EP161 - Technical Challenges in Transanal Specimen Extraction of Specimens in Robotic-Assisted Colectomy

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Purpose/Background: Natural orifice specimen extraction (NOSE) has been shown in studies of laparoscopic colorectal surgery to further reduce postoperative pain and length of stay by minimizing incision size. We sought to evaluate the feasibility of transanal specimen extraction in robotic-assisted partial colectomy by evaluating length of surgery, hospital length of stay, days to return of bowel function, and rates of significant complications. Our data indicate that this method is safe for patients undergoing robotic-assisted partial colectomy for a variety of indications, and that it can contribute to decreased postoperative pain, time to return of bowel function, and length of hospital stay without significantly increasing the rate of postoperative complications. Importantly, patient selection for this operation is essential for good outcomes and successful transanal specimen extraction.

Methods/Interventions: In a single-center case series of 19 patients undergoing robotic-assisted partial colectomy with transanal specimen extraction (TRE) between May 2022—September 2024, patients underwent surgery for diverticulitis (6), colonic dysmotility (1), rectal prolapse (5), sigmoid volvulus (1), unresectable sigmoid polyp (1), and sigmoid cancer (4).

Results/Outcomes: Average operative time among all 19 patients was 190.26 minutes (SD = ± 52.9min), or approximately 3 hours 10 minutes. Average length of stay was 2.84 days (SD ± 1.17d, range 1-5d). Average time to postoperative return of bowel function was 2 days (SD ± 0.82d, range 1-4d). Factors associated with inability to successfully perform TRE were specimen size, patient sex, patient anatomy and pelvic dimensions, and tumor size in cases of oncologic resection. Patients assigned female at birth (identifying as women or nonbinary / gender non-conforming) were more likely than men to successfully undergo TRE in our case series (13 women, 6 men). Patients were more likely to be able to undergo successful TRE when presenting for partial colectomy for non-oncologic indications (14 of 19 patients, 73.7%), due to the increased specimen size and concern for the need for full oncologic resection with nodal dissection in patients with colorectal cancer. Surgeon comfort with this method is also essential; throughout the 2 years of data collection, average operative times and length of stay downtrended, although these correlations were modest (operative time R2 = 0.0939, length of stay R2 = 0.1861).

Conclusion/Discussion: Prudent patient selection is critical for surgeons hoping to perform robotic-assisted colectomy with transanal specimen extraction. When applied to the appropriate patient population, this technique can avoid an additional or larger incision in patients undergoing robotic-assisted colon resection for a variety of indications. Future studies of robotic-assisted transrectal specimen extraction should compare these patients to patients undergoing traditional incisional extraction and evaluate differences in length of stay, time to return of bowel function, postoperative pain, postoperative complications, and pathologic margins in oncologic patients. These future studies can also help develop practice guidelines for which patients are candidates for NOSE based on their surgical indication, the size of specimen, and other anatomic constraints, and to allow for improved preoperative counseling and physician-patient discussion on the risks and benefits of NOSE versus incisional extraction.