Laparoscopic natural orifice specimen extraction for diverticular disease: a systematic review

Background: Diverticular disease is extremely common in the Western world, with a proportion of complications requiring colonic resection. Whilst laparoscopic surgery has its benefits, a large wound for specimen extraction predisposes to surgical site infection, prolonged pain and prolonged hospital admission. Natural orifice specimen extraction (NOSE) is an alternative technique that has not yet been widely adopted in diverticular disease surgery. The aim of this systematic review is to evaluate the evidence on the outcomes of NOSE in left sided resections for diverticular disease. Methods: A systematic review of PubMed, Ovid MEDLINE and EMBASE was performed to identify studies that reported outcomes for left sided resections with NOSE in diverticular disease. The studies reviewed were all human studies published in a peer-reviewed journal after 2010. The participants had to be over the age of 18 and the extraction site had to be transanal/transrectal. Articles that were not full text or not in English were excluded. These studies were assessed independently by two reviewers using a standardised pre-piloted form. Results: One hundred and eighty-seven articles were screened, with 9 articles meeting the inclusion criteria. The study sample size ranged from 8 to 157 participants, with a pooled total of 428 patients who had NOSE. Hospital length of stay varied from 4 to 6 days. Only 2 patients required conversion to transabdominal extraction. Pain scores were lower post-NOSE compared to traditional abdominal extraction in 2 out of 3 studies. The anastomotic leak rate varied from 0 to 18%. Six studies reported no surgical site infections and there was only 1 mortality. Conclusion: NOSE is a safe and feasible option for patients requiring left sided resection for diverticular disease based on the current available data. The literature demonstrates low rates of surgical site infection, mortality and reduced hospital length of stay.