With the rapid development of surgical technology, the theoretical framework of NOSES is becoming more and more perfect. With the development of NOSES, various problems will inevitably arise, such as immature technical operations, unfixed surgical team members and inability to accurately grasp the operation indications etc. Only by continuously summing up and improving the existing technical concepts, can the sustainable development of NOSES be realized and make it more vital. Based on my many years of clinical experience, the author summarizes the possible pitfalls and corresponding countermeasures in NOSES.

To improve the quality of life of patients suffered from familial adenomatous polyposis (FAP), we modify the preventive surgical method.

A retrospective analysis was performed on patients with FAP in Jiangsu Cancer Hospital from June 2019 to March 2020, of which natural orifice specimen extraction surgery (NOSES) was conducted. During the operation, the whole colorectal mesentery was dissociated, the rectum was freed and cut to the plane of the levator ANI. We insert the protective cover and pull out the whole large intestine and rectum through the end of the rectum. We cut the intestine 5 cm away from the ileocecal region and put the anvil at the end of the ileum. Then we reverse the rectum to treat the rectal polyps. At last, we do the end-to-end anastomosis. We collect and analyze the data of gender, height, weight, tumor markers, postoperative ventilation time, defecation situation at the first month, the third month and the sixth month after surgery.

Four patients were received modified NOSES successfully, laparoscopic resection of the colorectum. All patients recover successfully, without anastomotic leakage and massive bleeding and other big postoperative complications. No postoperative abdominal cavity infections were found. The distance from the anastomosis to the anus was negatively associated with the frequency of defection, especially at night.

The modified NOSES follows the aseptic and tumor-free principle. No major complications were found in our cases. The defecation function was improved significantly. Still, large-scale studies were needed in the future.

To investigate the risk factors of complications after laparoscopic radical resection for colorectal cancer by natural orifice specimen extraction surgery (NOSES).

A retrospective case-control study was conducted to collect and analyze the clinicopathological data of patients who underwent total laparoscopic radical resection for colorectal cancer by NOSES IV at Department of Colorectal Surgery, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College from January 2014 to June 2019. A total of 172 patients were included in the study. To analyze the relationship between the patient′s clinical data, such as general information, the surgeon′s experience, intraoperative conditions and the occurrence of postoperative complications. Univariate analysis were conducted by the chi-squared test. Multivariate logistic regression analysis was used to analyze statistically significant variables in univariate analysis.

Of the 172 patients, 21(12.2%) had complications after surgery. The incidence of postoperative complications ranged from high to low, respectively, for abdominal or pelvic infection (4.7%), anastomotic leakage (3.5%), abdominal hemorrhage (1.7%), pulmonary infection (1.7%), anastomotic stenosis (1.2%), rectovaginal leakage(1.2%), pulmonary embolism (1.2%), and incision infection (1.2%). On univariate analysis, the occurrence of postoperative complications was associated with tumor size (χ²=5.144, P=0.023)、operation eperience (χ²=4.412, P=0.042) and operaton time (χ²=4.713, P=0.030). Multivariable logistic regression analysis showed that operation time≥135min (OR=3.317, 95%CI: 1.024~10.747; P=0.046) was only independent risk factor for postoperative complications.

The operative time≥135 min was an independent risk factor for postoperative complications of NOSES IV in colorectal cancer. It is an effective guarantee to strictly observe the indication of NOSES and skillfully and flexibly use the laparocscopic instrument to reduce postoperative complications of NOSES.

To explore the effects of enhancing recovery after surgery (ERAS) nursing on postoperative recovery and mental state among colorectal cancer after natural orifice specimen extraction surgery (NOSES).

Ninety patients were enrolled. All the patients received natural orifice specimen extraction surgery from May 2018 to March 2019 and were divided into two groups with the method of random number table, 45 cases in each group. Observation group carried out ERAS nursing, while control group adopted routine nursing. To observe the differences in exhaust time, defecation time, hospitalization time, get out of bed time and the degree of anxiety and depression.

At admission, there was no difference in the degree of anxiety (t=0.744, P=0.461) and depression (t=-1.879, P=0.066). After intervention, there were significant differences in the degree of anxiety (t=-5.85, P<0.01) and depression (t=-6.04, P<0.01), exhaust time (t=-2.32, P=0.025), defecation time (t=-2.48, P=0.017), time to get out of bed (t=-3.15, P=0.003) and the hospitalization time (t=-4.05, P<0.01).

ERAS nursing can effectively improve the postoperative recovery after the natural orifice specimen extraction surgery and alleviate the degree of anxiety and depression.

To explore the safety and advantages of using our new self-made transparent screw-thread anal dilator in the treatment of ultra-low rectal cancer through natural orifice specimen extraction surgery (NOSES).

Retrospective analysis of 5 cases in which patients underwent the laparoscopy combined with transanal manual anastomosis precision functional sphincter-preserving NOSES surgery (PPS) for Ultra-Low Rectal Cancer using the new screw-thread anal dilator between May 2018 to June 2018 at Gastrointestinal Surgery Department, Shanghai Tenth People's Hospital. A summary was made of the patients' operation time, intraoperative bleeding volume, length of hospital stay, complications and anal function.

The PPS for Ultra-Low Rectal Cancer was successfully completed in all 5 patients. The average operation time was (217.01±37.75) min, the average intraoperative bleeding volume was (108.32±53.15) mL, the average length of hospital stay after operation was (6.34±1.72) days, average Wexner and Vaizey scores for anal function after operation were 3 points, and no significant complications occurred after operation.

Using the new screw-thread anal dilator in the treatment of ultra-low rectal cancer through PPS has proven to be safe and effective. Incision of abdomen to extract specimen was avoided, and the surgical trauma was significantly reduced. At the same time, the lesion can be precisely resected under direct vision, with post-operative anal function being preserved and improved to a great extent, thus improving quality of life after operation. Moreover, the device is operable, economical and practical; indeed, it is worth promoting and applying in clinic. However, the above conclusions still need to be further validated by clinical studies with large sample sizes.

Natural orifice specimen extraction surgery (NOSES) has been widely used in modern surgical treatment of colorectal cancer. Among them, NOSES for transvaginal specimens of right colon cancer has been proven to be safe and effective, and the trauma is smaller. However, the NOSES of male right colon cancer with transrectal extraction of specimen has not been reported at home and abroad. This article reports a case of total laparoscopic radical surgery for male right colon cancer with transrectal extraction of specimen without auxiliary incision. The aim is to find a way to avoid the auxiliary incision of the abdominal wall for patients with right colon cancer, especially for male patients.

Recently, natural orifice specimen extraction surgery (NOSES) have been developed rapidly in China. ″Chinese consensus of NOSES in colorectal neoplasm (2017)″ and ″International consensus of NOSES in colorectal neoplasm (2017)″ were published, which played important roles in regulating clinical practice of NOSES in China and even all over the world. However, with the improvment of NOSES, the colorectal NOSES has experienced an great progress. In this context, based on the consensus of 2017, the new verson of ″Chinese consensus of NOSES in colorectal neoplasm (2019)″ is revised and published, the theoretical and technical system of NOSES for colorectal cancer is improved in this new consensus in order to better guide clinical practice.

Laparoscopy has been widely used in the field of colorectal surgery. Compared with open surgery, it can reduce incision-related trauma and promote postoperative rehabilitation. However, in order to extract the specimens, laparoscopy-assisted surgery generally requires an abdominal incision, which increases the risk of postoperative pain and incision-related complications. Natural orifice transluminal endoscopic surgery (NOTES) aims to avoid abdominal incision and achieve scar-free surgery, which can not be popularized at present for the limitation of special instruments and difficult technologies. Natural orifice specimen extraction surgery (NOSES) emphasizes the specimen is removed through the natural lumen of the human body on the basis of the mature conventional minimally invasive technique, which can avoid the large incision of abdomen. Therefore, NOSES is easy to be accepted in theory and popularized in practice.

To evaluate the short-term efficacy of NOSES Jinling surgery in the treatment of intractable constipation.

Retrospective analysis of 8 surgical patients performed NOSES Jinling surgery in Jiangsu Subei People′s Hospital from July 2016 to May 2018. The general conditions and postoperative evaluation indexes were recorded.

General conditions: mean operative time (265.63±36.09) min, intraoperative bleeding (40±15.81) mL. NOSES evaluation index: no deaths during perioperative period, first anal exhaust time (61.75±12.13) h, first time of bedtime (50.38±12.39) h, first feeding time (61.13±12.24) h, first defecation time (77.50±12.69) h, postoperative complications (1 case of abdominal infection).

The short-term curative effect of NOSES Jinling surgery in the treatment of intractable constipation is affirmative, and the trauma is small, which can significantly reduce the psychological stress brought by the surgical incision, which is worth further promotion.

To study the feasibility and safety of natural orifice specimen extraction surgery (NOSES) in colorectal neoplasms by collecting the NOSES cases in colorectal surgery.

203 patients with colorectal cancer who underwent NOSES from May 2013 to May 2017 were enrolled. Data were collected including preoperative general data, postoperative pathological data, operative data and follow-up data.

The average age of patients was (58.7±11.9) years, the average BMI was (22.6±3.0) kg/m², 70.8% of neoplasms located in rectal. Pathological results showed that the proportion of middle differentiated adenocarcinoma was 69.4%, the average number of lymph node count was 12.9±5.1 and the average maximum diameter of tumor was (3.6±1.4) cm. The patients in stage I to IV were 23.2%, 41.4%, 24.1% and 3.4% respectively. 87.2% of the patients were treated with rectal specimen extractions and 12.8% by vaginal extractions. The average operation time was (198.9±55.2) minutes and the average blood loss was (73.7±54.2) mL. The average postoperative exhaust time was (44.5±20.5) hours and the average postoperative feeding time was (63.8±15.5) hours. The average postoperative hospital stay was (12.3±4.1) days and the incidence of complications was 11.9%, only two cases received reoperation in the period of hospitalization. The follow-up data showed that postoperative anal dysfunction accounted for 2.2% of total cases and no vaginal dysfunction was detected.

NOSES in colorectal neoplasms seems to be safe and feasible and the short-term effect of NOSES is good. This technology still need to be explored in clinical practice in the future.

In recent years, NOSES has become one of the most representative techniques in minimally invasive surgery. NOSES shows good minimally invasive advantages and caters to the surgeon′s operating philosophy, which has been promoted and popularized in China. However, NOSES is still in the early stages of development, and there are still many problems that need to be faced and addressed. We should not avoid talking about these issues, and we cannot easily deny them. On the contrary, what we should do is to analyze and summarize the existing technology in more depth. This is also the fundamental guarantee and necessary premise for the scientific development of NOSES.

To assess the clinical outcomes of trans-rectal extraction of specimen with double stapling anastomosis and trans-rectal extraction of specimen with single stapling anastomosis of 3D laparoscopic low anterior resection on rectal cancer.

We retrospectively analyzed the clinical and pathological features of 40 patients undergoing 3D laparoscopic anus-preserving operation for rectal cancer during January 2016 to March 2018 at Shanghai East Hospital. All patients were divided into two groups according to different anastomosis methods. (1) Twenty-nine cases were undergone trans-rectal extraction of specimen with double stapling anastomosis. Briefly, the specimen of rectum was moved out through the anus. Then an Endo linear cutting stapler was used to close the rectum. The anastomosis was accomplished with double-stapling technique. (2) Eleven cases were undergone trans-rectal extraction of specimen with single stapling anastomosis. After the specimen of rectum was moved out through the anus, the rectum was closed by purse-string suture with V-Loc stitches rather than the Endo linear cutting stapler. Then, the anastomosis was completed by a circular stapler in an end to end way. The operation time, blood loss, postoperative hospitalization days, exsufflation time, complications rates were compared between two groups. Wexner incontinence scoring criteria was used to assess the function of anal sphincter after the operation.

There was no significant difference between two groups in age, gender, BMI index, Tumor infiltration depth, operation time, blood loss, anal exhaust time, length of hospital stay, postoperative eating liquid time (P>0.05). According to WIS criteria, there were 76.9% patients whose anal sphincter function was good (WIS ≤10), and there was no patient with serious anal incontinence.

In 3D laparoscopic low anterior resection of rectal cancer, either trans-rectal extraction of specimen with double stapling anastomosis or trans-rectal extraction of specimen with single stapling anastomosis should be considered in an individualized way.

Natural orifice specimen extraction surgery (NOSES) can avoid additional abdominal incisions, improve cosmetic outcomes and have quick postoperative recovery. In our center, robotic anterior resection of rectal cancer without additional abdominal incision was performed innovatively using NOSES approach.

During October 2013 to December 2015, totally 19 patients undergoing this surgery were included into presented retrospective study. Patients′ clinicopathological characteristics, perioperative related outcomes, and follow-up outcomes were recorded.

All operations were carried out successfully. Patients recovered well after operation and discharged uneventfully. During the follow-up period, there is no serious abdominal and pelvic infections. No dysuria, sexual function disorder and fecal incontinence were found, and oncological outcomes were acceptable.

Taken together, robotic anterior resection of rectal cancer without abdominal incision is safe and feasible. Still, its long-term outcomes require increasing sample size and further investigation.

To analyse the results of peritoneal lavage cytology and microbiology in patients with total laparoscopic resection for colorectal cancer by NOSES.

Examination of cytology and microbiology of peritoneal lavage were performed for thirty colorectal cancer patients who underwent total laparoscopic resection by NOSES from January 2016 to April 2018, then compared with the other studies reported about peritoneal lavage for cytology and microbiology of open and laparoscopic radical resection for colorectal cancer at home and abroad.

Thirty colorectal cancer patients who underwent total laparoscopic resection by NOSES were performed the examination of peritoneal lavage for cytology and microbiology. There was no patients with positive cytology result (positive rate 0%), ten patients were with positive microbiology result (positive rate 33.3%) , no patients were with abdominopelvic cavity infection and tumor recurrence in abdominopelvic cavity. Our results were similar to the other studies reported about peritoneal lavage for cytology (0%~45.5%) and microbiology (20%~32.5%) of open and laparoscopic radical resection for colorectal cancer at home and abroad.

Total laparoscopic resection for colorectal cancer by NOSES didn't increase the rate of intraperitoneal implantation of colorectal cancer cells and intra-abdominal infections. It is worthy of clinical application and promotion conforming to the principle of aseptic and non tumor.