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Year : 2019  |  Volume : 2  |  Issue : 2  |  Page : 35-37

Alternative specimen extraction techniques complimenting enhanced recovery after surgery protocol in gastrointestinal malignancies: An early experience

Department of Laparoscopic and General Surgery, Sir Ganga Ram Hospital, Delhi, India

Date of Submission21-Jun-2020
Date of Acceptance04-Aug-2020
Date of Web Publication11-Aug-2020

Correspondence Address:
Neeraj Dhamija
C4A/48 C, Janakpuri, New Delhi - 110 058
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJCS.IJCS_8_20

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Background: Minimally invasive surgery is being increasingly implemented for Gastrointestinal (GI) malignancies. Site of specimen extraction after surgery influence the postoperative course by adding up-to the parietal wound morbidity. We studied the effect of alternative specimen extraction techniques on postoperative recovery and ease of implementation of ERAS protocol. Results: A single center prospective data of 32 patients were compiled and the alternative specimen extraction sites studied were Natural Orifice Specimen Extraction-Vagina (n=8), Proposed Stoma Site Specimen Extraction (n=19), Trans Anal Specimen Extraction (n=5). All the patients had ease in the implementation of ERAS protocol and showed enhance recovery after the surgery with minimal wound related morbidity. The average duration of stay in the hospital was 5.8 days (SD=1.4) and the time to start adjuvant therapy when needed was an average of 21.7 days (SD= 5.46). Conclusion: Alternative Specimen extraction techniques other than routine laparotomy compliment ERAS protocol initiation and implementation in patients undergoing Minimally invasive GI Oncological Surgery.

Keywords: Enhanced recovery after surgery protocol, minimally invasive surgery, specimen extraction

How to cite this article:
Dhamija N, Agarwal BB. Alternative specimen extraction techniques complimenting enhanced recovery after surgery protocol in gastrointestinal malignancies: An early experience. Indian J Colo-Rectal Surg 2019;2:35-7

How to cite this URL:
Dhamija N, Agarwal BB. Alternative specimen extraction techniques complimenting enhanced recovery after surgery protocol in gastrointestinal malignancies: An early experience. Indian J Colo-Rectal Surg [serial online] 2019 [cited 2022 Sep 25];2:35-7. Available from: https://www.ijcrsonweb.org/text.asp?2019/2/2/35/291869

  Introduction Top

Minimally invasive surgery (MIS) by decreasing wound-related parietal morbidity results in ease of implementation of the enhanced recovery after surgery (ERAS) protocol in gastrointestinal (GI) surgery.[1] Compared to traditional open technique, MIS results in less morbid parietal wound and leads to early ambulation and shortens convalescence.[2] When MIS is done for a GI malignancy, specimen extraction through laparotomy incision results in partial loss of the benefits of the MIS technique and causes an avoidable delay in the postoperative convalescence.

Any means of reducing the parietal wound morbidity by alternative techniques of specimen extraction following GI surgery will enhance and compliment the implementation of the ERAS protocols and results in hastened recovery and shorter convalescence following major abdominal surgery.[3]

In this study, we evaluated specimen extraction techniques other than routine laparotomy, post-GI surgical procedure, and its impact on the postoperative outcome.

  Materials and Methods Top

The study was conducted in the Department of Laparoscopic and General Surgery, Sir Ganga Ram Hospital, Delhi, India. All patients who underwent minimally invasive (laparoscopic and robotic) resection for GI malignancies between July 2014 and February 2020 were included in the study. Data were collected based on the previously set pro forma. Specific mention was made for factors influencing postoperative recovery including wound-related morbidity, time to discharge, and time to start adjuvant therapy wherever indicated. As a standard, all patients had implementation of the standard ERAS protocol in the postoperative period as per our set pro forma.

  Results Top

A total of 150 patients who justified the inclusion criteria were included in the study. Special consideration on the site of specimen extraction was made postminimally invasive resection. Out of 150 patients, 96 patients had routine extensions of the minimally invasive port site incisions and were excluded from the study. Another ten patients had conversion to open technique at various steps of procedure who were also excluded from the study.

Out of the remaining 44 patients, 12 patients have incomplete data or lost to follow-up for evaluation and were also excluded from the study.

A total of 32 patients were finally included for data analysis, the results of which are summarized in [Table 1].
Table 1: Demographic profile and clinical course

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  Discussion Top

Application of the minimally invasive route and ERAS protocol after surgery has proven its worth in the improvement of the postoperative outcome.[1],[4] Specimen extraction adds to the morbidity, especially after performing 80%–90% of the surgical procedure with the minimally invasive technique. The parietal wound created for the extraction of specimen is the major cause of concern as it can get infected, delays ambulation and prolongs hospital stay due to pain, and is prone to seedling by the underlying malignant disease from the extracted specimen.[5]

Any technique which reduces the parietal wound morbidity is a welcome approach to reduce the morbidity and thereby shortens convalescence. Furthermore, it will also result in early start of the adjuvant therapy whenever required.[6]

We specifically adapted means to reduce this parietal wound morbidity and made a special consideration on time to start chemotherapy postmajor abdominal surgery by minimally invasive technique for GI malignancies.

In our study, we had utilized the following alternative means of specimen extraction adapted in the study:

  • Proposed stoma site specimen extraction (PSSE) – 19/32 cases
  • Transanal specimen extraction (TASE) – 5/32 cases
  • Natural orifice specimen extraction (vagina) (NOSE-V) – 8/32 cases
  • Total number of cases = 32.
The median age of the patients was 56 years. The mean BMI was 29.36 kg/m2. The average duration of stay in the hospital was 5.8 days (standard deviation [SD] = 1.4). The average time duration to start chemotherapy was 21.7 days (SD = 5.46). The mean duration of follow-up was 9.5 months (SD = 6.08).

We had only one wound-related issue (3.1%) in a patient where specimen was extracted through the stoma site. The patient had a wound infection from the stoma skin margin which was managed conservatively. Morbidity specific to the different procedure as in Minimally invasive Pancreatic surgery is not discussed in detail and is beyond the scope of this article. During the mean period of follow-up of 9.5 months, we had a zero rate of surgical incision site hernias.

  Conclusion Top

MIS and ERAS protocol leads to shorter duration of convalescence.

Specimen extraction techniques such as PSSE, TASE, and NOSE-V lead to reduced parietal wound morbidity and thereby complimenting MIS and ERAS protocols.

PSPE, TASE, and NOSE may be adapted as an alternative site for specimen extraction while performing GI surgeries with acceptable morbidity in a select group of patients.

Further studies with larger case pools are needed to support the results of this early experience.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Pache B, Hübner M, Jurt J, Demartines N, Grass F. Minimally invasive surgery and enhanced recovery after sustablrgery: The ideal combination? J Surg Oncol 2017;116:613-6.  Back to cited text no. 1
Stănciulea O, Eftimie M, Moşteanu I, Tivadar B, Blăniţă D, Popescu I. Minimally invasive colorectal surgery - Present and future trends. Chirurgia (Bucur). 2019;114:167-173.  Back to cited text no. 2
Lukovich P, Bokor A. A laparoszkópos sebészet invazivitásának csökkentése természetes szájadékok és hasfali defektusok felhasználásával a műtéti specimen eltávolítására [Reducing invasiveness of laparoscopic surgery using natural orifices and abdominal wall defects for extraction of the specimen]. Orv Hetil 2015;156:552-7.  Back to cited text no. 3
Neeraj D, Agarwal B. Optimizing outcomes of colorectal surgery – The current perspectives. Current Med Res Pract 2016;6:69-78.  Back to cited text no. 4
Winslow ER, Fleshman JW, Birnbaum EH, Brunt LM. Wound complications of laparoscopic vs. open colectomy. Surg Endosc 2002;16:1420-5.  Back to cited text no. 5
Amore Bonapasta S, Checcacci P, Guerra F, Mirasolo VM, Moraldi L, Ferrara A, et al. Time-to-administration in postoperative chemotherapy for colorectal cancer: Does minimally-invasive surgery help? Minerva Chir 2016;71:173-9.  Back to cited text no. 6


  [Table 1]


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