Transanal Or Transabdominal Specimen Extraction After Laparoscopic Left Colectomy: Clinical Prospective Evaluation of Peritoneal Contamination Risks

Joel Leroy, MD FRCS, Federico Costantino, MD, Michele Diana, MD, Jacopo D’Agostino, MD, Didier Mutter, MD PhD, James Wu, MD, Jacques Marescaux, MD FRCS FACS. IRCAD-EITS, Department of Digestive and Endocrine Surgery, University Hospital of Strasbourg, France

Introduction: This prospective study aims to evaluate bacterial peritoneal contamination between different techniques of transabdominal or transanal specimen extraction in a consecutive cohort of patients requiring laparoscopic left colostomies.

Methods: During a 6-month period, we consecutively evaluated the presence of peritoneal cavity contamination in laparoscopic left colectomies using two different specimen extraction techniques, the transanal route with opening of the rectal stump or the classic route (transabdominal extraction using a short laparotomy). Systematic intraoperative bacteriological sampling was performed at the end of the procedure. Intraoperative data as well as microbiological and postoperative outcomes were evaluated prospectively.

Results: A total of 26 consecutive patients were included prospectively. In 16 (61.5%) patients, the specimen was delivery transanally. In the remaining 10 (38.5%) patients, a mini-laparotomy was used. All procedures were performed completely by laparoscopy. Mean operative time was 120 (+ / -41.9) and 117 (+ / -45.2) minutes for the transanal and the transabdominal route respectively. Contamination was present in 100% of intraoperative samples in both groups. Polybacterial growth was present in all peritoneal culture samples during the transanal specimen extraction but only in 80% patients when the transabdominal route was used. No wound infection-related complication were observed in both groups. Only a pelvic abscess was observed in 1 patient in the transabdominal group.

Conclusion: Peritoneal contamination may occur in laparoscopic colorectal surgery, regardless of the route chosen for surgical specimen extraction. The actual published rate of morbidity related to abdominal incisions during laparoscopic surgical procedures (infection and incisional hernia) can be reduced by specimen extraction through natural orifices. Extraction of the specimen through the anus does not increase risk of wound or intra-abdominal infection. Specimen anus delivery can be the way to allow a full development of NOTES techniques. More studies are nevertheless required to confirm these findings.