ORIGINALCONTRIBUTION

An Innovative Technique for ColorectalSpecimen Retrieval: A New Eraof “Natural Orifice Specimen Extraction”(N.O.S.E)Chinnusamy Palanivelu, M.Ch., F.R.C.S. �

Muthukumaran Rangarajan, M.S., Dip.M.I.S. �

Priyadarshan Anand Jategaonkar, M.S., D.N.B., M.R.C.S. �

Natesan Vijay Anand, M.S.

GEM Hospital and Postgraduate Institute, Ramnathapuram, Coimbatore, India

PURPOSE: The common incisions for transabdominalspecimen retrieval after laparoscopic colorectal surgeryare lower quadrant, midline, or transverse suprapubicincision. This study was designed to evaluate a novelmethod of specimen extraction after totally laparoscopicproctocolectomies.

METHODS: We retrospectively studied seven womenpatients from 2004 to 2007. The indication for surgerywas familial polyposis coexisting with adenocarcinoma ofthe upper rectum. A totally laparoscopic proctocolectomywith ileal pouch-anal anastomosis was successfully per-formed for all cases. The entire specimen was extractedvia a transvaginal route.

RESULTS: The mean age of the patients was 49.5 years, andmean body mass index was 25.3 kg/m2. The meanoperating time was 222.5 minutes, and average blood losswas 172 ml. The average hospital stay was 25.5 days.Postoperative complications included ileus (n=1), pou-chitis (n=1), and deep vein thrombosis (n=1). Thevaginal wound had healed completely by the first follow-up. There was no mortality.

CONCLUSIONS: Our technique of transvaginal retrievaleffectively prevents wound-related complications bycompletely eliminating minilaparotomies for specimenretrieval. It could be called “Natural Orifice SpecimenExtraction,” or N.O.S.E. We stress the need for innova-tions in specimen extraction, for which importance is notgiven by surgeons.

KEY WORDS: Laparoscopic proctocolectomy; Malignancy;Transvaginal; Specimen extraction.

A lthough colorectal procedures are performed lapa-roscopically, the resected specimen has to be delivered

from the peritoneal cavity, and for this reason a mini-laparotomy usually is used. This minilaparotomy involvescertain morbidity, which can be avoided if it is not used.There are two methods to achieve this: 1) perform a totallylaparoscopic procedure, and 2) use a natural orifice forspecimen retrieval. Posterior colpotomy was used since theearly 20th century but lost its popularity later to laparos-copy.1–3 There is a renewed interest in this approach,thanks to the introduction of “NOTES.” Reports of atotally laparoscopic total proctocolectomy (TPC) with ilealpouch-anal anastomosis (IPAA) for colorectal cancers arestill sparse.4 In this study, we present a small series ofpatients who underwent TPC + IPAA for familial adeno-matous polyposis (FAP) with coexisting carcinoma of therectum, which was performed totally laparoscopicallyfollowed by transvaginal specimen retrieval. Although thetransvaginal route has been used for minor procedures inthe past,5 this particular combination of a laparoscopicprocedure and technique of specimen retrieval has notbeen reported previously. This study was designed toevaluate this novel technique of specimen extraction.

MATERIALS AND METHODS

We prospectively studied seven women patients whosuffered from FAP coexisting with early adenocarcinomaof the upper rectum from 2004 to 2007 operated on atour institution. Proper informed consent was obtainedfrom the patients after clearance from the hospital EthicsCommittee. They were all married and had completedtheir families. All the patients underwent elective surgery:totally laparoscopic proctocolectomy with endostaplerileal pouch-anal anastomosis followed by transvaginalspecimen extraction. The presenting symptoms were lossof appetite and weight (n=4), bleeding per rectum (n=1),and anemia (n=5). Preoperative workup included bloodand urine investigations, blood grouping and typing,tumor marker levels, EKG, chest x-ray, ultrasonogram,

Presented at the meeting of the Association of Surgeons of India,Orissa, India, December 25 to 30, 2007.

Address of correspondence: Dr. Chinnusamy Palanivelu, M.Ch., F.R.C.S.,GEM Hospital and Postgraduate Institute, 45-A, Pankaja Mill Road,Ramnathapuram, Coimbatore 641045, India. E-mail: drcp@gemhospital.net

DOI: 10.1007/s10350-008-9316-2 � VOLUME 51: 1120–1124 (2008) � ©THE ASCRS 2008 � PUBLISHED ONLINE: 15 MAY 20081120

colonoscopy + biopsy, and CT scan for all the patients.Malnutrition and anemia were present in three patients,which were treated before surgery. Our gynecologistassessed the vaginal canal and cervix in all the patients.A thorough vaginal wash with 5 percent povidone-iodinesolution was administered by the patient on advice fromthe gynecologist. Prophylaxis for venous thromboembo-lism was administered (enoxaparin sodium, 0.6 ml) for allpatients, two hours before surgery.

ProcedureUnder general anesthesia, the patient was placed in thesupine/split-leg position. A nurse prepared the vaginawith another wash using 5 percent povidone-iodinesolution. The operating surgeon stood between the legsof the patient during the right and transverse colonmobilization and on the right side for left colonmobilization; the camera surgeon and scrub nurse stoodon the right and assistant on the left side. Pneumoper-itoneum was created through a transumbilical Veressneedle placement. Port positions were as follows: 10 mmumbilical port for camera, 12 mm disposable trocar in theright iliac fossa, 5 mm right lumbar port, 10 mmepigastric port midway between umbilicus and xiphister-num, and 5 mm left iliac fossa port. All the ports wereused interchangeably for the camera or hand instrumentsas per the need during dissection of the colon. Thedissection was commenced by mobilizing the left colonsafeguarding both the ureters. The inferior mesentericvessels were divided at their origin. Next, the rectum wasmobilized by dissecting the lateral pelvic peritoneal foldson both sides of the rectum up to the levator ani muscle.Retrorectal dissection was commenced in the avascularplane between the presacral fascia and the mesorectum toachieve a total mesorectal excision. Mobilization of the

transverse colon was achieved by dividing the splenocolicligament, gastrocolic omentum, hepatocolic ligament, andthe middle colic vessels. Finally, the right colon was mo-bilized and the right colic and ileocolic vessels were divided.Thus, the entire colorectum was completely mobilized.Next, the rectum was transected at the anorectal junctionby 60 mm golden-brown endo-GIA stapler (Ethicon Endo-surgery, Cincinnati, OH, USA), and the ileum was tran-sected approximately 7 to 10 cm proximal to the ileocolicjunction with a 60 mm endo-GIA stapler (EthiconEndosurgery, Cincinnati, OH, USA). With the help of thegynecologist, the posterior vaginal vault was opened with anultracision shears, and a long and wide endobag was placedin the vagina. A cervical colpotomy retractor (CCLretractor) with grasper was placed through this endobag(Fig. 1). The purpose of the retractor was to maintain thepneumoperitoneum by preventing gas leak through thevaginal opening. The resected colon was grasped and pulledgently through the vagina (Fig. 2). This was followed by aneasy retrieval of rest of the specimen without it directlytouching the vaginal wall. As soon as the specimen wasremoved, an anvil and umbilical tape measuring 15 cm wasintroduced into the peritoneal cavity through the vagina.This umbilical tape was used to measure the length of theterminal ileum needed for creating a 15-cm J-shape ilealpouch. The two arms of the J-pouch were aligned and fixedtogether with three 2–0 silk stay sutures (intracorporeal).A 1-cm ileotomy was made at the bend of the J-pouch. A60-mm (15 cm long) endo-GIA stapler (Ethicon Endo-surgery, Cincinnati, OH, USA) was introduced via the12-mm right iliac fossa port into the ileotomy to grasp thejejunum into its jaws and fired. In total, four such staplerswere used to create a 15-cm long J-pouch, “totally”laparoscopically. Hemostasis checked at the raw mucosaledges of the pouch. Anastomosis of the ileal pouch to theanal canal was achieved by laparoscopically fixing the anvilto the pouch and introducing a circular stapler through theanal canal stump. The circular stapler was docked with

FIGURE 1. Introduction of the CCL retractor along with an endobagthrough the “vaginotomy.”

FIGURE 2. Extraction of the specimen protected by an endobag.

PALANIVELU ET AL: SPECIMEN RETRIEVAL AFTER LAPAROSCOPIC PROCTOCOLECTOMY 1121

the anvil and fired. After removing the stapler gun, the“doughnuts” of tissue are checked. A thorough wash usingdiluted povidone-iodine solution and saline was given, andthe vaginal vault was finally sutured close with 2.0 Vicryl™(Ethicon, Cincinnati, OH, USA) (Fig. 3).

RESULTS

The mean age of the women was 49.5 (range, 34–65)years, and mean body mass index was 25.3 (range, 22–28.6) kg/m2. The mean operating time was 222.5 (range,165–280) minutes, and the average blood loss was 172(range, 95–250) ml; peroperative blood transfusion wasrequired for three patients. Postoperatively, oral diet wascommenced as and when the bowels were moved (3–5days), confirmed by positive bowel sounds. Postoperativecomplications included prolonged ileus with an anasto-motic leak in one patient, pouchitis in one patient, anddeep vein thrombosis in one patient—all of which weremanaged conservatively. There was no mortality. Theaverage hospital stay was 25.5 (range, 11–40) days. Thiswas because of a patient who developed an anastomoticleak on the fifth postoperative day. She was maintainedon “nil per oral” and total parenteral nutrition for 28 daysuntil the leak healed spontaneously. This was followed byloose stools for three days, so she stayed on for anotherseven days for a total of 40 postoperative days. An averageof 11.5 (range, 7–16) nodes was harvested per patient,which were positive in two patients. Only the node-positive patients (n=2) underwent six cycles of postop-erative chemotherapy. Histopathology confirmed well ormoderately differentiated adenocarcinoma in all cases,with low-grade or medium-grade dysplasia of the polyps.

All the margins of the resected specimen were negative fortumor. First follow-up was scheduled at 1 week, second at1 month, third at 3 months, fourth at 6 months, and finalfollow-up at 12 months. All the patients attended up tothe fourth follow-up, and five made it to the final. Onlyone patient reported recurrent pouchitis, which lasted forsix months and required medication, and one patient hadincreased frequency of stools. All patients who made it forthe 12-month follow-up underwent colposcopy and CTof the vagina and cervix to assess for metastasis, but theyhad no problems. The vaginal wound healed completelyfor all cases with no complaints of dyspareunia, whichwas confirmed on questioning during the first follow-up.

DISCUSSION

Although many reports in the literature describe the useof laparoscopic surgery for both benign and malignantcolorectal conditions, none of them give any importanceto specimen retrieval. Since the mid 1990s, Tsin6 haspioneered the transvaginal route for diagnostic as well astherapeutic culdoscopy and culdolaparoscopy. During thenext ten years, he has reported extensively on histechnique of posterior colpotomy to extract uterinemyomas, ovarian cysts, gall bladders, and appendixes.7,8

Tsin also has reported extracting an intact nephrectomyspecimen transvaginally.9 There are no reports in theliterature that describe colorectal specimen extractionthrough this route. In this article, we are concerned withthe retrieval of the specimen after laparoscopic resectionof the colorectum. There are four main incision sites thatare usually used for transabdominal specimen retrieval

FIGURE 3. Closed posterior vaginal vault with 2.0 Vicryl™ (Ethicon,Cincinnati, OH, USA).

FIGURE 4. Entire specimen—colorectum containing the multiplepolyps of FAP and carcinoma rectum.

PALANIVELU ET AL: SPECIMEN RETRIEVAL AFTER LAPAROSCOPIC PROCTOCOLECTOMY1122

after laparoscopic colorectal surgery. After ileocecalresection or right hemicolectomy, a right lower quadrantincision is usually enlarged for specimen removal—incision length 5 to 7 cm.10 The left lower quadrant in-cision is used for retrieval after left hemicolectomy,sigmoid resection, or low anterior resection.11 Both theseincisions are muscle-splitting, dividing the right or leftportion of the rectus muscle, and closed in individuallayers. For specimen retrieval after total colectomy, twoalternative incision sites are possible: periumbilical mid-line or transverse suprapubic incision. The suprapubicincision also can be used for placement of a hand-port inhand-assisted laparoscopic procedures (HALS). Surgeonswho practice HALS remove the specimen through thesame hand-port incision. Transperineal specimen retrievalusually is performed during low anterior resection orabdominoperineal resection, where the colorectum isremoved via an 8 to 10 cm perineal incision without aminilaparotomy. We think that this minilaparotomymight compromise the very benefits of minimally accesssurgery, which was what we set out to accomplish in thefirst place. The incidence of wound infections of theincision used for retrieval is 0 to 9 percent.12 Minilapar-otomy hernia is another complication, which occurs in <1percent of patients, and is most common in a periumbi-lical midline incision.13 The incidence of metastasesoccurring at port or retrieval incisions ranges from 0 to3.9 percent.14 Therefore, by completely avoiding mini-laparotomy for specimen extraction, these wound-relatedcomplications can be prevented. Endobags came intovogue with the hope of reducing port-site morbidity andare now deemed mandatory for all specimen deliveryregardless of pathology or surgical technique. In our smallseries, we performed a totally laparoscopic TPC withIPAA for colorectal familial polyposis associated withmalignancy. There are two novelties in this: 1) weperformed the IPAA completely laparoscopically, and 2)we delivered the specimen through the vagina. Since theentire operation was completed totally laparoscopically, aminilaparotomy was not necessary, neither for thespecimen retrieval nor the anastomosis. In case of familialpolyposis with malignancy, the specimen is obviouslygoing to be larger, because the entire colorectum alongwith its mesocolon with lymph nodes are included in thespecimen. Figure 4 shows the entire specimen with themultiple polyps and carcinoma that was successfullyextracted transvaginally. The transanal route also hasbeen described for specimen retrieval and ileoanalanastomosis, although this approach has a significantdisadvantage. In case of a handsewn anastomosis, a Scottretractor is usually used, which can cause damage to theinternal anal sphincter in up to 57 percent of patients.15

Since the benefits of totally laparoscopic TPC + IPAA wereproved, there have only been a few reports until recently.16

The combination of a totally laparoscopic TPC + IPAA

and transvaginal specimen retrieval makes an attractiveproposition in the surgery for cancers of the colorectum.Moreover, other surgeries, such as laparoscopic hysterec-tomy, could be combined with certain colorectal resec-tions, and the specimens could all be removed together.17

In our series, one patient underwent laparoscopic TPCcombined with a hysterectomy for symptomatic fibroids.The vaginal tube (CCL retractor) that was used tointroduce the endobag into the peritoneal cavity andretrieve the specimen is a standard instrument that we usefor total laparoscopic hysterectomies. It helps grasping andmanipulating the target organ during surgery and is usedto retrieve the uterus while maintaining the pneumoper-itoneum at all times. We utilized this instrument inextracting the colorectal specimen in our patients. In thesedays of “day-case” surgery and “fast-track rehabilitation,”avoiding a minilaparotomy would go a long way.18 It iscommon knowledge that NOTES is the recent develop-ment in the field of surgery, where natural orifices are usedas an access for performing surgery.19 Since NOTES wasintroduced, we have been toying with the idea of usingnatural orifices for specimen extraction, and the transva-ginal route seemed most promising. More and moresurgeons are switching to the NOTES technique, but aslong as laparoscopic surgery is still being performed, westress the need for developing “Natural Orifice SpecimenExtraction” (N.O.S.E) techniques. This can be consideredas a prequel to NOTES. The only disadvantages of thetransvaginal route are obvious: only married womenpatients can enjoy the benefits and risk of tumor seedingalong the colpotomy route. There was no evidence ofmetastasis in the vagina during the short-term follow-upin our patients, although long-term studies are needed toassess the exact incidence of “delivery-site” metastasis andthe morbidity of colpotomy. It must be stressed thattumor seeding should be prevented by adherence to soundlaparoscopic principles.

CONCLUSIONS

In our opinion, in this era during which a minilaparotomyis the preferred method for specimen retrieval in laparo-scopic colorectal surgery, transvaginal retrieval of specimenseems ideal because it avoids the potential damage of theanal sphincter and the potential risk of port-site metastasis.

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