Natural Orifice Specimen Extraction Surgery

transcript

Xishan WangEditor

Natural Orifice Specimen Extraction Surgery

Gastrointestinal Tumor

Second Edition

EditorXishan WangDepartment of Colorectal SurgeryCancer Institute & Hospital, Chinese Academy of Medical SciencesBeijing China

ISBN 978-981-15-7924-0 ISBN 978-981-15-7925-7 (eBook)https://doi.org/10.1007/978-981-15-7925-7Jointly published with People’s Medical Publishing House, PR of China

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The knowledge, experience and inertial thinking we currently possess are at times the greatest enemy of innovation, and a justification for the denial of others.

Lead the way with skill, win the future with virtue.

Be appreciative of others’ achievements;be critical with one’s own deficiencies.

The courage to question oneself makes one a real surgeon.

The moment our effort paid off marked our achievements as a thing of the past. Now is the time to set sail for the next destination.

The perfection of the human body makes up for the shortage of medicine and our self-righteousness.

——Xishan Wang王锡山

According to the latest data from National Cancer Center, the prevalence of gastrointestinal cancer in China is ranked the highest among malignant tumors, and its morbidity and mortality are still rising year by year. The prevention and treatment of gastrointestinal cancer in China is faced with serious challenges. As the main treatment of gastrointestinal tumors, surgery has made considerable progress and improvement in recent years, especially in minimally invasive treatment.

Professor Xishan is a leading figure in the field of colorectal cancer in China. It is witnessed by all that he has been engaging in the prevention, diagnosis, and treatment of colorectal can-cer in China. At the same time, as the academic leader of colorectal surgery in our hospital, he has achieved significant achievements in recent years. In 2019, over 3000 colorectal surgeries have been carried out in our hospital, and the number of colorectal tumor surgeries ranked first in China. In order to establish the brand of our department, he puts forward the two subject characteristics of “minimally invasive of minimally invasive, difficulty of difficulty,” which are the embodiment of his innovative consciousness and pioneering spirit. NOSES is the best manifestation of “minimally invasive of minimally invasive.” At present, up to 300 cases of NOSES are carried out in our hospital annually, which is leading both in China and in the world.

Surely, the innovation of any technique must be based on standardization, and the innova-tion of cancer treatment should be doubly cautious. As a new minimally invasive technique, the standardization of NOSES is not only applicable to individuals but also requires the whole surgical field to have its own standards. At present, Prof. Xishan has further improved the theo-retical system of NOSES. Over the last three years, he has written several monographs on NOSES in Chinese and foreign languages, which objectively demonstrate the feasibility and great social value of NOSES and again illustrate the broad application prospect of NOSES. In addition, a series of academic activities, such as hundreds of Chinese NOSES lecture tours and

Foreword by Jie He

NOSES seminars, have been carried out with the Chinese NOSES Alliance and the Chinese Cancer Center as the academic platform. Over 10,000 medical staff have been trained, which plays a great role in promoting the standardization of NOSES.

Within just a few years, NOSES has developed from a single procedure to a complete theo-retical system, from a single organ to applicable to abdominal and pelvic organs, and from several single centers to national and even the world. All these developments reflect the strong vitality of NOSES. I also believe that the publication of the second edition of the English monograph on NOSES for gastrointestinal cancer will have a profound impact on the interna-tional promotion of NOSES. It will inject new vitality to bringing the Chinese original mini-mally invasive technology to the world stage and lead the international minimally invasive surgery into a new era.

Jie HeAcademician, Chinese Academy of Sciences President, National Cancer Center of China

President, Cancer Hospital, Chinese Academy of Medical Sciences

Foreword by Jie He

I would like to thank Prof. Xishan Wang for the opportunity to write a preface for the second edition of the NOSES book on gastrointestinal tumors (English version). Minimally invasive surgery, represented by laparoscopic and robotic surgery, has been widely accepted and devel-oped in the field of gastrointestinal surgery. In the quest to avoid abdominal incisions, NOSES has been developed as a form of minimally invasive surgery and is becoming more popular in many sections of the world.

Other similar variations related to minimally invasive surgery include NOTES and TaTME. Compared to NOSES, NOTES seems to offer a more cosmetically pleasing effect but lacks high-level evidence-based supporting studies. TaTME has received a lot of attention around the world. Compared to NOSES, TaTME seems to be more technically demanding and less adaptable. TaTME has received significant scrutiny worldwide and time will tell if it remains a safe and feasible platform for rectal resection particularly due to concerns of increased local recurrence rates in rectal cancer. Unlike NOTES and TaTME, NOSES may be technically easier to adapt. A database of NOSES procedures established by Prof. Xishan Wang has over 6000 patients from more than 200 hospitals.

In August 2019, I was honored to be invited to Beijing to participate in the third International NOSES Symposium. Fifty international experts who specialize in NOSES-based surgery from 16 countries participated in a comprehensive symposium. Besides talks about the benefits of this platform, current technical bottlenecks and challenges were discussed. This was high-lighted by a live demonstration of surgery utilizing the NOSES techniques. Prof. Wang and his team showcased their technical skills and then invited us to visit their patients the following days as they recovered in the hospital. These patients were up and walking in the halls and progressing quickly in their recovery.

Prof. Wang has made considerable contributions in promoting minimally invasive surgery in China and other countries in the form of NOSES. He has established the China and International NOSES Alliance, which has provided a strong platform for academic communi-cation regarding NOSES. He has led a number of gastrointestinal NOSES expert consensus panels that have developed standards for NOSES worldwide. He has written NOSES books and monographs that have been translated into English, Korean, Russian, Japanese, and other languages for global promotion. In addition, he also organized nearly 100 NOSES training

Foreword by Tracy L. Hull

courses and lectures, which trained over 10,000 surgeons. The development and achievements of these efforts have played an important role in promoting the standardized treatment and safe technique of NOSES in the world.

Presently, few surgeons in the USA perform NOSES surgery. Through the efforts of sur-geons like Prof. Wang, more clinicians worldwide (including the USA) will be exposed to this platform and embrace its utility in performing surgery in a safe and truly minimally invasive fashion.

Tracy L. Hull President, American Society of Colon and Rectal Surgeons

President, Society of Pelvic Surgeons Section Chief, IBD of Department of Colorectal Surgery

The Cleveland Clinic Foundation

Foreword by Tracy L. Hull

With the fast development of minimally invasive surgery in the treatment of gastrointestinal disease, novel surgical techniques and methods to reduce surgical trauma have been introduced and become highly concerned issues in current clinical practice. Natural orifice specimen extraction surgery (NOSES), by avoiding abdominal incision, has been considered as a well- established surgical approach. Currently, NOSES represents the least invasive option in surgi-cal treatment of gastrointestinal diseases. Furthermore, more and more research results are published in support of the application of NOSES with acceptable short- and long-term outcomes.

In 2018, an international academic organization, the International Alliance of NOSES, was established with the aim of improving the clinical practice of NOSES worldwide. I am honored to be a member of this international organization. After that, we published one consensus of NOSES for colorectal cancer together, which systematically integrated technical variations of

Foreword by Antonio Longo

NOSES for colorectal cancer. In 2019, under the leadership of Prof. Wang, a new consensus of NOSES for gastric cancer was published by dozens of international surgical experts, providing a theoretical basis for healthy growth of NOSES involved in the field of gastrointestinal surgery.

As far as I know, many surgeons in Europe have performed NOSES in the treatment of colorectal disease. However, the general surgeon does not have the habit of working transa-nally, which may discourage the population from NOSES. Furthermore, the potential pitfalls of NOSES raised with this new technique still attract long-standing concerns, especially in terms of bacteriological results and oncological outcomes. In my opinion, the development of more specialized surgical devices will be a good direction for NOSES. The specialized surgi-cal devices for NOSES could be used to reduce the difficulty of surgery and the risk of complications.

In order to better standardize the development of NOSES technology, Prof. Wang and many experts have published several NOSES monographs to elaborate standard surgical techniques of NOSES. Two years ago, I have read the book NOSES—Colorectal Cancer written by Prof. Wang; this book fully presented all kinds of the NOSES techniques in the treatment of CRC, which has benefited me a lot.

Compared to open surgery and conventional laparoscopic surgery for gastrointestinal tumor, NOSES has numerous technical variations regarding specimen extraction and intraperitoneal bowel reconstruction. Today, I feel very surprised and excited to hear that Prof. Wang is about to publish the second edition NOSES—Gastrointestinal Tumor. This new book summarizes a wide variety of novel techniques and experience regarding NOSES in the treatment of gastro-intestinal tumor. I firmly believe that they could be available to be recommended to a broader surgical community and allow more patients to benefit in the world.

Antonio Longo Director, European Center of Coloproctology and Pelvic Diseases

Foreword by Antonio Longo

Clinical researchers at the Johns Hopkins University were the first to report the use of natural orifice transluminal endoscopic surgery (NOTES) in 2004. Developed through animal experi-ments, it has become more advanced minimally invasive surgery than laparoscopic and robotic surgery, and it is an ideal procedure with the best minimally invasive effect.

In the summer of 2007, the Korean NOTES Study Group was established, and academic conference has been held twice a year to discuss the development and application of laparo-scopic and endoscopic techniques in NOTES. These activities have played an important role in the promotion of NOTES technique in Korea. However, the NOTES technique still has many problems, including high technical difficulty, high dependency on device platform, and limited indicated population. Therefore, it will take a long time for this technique to be widely applied in clinical practice.

Foreword by Ho-Kyung Chun

On the basis of conventional laparoscopic surgical techniques, NOSES combines the “incision- free” concept of NOTES and the technique of specimen extraction through natural orifice. NOSES has both high feasibility of laparoscopic surgery and the good minimally inva-sive effect of NOTES. By avoiding auxiliary incision in the abdominal wall, this technique has light pain, quick recovery, good cosmetic effect of abdominal wall, less psychological distur-bance, and many other advantages. These advantages are essential to the physical and psycho-logical health of patients, especially those with cancer.

In the summer of 2012, I visited Prof. Wang Xishan for the first time and have learnt that he had performed the first case of laparoscopic NOTES for rectal cancer worldwide in 2010. I was amazed at the carrying out of this highly difficult minimally invasive technique under the con-dition of limited technical equipment, which inspired my great admiration for Prof. Wang Xishan’s innovative spirit. When I met Prof. Wang Xishan again in Beijing in 2016, he men-tioned that he had started carrying out colorectal NOSES procedures in 2013. In just three years, Prof. Wang has successfully completed more than 300 colorectal NOSES procedures. He also had them classified and integrated to form a complete technical and theoretical system. I was very pleasantly surprised by his achievement, which helps me gain a new understanding of the NOSES technique.

By now, Prof. Wang Xishan has published many monographs on NOSES, which play an important role in the promotion and development of NOSES. To facilitate the development of NOSES in Korea, I was honored to translate Professor Wang Xishan's monograph of NOSES for Colorectal Cancer into Korean. Since its publication, this book has been highly evaluated in the surgical field of Korea. It has also played an important role in the standardization of colorectal NOSES technique in Korea.

Now, I am glad to hear that Prof. Wang Xishan and dozens of international experts have collaboratively written the second edition of English monograph of NOSES for Gastrointestinal Cancer, which covers all NOSES techniques for gastrointestinal cancer. Many new techniques have been launched in an innovative manner, and the previous techniques have been improved and perfected, which injects new vitality into NOSES. I believe that the publication and distri-bution of this edition will play a positive role in promoting the standardized development of NOSES technique for gastrointestinal tumor in the field of minimally invasive surgery worldwide.

Ho Kyung ChunPresident, International Society of University Colon & Rectal Surgeons (ISUCRS)

President, Asia Pacific Federation of Coloproctology (APFCP)President, Eurasian Colorectal Technologies Association (ECTA)

Foreword by Ho-Kyung Chun

The Main Academic Title

The Chairman of Colorectal Cancer Committee of Chinese Medical Doctor Association; the Chairman of Colorectal Cancer Committee of Chinese Anti-Cancer Association; the President of International Alliance of NOSES; the President of China Alliance of NOSES; the Chairman of Youth Committee of Colorectal Cancer Committee of Chinese Anti-Cancer Association; the Vice Chairman of Tumor Metastasis Committee of Chinese Anti-Cancer Association; the Vice Chairman of MDT Committee of Chinese Medical Doctor Association; the Standing Committee of Surgeon Committee of Chinese Medical Doctor Association; the Chief Editor of Chinese Journal of Colorectal Diseases (Electronic Edition); President of Russian-Chinese Society of Colorectal Surgeons; Honorary Member of Russian School of Colorectal Surgery.

Introduction of Chief Editor

Scientific Research and Clinical Achievements

Totally, he has published 116 SCI papers; edited and participated in 18 monographs and 31 audiovisual materials related to colorectal cancer treatment; taken charge of more than 10 projects, including three projects of the National Natural Science Foundation, the National City cancer early diagnosis and early treatment; and presided over National Major Project of Precision Medicine titled “the application of precision medicine in colorectal cancer diagnosis and treatment.”

Novel Techniques

He is proficient in minimally invasive surgery for colorectal cancer as well as combined organ resection for difficult cases. Currently, he has improved the theoretical system of natural orifice specimen extraction surgery (NOSES) in the treatment of colorectal cancer, including 10 dif-ferent surgical procedures for colorectal cancer resection, and performed more than 500 cases of NOSES for colorectal cancer; this number ranked first in China. He established evaluation standard to determine low, ultra-low anastomosis surgery based on the tumor location to the dentate line instead of the anal verge; put forward the “risk investment theory” to make sphinc-ter preserving surgery a more scientific and standardized treatment system; carried out a vari-ety of difficult surgeries, such as hemicolectomy combined with pancreaticoduodenectomy; and proposed the distinction of concepts between combined organ resection and multiple organ resection. According to the different invasion manner (cancerous invasion or inflamma-tory invasion), he proposed refinement T4 staging recommendations. On the basis of the expanded radical resection of rectal cancer, the selective expanded radical resection of rectal cancer was proposed to fully retain the physiological function of patients after operation. In addition, other new technologies also include radical rectal cancer surgery through sacrococ-cygeal route, radical colectomy with the omentum preserved, and total colectomy with the rectal ampulla preserved. These clinical works play an important role of improving the current treatment status of colorectal cancer.

Student Training

At present, there are a total of 95 graduate students, including one professor, 10 associate pro-fessors, 8 master tutors, 9 students in the national academic community as academic part-time, and 15 students in the provincial academic community as academic part-time; some of these students were sent abroad including Britain, the USA, and Japan, to study further.

Introduction of Chief Editor

Introduction of Associate Editor

Atsushi NishimuraMDChief of Department of Surgery of Nagaoka Chuo General HospitalBoard Certified Surgeon in Japan Surgical SocietyBoard Certified Surgeon in GastroenterologyCouncilor of Japan Society for Endoscopic SurgeryQualified Surgeon of Endoscopic Surgical Skill Qualification System

Cuneyt KayaalpProfessorChief of Gastrointestinal Surgery Department of Inonu UniversityMember of Turkish Surgical Society, Society of Surgery Days, Turkish Laparoscopic Endoscopic Surgery Association, Turkish HBP Surgery Society, Turkish Gastrointestinal Surgery SocietyVice president of Turkish Bariatric Metabolic Surgery AssociationPresident of MAGIC (Malatya Gastro-Intestinal Chirurgie)

Joaquim Manuel da Costa PereiraProfessorDirector Surgical Service and of Colorectal Unity of Hospital de Braga.Director of Courses of Advanced Colorectal Laparoscopic Surgery of Portuguese Society of Minimally Invasive Surgery.Director of Courses of Intestinal Anastomosis of Portuguese Society of Minimally Invasive Surgery.Director of Courses of Laparoscopic Suture of Portuguese Society of Minimally Invasive Surgery.Member of Direction of Portuguese Society of Coloproctology.Honorary Consultant Surgeon of Vigo University Hospital

Joel LeroyMD, FRCS, Professor of SurgeryFounder and Chairman Hanoi High Tech and Digestive Center, Saint Paul HospitalChairman of Colorectal Department HDC, Digestive Colorectal SurgeonProfessor Honoris Causa Hanoi Medical University

Petr V. TsarkovMD, Professor, PhD, FASCRS (Hon)Director of Clinic of Colorectal and Minimally Invasive Surgery, Chief of Research Educational Clinical Center of Colorectal and Endoscopic Surgery of Sechenov First Moscow Medical State UniversityFounding Member of Russian Coloproctology AssociationInternational Society of University Colorectal Surgeons (ISUCRS)President Eurasian Colorectal Technologies Association (ECTA)Member of European Society of Coloproctology (ESCP)Honorary Fellow of American Society of Colon and Rectal Surgeons (ASCRS)Member of European Association of Endoscopic Surgery (EAES)Founding Member and Board Chairman of Russian Society of Colorectal Surgeons (RSCRS)

William Tzu-Liang ChenMD, Associate Professor of SurgeryVice-Superintendent of International Medicine Center, Chairman of Department of Surgery, Director of Minimally Invasive Center of China Medical University HospitalMember of American Society of Colon and Rectal SurgeonsMember of Society of American Gastrointestinal Endoscopic SurgeonsBoard Member of Endo-laparoscopic Surgeons of AsiaBoard Member of Asia-Pacific Endo-laparoscopic SurgeonsBoard Member of Asian Endoscopic Task Force

At the completion of the second edition of the English book on NOSES, I am overwhelmed with emotions. When the first edition of the Chinese book on NOSES was published, I was very excited and wrote as follows: “NOSES is the integration of idea and technology, the col-lision of inspiration and practice, the mutual assistance of trust and motivation, the agreement of norms and innovation, and the progress of development and wishes.” After several years of accumulation and development, the Chinese book on NOSES has been rapidly updated from the first edition of NOSES for Colorectal Tumors to the third edition of NOSES for Abdominal and Pelvic Tumors, and many foreign language translations have been published successively. I hereby share with you some of my rational reflections on this technique.

The direction for the future development of gastrointestinal surgery must be innovation. The revolution and innovation of medicine relies on the progress of physics, mechanical engi-neering, material science, and other related disciplines, as well as the development of various instruments and energy platforms such as laparoscopy and Da Vinci robot. The perfection of the human body also makes up for the arrogance and self-righteousness of medicine. Open surgery has been the mainstay of surgical treatment for hundreds of years. In the past 30 years, the once controversial laparoscopic surgery has been widely accepted and popularized. Similarly, we are making continuous progress and improvement in the development of NOSES. At present, the techniques of laparoscopic organ resection and digestive tract recon-struction by gastrointestinal surgeons are very mature. However, how to select a rational approach to achieve better specimen extraction still warrants consideration. Since incisions for specimen extraction are inevitable, why do not we choose the more concealed, scarless, and less painful approaches. The advent of NOSES happens to meet these requirements.

With regard to NOSES, we must answer three questions: (1) What is it? (2) Why we do this? (3) How to do this?

Firstly, we must answer “What is NOSES?.” NOSES is a kind of operation in which all operative procedures are performed in the abdominal cavity, and the specimen is extracted through the natural orifice. This operation can be performed on all organs in the abdomen and pelvis. NOSES originated from the concepts of incision-free, Like-NOTES, etc. This book illustrates the concepts of NOSES, NOTES, and taTME and their mutual relations, which facilitates the development, improvement, and perfection of these techniques.

Secondly, we must answer “Why we do NOSES?” This should be discussed from two per-spectives of both doctors and patients. For patients, “incision-free” is a novel idea, which can relieve or even eliminate postoperative pain, reduce abdominal wall dysfunction, provide good cosmetic appearance, and give them positive social psychosocial suggestions. With these advantages, NOSES facilitates the establishment of self-confidence, accelerates postoperative rehabilitation, and helps the patients to have a better return to society. For doctors, they should keep “two senses and two pursuits” in the process of practicing medicine. “Two senses” are the “sense of accomplishment” and the “sense of guilt.” “Two pursuits” of surgeons are “full understanding of the 3D anatomical structure” and “every movement is the crystallization of wisdom.” Doctors would feel the sense of happiness and fulfillment when their patients have good feelings and quick recovery. Thus, NOSES has a positive impact on both doctors and patients, which indicates that it is a better surgical procedure with good prospects.

Preface

Finally, we must answer “How to do NOSES?” Surgeons should explore new clinical tech-niques in a pragmatic manner and carry out the clinical practice of a series of procedures in a healthy, scientific, and orderly way. The members of Chinese NOSES Alliance have done a great deal of work for this purpose. Their hard work is far more than a mere pursuit of personal development. At the height of industry progress and national rejuvenation, they are striving to get the voice of Chinese surgeons heard in the global medical world. They appreciate other people’s achievements with an open mind and critically review their own limitations. With the broad mind and wide vision of the members of Chinese NOSES Alliance, NOSES is destined to have the characteristics of “standardization, innovation, pragmatism, truth-seeking, and advancing.” We have accommodated the opinions and suggestions of all aspects and recognize NOSES as the direction and goal of future development. On this basis, NOSES has developed rapidly and vigorously. With the increased diversity of involved tissues and organs, the number of hospitals, specialists, and operation cases of NOSES in China is increasing year by year. The overall complications have not been increased significantly, which sufficiently demon-strated the safety and feasibility of NOSES.

The International NOSES Alliance has been established, and each province has set up the secondary branch of the Alliance successively, which provides a strong organizational guaran-tee for the healthy development of NOSES. In order to standardize the clinical development of NOSES, with the efforts of all members of this alliance, the Chinese Consensus on NOSES and the International Consensus on NOSES were formulated successively to make NOSES reason-able and evidence based. In addition, a series of academic activities, such as international NOSES academic conference, Chinese NOSES lecture tour, NOSES seminar, NOSES live surgical demonstration, and expert symposium, have been carried out with the Chinese NOSES Alliance and the Chinese Journal of Colorectal Diseases as the academic platform. These have greatly promoted the clinical popularization of NOSES and benefited more patients. The suc-cessive publications of NOSES books in English, Korean, Japanese, and Russian have signifi-cantly promoted the international popularization and exchange of NOSES. We firmly believe that all specialties will publish their respective NOSES monographs in the near future.

The successful publications of many NOSES monographs are not possible without the wis-dom and hard work of all the editors and the guidance and help of Academician He Jie, Prof. Zheng Shu, Prof. Zheng Minhua, Academician Chen Xiaoping, Academician Fan Daiming, and Academician Guo Yinglu. It is also inseparable from the support and dedication of Prof. Petr V. Tsarkov, Prof. Atsushi Nishimura, Prof. Cuneyt Kayaalp, Prof. Ho-Kyung Chun, Prof. Joaquim Manuel da Costa Pereira, Prof. William Tzu-Liang Chen, and other international col-leagues for the promotion of NOSES. I would like to extend our sincere gratitude to all of them.

NOSES is not just a great work of doctors, but also the gospel of patients. NOSES not only belongs to China, but also belongs to the world.

Beijing, China Xishan Wang

Preface

Part I General Statement

1 Overview of NOSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Xishan Wang

2 Perioperative Preparation of NOSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Xishan Wang, Yinggang Chen, Lei Yu, and Rui Huang

3 Laparoscopic Abdominal Pelvic Anatomical Landmarks and Essentials of Surgical Exploration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Haipeng Chen, Xu Guan, and Xishan Wang

Part II NOSES for Colorectal Cancer

4 Laparoscopic Lower Rectal Cancer Resection with Transanal Specimen Extraction (CRC-NOSES IA, IB, and IB+, Eversion Method). . . . . . . . . . . . . . . . 43Xishan Wang, Enrui Liu, and Haipeng Chen

5 Laparoscopic Ultralow Rectal Cancer Resection with Transanal Specimen Extraction: Park Method (CRC-NOSES IC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67Xishan Wang, Yinghu Jin, and Zheng Jiang

6 Laparoscopic Ultralow Rectal Cancer Resection with Transanal Specimen Extraction: Intersphincteric Resection Method (CRC-NOSES ID) . . . . . . . . . . . 81Xishan Wang, Meng Wang, and Zheng Jiang

7 Laparoscopic Ultralow Rectal Cancer Resection with Transanal Specimen Extraction: Bacon Method (CRC-NOSES IE) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95Bo Jiang and Yi Feng

8 Laparoscopic Lower Rectal Cancer Resection with Rectal Eversion and Extra- Abdominal Resection: Tsarkov Method (CRC-NOSES IF) . . . . . . . . . 109Sergey Efetov, Inna Tulina, and Petr V. Tsarkov

9 Laparoscopic Middle Rectal Cancer Resection with Transanal Specimen Extraction (CRC-NOSES II) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121Xishan Wang, Ziming Yuan, and Zhixun Zhao

10 Laparoscopic Middle Rectal Cancer Resection with Transvaginal Specimen Extraction (CRC-NOSES III) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139Xishan Wang, Qian Zhang, and Haipeng Chen

11 Laparoscopic Upper Rectal Cancer Resection with Transanal Specimen Extraction (CRC-NOSES IV) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157Xishan Wang, Song Wang, and Peng Sun

Contents

12 Laparoscopic Upper Rectal Cancer Resection with Transvaginal Specimen Extraction (CRC-NOSES V) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171Xishan Wang and Zhixun Zhao

13 Laparoscopic Left Hemicolectomy with Transanal Specimen Extraction (CRC- NOSES VI A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187Xishan Wang and Zheng Jiang

14 Laparoscopic Left Hemicolectomy with Transrectal Specimen Extraction (CRC- NOSES VIB) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205Haipeng Chen, Zhaoxu Zheng, and Xishan Wang

15 Laparoscopic Left Hemicolectomy with Transvaginal Specimen Extraction (CRC- NOSES VII) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221Xishan Wang, Zheng Liu, and Zhao Lu

16 Laparoscopic Right Hemicolectomy with Transvaginal Specimen Extraction (CRC-NOSES VIIIA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237Xishan Wang, Xu Guan, and Haiyang Huang

17 Laparoscopic Right Hemicolectomy with Transrectal Specimen Extraction (CRC- NOSES VIIIB) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255Xiyue Hu and Haitao Zhou

18 Laparoscopic Right Hemicolectomy with Transcolonic Specimen Extraction (CRC-NOSES VIIIC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269Jian Peng

19 Laparoscopic Total Colectomy with Transanal Specimen Extraction (CRC-NOSES IX) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283Xishan Wang and Zheng Jiang

20 Laparoscopic Total Colectomy with Transvaginal Specimen Extraction (CRC- NOSES X) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303Xishan Wang, Zheng Jiang, and Runkun Yang

21 Transanal Total Mesorectal Excision (taTME) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319Liang Kang

Part III NOSES for Gastrointestinal Cancer

22 Laparoscopic Distal Gastrectomy (Billroth I) with Transrectal Specimen Extraction (GC-NOSES I) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335Su Yan

23 Laparoscopic Distal Gastrectomy (Billroth I) with Transvaginal Specimen Extraction (GC-NOSES II) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345Su Yan

24 Laparoscopic Distal Gastrectomy (Billroth II) with Transrectal Specimen Extraction (GC-NOSES III) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355Gang Yu

25 Laparoscopic Distal Gastrectomy (Billroth II) with Transvaginal Specimen Extraction (GC-NOSES IV) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369Gang Yu

Contents

26 Laparoscopic Proximal Gastrectomy with Transrectal Specimen Extraction (GC-NOSES V) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 387Gang Yu

27 Laparoscopic Proximal Gastrectomy with Transvaginal Specimen Extraction (GC-NOSES VI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 401Gang Yu

28 Laparoscopic Total Gastrectomy with Transrectal Specimen Extraction (GC-NOSES VII) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 415Gang Yu

29 Laparoscopic Total Gastrectomy with Transvaginal Specimen Extraction (GC-NOSES VIII) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 431Gang Yu

30 Robotic Gastric Tumor Resection with Transoral Specimen Extraction (GC-NOSES IX) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 447Zhiwei Jiang

31 Laparoscopic Small Intestinal Tumor Resection with Transrectal Specimen Extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 455Haitao Zhou

32 Laparoscopic Small Intestinal Tumor Resection with Transvaginal Specimen Extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465Xishan Wang and Haipeng Chen

Part IV Special and Extended Resection Surgery with NOSES

33 Laparoscopic Extended Lower Rectal Cancer Resection with En Bloc Lateral Lymph Node Dissection (Wang’s Approach) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 475Xishan Wang, Zhaoxu Zheng, and Haipeng Chen

34 Laparoscopic Right Hemicolectomy and Sigmoidectomy with Transvaginal Specimen Extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 491Xishan Wang and Haipeng Chen

35 Laparoscopic Right Hemicolectomy and Rectal Cancer Resection with Transrectal Specimen Extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 507Guiyu Wang, Tianyi Ma, and Qian Zhang

36 Laparoscopic Rectal Cancer Resection Combined with Liver Metastasis Resection with Transanal Specimen Extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 523Chuangang Fu

37 Laparoscopic Right Hemicolectomy Combined with Pancreaticoduodenal Resection with Natural Orifice Specimen Extraction . . . . . . . . . . . . . . . . . . . . . . . 539Gang Yu

Part V Complications and Management of NOSES

38 Complications and Management of NOSES for Gastrointestinal Tumor . . . . . . . 559Yinggang Chen, Yantao Tian, and Qian Liu

Contents

Part VI Collection of Expert Experience on NOSES

39 Experience Sharing in NOSES for Colorectal Cancer . . . . . . . . . . . . . . . . . . . . . . 567Qingchao Tang, Haipeng Chen, and Xishan Wang

40 Totally Laparoscopic Colectomy for Colorectal Cancer with Natural Orifice Specimen Extraction Combined with Reduced-Port Surgery: Japanese Experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 587Atsushi Nishimura, Mikako Kawahara, Yasuyuki Kawachi, Shigeto Makino, Chie Kitami, and Keiya Nikkuni

41 Laparoscopic-Assisted Natural Orifice Specimen Extraction Colectomy Using a Cai Tube for Left-Sided Colonic Carcinomas . . . . . . . . . . . . . . . . . . . . . . . 595Jianchun Cai and Shuzhen Xu

42 Laparoscopic Total Colectomy Combined with NOSES: Turkish Experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 601Cuneyt Kayaalp

43 Operating Points of Aseptic and Tumor- Free Operation in NOSES for Rectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 605Chuangang Fu

44 Application of Reverse Puncture Technique to Place Anvil for Laparoscopic Colorectal Resection with NOSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 607Qingsi He and Hui Qu

45 New Method of Modified NOSES I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 615Junhong Hu

46 Laparoscopic Resection of Tumors of Left Colon, Sigmoid Colon, and Upper Rectum with Transanal Specimen Extraction (NOSES IV and VI): Portuguese Experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 617Joaquim Manuel da Costa Pereira and Carlos Costa Pereira

47 NOSES in Colorectal Surgery: Vietnamese Experience . . . . . . . . . . . . . . . . . . . . . 623Joel Leroy, Frederic Bretagnol, and Dan Nguyen

48 Robotic Radical Resection for Lower Rectal Carcinoma with Transanal Pullout of Rectum Eversion and Extracorporeal Resection Technique . . . . . . . . . 635Taiyuan Li and Lei Xiong

49 Application of OrVil™ and NOSES in Total Laparoscopic Gastrectomy for Female . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 639Dan Ma

50 Experience Sharing of Key Points in NOSES for Colorectal Cancer . . . . . . . . . . . 645Xuejun Sun

51 Experience and Skill Sharing on NOSES in the Left and Right Colon . . . . . . . . . 647Guiyu Wang

52 Natural Orifice Specimen Extraction in Laparoscopic Anterior Resection (NOSE- LAR): Taiwanese Experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 651Ming Li Leonard Ho and William Tzu-Liang Chen

53 Reduced Port Laparoscopic Anterior Resection with Transrectal Specimen Extraction and Single-Stapled Anastomosis: Taiwanese Experience . . . . . . . . . . . 657Sheng-Chi Chang, Ming Li Leonard Ho, and William Tzu-Liang Chen

Contents

54 Robotic Single Stapling Coloanal/Colorectal Anastomosis with Transanal Specimen Extraction for Anterior Resection of Rectosigmoid Tumor . . . . . . . . . . 661Hongliang Yao

55 Conformal Sphincter-Preserving Operation + NOSES I (CSPO + NOSES I) for Extremely Low Rectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 663Wei Zhang and Zheng Lou

56 Laparoscopic Complex NOSES Surgery of Colorectal Tumor . . . . . . . . . . . . . . . . 667Yangchun Zheng and Yuanyi Rui

Appendix A: International Consensus on Natural Orifice Specimen Extraction Surgery (NOSES) for Colorectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 673

Appendix B: International Consensus on Natural Orifice Specimen Extraction Surgery (NOSES) for Gastric Cancer (2019) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 683

Postscript . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 691

Content Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 693

Contents

Frederic Bretagnol High Tech Digestive Center, Saint Paul University Hospital, Hanoi, Vietnam

Jianchun Cai Department of Gastrointestinal Surgery, Zhongshan Hospital of Xiamen University, Xiamen, China

Sheng-Chi Chang Division of Colorectal Surgery, China Medical University Hospital, Taichung, Taiwan

Haipeng Chen Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China

William Tzu-Liang Chen Department of Colorectal Surgery, China Medical University Hsinchu Hospital, Taichung, Taiwan

Yinggang Chen Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Shenzhen Center, Shenzhen, China

Joaquim Manuel da Costa Pereira Department of Surgery, Hospital de Braga, Braga, Portugal

Sergey Efetov Colorectal Surgery Department, Sechenov First Moscow State Medical University, Moscow, Russia

Yi Feng Anal and Colorectal Surgery, Shanxi Cancer Hospital, Affiliated Cancer Hospital of Shanxi Medical University, Taiyuan, China

Chuangang Fu Department of Gastrointestinal Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China

Xu Guan Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China

Qingsi He Department of General Surgery, Shandong University Qilu Hospital, Jinan, China

Ming Li Leonard Ho Department of General Surgery, Sengkang General Hospital, Singapore, Singapore

Haiyang Huang Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China

Rui Huang Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China

Hanqing Hu Department of Colorectal Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China

Junhong Hu Department of General Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China

Contributors

Xiyue Hu Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China

Bo Jiang Anal and Colorectal Surgery, Shanxi Cancer Hospital, Affiliated Cancer Hospital of Shanxi Medical University, Taiyuan, China

Jun Jiang Diagnostic Imaging Department, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China

Zheng Jiang Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China

Zhiwei Jiang Department of General Surgery, Jiangsu Province Hospital of Traditional Chinese Medicine, Nanjing, China

Yinghu Jin Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China

Liang Kang Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China

Yasuyuki Kawachi Nagaoka Chuo General Hospital, Niigata, Japan

Mikako Kawahara Nagaoka Chuo General Hospital, Niigata, Japan

Cuneyt Kayaalp Department of Gastrointestinal Surgery, Inonu University, Malatya, Turkey

Chie Kitami Nagaoka Chuo General Hospital, Niigata, Japan

Joel Leroy High Tech Digestive Center, Saint Paul University Hospital, Hanoi, Vietnam

Taiyuan Li Department of General Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, China

Enrui Liu Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China

Hengchang Liu Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China

Qian Liu Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China

Zheng Liu Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China

Zheng Lou Department of Colorectal Surgery, Changhai Hospital, Navy Medical University, Shanghai, China

Zhao Lu Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China

Chenxi Ma Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China

Dan Ma Department of General Surgery, Xinqiao Hospital, The Third Military Medical University, Chongqing, China

Tianyi Ma Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China

Contributors

Xiaolong Ma Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China

Shigeto Makino Nagaoka Chuo General Hospital, Niigata, Japan

Dan Nguyen High Tech Digestive Center, Saint Paul University Hospital, Hanoi, Vietnam

Keiya Nikkuni Nagaoka Chuo General Hospital, Niigata, Japan

Atsushi Nishimura Nagaoka Chuo General Hospital, Niigata, Japan

Jian Peng Hepatobiliary and Enteric Surgery Research Center, Xiangya Hospital, Central South University, Changsha, Hunan, China

Carlos Costa Pereira Department of Surgery, Hospital de Braga, Braga, Portugal

Tianyu Qiao Department of Pancreatic Stomach Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China

Hui Qu Department of General Surgery, Shandong University Qilu Hospital, Jinan, China

Jichuan Quan Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China

Yuanyi Rui Department of Gastrointestinal Surgery, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Cancer Hospital Affiliate to School of Medicine, UESTC, Chengdu, China

Peng Sun Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Shenzhen Center, Shenzhen, China

Xuejun Sun Department of General Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China

Qingchao Tang Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China

Yantao Tian Department of Colorectal Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China

Petr V. Tsarkov Clinic of Colorectal and Minimally Invasive Surgery, Sechenov First Moscow State Medical University, Moscow, Russia

Inna Tulina Clinic of Colorectal and Minimally Invasive Surgery, Sechenov First Moscow State Medical University, Moscow, Russia

Guiyu Wang Department of Colorectal Cancer Surgery, Cancer Hospital of the University of Chinese Academy of Sciences, Hangzhou, China

Meng Wang Department of Colorectal Cancer Surgery, Cancer Hospital of the University of Chinese Academy of Sciences, Hangzhou, China

Song Wang Department of Colorectal Cancer Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China

Xishan Wang Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China

Lei Xiong Department of General Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, China

Contributors

Shuzhen Xu Department of Gastrointestinal Surgery, Zhongshan Hospital of Xiamen University, Xiamen, China

Ming Yang Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China

Runkun Yang Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China

Su Yan Department of Gastrointestinal Surgery, Affiliated Hospital of Qinghai University, Qinghai University, Xining, China

Hongliang Yao Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China

Gang Yu Department of General Surgery, Qilu Hospital of Shandong University (Qingdao), Qingdao, China

Lei Yu Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China

Ziming Yuan Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China

Hongmei Zhang Diagnostic Imaging Department, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China

Mingguang Zhang Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China

Qian Zhang Department of Colorectal Cancer Surgery, Cancer Hospital of the University of Chinese Academy of Sciences, Hangzhou, China

Wei Zhang Department of Colorectal Surgery, Changhai Hospital, Navy Medical University, Shanghai, China

Zhixun Zhao Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China

Yangchun Zheng Department of Gastrointestinal Surgery, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Cancer Hospital Affiliate to School of Medicine, UESTC, Chengdu, China

Zhaoxu Zheng Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China

Haitao Zhou Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China

Meng Zhuang Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China

Contributors

Natural Orifice Specimen Extraction Surgery

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