To describe the technical experience and specimen extraction decisions in patients undergoing natural orifice specimen extraction surgery (NOSES) for right colon cancer with synchronous second primary tumors.

This single-center retrospective case series included three patients who underwent simultaneous totally laparoscopic resection and NOSES in July 2026. The second primary tumors were upper rectal cancer, a gastric gastrointestinal stromal tumor with malignant potential, and lower rectal cancer. Clinicopathological findings, reconstruction, extraction routes, in-hospital recovery, and complications within 30 days after surgery were reviewed.

In P1, both specimens were removed transanally through the rectal stump created during rectal resection. In P2, the gastric and right-colon specimens were removed transanally through an anterior rectotomy. In P3, the rectal lesion was resected by transanal eversion, and the right-colon specimen was extracted transvaginally. Operative time ranged from 136 to 242 min, blood loss from 20 to 30 mL, and postoperative hospital stay from 5 to 7 days. Extraction was completed without an additional abdominal extraction incision in all three patients, and no Clavien-Dindo grade II or higher complications occurred within 30 postoperative days. All three patients recovered well.

These cases illustrate the technical implementation of different NOSES extraction routes during simultaneous resection. Decisions should account for the oncological resection plan, usable access, and specimen characteristics. These short-term observations do not establish the safety or functional benefit of individual routes; long-term oncological outcomes require further follow-up.