Surgical Endoscopy

, Volume 32, Issue 3, pp 1336–1343 | Cite as

Inflammatory response and peritoneal contamination after transrectal natural orifice specimen extraction (NOSE) versus mini-laparotomy: a porcine in vivo study

  • Jonas D. Senft
  • Tilman Dröscher
  • Philip Gath
  • Philip C. Müller
  • Adrian Billeter
  • Beat P. Müller-Stich
  • Georg R. Linke



Transrectal natural orifice specimen extraction (NOSE) avoids abdominal organ retrieval during laparoscopic procedures and may reduce surgical trauma. However, this has not been proven clinically and transrectal peritoneal contamination is feared to cause infectious complications. This experimental study was designed to evaluate inflammatory response and peritoneal contamination after transrectal NOSE versus mini-laparotomy.


24 German Landrace pigs underwent transrectal NOSE (N = 12) or mini-laparotomy (N = 12) for standardized extraction of water-instilled balloon. Blood samples were taken for analysis of leucocytes, CRP, IL-6, IL-10, and TNFα at 6, 12, 24, 48, 72 h as well as 7 and 14 days postoperatively. After 14 days laparoscopy was performed to inspect the abdomen and for microbiological swab sampling.


Leucocytes were higher in the NOSE group at 72 h (19.3 ± 3.9/nl vs. 15.8 ± 4.2/nl, p = 0.046). IL-6 was lower in the NOSE group at day 7 (165 ± 100/nl vs. 306 ± 70/nl, p = 0.030). No difference was found comparing inflammatory parameters at all other time points. No difference was found regarding peritoneal contamination, which was 58.3% (7/12) in the NOSE group and 41.7% (5/12) in the MiniLap group (p = 0.414).


The results suggest a pronounced acute inflammatory response after transrectal NOSE compared to mini-laparotomy, while late cytokine response seems to be less after transrectal NOSE, which may reflect less intense wound healing process. Using standardized rectal decontamination and endolumenal colon occlusion transrectal NOSE seems to be safe and comparable to mini-laparotomy with regard to peritoneal contamination. Clinical evidence is needed now to weight transrectal NOSE against mini-laparotomy during laparoscopic surgery.


Endoscopy Natural orifice specimen extraction (NOSE) Natural orifice translumenal endoscopic surgery (NOTES) Transanal Transrectal 



Natural orifice specimen extraction


Natural orifice translumenal endoscopic surgery



The authors wish to thank Béivin Pyne for revising this manuscript as a native English speaker.


This study was funded by institutional means of the University of Heidelberg.

Compliance with ethical standards


This study was funded solely by institutional means from the University Hospital of Heidelberg. The authors Jonas D. Senft, Tilman Dröscher, Philip Gath, Philip C. Müller, Adrian Billeter, Beat P. Müller-Stich and Georg R. Linke have no conflict of interest or financial ties to disclose.


  1. 1.
    Lehmann KS, Ritz JP, Wibmer A, Gellert K, Zornig C, Burghardt J, Büsing M, Runkel N, Kohlhaw K, Albrecht R, Kirchner TG, Arlt G, Mall JW, Butters M, Bulian DR, Bretschneider J, Holmer C, Buhr HJ (2010) The German registry for natural orifice translumenal endoscopic surgery: report of the first 551 patients. Ann Surg 252:263–270. doi: 10.1097/SLA.0b013e3181e6240f CrossRefPubMedGoogle Scholar
  2. 2.
    Zorron R, Phillips HN, Coelho D, Flach L, Lemos FB, Vassallo RC (2012) Perirectal NOTES access: “down-to-up” total mesorectal excision for rectal cancer. Surg Innov 19:11–19. doi: 10.1177/1553350611409956 CrossRefPubMedGoogle Scholar
  3. 3.
    Leroy J, Costantino F, Cahill RA, D’Agostino J, Morales A, Mutter D, Marescaux J (2011) Laparoscopic resection with transanal specimen extraction for sigmoid diverticulitis. Br J Surg 98:1327–1334. doi: 10.1002/bjs.7517 CrossRefPubMedGoogle Scholar
  4. 4.
    Wolthuis AM, Fieuws S, Van Den Bosch A, de Buck van Overstraeten A, D’Hoore A (2015) Randomized clinical trial of laparoscopic colectomy with or without natural-orifice specimen extraction. Br J Surg 102:630–637. doi: 10.1002/bjs.9757 CrossRefPubMedGoogle Scholar
  5. 5.
    Ni Choileain N, Redmond HP (2006) Cell response to surgery. Arch Surg 141:1132–1140. doi: 10.1001/archsurg.141.11.1132 CrossRefPubMedGoogle Scholar
  6. 6.
    Costantino FA, Diana M, Wall J, Leroy J, Mutter D, Marescaux J (2012) Prospective evaluation of peritoneal fluid contamination following transabdominal vs. transanal specimen extraction in laparoscopic left-sided colorectal resections. Surg Endosc 26:1495–1500. doi: 10.1007/s00464-011-2066-6 CrossRefPubMedGoogle Scholar
  7. 7.
    Sidhwa F, Itani KMF (2015) Skin preparation before surgery: options and evidence. Surg Infect (Larchmt) 16:14–23. doi: 10.1089/sur.2015.010 CrossRefGoogle Scholar
  8. 8.
    Senft JD, Carstensen B, Mischnik A, Warschkow R, Müller-Stich BP, Linke GR (2015) Endolumenal colon occlusion reduces peritoneal contamination during a transrectal NOTES procedure: a controlled porcine survival study. Surg Endosc. doi: 10.1007/s00464-015-4582-2 PubMedGoogle Scholar
  9. 9.
    Müller-Stich BP, Senft JD, Lasitschka F, Shevchenko M, Billeter AT, Bruckner T, Kenngott HG, Fischer L, Gehrig T (2014) Polypropylene, polyester or polytetrafluoroethylene-is there an ideal material for mesh augmentation at the esophageal hiatus? Results from an experimental study in a porcine model. Hernia 18:873–881. doi: 10.1007/s10029-014-1305-x CrossRefPubMedGoogle Scholar
  10. 10.
    Linke GR, Carstensen B, Kähler G, Zerz A, Shevchenko M, Warschkow R, Lasitschka F, Kenngott HG, Senft J, Müller-Stich BP (2013) Endolumenal colon occlusion device for transanal and transrectal surgery–a porcine feasibility study. Langenbecks Arch Surg 398:595–601. doi: 10.1007/s00423-013-1074-5 CrossRefPubMedGoogle Scholar
  11. 11.
    Senft JD, Gath P, Dröscher T, Müller PC, Carstensen B, Nickel F, Müller-Stich BP, Linke GR (2016) New device for transrectal trocar placement and rectal sealing for NOTES: a porcine in vivo and human cadaver study. Surg Endosc 30:4383–4388. doi: 10.1007/s00464-016-4756-6 CrossRefPubMedGoogle Scholar
  12. 12.
    Mischnik A, Mieth M, Busch CJ, Hofer S, Zimmermann S (2012) First evaluation of automated specimen inoculation for wound swab samples by use of the Previ Isola system compared to manual inoculation in a routine laboratory: finding a cost-effective and accurate approach. J Clin Microbiol 50:2732–2736. doi: 10.1128/JCM.05501-11 CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Fritz S, Hackert T, Hartwig W, Rossmanith F, Strobel O, Schneider L, Will-Schweiger K, Kommerell M, Büchler MW, Werner J (2010) Bacterial translocation and infected pancreatic necrosis in acute necrotizing pancreatitis derives from small bowel rather than from colon. Am J Surg 200:111–117. doi: 10.1016/j.amjsurg.2009.08.019 CrossRefPubMedGoogle Scholar
  14. 14.
    Baker TA, Romero J, Bach HH 4th, Strom JA, Gamelli RL, Majetschak M (2012) Systemic release of cytokines and heat shock proteins in porcine models of polytrauma and hemorrhage*. Crit Care Med 40:876–885. doi: 10.1097/CCM.0b013e318232e314 CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Bulian DR, Knuth J, Cerasani N, Sauerwald A, Lefering R, Heiss MM (2013) Transvaginal/transumbilical hybrid-NOTES-versus 3-trocar needlescopic cholecystectomy: short-term results of a randomized clinical trial. Ann Surg. doi: 10.1097/SLA.0000000000000218 Google Scholar
  16. 16.
    Kloosterman T, von Blomberg BM, Borgstein P, Cuesta MA, Scheper RJ, Meijer S (1994) Unimpaired immune functions after laparoscopic cholecystectomy. Surgery 115:424–428PubMedGoogle Scholar
  17. 17.
    Lin Z-Q, Kondo T, Ishida Y, Takayasu T, Mukaida N (2003) Essential involvement of IL-6 in the skin wound-healing process as evidenced by delayed wound healing in IL-6-deficient mice. J Leukoc Biol 73:713–721CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2017

Authors and Affiliations

  • Jonas D. Senft
    • 1
  • Tilman Dröscher
    • 1
  • Philip Gath
    • 1
  • Philip C. Müller
    • 1
  • Adrian Billeter
    • 1
  • Beat P. Müller-Stich
    • 1
  • Georg R. Linke
    • 1
    • 2
  1. 1.Department of General, Visceral and Transplant SurgeryUniversity of HeidelbergHeidelbergGermany
  2. 2.Department of SurgerySpital STS AGThunSwitzerland

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