NOSE — Keyhole Bowel Surgery with Natural Orifice Specimen Extraction

NOSE (Natural Orifice Specimen Extraction) is an extraction method used in keyhole (laparoscopic) bowel operations. In standard keyhole operations the surgeon works through a few small openings in the abdominal wall; however, an additional incision of a few centimetres is usually needed to take out the removed piece of bowel. With the NOSE method, this additional incision is not needed.

The tissue that needs to be removed is taken out in a protective sleeve through one of the body’s natural openings — the back passage (anus) or, in female patients, the vagina. This eliminates the largest incision in the abdominal wall; it is thought that this may help reduce wound pain and the likelihood of wound infection and incisional hernia.

NOSE is a field in which scientific research is ongoing worldwide and in Türkiye. Prof. Dr. Ersin Gündoğan also has international scientific publications on this subject.

The NOSE method is mostly considered in operations on the large bowel (colon) and the rectum (the last part of the large bowel). It may be considered in the following situations:

• Colon or rectal tumours of suitable size and stage
• Large polyps that cannot be removed endoscopically
• Benign bowel diseases requiring surgery, such as diverticular disease

The method is not suitable for every patient. The size of the tissue to be removed, the location and stage of the tumour, body build, previous abdominal operations and accompanying illnesses affect the decision. With very large tumours or a narrow pelvis, extraction through a natural opening may not be possible. Whether it is suitable for you is decided together with your doctor after assessing your examination and imaging results.

The operation is performed under general anaesthesia. A camera and surgical instruments are inserted through a few small openings (about 0.5–1 cm) in the abdominal wall; the whole operation is carried out by the keyhole method, guided by the screen image.

After the diseased part of the bowel has been freed from the surrounding tissues and cut, the piece to be removed is placed in a protective bag or sleeve inside the abdomen. It is then taken out through the back passage or, in female patients, through a small passage made in the back wall of the vagina. The remaining ends of the bowel are rejoined inside the abdomen with special instruments (anastomosis). If extraction was through the vagina, the small opening there is repaired with stitches.

At the end of the operation, only small scars from the instrument entry sites remain on the abdomen; no separate large incision is made to remove the tissue.

As with any operation, the NOSE method carries some risks:

• General risks of bleeding, infection and those related to anaesthesia
• Leakage where the bowel ends are joined (anastomotic leak)
• Infection inside the abdomen due to bowel contents spilling into the abdomen; measures such as a protective sleeve and washing are used to reduce this risk
• Injury to the natural opening through which the tissue is removed; with extraction through the vagina, short-term discharge or tenderness
• Switching to the open method if considered necessary during the operation (conversion)

The likelihood of these risks in your situation varies from person to person. At the pre-operative consultation, your doctor will assess the possible risks with you in detail.

The hospital stay is usually a few days; this period may vary according to the extent of the operation and your general health. Getting up early and starting to eat and drink as your doctor recommends support recovery.

Because there is no large incision in the abdominal wall, pain may be milder in most patients; nevertheless, the experience of pain is individual and the necessary pain control is provided. The removed tissue is sent for pathology examination; the result is shared with you at the follow-up examination. If you were operated on because of a tumour, your follow-up plan is arranged according to this result.

After discharge, if symptoms such as fever, increasing abdominal pain, unexpected bleeding from the back passage or the vagina, or vomiting occur, it is important to contact your doctor without delay.