Safety and feasibility of single-operator-conducted natural orifice specimen extraction surgery (NOSES) for sigmoid colon and upper rectal cancer

Safety and feasibility of single-operator-conducted natural orifice specimen extraction surgery (NOSES) for sigmoid colon and upper rectal cancer | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Safety and feasibility of single-operator-conducted natural orifice specimen extraction surgery (NOSES) for sigmoid colon and upper rectal cancer Sicong Lai, Fengyun Pei, Yuefang Chen, Qijun Yao, Zhimin Liu, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7770192/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Laparoscopic colectomy has become a standard minimally invasive approach for the treatment of colorectal cancer. Ongoing efforts aim to minimize the surgical trauma associated with the procedure and reduce the number of port sites. This study was conducted to develop and evaluate a novel technique of single-operator-conducted natural orifice specimen extraction surgery (NOSES) for sigmoid colon and upper rectal cancer resections. Methods A retrospective review was conducted on 12 consecutive patients with sigmoid colon or upper rectal cancer treated at the Sixth Affiliated Hospital of Sun Yat-sen University between June 2022 and June 2023. All procedures were performed by a single surgeon using a modified three-port laparoscopic approach with transanal specimen extraction. Perioperative parameters including blood loss, operation time, postoperative recovery, and oncological outcomes were analyzed. Results The cohort demonstrated favorable surgical outcomes with a mean operation time of 127.17 ± 20.59 minutes and the mean intraoperative blood loss of 16.83 ± 12.07 ml. All specimens were successfully retrieved through the natural orifice with a mean tumor diameter of 3.12 ± 1.07 cm. The mean postoperative hospital stay of 5.83 ± 1.64 days. Histopathological examination confirmed R0 resection in all cases. No procedure-related complications or mortality occurred during the 30-day postoperative period. Conclusions Single-operator-conducted NOSES represents a safe and technically feasible approach for selected patients with sigmoid colon or upper rectal cancer. This modified technique preserves the advantages of minimally invasive surgery while achieving satisfactory oncological outcomes. Further prospective studies with larger cohorts are warranted to validate these findings. Colorectal cancer Single operator NOSES Laparoscopic colectomy Figures Figure 1 Figure 2 Introduction Colorectal cancer (CRC) is one of the most common malignant tumors, and radical surgical resection remains the primary method for the treatment of patients with resectable CRC[ 1 ]. The increasingly widespread use of laparoscopic techniques has demonstrated outcomes comparable to open surgery in terms of patient prognosis and hospitalization duration. Laparoscopic colorectal cancer resection offers distinct advantages including reduced incision size, decreased perioperative complication rates, accelerated postoperative recovery, and enhanced patient satisfaction[ 2 – 5 ]. Conventional multiport laparoscopic colorectal cancer resection generally require five abdominal access ports and an auxiliary incision for specimen extraction. This configuration not only compromises cosmetic outcomes but also increases risks of port-related complications such as incisional herniation and surgical site infection. To balance aesthetics and maximize the benefits of minimally invasive surgery, the development of reduced-port laparoscopic surgeries, including four-port, three-port, two-port, and even single-port procedures, has emerged[ 6 – 9 ]. Moreover, with the evolving concept of natural orifice specimen extraction surgery (NOSES), laparoscopic surgery for CRC has become more minimally invasive[ 10 , 11 ]. Conventional laparoscopic colorectal cancer resection necessitates a three-member operative team comprising a primary surgeon, a surgical assistant, and a dedicated camera holder. This configuration requires close collaboration to achieve optimal surgical outcomes[ 12 ]. Suboptimal technical proficiency in either the assistant or camera operator may lead to compromised visualization of critical anatomical landmarks, disruption of surgical ergonomics through instrument collision, extended operative duration, and potential iatrogenic organ injury. These intraoperative challenges collectively contribute to increased technical complexity and may adversely impact both short-term postoperative recovery and long-term oncological prognosis. Robot-assisted surgery (RAS) enhances precision, offers stereoscopic visualization, and provides flexible robotic arm movement, enabling surgeons to perform more precise and complex procedures with greater control[ 13 – 15 ]. Smaller incisions and reduced surgical trauma promote faster patient recovery, while the robotic system’s remote-control capabilities open new possibilities for telemedicine and remote surgery. These advantages collectively improve surgical outcomes, alleviate patient discomfort, and shorten hospitalization time. However, the widespread adoption of RAS is hindered by its high cost, steep learning curve, and reliance on complex robotic systems, which may be susceptible to technical issues. In our previous study, we published the first case report on single-operator-conducted NOSES for a patient with sigmoid colon cancer[ 16 ]. Building on this, we applied this surgical approach to perform radical resections in 12 cases of sigmoid colon and upper rectal cancers, evaluating its safety and efficacy. Methods Patients and study design A prospective, single-center analysis of 12 cases of sigmoid colon or upper rectal cancer patients was performed at The Sixth Affiliated Hospital, Sun Yat-sen University from June 2022 to June 2023. Key inclusion criteria included: the colonoscopy biopsy pathology results confirmed colorectal adenocarcinoma, or the colorectal adenoma could not be removed endoscopically; chest, abdomen, and pelvis enhanced CT scans clearly indicated the tumor located in sigmoid colon or upper rectum, with no evidence of distant metastasis; tumor diameters smaller than 5 cm; Eastern Cooperative Oncology Group (ECOG) is 0–1 points. All participants provided written informed consent prior to their participation in the study. The clinical characteristics of patients are shown in Table 1 . Table 1 Clinical characteristics of patients Characteristics N (%) / mean ± SD Age (years) 56.92 ± 16.73 Gender Male 5 (41.67%) Female 7 (58.33%) BMI (kg/m 2 ) 22.53 ± 2.48 Tumor location Sigmoid colon 7 (58.33%) Upper rectum 5 (41.67%) CEA (ng/ml) 2.88 ± 1.57 CA19-9 (U/ml) 15.28 ± 23.83 Tumor size (cm) 3.12 ± 1.07 SD: standard deviation; BMI: body mass index; CEA: carcinoembryonic antigen; CA19-9: carbohydrate antigen 19 − 9. Surgical technique The surgical procedure was performed under general anesthesia with endotracheal intubation, and the patient was placed in a modified lithotomy position. Three working ports were inserted, including a 12-mm subumbilical trocar located below the navel for the introduction of a 30-degree oblique laparoscope, a 5-mm trocar in the right middle abdomen as an auxiliary port, and a 12-mm trocar in the lower right abdomen as the main operating port. The laparoscope was fixed on a pneumatic arm (NSK Ltd, Japan), allowing the surgeon to adjust its position and angle (Fig. 1 ). An exploration of the abdominal cavity was conducted to rule out distant metastases. The left colon was mobilized, and blood vessels were isolated according to the principles of radical tumor resection. Using an endoscopic linear cut stapler, the colon was cut 10 cm proximal and distal to the tumor. The specimen was pulled out through the anus, and a stapled anastomosis was used for reconstruction. The surgical procedure is detailed in the surgical video published by us previously[ 16 ]. Pathological specimen quality assessment After the surgical specimen is removed, it is essential to assess the integrity of the colorectal tumor. The tumor should be dissected along the longitudinal axis of the bowel, avoiding the lesion. The cut specimen's mucosal surface should be laid flat on a board or similar surface, stretched and fixed in a near-physiological state (using a ruler for reference). The following measurements should be taken and recorded: the distance from the tumor's proximal margin to the anal verge (distal margin), the size of the tumor, and the ratio of the tumor's maximum diameter to the transverse diameter of the bowel. Statistical analysis All statistical analyses were conducted with SPSS 24.0 (SPSS Inc., Chicago, IL, USA). Descriptive outcomes were reported as numbers and percentages or mean and standard deviation (SD). Results Characteristics of the patients The clinical characteristics of the patients are summarized in Table 1 . Of the twelve patients, five were male and seven were female. The mean age of the patients was 56.92 ± 16.73 years, and the mean BMI was 22.53 ± 2.48 kg/m². Seven patients had tumors located in the sigmoid colon, while the remaining five patients had tumors in the upper rectum. The mean tumor diameter was 3.12 ± 1.07 cm. As of the cutoff date (June 10, 2025), the median duration of follow up was 33.92 months (range, 22.10 to 35.73 months), all patients were alive without disease (Fig. 2 ). Perioperative clinical outcomes All patients underwent laparoscopic single-operator-conducted colorectal resection. The mean operation time was 127.17 ± 20.59 minutes, and the mean intraoperative blood loss was 16.83ml. None of the patients had intraoperative complication. None of the patients performed blood transfusion or enterostomy. Eleven patients (91.67%) had specimens extracted through the anus, while one patient, after unsuccessful attempts at transanal specimen retrieval, underwent specimen retrieval through an abdominal incision. After surgery, one patient developed a fever, which was relieved after a short period of conservative treatment. The mean postoperative hospital stay was 5.83 days. Perioperative clinical outcomes are shown in Table 2 . Table 2 Perioperative clinical outcomes Outcomes N (%) / mean ± SD Operative time (min) 127.17 ± 20.59 Blood loss (ml) 16.83 ± 12.07 Blood transfusion rate 0 Intraoperative complications 0 Conversion laparoscopy 0 Pathway for specimen retrieval natural orifice 11 (91.67%) abdominal incision 1 (8.33%) Enterostomy 0 Complications within 30d Bowel obstruction 0 Fever 1 (8.33%) Anastomotic leakage 0 Intra-abdominal bleeding 0 Postoperative hospital stays(d) 5.83 ± 1.64 SD: standard deviation. Postoperative pathologic outcomes Postoperative pathological outcomes showed that all the tumors were excised en bloc and there was no positive margin. Among the twelve patients, eleven were diagnosed with adenocarcinoma, while the remaining patient had a tubular adenoma of the colon. Five patients (41.67%) had stage I tumors, two patients (16.67%) had stage II tumors, and two patients (16.67%) had stage III tumors. The mean tumor size was 3.12 ± 1.07 cm and the mean total number of lymph nodes harvested was 24.08 ± 4.85. Pathological characteristics are shown in Table 3 . Table 3 Postoperative pathologic outcomes Outcomes N (%) / mean ± SD Tubular adenoma 1 (8.33%) Adenocarcinoma 11 (91.67%) TNM stage Ⅰ 5 (41.67%) Ⅱ 2 (16.67%) Ⅲ 2 (16.67%) T stage Tis 2 (16.67%) T1 4 (33.33%) T2 1 (8.33%) T3 4 (33.33%) T4 0 N stage N0 9 (75.00%) N1 2 (16.67%) N2 0 Positive margin 0 Number of lymph nodes harvested 24.08 ± 4.85 SD: standard deviation; TNM: tumor node metastasis. Discussion Laparoscopic techniques have been widely applied in the surgical treatment of CRC, with conventional laparoscopic surgery typically opting for the 5-port approach[ 17 ]. To further reduce surgical trauma, reduced-port laparoscopy, including single-port laparoscopy have emerged[ 18 – 20 ]. Single-port laparoscopic surgery requires only one incision, but the "chopstick effect" may result in a suboptimal surgical field and increased difficulty in surgical maneuvers[ 21 , 22 ]. In this study, we innovated a laparoscopic single-operator-conducted NOSES, which combined reduced-port laparoscopy with NOSES and employed a three-port laparoscopic approach with specimen retrieval through the anus. This study utilized a pneumatic arm to replace the need for a camera operator in traditional laparoscopic surgery, and the entire surgical process was completed by the primary surgeon alone. Lee et al. reported on 359 cases of CRC surgery in South Korea, with the operative times for single-port and traditional multi-port laparoscopic surgery being 175.6 and 164.3 minutes, respectively[ 23 ]. This trial concluded that single-port laparoscopic surgery (SPLS) is a safe and technically viable option for the treatment of colon cancer. However, in this study, the mean operation time was 127.17 minutes, which was significantly lower than the surgical time reported in the Lee study. We believe this difference can be attributed to the reduced reliance on assistants in single-operator-conducted laparoscopic surgery. This not only eliminates the time loss associated with waiting for assistant coordination but also reduces the risk of accidental injury caused by insufficient experience from the assistant, as well as the time required for managing subsequent injuries. Additionally, the primary surgeon's ability to optimize the surgical field exposure and execute precise maneuvers further contributed to a shorter operation time. Furthermore, the earlier tumor staging and smaller tumor size in the patients of this study were also important factors influencing the reduced surgery time. All patients in this study successfully underwent surgery performed by a single surgeon using the three-port laparoscopic approach. However, in one case, transanal specimen retrieval was unsuccessful, necessitating conversion to abdominal extraction. Although the patient had a relatively small tumor measuring 4 cm in diameter, prior neoadjuvant chemotherapy had resulted in increased intestinal stiffness and some degree of edema, making distal rectal extraction challenging. Consequently, for colorectal cancer patients with larger tumors or those who have undergone neoadjuvant therapy, careful evaluation should be conducted to determine whether this surgical approach is applicable, in order to avoid unnecessary surgical complications. In this study, no patients experienced complications such as anastomotic fistulas or intra-abdominal bleeding after surgery. One patient developed a postoperative fever, which resolved with a short course of anti-infective treatment. Previous research has shown that, in CRC patients, the safety of single-port or reduced-port surgeries is similar to that of traditional five-port laparoscopic surgery[ 23 – 25 ]. Pathological examination in this study confirmed that all cases yielded high-quality surgical specimens, meeting the NCCN guidelines for distant and circumferential margins as well as the required number of retrieved lymph nodes. The limitations of this study include but are not limited to, a small sample size and a short postoperative follow-up period. To further explore the safety of this new surgical approach, multicenter randomized controlled trials and long-term follow-ups are needed. Additionally, it is necessary to establish a comprehensive quality control standard for colorectal tumor surgery, which will facilitate the widespread adoption and dissemination of this new surgical method. In conclusion, this study confirms that the single-operator-conducted NOSES for sigmoid colon and upper rectal cancer is a safe and feasible surgical approach. It can be selectively performed in patients who meet specific criteria. Further prospective studies with larger cohorts are warranted to validate these findings. Declarations Consent for publication All authors have consented to the publication of this manuscript. Acknowledgements We would like to express our sincere gratitude to the participants and their families for their invaluable contribution to this study. Without their willingness to participate and their support, this research would not have been possible. We also extend our appreciation to all individuals who assisted in the data collection and provided support throughout the study. Data availability statements All data and material during the current study are available from the corresponding author on reasonable request. Ethics approval and consent to participate All participants provided written informed consent prior to their participation in the study. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This study has received the approval (2025ZSLYEC-126) of the Ethics Committee of the Sixth Affiliated Hospital, Sun Yat-sen University. Conflict of interest The authors declare that they have no conflict of interest. Funding The study was supported by the National Key Clinical Discipline, the National Natural Science Foundation of China (Grant 82473359); Guangdong Province Basic and Applied Basic Research Fund Project (No. 2025A1515012732); Sun Yat-Sen University Clinical Research ‘5010’ Program (No. 2025003); the 1010 Project of the Sixth Affiliated Hospital of Sun Yat-sen University [Grant 1010CG (2020)-20]. Authors’ contributions Conception and design (J.H.); writing and revision of the manuscript (S.L., F.P., Y.C., Q.Y.); pathological diagnosis and analysis (Y.Z.); generating figures and provided comments (F.H., Q.Y., Z.L., M.W.); review of the manuscript (J.H.). All the authors analyzed the data. References Bray F, Laversanne M, Sung H, Ferlay J, Siegel RL, Soerjomataram I, Jemal A. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2024;74(3):229–63. Monson JR. Advanced techniques in abdominal surgery. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7770192","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":544385500,"identity":"3bf1f33a-6ab8-4099-97a5-b76f4969bc89","order_by":0,"name":"Sicong Lai","email":"","orcid":"","institution":"Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"Sicong","middleName":"","lastName":"Lai","suffix":""},{"id":544385501,"identity":"57478b32-14e1-4823-bbc2-4d83e3ee667c","order_by":1,"name":"Fengyun Pei","email":"","orcid":"","institution":"Sun Yat-sen 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14:39:57","extension":"xml","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":80035,"visible":true,"origin":"","legend":"","description":"","filename":"583a26e94d7c406b9235f4f4b216ebcd1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7770192/v1/0cd568943b34b9d4498f8ec2.xml"},{"id":96302100,"identity":"ff5aa5f9-4d47-43d4-a80e-00a4b31dacfc","added_by":"auto","created_at":"2025-11-19 14:39:57","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":88220,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7770192/v1/cdbc6b65a8600b592aefb4b4.html"},{"id":96365018,"identity":"7caa1fb0-1efa-4afe-a1e4-9362a9a45144","added_by":"auto","created_at":"2025-11-20 10:09:55","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":133066,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eArrangement of port sites. \u003c/strong\u003eThree working ports were inserted, including a 12-mm subumbilical trocar located below the navel for the introduction of a 30-degree oblique laparoscope, a 5-mm trocar in the right middle abdomen as an auxiliary port, and a 12-mm trocar in the lower right abdomen as the main operating port. The laparoscope was fixed on a pneumatic arm (NSK Ltd, Japan), allowing the surgeon to adjust its position and angle.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7770192/v1/4b3a78314d9717366a5e58b4.jpeg"},{"id":96364658,"identity":"5ef162e5-b375-4265-bdbf-5570a564010d","added_by":"auto","created_at":"2025-11-20 10:09:31","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":34133,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDisease-free survival (DFS) curves of all patients. \u003c/strong\u003eDFS was calculated from the time of surgery to the time of recurrence or death. The median follow-up was 33.92 months. The numbers of patients at risk in 6-month intervals are included below the x-axis.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7770192/v1/9b1f7eddb6084b69cc4bdbeb.jpeg"},{"id":106745411,"identity":"22a64b37-ac7b-42ed-b8b2-77be26ed0828","added_by":"auto","created_at":"2026-04-13 05:26:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":819573,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7770192/v1/eb4344a4-14ee-4a08-aa0d-0e928522df06.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Safety and feasibility of single-operator-conducted natural orifice specimen extraction surgery (NOSES) for sigmoid colon and upper rectal cancer","fulltext":[{"header":"Introduction","content":"\u003cp\u003eColorectal cancer (CRC) is one of the most common malignant tumors, and radical surgical resection remains the primary method for the treatment of patients with resectable CRC[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The increasingly widespread use of laparoscopic techniques has demonstrated outcomes comparable to open surgery in terms of patient prognosis and hospitalization duration. Laparoscopic colorectal cancer resection offers distinct advantages including reduced incision size, decreased perioperative complication rates, accelerated postoperative recovery, and enhanced patient satisfaction[\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Conventional multiport laparoscopic colorectal cancer resection generally require five abdominal access ports and an auxiliary incision for specimen extraction. This configuration not only compromises cosmetic outcomes but also increases risks of port-related complications such as incisional herniation and surgical site infection. To balance aesthetics and maximize the benefits of minimally invasive surgery, the development of reduced-port laparoscopic surgeries, including four-port, three-port, two-port, and even single-port procedures, has emerged[\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Moreover, with the evolving concept of natural orifice specimen extraction surgery (NOSES), laparoscopic surgery for CRC has become more minimally invasive[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eConventional laparoscopic colorectal cancer resection necessitates a three-member operative team comprising a primary surgeon, a surgical assistant, and a dedicated camera holder. This configuration requires close collaboration to achieve optimal surgical outcomes[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Suboptimal technical proficiency in either the assistant or camera operator may lead to compromised visualization of critical anatomical landmarks, disruption of surgical ergonomics through instrument collision, extended operative duration, and potential iatrogenic organ injury. These intraoperative challenges collectively contribute to increased technical complexity and may adversely impact both short-term postoperative recovery and long-term oncological prognosis.\u003c/p\u003e\u003cp\u003eRobot-assisted surgery (RAS) enhances precision, offers stereoscopic visualization, and provides flexible robotic arm movement, enabling surgeons to perform more precise and complex procedures with greater control[\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Smaller incisions and reduced surgical trauma promote faster patient recovery, while the robotic system\u0026rsquo;s remote-control capabilities open new possibilities for telemedicine and remote surgery. These advantages collectively improve surgical outcomes, alleviate patient discomfort, and shorten hospitalization time. However, the widespread adoption of RAS is hindered by its high cost, steep learning curve, and reliance on complex robotic systems, which may be susceptible to technical issues.\u003c/p\u003e\u003cp\u003eIn our previous study, we published the first case report on single-operator-conducted NOSES for a patient with sigmoid colon cancer[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Building on this, we applied this surgical approach to perform radical resections in 12 cases of sigmoid colon and upper rectal cancers, evaluating its safety and efficacy.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003ePatients and study design\u003c/h2\u003e\u003cp\u003eA prospective, single-center analysis of 12 cases of sigmoid colon or upper rectal cancer patients was performed at The Sixth Affiliated Hospital, Sun Yat-sen University from June 2022 to June 2023. Key inclusion criteria included: the colonoscopy biopsy pathology results confirmed colorectal adenocarcinoma, or the colorectal adenoma could not be removed endoscopically; chest, abdomen, and pelvis enhanced CT scans clearly indicated the tumor located in sigmoid colon or upper rectum, with no evidence of distant metastasis; tumor diameters smaller than 5 cm; Eastern Cooperative Oncology Group (ECOG) is 0\u0026ndash;1 points. All participants provided written informed consent prior to their participation in the study. The clinical characteristics of patients are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eClinical characteristics of patients\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN (%) / mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e56.92\u0026thinsp;\u0026plusmn;\u0026thinsp;16.73\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (41.67%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (58.33%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22.53\u0026thinsp;\u0026plusmn;\u0026thinsp;2.48\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTumor location\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSigmoid colon\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (58.33%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUpper rectum\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (41.67%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCEA (ng/ml)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.88\u0026thinsp;\u0026plusmn;\u0026thinsp;1.57\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCA19-9 (U/ml)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15.28\u0026thinsp;\u0026plusmn;\u0026thinsp;23.83\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTumor size (cm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.12\u0026thinsp;\u0026plusmn;\u0026thinsp;1.07\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSD: standard deviation; BMI: body mass index; CEA: carcinoembryonic antigen; CA19-9: carbohydrate antigen 19\u0026thinsp;\u0026minus;\u0026thinsp;9.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSurgical technique\u003c/h3\u003e\n\u003cp\u003eThe surgical procedure was performed under general anesthesia with endotracheal intubation, and the patient was placed in a modified lithotomy position. Three working ports were inserted, including a 12-mm subumbilical trocar located below the navel for the introduction of a 30-degree oblique laparoscope, a 5-mm trocar in the right middle abdomen as an auxiliary port, and a 12-mm trocar in the lower right abdomen as the main operating port. The laparoscope was fixed on a pneumatic arm (NSK Ltd, Japan), allowing the surgeon to adjust its position and angle (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). An exploration of the abdominal cavity was conducted to rule out distant metastases. The left colon was mobilized, and blood vessels were isolated according to the principles of radical tumor resection. Using an endoscopic linear cut stapler, the colon was cut 10 cm proximal and distal to the tumor. The specimen was pulled out through the anus, and a stapled anastomosis was used for reconstruction. The surgical procedure is detailed in the surgical video published by us previously[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003ePathological specimen quality assessment\u003c/h3\u003e\n\u003cp\u003eAfter the surgical specimen is removed, it is essential to assess the integrity of the colorectal tumor. The tumor should be dissected along the longitudinal axis of the bowel, avoiding the lesion. The cut specimen's mucosal surface should be laid flat on a board or similar surface, stretched and fixed in a near-physiological state (using a ruler for reference). The following measurements should be taken and recorded: the distance from the tumor's proximal margin to the anal verge (distal margin), the size of the tumor, and the ratio of the tumor's maximum diameter to the transverse diameter of the bowel.\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eAll statistical analyses were conducted with SPSS 24.0 (SPSS Inc., Chicago, IL, USA). Descriptive outcomes were reported as numbers and percentages or mean and standard deviation (SD).\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eCharacteristics of the patients\u003c/h2\u003e\u003cp\u003eThe clinical characteristics of the patients are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Of the twelve patients, five were male and seven were female. The mean age of the patients was 56.92\u0026thinsp;\u0026plusmn;\u0026thinsp;16.73 years, and the mean BMI was 22.53\u0026thinsp;\u0026plusmn;\u0026thinsp;2.48 kg/m\u0026sup2;. Seven patients had tumors located in the sigmoid colon, while the remaining five patients had tumors in the upper rectum. The mean tumor diameter was 3.12\u0026thinsp;\u0026plusmn;\u0026thinsp;1.07 cm. As of the cutoff date (June 10, 2025), the median duration of follow up was 33.92 months (range, 22.10 to 35.73 months), all patients were alive without disease (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003ePerioperative clinical outcomes\u003c/h3\u003e\n\u003cp\u003eAll patients underwent laparoscopic single-operator-conducted colorectal resection. The mean operation time was 127.17\u0026thinsp;\u0026plusmn;\u0026thinsp;20.59 minutes, and the mean intraoperative blood loss was 16.83ml. None of the patients had intraoperative complication. None of the patients performed blood transfusion or enterostomy. Eleven patients (91.67%) had specimens extracted through the anus, while one patient, after unsuccessful attempts at transanal specimen retrieval, underwent specimen retrieval through an abdominal incision. After surgery, one patient developed a fever, which was relieved after a short period of conservative treatment. The mean postoperative hospital stay was 5.83 days. Perioperative clinical outcomes are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePerioperative clinical outcomes\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOutcomes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN (%) / mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOperative time (min)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e127.17\u0026thinsp;\u0026plusmn;\u0026thinsp;20.59\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlood loss (ml)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16.83\u0026thinsp;\u0026plusmn;\u0026thinsp;12.07\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlood transfusion rate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntraoperative complications\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConversion laparoscopy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePathway for specimen retrieval\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003enatural orifice\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11 (91.67%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eabdominal incision\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (8.33%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEnterostomy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComplications within 30d\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBowel obstruction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFever\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (8.33%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnastomotic leakage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntra-abdominal bleeding\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePostoperative hospital stays(d)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5.83\u0026thinsp;\u0026plusmn;\u0026thinsp;1.64\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSD: standard deviation.\u003c/p\u003e\n\u003ch3\u003ePostoperative pathologic outcomes\u003c/h3\u003e\n\u003cp\u003ePostoperative pathological outcomes showed that all the tumors were excised en bloc and there was no positive margin. Among the twelve patients, eleven were diagnosed with adenocarcinoma, while the remaining patient had a tubular adenoma of the colon. Five patients (41.67%) had stage I tumors, two patients (16.67%) had stage II tumors, and two patients (16.67%) had stage III tumors. The mean tumor size was 3.12\u0026thinsp;\u0026plusmn;\u0026thinsp;1.07 cm and the mean total number of lymph nodes harvested was 24.08\u0026thinsp;\u0026plusmn;\u0026thinsp;4.85. Pathological characteristics are shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePostoperative pathologic outcomes\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOutcomes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN (%) / mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTubular adenoma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (8.33%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAdenocarcinoma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11 (91.67%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTNM stage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eⅠ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (41.67%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eⅡ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (16.67%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eⅢ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (16.67%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eT stage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (16.67%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eT1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (33.33%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eT2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (8.33%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eT3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (33.33%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eT4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN stage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9 (75.00%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (16.67%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePositive margin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of lymph nodes harvested\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24.08\u0026thinsp;\u0026plusmn;\u0026thinsp;4.85\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSD: standard deviation; TNM: tumor node metastasis.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eLaparoscopic techniques have been widely applied in the surgical treatment of CRC, with conventional laparoscopic surgery typically opting for the 5-port approach[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. To further reduce surgical trauma, reduced-port laparoscopy, including single-port laparoscopy have emerged[\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Single-port laparoscopic surgery requires only one incision, but the \"chopstick effect\" may result in a suboptimal surgical field and increased difficulty in surgical maneuvers[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In this study, we innovated a laparoscopic single-operator-conducted NOSES, which combined reduced-port laparoscopy with NOSES and employed a three-port laparoscopic approach with specimen retrieval through the anus. This study utilized a pneumatic arm to replace the need for a camera operator in traditional laparoscopic surgery, and the entire surgical process was completed by the primary surgeon alone.\u003c/p\u003e\u003cp\u003eLee et al. reported on 359 cases of CRC surgery in South Korea, with the operative times for single-port and traditional multi-port laparoscopic surgery being 175.6 and 164.3 minutes, respectively[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. This trial concluded that single-port laparoscopic surgery (SPLS) is a safe and technically viable option for the treatment of colon cancer. However, in this study, the mean operation time was 127.17 minutes, which was significantly lower than the surgical time reported in the Lee study. We believe this difference can be attributed to the reduced reliance on assistants in single-operator-conducted laparoscopic surgery. This not only eliminates the time loss associated with waiting for assistant coordination but also reduces the risk of accidental injury caused by insufficient experience from the assistant, as well as the time required for managing subsequent injuries. Additionally, the primary surgeon's ability to optimize the surgical field exposure and execute precise maneuvers further contributed to a shorter operation time. Furthermore, the earlier tumor staging and smaller tumor size in the patients of this study were also important factors influencing the reduced surgery time.\u003c/p\u003e\u003cp\u003eAll patients in this study successfully underwent surgery performed by a single surgeon using the three-port laparoscopic approach. However, in one case, transanal specimen retrieval was unsuccessful, necessitating conversion to abdominal extraction. Although the patient had a relatively small tumor measuring 4 cm in diameter, prior neoadjuvant chemotherapy had resulted in increased intestinal stiffness and some degree of edema, making distal rectal extraction challenging. Consequently, for colorectal cancer patients with larger tumors or those who have undergone neoadjuvant therapy, careful evaluation should be conducted to determine whether this surgical approach is applicable, in order to avoid unnecessary surgical complications.\u003c/p\u003e\u003cp\u003eIn this study, no patients experienced complications such as anastomotic fistulas or intra-abdominal bleeding after surgery. One patient developed a postoperative fever, which resolved with a short course of anti-infective treatment. Previous research has shown that, in CRC patients, the safety of single-port or reduced-port surgeries is similar to that of traditional five-port laparoscopic surgery[\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Pathological examination in this study confirmed that all cases yielded high-quality surgical specimens, meeting the NCCN guidelines for distant and circumferential margins as well as the required number of retrieved lymph nodes.\u003c/p\u003e\u003cp\u003eThe limitations of this study include but are not limited to, a small sample size and a short postoperative follow-up period. To further explore the safety of this new surgical approach, multicenter randomized controlled trials and long-term follow-ups are needed. Additionally, it is necessary to establish a comprehensive quality control standard for colorectal tumor surgery, which will facilitate the widespread adoption and dissemination of this new surgical method.\u003c/p\u003e\u003cp\u003eIn conclusion, this study confirms that the single-operator-conducted NOSES for sigmoid colon and upper rectal cancer is a safe and feasible surgical approach. It can be selectively performed in patients who meet specific criteria. Further prospective studies with larger cohorts are warranted to validate these findings.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have consented to the publication of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to express our sincere gratitude to the participants and their families for their invaluable contribution to this study. Without their willingness to participate and their support, this research would not have been possible. We also extend our appreciation to all individuals who assisted in the data collection and provided support throughout the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data and material during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants provided written informed consent prior to their participation in the study. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.\u0026nbsp;This study has received the approval (2025ZSLYEC-126) of the Ethics Committee of the Sixth Affiliated Hospital, Sun Yat-sen University.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was supported by the National Key Clinical Discipline, the National Natural Science Foundation of China (Grant 82473359);\u0026nbsp;Guangdong Province Basic and Applied Basic Research Fund Project (No. 2025A1515012732); Sun Yat-Sen University Clinical Research \u0026lsquo;5010\u0026rsquo; Program (No. 2025003);\u0026nbsp;the 1010 Project of the Sixth Affiliated Hospital of Sun Yat-sen University [Grant 1010CG (2020)-20].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConception and design (J.H.); writing and revision of the manuscript (S.L., F.P., Y.C., Q.Y.); pathological diagnosis and analysis (Y.Z.); generating figures and provided comments (F.H., Q.Y., Z.L., M.W.); review of the manuscript (J.H.). All the authors analyzed the data.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBray F, Laversanne M, Sung H, Ferlay J, Siegel RL, Soerjomataram I, Jemal A. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2024;74(3):229\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMonson JR. Advanced techniques in abdominal surgery. BMJ. 1993;307(6915):1346\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSubramonian K, DeSylva S, Bishai P, Thompson P, Muir G. Acquiring surgical skills: a comparative study of open versus laparoscopic surgery. Eur Urol. 2004;45(3):346\u0026ndash;51. author reply 351.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBonjer HJ, Deijen CL, Haglind E, Group CIS. A Randomized Trial of Laparoscopic versus Open Surgery for Rectal Cancer. 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Safety and effectiveness of reduced-port laparoscopic sleeve gastrectomy in Asian morbidly obese patients. Sci Rep. 2021;11(1):23511.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLi L, Liu L, Liu X, Zhong Q. Comparison of efficacy of single-port laparoscopy and multi-port laparoscopy in colorectal resection: A systematic review and meta-analysis. Asian J Surg. 2021;44(12):1611\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSong Z, Liu K, Li Y, Shi Y, Jiang Y, Wang C, Chen X, Zhang T, Ji X, Zhao R. Short-Term Outcomes of Single-Incision Laparoscopic Surgery for Colorectal Cancer: A Single-Center, Open-Label, Non-Inferiority, Randomized Clinical Trial. Front Oncol. 2021;11:762147.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWang S, Tang J, Sun W, Yao H, Li Z. The natural orifice specimen extraction surgery compared with conventional laparoscopy for colorectal cancer: A meta-analysis of efficacy and long-term oncological outcomes. Int J Surg. 2022;97:106196.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDobo N, Marki G, Hudelist G, Csibi N, Brubel R, Acs N, Bokor A. Laparoscopic natural orifice specimen extraction colectomy versus conventional laparoscopic colorectal resection in patients with rectal endometriosis: a randomized, controlled trial. Int J Surg. 2023;109(12):4018\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLim DR, Min BS, Kim MS, Alasari S, Kim G, Hur H, Baik SH, Lee KY, Kim NK. Robotic versus laparoscopic anterior resection of sigmoid colon cancer: comparative study of long-term oncologic outcomes. Surg Endosc. 2013;27(4):1379\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDe Cillis S, Geretto P, Phe V. Opening the Horizons of Functional Urology and Neurourology to Robot-assisted Surgery. Eur Urol. 2023;83(3):189\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMerseburger AS, Herrmann TR, Shariat SF, Kyriazis I, Nagele U, Traxer O, Liatsikos EN. European Association of U: EAU guidelines on robotic and single-site surgery in urology. Eur Urol. 2013;64(2):277\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFeng Q, Yuan W, Li T, Tang B, Jia B, Zhou Y, Zhang W, Zhao R, Zhang C, Cheng L, et al. Robotic versus laparoscopic surgery for middle and low rectal cancer (REAL): short-term outcomes of a multicentre randomised controlled trial. Lancet Gastroenterol Hepatol. 2022;7(11):991\u0026ndash;1004.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHuang J, Lai S, Yao Q, Pei F, Zhao Y, Huang M. Single-operator-conducted natural orifice specimen extraction surgery (NOSES) for sigmoid colon cancer. Gastroenterol Rep (Oxf). 2022;10:goac054.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGreene FL. Laparoscopic management of colorectal cancer. CA Cancer J Clin. 1999;49(4):221\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWei PL, Huang YJ, Wang W, Huang YM. Comparison of robotic reduced-port and laparoscopic approaches for left-sided colorectal cancer surgery. Asian J Surg. 2023;46(2):698\u0026ndash;704.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLiu ZM, Yao QJ, Pei F, He F, Zhao Y, Huang J. Efficacy and safety of reduced-port laparoscopic surgery versus conventional laparoscopic surgery for colorectal cancer. BMC Cancer. 2025;25(1):187.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKim SJ, Ryu GO, Choi BJ, Kim JG, Lee KJ, Lee SC, Oh ST. The short-term outcomes of conventional and single-port laparoscopic surgery for colorectal cancer. Ann Surg. 2011;254(6):933\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGandhi DP, Ragupathi M, Patel CB, Ramos-Valadez DI, Pickron TB, Haas EM. Single-incision versus hand-assisted laparoscopic colectomy: a case-matched series. J Gastrointest Surg. 2010;14(12):1875\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCianchi F, Qirici E, Trallori G, Mallardi B, Badii B, Perigli G. Single-incision laparoscopic colectomy: technical aspects and short-term results. Updates Surg. 2012;64(1):19\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLee YS, Kim JH, Kim HJ, Lee SC, Kang BM, Kim CW, Lim SW, Lee SH, Kim JG. Short-term Outcomes of Single-port Versus Multiport Laparoscopic Surgery for Colon Cancer: The SIMPLE Multicenter Randomized Clinical Trial. Ann Surg. 2021;273(2):217\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWatanabe J, Ishibe A, Suwa H, Ota M, Fujii S, Kubota K, Kunisaki C, Endo I. Long-term Outcomes of a Randomized Controlled Trial of Single-incision Versus Multi-port Laparoscopic Colectomy for Colon Cancer. Ann Surg. 2021;273(6):1060\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhang X, Yuan H, Tan Z, Li G, Xu Z, Zhou J, Fu J, Wu M, Xi J, Wang Y. Long-term outcomes of single-incision plus one-port laparoscopic surgery versus conventional laparoscopic surgery for rectosigmoid cancer: a randomized controlled trial. BMC Cancer. 2023;23(1):1204.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Colorectal cancer, Single operator, NOSES, Laparoscopic colectomy","lastPublishedDoi":"10.21203/rs.3.rs-7770192/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7770192/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eLaparoscopic colectomy has become a standard minimally invasive approach for the treatment of colorectal cancer. Ongoing efforts aim to minimize the surgical trauma associated with the procedure and reduce the number of port sites. This study was conducted to develop and evaluate a novel technique of single-operator-conducted natural orifice specimen extraction surgery (NOSES) for sigmoid colon and upper rectal cancer resections.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003e A retrospective review was conducted on 12 consecutive patients with sigmoid colon or upper rectal cancer treated at the Sixth Affiliated Hospital of Sun Yat-sen University between June 2022 and June 2023. All procedures were performed by a single surgeon using a modified three-port laparoscopic approach with transanal specimen extraction. Perioperative parameters including blood loss, operation time, postoperative recovery, and oncological outcomes were analyzed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe cohort demonstrated favorable surgical outcomes with a mean operation time of 127.17\u0026thinsp;\u0026plusmn;\u0026thinsp;20.59 minutes and the mean intraoperative blood loss of 16.83\u0026thinsp;\u0026plusmn;\u0026thinsp;12.07 ml. All specimens were successfully retrieved through the natural orifice with a mean tumor diameter of 3.12\u0026thinsp;\u0026plusmn;\u0026thinsp;1.07 cm. The mean postoperative hospital stay of 5.83\u0026thinsp;\u0026plusmn;\u0026thinsp;1.64 days. Histopathological examination confirmed R0 resection in all cases. No procedure-related complications or mortality occurred during the 30-day postoperative period.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eSingle-operator-conducted NOSES represents a safe and technically feasible approach for selected patients with sigmoid colon or upper rectal cancer. This modified technique preserves the advantages of minimally invasive surgery while achieving satisfactory oncological outcomes. Further prospective studies with larger cohorts are warranted to validate these findings.\u003c/p\u003e","manuscriptTitle":"Safety and feasibility of single-operator-conducted natural orifice specimen extraction surgery (NOSES) for sigmoid colon and upper rectal cancer","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-19 14:39:52","doi":"10.21203/rs.3.rs-7770192/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"91358214-7487-4e8d-8acc-3c73645529ad","owner":[],"postedDate":"November 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-13T05:25:39+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-19 14:39:52","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7770192","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7770192","identity":"rs-7770192","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}