colectomy to laparoscopic NOSE-colectomy is substantial in comparison to the presumed benefit. Indeed, presumed short-term advantages are less morbidity and less postoperative pain leading to a decrease in stress response and length of hospital stay. However, advanced technical skills are required with experience in laparoscopic colorectal surgery, NOSE-techniques, and familiarity with creating an intracorporeal anastomosis.

Specimen extraction without rectal protection is an option for benign disease, but this can be difficult, because the specimen can become stuck in the rectum [28, 29]. Originally, transrectal specimen retrieval involved a specimen-retrieval pouch , but positional changes of the specimen and air trapping in the bag often hampered extraction. Moreover, the specimen can bunch up and become impossible to extract. To solve this problem and expand the indications for NOSE-colectomy with transrectal specimen extraction, a plastic sleeve can be inserted through the anorectum to protect the rectal lumen, so that the specimen can be extracted in a straight rather than coiled up configuration. Specimen extraction is either performed with a long laparoscopic grasper or a long ring forceps.

Drawbacks of this modified technique include the fact that the end of the sleeve is left open, so that the rectum more or less is protected by a “plastic tunnel” instead of a hermetically closed bag. Most authors recommend rectal protection during specimen extraction, especially when resections are performed for malignant disease. This can be accomplished with a specimen-retrieval pouch or by inserting a rigid rectoscope normally used during transanal endoscopic microsurgery (TEM). Insertion of a rigid rectoscope requires anal dilation, and the inner diameter of the rectoscope will determine the maximum size of the specimen to be retrieved. Therefore, larger specimens should be extracted in a retrieval pouch, which is impermeable to fluids, thus minimizing the risk of tumor cell dissemination. Because colorectal anastomosis is made using a triple-stapling technique, proximal diverticular disease could lead to an anastomotic leak, due to inadvertent diverticulum cross-stapling. This should be assessed on preoperative CT scanning and avoided at operation.

Outcomes

It is difficult to report postoperative outcomes including morbidity and length of hospital stay following transanal and transrectal NOSE, because of heterogeneity between studies (Table 40.1). Differences in technique , such as the number of abdominal ports (three to five ports), rectal protection (none, rigid rectoscope, camera sleeve, or retrieval bag), and anastomotic technique (double stapled and triple stapled), will impact outcomes. In general, it is accepted that laparoscopic NOSE-colectomy is as safe as conventional laparoscopic resection with an anastomotic leak rate ranging 2–5% [23, 30]. Although anastomotic leakage is the most serious complication, intraluminal bleeding remains a concern with an incidence around 4.5% [14]. If anastomotic bleeding occurs, it can be controlled endoscopically without significant impact on recovery. Transrectal NOSE is a valid option for specimen extraction and the creation of a colorectal anastomosis because of its applicability in both male and female patients and for a wide range of left-sided colonic pathologies including diverticulitis, endometriosis, adenoma, and carcinoma. Moreover, the direct access to the peritoneal cavity provided by the transrectal route further contributes to the feasibility of this approach.

Table 40.1

Studies that describe outcome of transrectal and transanal NOSE-procedures

Author	Year	Type of study	N	Indication	Ports (N)	Protection	Anastomosis	Mean OR time (min)	Morbidity (N, Clavien-Dindo grade)	Median LOS (days)
Transrectal NOSE
Franklin [31]	2013	Case series	277	Benign and malignant	4	Retrieval bag	TS	164.7	Leakage (3, 3b)	6.9^a
Han [32]	2013	Case series	34	Malignant	5	TEM and bag	DS	151.6	Leakage (6, 3b)	9
Leung [33]	2013	RCT	35	Malignant	4	TEO	DS	105^b	None	5
Zhang [34]	2014	Case-matched	65	Malignant <6 cm	4	Soft tissue retractor	TS	111.6	Leakage (2, 3b)	9^a
Wolthuis [14]	2015	Case series	110	Benign and malignant <4 cm	4	Retrieval bag	TS	90^b	Leakage (1, 3b), LGIB (2, 3b)	4
Lamm [35]	2015	Case series	40	Benign	5	Soft tissue retractor	DS/TS	173^b	Peritonitis (1, 3b), LGIB (2, 3b), leakage (1, 4a)	6
Huang [36]	2016	Case series	32	Malignant <6.5 cm	4	TEO	TS	192	SSI (1), ileus (2)	6.5^a
Saurabh [37]	2017	Case-matched	82	Malignant <5 cm	4	TEO	SS	227.9	Leakage (2, 3b)	4.8^a
Shimizu [38]	2017	Case series	40	Malignant <3 cm	NA	NA	NA	223.8	Leakage (1, 3a)	10.2^a
Transanal NOSE
Rullier [19]	2003	Case series	32	Malignant	NA	None	Hand-sewn	420^b	22% major	9
Marks [10]	2010	Case series	79	Malignant	3–6	None	Hand-sewn	NA	19% minor, 11% major	5
Kang [39]	2012	Comparative	53	Malignant	5(6)	Retrieval bag	SS	357	Leakage (4), abscess (2)	9
Bie [40]	2013	Case series	131	Malignant	NA	None	SS	166^b	None	10
Denost [20]	2015	Comparative	122	Malignant	5	None	Hand-sewn	NA	15% major	9
Rasulov [41]	2016	Case series	30	Malignant	4	None	Stapled/hand-sewn	320^b	27% minor	8

Note: Only studies with a sample size >30 patients are shown

DS double stapled, LGIB low gastrointestinal bleeding, LOS length of stay, NA not available, N number of patients, OR operating room, RCT randomized controlled trial, TEA transanal endoscopic applicator, TEM transanal endoscopic microsurgery, TEO transanal endoscopic operation, SS single stapled, TS triple stapled