Total laparoscopic right hemicolectomy with transvaginal specimen extraction for the treatment of right-sided colon cancer: a local experience

doi:10.21203/rs.3.rs-1888546/v1

Background

To investigate the safety, feasibility, and oncological outcomes of total laparoscopic right hemicolectomy with transvaginal specimen extraction in the treatment of right-sided colon cancer.

Methods

We retrospectively reviewed patients with right-sided colon cancer who received total laparoscopic right hemicolectomy in our hospital between January 2017 and January 2020. The patients who underwent abdominal incision were included in the control group and the patients who underwent vaginal incision group were included in the study group. The perioperative characteristics and outcomes were compared between these two groups.

Results

25 patients were included in the study group and 55 patients were included in the control group. In terms of baseline data, including age, preoperative body mass index, American Society of Anesthesiologists classification, tumor transverse diameter, tumor location, pathologic differentiation, preoperative clinical staging, there were no significant differences between the two groups (P > 0.05). There were no significant differences in terms of operative duration, intraoperative blood loss, length of resected colon, number of detected lymph nodes, postoperative complications, and postoperative pathological stages between the two groups (P > 0.05). There were statistically significant differences in postoperative pain intensity, time to passage of flatus, and length of postoperative hospital stay between the two groups (P < 0.05). The sexual function index survey showed a statistically significant difference at 3 months (P < 0.05), but not 6 months (P > 0.05), after the surgery between the two groups. The one-year tumor-free survival rate was 100% in both groups.

Conclusions

Total laparoscopic right hemicolectomy with transvaginal specimen extraction is a safe and feasible method, with satisfactory oncological outcomes, to treat patients with right-sided colon cancer.

Colon cancer

laparoscopic right hemicolectomy

natural orifice transluminal specimen extraction

transvaginal specimen extraction

With the development of minimally invasive techniques, natural orifice specimen extraction surgery (NOSES) without an abdominal wall incision has become increasingly popular especially in the field of colorectal malignancy surgery^[1–4]. However, most of the previously reported colorectal NOSES procedures used the transanal route to extract the specimen. Limited studies have performed NOSES procedures with transvaginal specimen extraction, due to the unfamiliarity of the gynecologic anatomy by colorectal surgeons and the relative technical difficulty in anastomosing resected bowels under the laparoscope. Here, we retrospectively reviewed patients who received total laparoscopic right hemicolectomy with transvaginal specimen extraction to treat right-sided colon cancers in our hospital. We evaluated and compared their clinical characteristics and surgical outcomes with other patients who received total laparoscopic right hemicolectomy with transabdominal specimen extraction during the same period.

Study design and participants

We conducted a retrospective study and reviewed the medical records of patients who received treatment for right-sided colon cancer in our center between January 2017 and January 2020. The study protocol was approved by the hospital Ethics Committee. Informed consent was waived due to the retrospective design of the study.

The inclusion criteria of patients were as follows: 1)all patients voluntarily requested surgery and signed Agreement on Operation; 2) tumor diameter ≤ 5 cm, with no invasion of surrounding tissues or distant metastasis; 3) body mass index (BMI) ≤ 28 kg/m²; 4) no previous major surgery in the abdominal or pelvic area; 5) normal cardiopulmonary functions; 6) all operations were performed by experienced senior chief physicians who had received the same training; 7) received total laparoscopic right hemicolectomy with either transvaginal specimen extraction or transabdominal specimen extraction. Patients with incomplete medical records were excluded from this study.

A total of 80 patients who met the above criteria were retrieved, of which 25 patients underwent transvaginal laparoscopic right hemicolectomy and were included in the study group. There were 55 patients who underwent total laparoscopic right hemicolectomy through abdominal incision and were included in the control group.

Surgical procedure

Patients were given liquid diet one day before operation. Bowel cleaning was performed by oral intake of polyethylene glycol the night before the procedure. Patients who underwent transvaginal specimen extraction received vaginal cleaning with iodine. An indwelling Foley catheter was placed routinely preoperatively. All surgical procedures were performed under general anesthesia with tracheal intubation.

Patients who were scheduled for transvaginal specimen extraction were placed in the lithotomy position with both legs kept flat. The primary operator stood on the left side of the patient and the first assistant stood on the right side. The assistant who held the laparoscope stood between the patient’s legs. Trocars were inserted using a five-hole approach, with a 10-mm hole below the umbilicus for observation, a 12-mm hole in the left upper abdomen wall as the main operation site, and a 5-mm auxiliary operation hole in the left lower abdomen wall. The first assistant controlled two 5-mm auxiliary operation hole in the right upper and right lower abdomen wall. The abdominal cavity was first explored to clarify the location and size of the tumor, as well as any possible peritoneal metastasis. The resected area and the feasibility of transvaginal specimen extraction were assessed. Abdominal surgery was performed as the following steps: 1) consistent with conventional multi-port laparoscopic operation, the retroperitoneum was opened in front of the superior mesenteric vein, the right Toldt fascia was separated and the lymph nodes around the superior mesenteric vessels were cleared (Fig. 1a). At the sites close to the vascular originating points, the ileocolic artery and vein, the right colonic artery and vein, the right branch of the middle colonic artery and vein (or the main trunk of the middle colonic artery and vein in cases of the transverse colon tumor near the hepatic flexure) were separated and clamped (Fig. 1b and 1c). The right colon was fully freed outward and upward along the Toldt fascia, while taking precautions to protect the right ureter and duodenum. The right part of gastrocolic ligament was dissected to free the entire right colon. The sites to resect the ileum and transverse colon were identified and the corresponding mesentery and vessels were dissected. The transverse colon and ileum were resected using an intraluminal linear cutter stapler (Fig. 2a and 2b). 2) The primary operator switched positions with the first assistant and stood on the right side of the patient. The right lower abdominal wall hole was also switched with the left upper abdominal wall hole to become a 12-mm main operating site to anastomose the colon. After placing a stitch to align the end of the ileum with the colon stump and making sure that there was no intestinal torsion, the primary operator used an ultrasonic knife to make a small incision in the opposite corner of each stump. Then, an intraluminal linear cutter stapler was inserted to complete the side-to-side anastomosis of the ileum and transverse colon (Figs. 2c). After the jointed opening was closed by a linear cutter stapler, the site of the anastomosis was reinforced by suturing the seromuscular layer. 3)The resected specimen was placed into a 30–40-cm long sterile bag, which was introduced into the abdominal cavity through the main operating hole (Fig. 3a). The bag was sealed and temporarily stored above the liver. 4) During perineal operation, the patient’s head was lowered and their feet were raised to fully expose the perineum. The posterior vaginal wall was visualized under a vaginal speculum and disinfected with iodine. Following the guidance of oval forceps, the posterior vaginal wall was incised 3–5 cm transversely in the posterior vaginal fornix using an electric knife (Fig. 3b). The bag containing the resected specimen was clamped by the oval forceps and pulled through the vaginal incision to the vaginal opening. The bag was opened to remove the specimen and then the bag was taken out (Fig. 3c). 5) The pneumoperitoneum was re-established, and the pelvic cavity and vagina were irrigated with a diluted iodine solution. The vaginal incision was closed laparoscopically or via the perineum with continuous absorbable sutures. After careful inspections to ensure no intra-abdominal bleeding, intestinal injury, or mesenteric rotation, the abdominal cavity was flushed and the abdominal drainage catheter was placed.

Patients who were scheduled for transabdominal specimen extraction were supinely placed. The steps in the abdominal operation were the same as those described above. Following completion of intestinal reconstruction, the resected specimen was removed through an abdominal incision made approximately 5 cm above the umbilicus. Then, the abdominal cavity was flushed and a drainage catheter was placed under the re-established pneumoperitoneum.

Postoperative pathological staging refered to the 8th edition of UICC TNM Classification of Malignant Tumours. Patients with postoperative pathological assessment of stage IIb (T4aN0M0) or above received routine chemotherapy with the XELOX regimen (capecitabine combined with oxaliplatin) for six courses.

Outcome measurements

Patients were assigned to either the study group (transvaginal specimen extraction) or the control group (transabdominal specimen extraction). The baseline information of the two group is compared, including age, BMI, American Society of Anesthesiologists (ASA) classification, tumor transverse diameter, tumor location, pathologic differentiation, preoperative clinical staging, etc. The operation time, intraoperative blood loss, length of resected bowel, number of harvested lymph nodes, visual analog scale (VAS) for pain intensity, postoperative complications, postoperative anal exhaust time, postoperative length of hospital stay, postoperative pathological staging, sexual activity (female sexual function index [FSFI]) ^[5], and tumor recurrence or metastasis were recorded. Patients were followed up in the clinic or through telephone interview until January 2021.

Statistical analysis

Continuous data are presented as mean ± standard deviation (SD) and compared by student t test. Enumeration data are compared by Chi square test. All statistical analyses were performed in SPSS (version 20.0, IBM, New York, USA). A P-value < 0.05 was considered statistically significant.

In terms of baseline data, including age, preoperative MBI, ASA classification, tumor transverse diameter, tumor location, pathologic differentiation, preoperative clinical staging, there were no significant differences between the two groups (P > 0.05), as shown in Table 1. In terms of intraoperative and postoperative information, including operative duration, intraoperative blood loss, length of resected bowel, number of harvested lymph nodes, postoperative complications, postoperative pathological staging, and numbers of patients received postoperative chemotherapy, there were no significant differences between the two groups (P > 0.05). There were statistically significant differences in the postoperative VAS, time to passage of flatus, and length of postoperative hospital stay between the two groups (P < 0.05) (Table 2).

15 patients in the study group and 35 patients in the control group had preoperative sexual activities and gradually resumed sexual life 3 months after the surgery. The preoperative FSFI was not significantly different between the two groups(P > 0.05). In the study group, the FSFI scores before and at 3 and 6 months after surgery were 22.41±0.76, 19.97±0.60, and 22.25±0.74, respectively, with a significant intragroup difference (P < 0.05). In the control group, there were no significant intragroup difference (P > 0.05). The FSFI was significantly different at 3 months, but not at 6 months, after the surgery between the two groups (Table 3).

In the study group, five patients had postoperative complications. Among them, two patients had postoperative intestinal obstruction, which was relieved by fasting and treatment with somatostatin for 1 week. One patient developed a urinary tract infection, which was treated by oral antibiotics. Two patients developed pulmonary infection. There were no complications such as vaginal bleeding, intra-abdominal bleeding, pelvic infection, and anastomotic leakage or stenosis. In the control group, ten patients developed complications, including three patients with intestinal obstruction, two patients with urinary tract infection, and five patients with pulmonary infection.

The follow-up time was 12 ~ 36 months. The median follow-up time was 20 months in the study group and 21 months in the control group. The 1-year survival rate was 100% in both groups, with no tumor recurrence or metastasis identified.

After more than two decades of developments, laparoscopic procedures have been widely used in colorectal cancer surgery. Several studies have also demonstrated that laparoscopic colorectal cancer surgery has the advantages of less pain, early recovery of gastrointestinal function, shorter length of hospital stay, and better cosmetic results than open surgery^[6–8]. These studies also confirmed that the oncological effect of laparoscopic surgery is similar to that of open surgery. Currently, laparoscopic right hemicolectomy (including extended right hemicolectomy) is the routine choice to treat right-sided colon cancer (including tumors located in the cecum, ascending colon, and hepatic flexure of the colon). However, in addition to 4–5 abdominal wall holes for the laparoscopic procedure, the current laparoscopic right hemicolectomy also requires a 4–6-cm long auxiliary abdominal wall incision to extract the resected specimen and complete the extracorporeal bowel anastomosis. These abdominal wall incisions can result in abdominal wall trauma, postoperative wound pain, increased risk of incision-related complications (such as postoperative incisional infection, intestinal adhesions at the site of incision, incisional hernia, incisional tumor implantation), poor cosmetic outcomes, delayed postoperative ambulation and hospital discharge time, and increased medical expenses ^[9–11]. One study even reported that laparoscopic colorectal cancer surgery with specimen extraction through a median abdominal auxiliary incision had similar incidences of incisional hernia and infection compared to open surgery ^[12]. Therefore, it is important to develop minimally invasive methods to extract the resected specimen and decrease the surgical risks.

In recent years, with further advances in minimally invasive surgery in the field of colorectal surgery, some new techniques have been developed to alleviate trauma from the abdominal wall auxiliary incision; these include transumbilical single-port laparoscopic surgery, natural orifice transluminal endoscopic surgery (NOTES), and NOSES. However, single-port transumbilical laparoscopic colorectal surgery has some technical limitations, including insufficient visual field exposure, as well as interferences and collisions of instruments in the abdominal cavity ^{[13, 14]}; these have limited its application in colorectal surgery. Moreover, complete NOTES remains under investigation in animal experiments and simple clinical trials due to the shortage of satisfactory operating instruments, the lack of surgical experience and ethical considerations^[15]. Therefore, further research is required before NOTES is widely adopted in clinical practice.

As a bridge procedure between traditional laparoscopic surgery and NOTES, NOSES does not only have the advantages of traditional laparoscopic surgery, but also improve the cosmetic outcome of the incision, reduces postoperative pain, accelerates the recovery of gastrointestinal functions, and minimizes incision-related complications ^[4,6−8]. NOSES also has a relatively short learning curve and requires no special surgical instruments. As a result, NOSES has gradually become a favored procedure by minimally invasive surgeons, with an increasing number of reported NOSES performed for colorectal cancer. At this time, the most frequently used methods to remove resected specimens during NOSES for colorectal cancer are through the transanal or transvaginal route. The anus is the preferred lumen to extract the colorectal specimens, which is consistent with the basic requirements of minimally invasive surgery and is more frequently reported in the literature. However, the transanal route can be affected by the location and size of the tumor, and is therefore only indicated for patients with small and low-situated tumors (usually located at the distal sigmoid and rectum). Compared to the anus, the vagina has advantages including better elasticity, a more adequate blood supply, stronger healing ability, and easier operation ^[16–18]. Therefore, the transvaginal route is considered to be the ideal choice for specimen retrieval for the laparoscopic colorectal surgery on large and high-situated tumors (such as laparoscopic right hemicolectomy). Literature from various locations worldwide has reported that this procedure was performed to extract the specimen via the transvaginal route during colorectal cancer surgery ^[16–20]. However, transvaginal NOSES during colorectal cancer surgery has not yet gained widespread clinical applications due to the following limitations: 1) the technique can only be performed in female patients; 2) the vaginal wall incision may increase the risk of associated complications, such as vaginal paresthesia, delivery disorder, dysmenorrhea, and sexual dysfunction; 3) technical difficulty in completing the endoscopic bowel anastomosis during the right hemicolectomy; and 4) ethical considerations. Among the above factors, concern about sexual dysfunction is the most common.

To explore the optimal surgical approach to extract the resected specimen during laparoscopic right hemicolectomy, we selected some patients with early stage right-sided colon cancer to perform laparoscopic right hemicolectomy with transvaginal specimen extraction. The short-term outcomes were encouraging. There were no complications associated with vaginal incision, such as vaginal bleeding, pain, abnormal sensation, or pelvic abscess.

The 15 patients in the study who had sexual activities before the surgery gradually resumed their sexual life 3–6 months after the surgery. There was no significant difference about the FSFI scores before and 6 months after surgery. This indicated that the postoperative sexual life may be improved due to the disappearance of physical discomfort symptoms and the gradual improvement of patients' mood after lesion resection. Several international retrospective studies have also shown that laparoscopic right hemicolectomy with transvaginal specimen extraction had no significant effect on the vaginal sensation, ability to achieve orgasm, pregnancy rate, or incidence of dyspareunia ^{[19, 20]}.

Tumor recurrence and pelvic implant metastasis are very worrying problems in transvaginal surgery. Several studies have compared the data between conventional laparoscopic colorectal cancer surgery and transvaginal NOSES surgery ^[21–24]. The outcomes of these two procedures were comparable with no evidence of vaginal metastasis in the later procedure. Therefore, transvaginal NOSES was considered an oncologically safe procedure. In our study, we found no patients with tumor recurrence or pelvic implant metastasis. Therefore, we believe that the risk of tumor recurrence and pelvic implant metastasis of transvaginal NOSES should not be higher than that of traditional laparoscopic surgery as long as the principles of surgical oncology and specimen handling norms are observed.

In order to reduce complications and achieve the best therapeutic effect, we believe that the following points should be paid attention to in the perioperative period: 1) Adequate intestinal preparation was performed before operation to avoid contamination of the abdominal cavity by fecal materials during intraoperative intestinal dissection. Before intraperitoneal intestinal dissection, iodine gauze was placed around the intestine for protection, and after the surgery, diluted iodine solution was used to flush the abdominal cavity. No incidences of abdominal or pelvic infections occurred in our study. 2) The excised specimen was tightly sealed in a specimen bag and then removed through the vagina to avoid the shedding and implantation of the tumor cells caused by squeezing the tumor during the process of specimen extraction. 3) Although the main operation hole was in the left upper abdomen wall, the operating surgeon switched to the right lower abdomen operation hole to obtain better angle and space for the bowel anastomosis. When closing the jointed opening, we placed three stitches first to pull and align together the opposite sides of ileum and transverse colon. After the anastomosis, we further sutured the seromuscular layer to wrap around the anastomosis to reduce the incidence of anastomotic leakage. 4) The vaginal incision should be at the posterior fornix, given that it was easy to operate due to the lack of adjacent important organs and fewer nerves and blood vessels than the rest of the posterior wall. 5) Before the incision of the vagina, it is important to assess the tumor size, mesangial hypertrophy, and the feasibility of extracting the specimen through the vagina. Every effort should be applied to avoid tearing the vagina during the extraction. 6) NOSES surgery commonly carries certain technical difficulties, and the duration of the procedure is long, involving trimming of the resected intestinal mesentery and anastomosing the ileum and transverse colon under the laparoscope. Therefore, the procedure should be performed by surgeons experienced in laparoscopic surgery to ensure the quality of the operation and to reduce the incidence of serious complications such as anastomotic leakage and stenosis.

Transvaginal laparoscopic right hemicolectomy for the treatment of right colon cancer is technically safe and feasible and had satisfactory mid-term oncological outcomes, thought the long-term effect still needs to be verified by a larger sample of prospective randomized controlled trials. The indications of surgery should be strictly mastered before conclusive evidence-based medical evidence is obtained.

NOSES , natural orifice specimen extraction surgery

BMI,body mass index

ASA,American Society of Anesthesiologists

UICC, Union for International Cancer Control

TNM, tumor, node and metastasis

VAS, visual analog scale

FSFI, female sexual function index

SD, standard deviation

NOTES, natural orifice transluminal endoscopic surgery

Ethics and Consent to participate

The study have been performed in accordance with the guidelines and regulations of the Declaration of Helsinki and had the approval of the Medical Ethics Committee of the First People’s Hospital of Foshan. The informed consent of all subjects or their legal guardians has been obtained for this study.

Consent for publication

Jianzhong Deng, Zilang Zhang, Yiban Lin, Xiaoxi Guo, Zhaoyang Li, Si Yu have approved submission of the manuscript for publication.

Availability of data and materials

The datasets generated during the current study are not publicly available due to some relevant local regulations but are available from the corresponding author on reasonable request.

Funding

The study didn’t get any support in the form of funds, grants, equipment drugs, or all of these.

Authors Contributions

Jianzhong Deng was responsible for summarization and writing. Si Yu was responsible for correspondence and design and guidance of the study. Zilang Zhang and Yiban Lin was responsible for preparatory work. Xiaoxi Guo and Zhaoyang Li was responsible for implementation of the study.

Competing interests

Jianzhong Deng, Zilang Zhang, Yiban Li, Xiaoxi Guo, Zhaoyang Li and Si Yu have no financial and non-financial competing interests.

Acknowledgments

All the authors express sincere thanks to all colleagues in the Department of General Surgery of The First People’s Hospital of Foshan for their help in this study.

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table1 Comparison of baseline data between study group and control group
			Study group	Control group	T/χ²	P	Note
n			25	55
Age(years)			62.2±8.7	63.7±5.5	-0.942	0.349	T test
Mean preoperative BMI(kg/m²)			23.6±1.1	24.1±1.0	-1.805	0.075	T test
ASA classification		I	5	10	0.141	0.932	χ²test
		II	15	32
		III	5	13
Mean tumor diameter(cm)			4.2±0.8	4.5±0.8	-1.553	0.124	T test
Tumor location	Cecum/ascending colon		10	20	0.097	0.755	χ²test
	the hepatic flexure/transverse colon		15	35
Pathologic differentiation	High differentiation		5	12	0.607	0.738	χ²test
	Moderate differentiation		17	33
	Low differentiation		3	10
Preoperative clinical staging	II		7	20	0.538	0.463	χ²test
	III		18	35
Note：study group：transvaginal specimen extraction；control group：transabdominal specimen extraction。P < 0.05 was considered to be statistically significant.

Table 2 Comparison of intraoperative and postoperative conditions between the two group
		Study group	Control group	T/χ²	P	Note
n		25	55
Mean operation time(min)		202±29	195±13	1.318	0.191	T test
Mean blood loss(ml)		62±28	66±25	-0.645	0.521	T test
Mean length of resected bowel(cm)		35±5	37±4	-1.094	0.277	T test
Mean number of harvested lymph nodes		22±4	20±4	1.638	0.106	T test
Cases of postoperative complications		5	10	0.037	0.847	χ²test
Postoperative pathological staging	I	5	10	0.555	0.758	χ²test
	II	11	29
	III	9	16
Cases of postoperative chemotherapy cases		15	30	0.208	0.649	χ²test
Mean postoperative VAS		3.2±1.0	4.8±1.2	-6.026	0.000	T test
Mean postoperative anal exhaust time(h)		73±11	89±10	-6.542	0.000	T test
Mean postoperative hospital stay(d)		7.4±1.0	8.5±1.0	-4.678	0.000	T test
Note：study group：transvaginal specimen extraction；control group：transabdominal specimen extraction。P < 0.05 was considered to be statistically significant.

Table 3 Comparison of FSFI in/between the two groups
groups time	Before operation (A)	3 months after operation (B)	T (Comparison between A and B)	P (Comparison between A and B)	6 months after operation (C)	T (Comparison between A and C)	P (Comparison between A and C)
The study group(n=15)	22.41±0.76	19.97±0.60	9.753	0.000	22.25±0.74	0.573	0.571
The control group(n=35)	22.28±0.71	22.04±1.62	0.801	0.427	22.16±0.86	0.605	0.547
T	0.574	-6.588			0.338
p	0.569	0.000			0.736
Note：the study group：transvaginal specimen extraction；the control group：transabdominal specimen extraction。P < 0.05 was considered to be statistically significant. FSFI：female sexual function index.

No competing interests reported.

Total laparoscopic right hemicolectomy with transvaginal specimen extraction for the treatment of right-sided colon cancer: a local experience

Status:

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Abstract

Background

Methods

Results

Conclusions

Figures

Introduction

Materials And Methods

Study design and participants

Surgical procedure

Outcome measurements

Statistical analysis

Results

Discussion

Conclusion

Abbreviations

Declarations

References

Tables

Additional Declarations

Status:

Version 1