LAPAROSCOPIC COLECTOMY USING THE N.O.S.E. TECHNIQUE - VIDEO

Introduction The “Natural Orifice Specimen Extraction” (N.O.S.E.) technique offers benefits when properly indicated, but its use is not yet routine. It results in less pain, reduced medication needs, and quicker return to intestinal activity compared to conventional open colectomy.

Case Presentation A 48-year-old female patient presented with a six-month history of blood in her stool. Colonoscopy revealed a friable, hardened, 5 cm lesion at the rectosigmoid junction, without causing stenosis. A laparoscopic approach using the N.O.S.E. technique was chosen. The specimen was extracted transrectally without requiring an abdominal incision. A colorectal anastomosis was performed intracorporeally. The procedure was a laparoscopic left colectomy with N.O.S.E. Pneumoperitoneum was established using the Hasson technique, supraumbilically, with a 10mm trocar and the introduction of the optics. Four more trocars were placed: a 12mm trocar in the right iliac fossa (P2), 5mm trocars in the right hypochondrium (P3), left hypochondrium (P4), and left iliac fossa (P5). The inferior mesenteric vein was identified, and subsequent dissection of the peritoneum in the paraduodenal fossa was performed. The inferior mesenteric vein was ligated with two LT-300 clips and a bipolar clamp. The sigmoid colon and descending colon were mobilized up to the splenic flexure along the left lateral wall, with separation of the left ureter and gonadal vessels. Linear stapling was performed with at least a 5cm margin proximal and distal to the tumor. The distal stapler line was removed, and a Forrester clamp was inserted through the rectum to extract the surgical specimen. A circular stapler was introduced through the rectum to perform a mechanical end-to-end anastomosis. The leak test was negative. The pathology report indicated a 4.0 cm invasive adenocarcinoma, grade G2, infiltrating into the peri-intestinal adipose tissue, with no vascular or perineural invasion. Peritumoral inflammatory infiltrate was present. Surgical margins were clear, and no lymph node involvement was found (0/17). Pathological staging was pT3pN0.

Discussion The N.O.S.E. technique offers advantages such as less postoperative pain and a shorter duration of metabolic ileus. Surgical specimens are smaller (less than 6.5cm), with minimal mesorectal thickening. Given the aesthetic appeal and the patient's suitability for this technique, it was chosen for the surgery. While still not widely used, it is a good option for colorectal surgeries.

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
25 April 2025