Transanal extraction of the specimen during laparoscopic colectomy

Transanal hybrid colon resection: techniques and outcomes for benign colorectal diseases

BACKGROUND

Transanal hybrid rectal and colon resection have been introduced in recent years at dedicated surgical centers. The anus is used as a natural orifice for large size access. The use of transanal hybrid colectomy techniques is still in its infancy with outcomes and unique complications being identified. The purpose of this work is the evaluation of outcomes for transanal hybrid colon resections (ta-CR), including intra operative and postoperative complications, results, and advantages.

METHODS

A prospectively maintained database was analyzed. Inclusion criteria were any patient who underwent ta-CR for rectal prolapse, slow transit, obstructive defaecation, and chronic sigmoid diverticulitis. Patients were excluded from ta-CR if BMI > 30, major previous abdominal surgery, or presence of a large inflammatory mass in diverticulitis. Transanal access was used for all operative steps requiring access of more than 5 mm, such as staplers, large graspers, and specimen retrieval. Data acquisition and analysis was performed for operative time, complications, and postoperative quality of life.

RESULTS

From 2012 to 2017, 82 patients underwent ta-CR [33 males, 49 females, median age 58 (24-80)]. Transanal-subtotal colectomy and ta-CR for constipation was performed in 12 patients; ta-CR and rectopexy in 31, and ta-CR for diverticulitis was performed in 39 patients. Conversion to traditional approach was required in 3 cases (3.6%). Intraoperative complication included 1 rectal tear requiring intervention. Post-op complications included 3 leaks requiring laparoscopic and 1 open revision, the latter developed wound infection and an incisional hernia. Gastrointestinal Quality of Life Index (GIQLI) improved significantly from preoperative 89 to postoperative 119 (p < 0.001). No patients with ta-CR without open revision developed a hernia post-op with median 18 months follow-up.

CONCLUSIONS

ta-CR is a safe and effective NOTES Hybrid technique for colorectal procedures in selected patients with benign colon disorders. GIQLI shows improvement and this technique can have the potential in preventing wound and hernia complications.

Laparoscopy-Assisted Natural Orifice Specimen Extraction to Treat Tumors of the Sigmoid Colon and Rectum: The Short- and Long-Term Outcomes of a Retrospective Study

Background: Few studies have assessed the short- and long-term outcomes of laparoscopically assisted natural orifice specimen extraction (NOSE) in patients with sigmoid colon and rectal tumors. We investigated the short- and long-term outcomes of patients undergoing laparoscopic-assisted NOSE for tumors of the sigmoid colon and rectum. Methods: Ninety-eight patients with sigmoid colon and rectal tumors undergoing laparoscopic-assisted NOSE were included. The tumor was classified according to its distance from the anal verge: Group 1 (15-30 cm), Group 2 (5-15 cm), and Group 3 (≤5 cm). In Group 1 patients, a laparoscopic surgical specimen collection bag was used as a special transrectal device. In Group 2 patients, transanal endoscopic microsurgery device and specimen collection bag were used. In Group 3 patients, a Lone-Star retractor was used. The demographic characteristics and intra- and postoperative outcomes were measured. Results: In Group 1, 1 patient had respiratory disease and 1 had enterocolitis as short-term postoperative complications. One patient showed intestinal obstruction as a long-term postoperative complication. In Group 2, 2 patients had an ileus, 1 had an anastomotic leak, 2 had urinary retention, and 1 had respiratory disease as short-term complications. Only one patient had a long-term complication: anastomotic stenosis. In Group 3, short-term complications were present in 3 patients: 1 had hemorrhage, 1 had urinary retention, and 1 had respiratory disease. Long-term complications included one case of anastomotic stenosis and one of intestinal obstruction. Conclusions: NOSE is safe and cosmetically and theoretically superior to conventional laparoscopy when different devices are used according to the tumor's location.

Unlimited-Length Proctocolectomy Utilizing Sequential Intussusception and Pull-Through

Transanal, hybrid natural orifice translumenal endoscopic surgery (NOTES) and NOTES-assisted natural orifice specimen extraction techniques hold promise as leaders in the field of natural orifice surgery. We report the feasibility of a novel NOTES assisted technique for unlimited length, clean, endolumenal proctocolectomy in a porcine model. This technique is a modification of a transanal intussusception and pull-through procedure recently published by our group. Rectal mobilization was achieved laparoscopically; this was followed by a transanal recto-rectal intussusception and pull-through (IPT). IPT was established in a stepwise fashion. First, the proximal margin of resection was attached laparoscopically to the shaft of the anvil of an end-to-end circular stapler with a ligature around the rectum. Second, this complex was pulled transanally to produce IPT. To achieve an unlimited-length proctocolectomy, the IPT step was repeated several times prior to bowel resection. This was facilitated by removing the ligature applied in the first step of this procedure. Once sequential IPT established the desired length of bowel to be resected, a second ligature was placed around the rectum approximating the proximal and distal resection margins. The specimen was resected and extracted by making a full-thickness incision through the 2 bowel walls. The anastomosis was achieved by deploying the stapler. The technique was found to be feasible. Peritoneal samples, collected after transanal specimen extraction, did not demonstrate bacterial growth. The minimally invasive nature of this evolving technique as well as its aseptic bowel manipulation has the potential to limit the complications associated with abdominal wall incision and surgical site infection.

Transrectal Rigid-Hybrid Natural Orifice Translumenal Endoscopic Sigmoidectomy for Diverticular Disease: A Prospective Cohort Study

BACKGROUND

Our goal was to evaluate the feasibility of transrectal rigid hybrid natural orifice translumenal endoscopic surgery (NOTES) sigmoidectomy (trNS) in a series of consecutive prospective patients with diverticular disease. The NOTES for left colectomy offers patients reduced pain and easier recovery. Limited data are available for trNS, which is considered safe for various indications. However, the technique is not standardized, and patients in the reported series are highly selected.

STUDY DESIGN

Patients scheduled for trNS were entered into a prospective registry on an intention-to-treat basis. The primary endpoint was trNS feasibility, and secondary endpoints were morbidity, pain, length of stay, and inflammatory response. A medial-to-lateral dissection with full mobilization of the splenic flexure and total intracorporeal anastomosis was performed. The rectum was covered with a wound protector for transrectal extraction.

RESULTS

Of 95 elective sigmoidectomies, 81% (n = 77) were enrolled for either transvaginal NOTES resection (n = 37) or trNS (n = 40). There was no difference in body mass index or indication between patients undergoing laparoscopic-assisted sigmoidectomy (LAS), transvaginal resection, or trNS, although trNS patients were younger. Mainly because of a mismatch of bulky specimen and narrow pelvis, 17.5% of trNS were converted to LAS. Major morbidity was 10%, including 2 septic complications. During the study, the anastomosis technique was changed from double stapled end-to-end to side-to-end anastomosis.

CONCLUSIONS

Transrectal rigid hybrid natural orifice translumenal endoscopic sigmoidectomy is feasible and safe in a high proportion of unselected consecutive patients with diverticular disease undergoing elective treatment. Intracorporeal side-to-end anastomosis is the preferred technique, and trNS should be offered for elective sigmoidectomy presupposing advanced laparoscopic experience.

New approaches in laparoscopic surgery for colorectal diseases: The totally laparoscopic and single-incision approaches

More than 20 years have passed since the first report of laparoscopic colectomy in 1991. Thereafter, laparoscopic surgery for the management of colorectal diseases has been widely accepted as a prevailing option because of improved cosmetic outcomes, less postoperative pain, and shorter hospital stay in comparison with open surgery. To further the principle of minimally invasive surgery, two new approaches have been developed in this rapidly evolving field. The first is the totally laparoscopic approach. Currently most of standard techniques inevitably involve an abdominal incision for retrieval of the specimen and preparation for anastomosis, which might compromise the benefits of laparoscopic surgery. The totally laparoscopic approach dispenses with this incision by combining completely intraperitoneal anastomosis with retrieval of the specimen via a natural orifice, such as the anus or the vagina. Our new and reliable technique for intraperitoneal anastomosis is also described in detail in this article. The second is the single-incision approach. While three to six ports are needed in standard laparoscopic surgery, the single-incision approach uses the umbilicus as the sole access to the abdominal cavity. All of the laparoscopic procedures are performed entirely through the umbilicus, in which the surgical scar eventually becomes hidden, achieving virtually scarless surgery. This article reviews the current status of these two approaches and discusses the future of minimally invasive surgery for colorectal diseases.

Transanal total mesorectal excision in rectal cancer: short-term outcomes in comparison with laparoscopic surgery

OBJECTIVE

The aim of this study was to compare short-term results obtained with transanal total mesorectal excision (TME) and laparoscopic surgery.

BACKGROUND

Transanal TME appears as an alternative in the treatment of rectal cancer and other rectal disease. Natural orifices transluminal endoscopic surgery using the rectum as access in colorectal surgery is intuitively better suited than other access routes.

METHODS

All consecutive patients with middle or low rectal cancer submitted to surgery were included into a prospective cohort and treated by transanal TME assisted by laparoscopy. They were compared with a retrospective cohort of consecutive patients of identical characteristics treated by laparoscopic TME in the immediate chronological period.

RESULTS

Thirty-seven patients were included in both study groups. No differences were observed between them with respect to baseline characteristics, thus emphasizing the comparability of both cohorts. Surgical time was higher in the laparoscopy group (252 ± 50 minutes) than in the transanal group (215 ± 60 minutes) (P < 0.01). Moreover, coloanal anastomosis was performed less frequently (16% vs 43%, respectively; P = 0.01) and distal margin was lower (1.8 ± 1.2 mm vs 2.7 ± 1.7 mm, respectively; P = 0.05) in the laparoscopy group than in the transanal one. Although there was no significant difference in 30-day postoperative complication rate (laparoscopy, 51% vs transanal, 32%; P = 0.16), early readmissions were more frequent in the laparoscopy group than in the transanal one (22% vs 6%, respectively; P = 0.03).

CONCLUSIONS

Evaluation of short-term outcomes demonstrated that transanal TME is a feasible and safe technique associated with a shorter surgical time and a lower early readmission rate.

Next step in minimally invasive surgery: hybrid image-guided surgery

Surgery, interventional radiology, and advanced endoscopy have all developed minimally invasive techniques to effectively treat a variety of diseases with positive impact on patients' postoperative outcomes. However, those techniques are challenging and require extensive training. Robotics and computer sciences can help facilitate minimally invasive approaches. Furthermore, surgery, advanced endoscopy, and interventional radiology could converge towards a new hybrid specialty, hybrid image-guided minimally invasive therapies, in which the three fundamental disciplines could complement one another to maximize the positive effects and reduce the iatrogenic footprint on patients. The present manuscript describes the fundamental steps of this new paradigm shift in surgical therapies that, in our opinion, will be the next revolutionary step in minimally invasive approaches.

Novel Totally Laparoscopic Endolumenal Rectal Resection With Transanal Natural Orifice Specimen Extraction (NOSE) Without Rectal Stump Opening: A Modification of Our Recently Published Clean Surgical Technique in a Porcine Model

Our group has recently described a novel technique for clean endolumenal bowel resection, in which abdominal and transanal approaches were used. In the current study, 2 modifications of this procedure were tested for feasibility in a porcine model. A laparoscopic approach to the peritoneal cavity was employed in rectal mobilization; this was followed by a transanal rectorectal intussusception and pull-through (IPT). IPT was established in a stepwise fashion. First, the proximal margin of resection was attached to the shaft of the anvil of an end-to-end circular stapler with a ligature around the rectum. Second, this complex was pulled transanally to produce IPT. Once IPT was established, a second ligature was placed around the rectum approximating the proximal and distal resection margins. This was followed by a purse string suture through 2 bowel walls, encircling the shaft of the anvil just proximal to the ligatures. The specimen was resected and extracted by making a full-thickness incision through the 2 bowel walls distal to the previously placed purse string suture and ligatures. The anastomosis was achieved by applying the stapler. The technique was found to be feasible. Peritoneal samples, collected after transanal specimen extraction, did not demonstrate bacterial growth. Although, this is a novel and evolving procedure, its minimally invasive nature, as well as aseptic bowel manipulation during endolumenal rectal resection, has the potential to limit the complications associated with abdominal wall incision and surgical site infection.

Prospective randomized trial of hybrid NOTES colectomy versus conventional laparoscopic colectomy for left-sided colonic tumors

BACKGROUND

We conducted a randomized study of a laparoscopic technique for removing left-sided colon tumors that can reduce postoperative pain and other wound-related complications compared to the conventional technique. It is a novel technique of hybrid natural orifice translumenal endoscopic surgery (NOTES) colectomy (HNC) whereby laparoscopic colonic mobilization, transection, and anastomosis are performed intracorporeally. The specimen is then delivered through the anus using the transanal endoscopic operation (TEO) device, precluding the need for mini-laparotomy. We compared the short-term outcomes of patients who underwent HNC with those who underwent conventional laparoscopic colectomy (CL).

METHODS

Patients suffering left-sided colonic tumor were recruited and were randomized into two groups: HNC and CL. Operative data and complications were prospectively recorded and analyzed.

RESULTS

During a 3-year period, we recruited 70 patients (35 per group). No significant difference was observed between the two groups with respect to operating time (105 vs. 100 min, p = 0.851), blood loss (30 vs. 30 ml, p = 0.954), or length of hospital stay (5 vs. 5 days, p = 0.990). The maximum pain score during the first week was significantly lower in the HNC group (1 vs. 2, p = 0.017). No patients in the HNC group developed wound infection, whereas four patients in the CL group did so (p = 0.005).

CONCLUSIONS

With this hybrid NOTES technique, selected patients with left-sided colonic tumors can enjoy the full benefits of minimally invasive surgery with significantly less wound pain and a lower wound infection rate than are observed with CL.

Totally laparoscopic intracorporeal anastomosis with natural orifice specimen extraction (NOSE) techniques, particularly suitable for bowel endometriosis

The objective of this retrospective study was to evaluate the feasibility of natural orifice specimen extraction (NOSE) techniques in 41 patients undergoing bowel resection for treatment of deep infiltrating endometriosis. In all patients laparoscopic treatment of rectovaginal endometriosis with bowel resection had been performed. In 32 patients the classic approach was adopted (group 1), and in 9 a NOSE technique was performed (group 2). Demographic, operative, and postoperative data were compared. Statistical analyses were performed using SPSS software, version 16.0. When needed, qualitative variables were compared using the χ(2) test or the Fisher exact test. Quantitative variables using the t-test were used. The threshold of statistical significance was set at p = .05. No statistically significant difference was observed between the 2 groups. Eight complications (19.5%) were observed, 2 minor (4.8%) and 6 major (14.6%). Of major complications, 2 were observed in the NOSE group (n = 2; 22.2%). It was concluded that the NOSE technique is a feasible approach in patients undergoing bowel resection for treatment of deep infiltrating endometriosis.

Mini-invasive surgery for colorectal cancer

Laparoscopic techniques have been extensively used for the surgical management of colorectal cancer during the last two decades. Accumulating data have demonstrated that laparoscopic colectomy is associated with better short-term outcomes and equivalent oncologic outcomes when compared with open surgery. However, some controversies regarding the oncologic quality of mini-invasive surgery for rectal cancer exist. Meanwhile, some progresses in colorectal surgery, such as robotic technology, single-incision laparoscopic surgery, natural orifice specimen extraction, and natural orifice transluminal endoscopic surgery, have been made in recent years. In this article, we review the published data and mainly focus on the current status and latest advances of mini-invasive surgery for colorectal cancer.

Transanal colorectal resection using natural orifice translumenal endoscopic surgery (NOTES)

The surgical management of rectal cancer has evolved over the past century, with total mesorectal excision (TME) emerging as standard of care. As a result of the morbidity associated with open TME, minimally invasive techniques have become popular. Natural orifice translumenal endoscopic surgery (NOTES) has been held as the next revolution in surgical techniques, offering the possibility of 'incisionless' TME. Early clinical series of transanal TME with laparoscopic assistance (n = 72) are promising, with overall intraoperative and postoperative complication rates of 8.3% and 27.8%, respectively, similar to laparoscopic TME. The mesorectal specimen was intact in all patients, and 94.4% had negative margins. There was no oncological recurrence in average-risk patients at short-term follow up, and 2-year survival rates in high-risk patients were comparable to that after laparoscopic TME. These preliminary studies demonstrate transanal NOTES TME with laparoscopic assistance to be clinically feasible and safe given careful patient selection, surgical expertise, and appropriate procedural training. We are hopeful that with optimization of transanal instruments and surgical techniques, pure transanal NOTES TME will become a viable alternative to open and laparoscopic TME in the future.

Collaboration between laparoscopic surgery and endoscopic resection: an evidence-based review

Developments in endoscopy and laparoscopy have made monumental changes to the way gastrointestinal diseases are being managed. Many diseases that were traditionally managed by open surgical resection could now be treated by endoscopy alone. However, there are still instances where endoscopic treatment alone is inadequate for disease control and laparoscopic surgery is required. In addition, the collaboration between laparoscopic surgery and endoscopic submucosal dissection or other endoscopic resectional techniques represents a new frontier for further research. The present manuscript aims to discuss the complementary role of laparoscopic surgery to endoscopic resection in the traditional context and also its future development.

Transanal minimally invasive surgery for total mesorectal excision

Transanal TME is a new and important application for TAMIS. It allows for resection and mobilization of the rectum while preserving the quality of the mesorectal envelop. This new approach has gained considerable interest not only because of its minimally invasive nature, but because TAMIS-TME offers a solution to one of the most difficult problems in rectal cancer surgery: Specifically, access to the distal rectum in obese male patients with a narrow pelvis. Recently, transanal TME has become one of the most rapidly expanding areas in rectal cancer surgery. Interestingly, the origin and inception of this approach began decades ago. The evolution of transanal TME with a historical perspective is described.

Transvaginal pure NOTES sigmoid resection using a single port device

BACKGROUND

The amount of published experience using natural orifice transluminal endoscopic surgery (NOTES) is increasing. However, approximately half of the technical approaches described include NOTES as part of a hybrid procedure. Colonic resections performed using NOTES have mainly been described using a hybrid approach.

METHODS

An 84-year-old female presented with a symptomatic volvulus of the sigmoid colon. Endoscopic detorsion and desufflation were successfully performed. Definitive treatment was accomplished by performing a sigmoid resection entirely via a transvaginal route using a single port device (SILS™ Covidien, Westbury, MA, USA).

RESULTS

Operative time was 135 min. No intraoperative or postoperative complications occurred. Only minimal narcotic analgesia was required and oral intake was initiated on postoperative day 3. At the last follow-up assessment, 2 months postoperatively, no complications or recurrent volvulus were observed.

CONCLUSION

Transvaginal NOTES sigmoid colectomy for sigmoid volvulus is feasible and can be performed safely.

Surgical strategy in endometriosis

Endometriosis is a common disease affecting young women. Its clinical manifestations include pain and infertility, and it can dramatically affect quality of life. Treatments should be tailored to address the wishes of women according to the specific characteristics of the disease. Although many questions remain unanswered, strong evidence supports the use of laparoscopic surgery to improve pain and infertility. The systematisation of strategy is essential to make surgery more reproducible, safer and less time-consuming. Nevertheless, even in the most expert hands, complications may occur. Further investigations are needed to compare the different approaches. Outcomes must, however, include pain, fertility, organ dysfunction, and quality of life.

Integration of transanal specimen extraction into laparoscopic anterior resection with total mesorectal excision for rectal cancer: a consecutive series of 179 patients

BACKGROUND AND OBJECTIVES

This prospective study focused on patients with rectal cancer who underwent transanal specimen extraction after laparoscopic anterior resection with total mesorectal excision and specifically aims to investigate whether the transanal approach can be accepted as a safe and effective method for extracting the malignant specimen from the peritoneal cavity.

PATIENTS AND METHODS

A prospectively designed database of a consecutive series of patients undergoing laparoscopic low anterior resection for rectal malignancy with various tumor-node-metastasis (TNM) classifications from April 1991 to May 2011 at the Texas Endosurgery Institute was analyzed. Patient selection for transanal specimen extraction and intracorporeal anastomosis was made on the basis of size of the pathology and distance of rectal lesions from the anal verge.

RESULTS

179 anterior resections were completed laparoscopically with intracorporeal anastomosis and transanal specimen extraction. The operating time for the entire procedures including resection, anastomosis, and specimen extraction was 170.9 ± 51.2 min, blood loss during the procedures was 86.4 ± 37.7 ml, and distance of the lower edge of the lesion from the anal verge was measured to be 11.3 ± 7.3 cm. Postoperatively, three patients developed anastomotic leakage with a leak rate of 1.7%, and the overall major complication rate after the procedures was 5.0%. Length of hospital stay was 6.9 ± 2.8 days. Two-year follow-up showed development of anal stenosis in three patients (2.0%) and erectile dysfunction in one patient (0.36%) after surgery. Finally, 9 out of 179 patients who underwent laparoscopic anterior resection with transanal specimen extraction were confirmed to have cancer recurrence, with 2-year local recurrence rate of 5.0%.

CONCLUSIONS

Transanal specimen extraction in laparoscopic rectal cancer resection is a safe and effective approach with comparable local cancer recurrence rate and postoperative complication rates, suggesting it can be integrated into laparoscopic anterior resection for rectal cancer.

Prospective evaluation of peritoneal fluid contamination following transabdominal vs. transanal specimen extraction in laparoscopic left-sided colorectal resections

BACKGROUND

Natural orifice specimen extraction (NOSE) in colorectal surgery prevents the need for an enlarged port site or minilaparotomy to extract the surgical specimen. The downside of this technique may be an increased risk of bacterial contamination of the peritoneal cavity from the external milieu. The aim of this study was to prospectively analyze the peritoneal bacterial contamination in NOSE and non-NOSE laparoscopic colorectal procedures.

METHODS

Consecutive patients operated for sigmoid diverticulitis with laparoscopic approach and transanal extraction of the specimen from January to December 2010 at our university hospital were enrolled. Patients who underwent a laparoscopic sigmoidectomy in the same study period with conventional specimen extraction were used as reference. Peritoneal fluid samples were collected under sterile conditions at the end of the procedure and sent for gram stain as well as anaerobic, aerobic, and fungal cultures.

RESULTS

Twenty-nine patients underwent laparoscopic sigmoidectomy for diverticulitis with transanal NOSE, while 9 patients underwent laparoscopic sigmoidectomy with conventional specimen extraction during the same period. The two groups were successfully matched 1:2 (17 NOSE and 9 non-NOSE) according age, sex, ASA, and Charlson comorbidity score. The contamination rate of peritoneal fluid was 100% vs. 88.9% in NOSE and non-NOSE procedures, respectively (P = 0.23). Overall and major complications rates were 27.6% vs. 11.10% (P = 0.41) and 5.08% vs. 11.1% (P = 1) in NOSE vs. non-NOSE procedures, respectively. In the NOSE group there was a statistically significant lower consumption of oral paracetamol (P = 0.007) and of oral tramadol (P = 0.02).

CONCLUSIONS

Although a higher peritoneal contamination was found in the NOSE procedures, there were no significant differences in clinical outcomes relative to standard approach. Avoiding a minilaparotomy to extract the specimen resulted in a significantly lower postoperative analgesic requirement in the NOSE group.

Prospective evaluation of peritoneal fluid contamination following transabdominal vs. transanal specimen extraction in laparoscopic left-sided colorectal resections

BACKGROUND

Natural orifice specimen extraction (NOSE) in colorectal surgery prevents the need for an enlarged port site or minilaparotomy to extract the surgical specimen. The downside of this technique may be an increased risk of bacterial contamination of the peritoneal cavity from the external milieu. The aim of this study was to prospectively analyze the peritoneal bacterial contamination in NOSE and non-NOSE laparoscopic colorectal procedures.

METHODS

Consecutive patients operated for sigmoid diverticulitis with laparoscopic approach and transanal extraction of the specimen from January to December 2010 at our university hospital were enrolled. Patients who underwent a laparoscopic sigmoidectomy in the same study period with conventional specimen extraction were used as reference. Peritoneal fluid samples were collected under sterile conditions at the end of the procedure and sent for gram stain as well as anaerobic, aerobic, and fungal cultures.

RESULTS

Twenty-nine patients underwent laparoscopic sigmoidectomy for diverticulitis with transanal NOSE, while 9 patients underwent laparoscopic sigmoidectomy with conventional specimen extraction during the same period. The two groups were successfully matched 1:2 (17 NOSE and 9 non-NOSE) according age, sex, ASA, and Charlson comorbidity score. The contamination rate of peritoneal fluid was 100% vs. 88.9% in NOSE and non-NOSE procedures, respectively (P = 0.23). Overall and major complications rates were 27.6% vs. 11.10% (P = 0.41) and 5.08% vs. 11.1% (P = 1) in NOSE vs. non-NOSE procedures, respectively. In the NOSE group there was a statistically significant lower consumption of oral paracetamol (P = 0.007) and of oral tramadol (P = 0.02).

CONCLUSIONS

Although a higher peritoneal contamination was found in the NOSE procedures, there were no significant differences in clinical outcomes relative to standard approach. Avoiding a minilaparotomy to extract the specimen resulted in a significantly lower postoperative analgesic requirement in the NOSE group.