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Xishan Wang
Editor
Natural Orifice
Specimen Extraction
Surgery
Gastrointestinal Tumor
Second Edition
123
Natural Orifice Specimen Extraction Surgery
Xishan Wang
Editor
Natural Orifice Specimen

Extraction Surgery
Gastrointestinal Tumor
Second Edition
Editor
Xishan Wang
Department of Colorectal Surgery
Cancer Institute & Hospital, Chinese Academy of Medical Sciences
Beijing
China
ISBN 978-981-15-7924-0 ISBN 978-981-15-7925-7 (eBook)

https://doi.org/10.1007/978-981-15-7925-7
Jointly published with People’s Medical Publishing House, PR of China
© People’s Medical Publishing House, PR of China 2021

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The knowledge, experience and inertial thinking we currently possess are at times
the greatest enemy of innovation, and a justification for the denial of others.
Lead the way with skill, win the future with virtue.
Be appreciative of others’ achievements;

be critical with one’s own deficiencies.
The courage to question oneself makes one a real surgeon.
The moment our effort paid off marked our achievements as a thing of the
past. Now is the time to set sail for the next destination.
The perfection of the human body makes up for the shortage of medicine and
our self-righteousness.
——Xishan Wang
王锡山
Foreword by Jie He
According to the latest data from National Cancer Center, the prevalence of gastrointestinal
cancer in China is ranked the highest among malignant tumors, and its morbidity and mortality
are still rising year by year. The prevention and treatment of gastrointestinal cancer in China is
faced with serious challenges. As the main treatment of gastrointestinal tumors, surgery has
made considerable progress and improvement in recent years, especially in minimally invasive
treatment.
Professor Xishan is a leading figure in the field of colorectal cancer in China. It is witnessed
by all that he has been engaging in the prevention, diagnosis, and treatment of colorectal can-
cer in China. At the same time, as the academic leader of colorectal surgery in our hospital, he
has achieved significant achievements in recent years. In 2019, over 3000 colorectal surgeries
have been carried out in our hospital, and the number of colorectal tumor surgeries ranked first
in China. In order to establish the brand of our department, he puts forward the two subject
characteristics of “minimally invasive of minimally invasive, difficulty of difficulty,” which are
the embodiment of his innovative consciousness and pioneering spirit. NOSES is the best
manifestation of “minimally invasive of minimally invasive.” At present, up to 300 cases of
NOSES are carried out in our hospital annually, which is leading both in China and in the
world.
Surely, the innovation of any technique must be based on standardization, and the innova-
tion of cancer treatment should be doubly cautious. As a new minimally invasive technique, the
standardization of NOSES is not only applicable to individuals but also requires the whole
surgical field to have its own standards. At present, Prof. Xishan has further improved the theo-
retical system of NOSES. Over the last three years, he has written several monographs on
NOSES in Chinese and foreign languages, which objectively demonstrate the feasibility and
great social value of NOSES and again illustrate the broad application prospect of NOSES. In
addition, a series of academic activities, such as hundreds of Chinese NOSES lecture tours and
vii
viii Foreword by Jie He
NOSES seminars, have been carried out with the Chinese NOSES Alliance and the Chinese
Cancer Center as the academic platform. Over 10,000 medical staff have been trained, which
plays a great role in promoting the standardization of NOSES.
Within just a few years, NOSES has developed from a single procedure to a complete theo-
retical system, from a single organ to applicable to abdominal and pelvic organs, and from
several single centers to national and even the world. All these developments reflect the strong
vitality of NOSES. I also believe that the publication of the second edition of the English
monograph on NOSES for gastrointestinal cancer will have a profound impact on the interna-
tional promotion of NOSES. It will inject new vitality to bringing the Chinese original mini-
mally invasive technology to the world stage and lead the international minimally invasive
surgery into a new era.
Jie He
Academician, Chinese Academy of Sciences
President, National Cancer Center of China
President, Cancer Hospital, Chinese Academy of Medical Sciences
Foreword by Tracy L. Hull
I would like to thank Prof. Xishan Wang for the opportunity to write a preface for the second
edition of the NOSES book on gastrointestinal tumors (English version). Minimally invasive
surgery, represented by laparoscopic and robotic surgery, has been widely accepted and devel-
oped in the field of gastrointestinal surgery. In the quest to avoid abdominal incisions, NOSES
has been developed as a form of minimally invasive surgery and is becoming more popular in
many sections of the world.
Other similar variations related to minimally invasive surgery include NOTES and
TaTME. Compared to NOSES, NOTES seems to offer a more cosmetically pleasing effect but
lacks high-level evidence-based supporting studies. TaTME has received a lot of attention
around the world. Compared to NOSES, TaTME seems to be more technically demanding and
less adaptable. TaTME has received significant scrutiny worldwide and time will tell if it
remains a safe and feasible platform for rectal resection particularly due to concerns of
increased local recurrence rates in rectal cancer. Unlike NOTES and TaTME, NOSES may be
technically easier to adapt. A database of NOSES procedures established by Prof. Xishan
Wang has over 6000 patients from more than 200 hospitals.
In August 2019, I was honored to be invited to Beijing to participate in the third International
NOSES Symposium. Fifty international experts who specialize in NOSES-based surgery from
16 countries participated in a comprehensive symposium. Besides talks about the benefits of
this platform, current technical bottlenecks and challenges were discussed. This was high-
lighted by a live demonstration of surgery utilizing the NOSES techniques. Prof. Wang and his
team showcased their technical skills and then invited us to visit their patients the following
days as they recovered in the hospital. These patients were up and walking in the halls and
progressing quickly in their recovery.
Prof. Wang has made considerable contributions in promoting minimally invasive surgery
in China and other countries in the form of NOSES. He has established the China and
International NOSES Alliance, which has provided a strong platform for academic communi-
cation regarding NOSES. He has led a number of gastrointestinal NOSES expert consensus
panels that have developed standards for NOSES worldwide. He has written NOSES books
and monographs that have been translated into English, Korean, Russian, Japanese, and other
languages for global promotion. In addition, he also organized nearly 100 NOSES training
ix
x Foreword by Tracy L. Hull
courses and lectures, which trained over 10,000 surgeons. The development and achievements
of these efforts have played an important role in promoting the standardized treatment and safe
technique of NOSES in the world.
Presently, few surgeons in the USA perform NOSES surgery. Through the efforts of sur-
geons like Prof. Wang, more clinicians worldwide (including the USA) will be exposed to this
platform and embrace its utility in performing surgery in a safe and truly minimally invasive
fashion.
Tracy L. Hull
President, American Society of Colon and Rectal Surgeons
President, Society of Pelvic Surgeons
Section Chief, IBD of Department of Colorectal Surgery
The Cleveland Clinic Foundation
Foreword by Antonio Longo
With the fast development of minimally invasive surgery in the treatment of gastrointestinal
disease, novel surgical techniques and methods to reduce surgical trauma have been introduced
and become highly concerned issues in current clinical practice. Natural orifice specimen
extraction surgery (NOSES), by avoiding abdominal incision, has been considered as a well-
established surgical approach. Currently, NOSES represents the least invasive option in surgi-
cal treatment of gastrointestinal diseases. Furthermore, more and more research results are
published in support of the application of NOSES with acceptable short- and long-term
outcomes.
In 2018, an international academic organization, the International Alliance of NOSES, was
established with the aim of improving the clinical practice of NOSES worldwide. I am honored
to be a member of this international organization. After that, we published one consensus of
NOSES for colorectal cancer together, which systematically integrated technical variations of
xi
xii Foreword by Antonio Longo
NOSES for colorectal cancer. In 2019, under the leadership of Prof. Wang, a new consensus of
NOSES for gastric cancer was published by dozens of international surgical experts, providing
a theoretical basis for healthy growth of NOSES involved in the field of gastrointestinal
surgery.
As far as I know, many surgeons in Europe have performed NOSES in the treatment of
colorectal disease. However, the general surgeon does not have the habit of working transa-
nally, which may discourage the population from NOSES. Furthermore, the potential pitfalls
of NOSES raised with this new technique still attract long-standing concerns, especially in
terms of bacteriological results and oncological outcomes. In my opinion, the development of
more specialized surgical devices will be a good direction for NOSES. The specialized surgi-
cal devices for NOSES could be used to reduce the difficulty of surgery and the risk of
complications.
In order to better standardize the development of NOSES technology, Prof. Wang and many
experts have published several NOSES monographs to elaborate standard surgical techniques
of NOSES. Two years ago, I have read the book NOSES—Colorectal Cancer written by Prof.
Wang; this book fully presented all kinds of the NOSES techniques in the treatment of CRC,
which has benefited me a lot.
Compared to open surgery and conventional laparoscopic surgery for gastrointestinal tumor,
NOSES has numerous technical variations regarding specimen extraction and intraperitoneal
bowel reconstruction. Today, I feel very surprised and excited to hear that Prof. Wang is about
to publish the second edition NOSES—Gastrointestinal Tumor. This new book summarizes a
wide variety of novel techniques and experience regarding NOSES in the treatment of gastro-
intestinal tumor. I firmly believe that they could be available to be recommended to a broader
surgical community and allow more patients to benefit in the world.
Antonio Longo
Director, European Center of Coloproctology and Pelvic Diseases
Foreword by Ho-Kyung Chun
Clinical researchers at the Johns Hopkins University were the first to report the use of natural
orifice transluminal endoscopic surgery (NOTES) in 2004. Developed through animal experi-
ments, it has become more advanced minimally invasive surgery than laparoscopic and robotic
surgery, and it is an ideal procedure with the best minimally invasive effect.
In the summer of 2007, the Korean NOTES Study Group was established, and academic
conference has been held twice a year to discuss the development and application of laparo-
scopic and endoscopic techniques in NOTES. These activities have played an important role in
the promotion of NOTES technique in Korea. However, the NOTES technique still has many
problems, including high technical difficulty, high dependency on device platform, and limited
indicated population. Therefore, it will take a long time for this technique to be widely applied
in clinical practice.
xiii
xiv Foreword by Ho-Kyung Chun
On the basis of conventional laparoscopic surgical techniques, NOSES combines the

“incision-free” concept of NOTES and the technique of specimen extraction through natural
orifice. NOSES has both high feasibility of laparoscopic surgery and the good minimally inva-
sive effect of NOTES. By avoiding auxiliary incision in the abdominal wall, this technique has
light pain, quick recovery, good cosmetic effect of abdominal wall, less psychological distur-
bance, and many other advantages. These advantages are essential to the physical and psycho-
logical health of patients, especially those with cancer.
In the summer of 2012, I visited Prof. Wang Xishan for the first time and have learnt that he
had performed the first case of laparoscopic NOTES for rectal cancer worldwide in 2010. I was
amazed at the carrying out of this highly difficult minimally invasive technique under the con-
dition of limited technical equipment, which inspired my great admiration for Prof. Wang
Xishan’s innovative spirit. When I met Prof. Wang Xishan again in Beijing in 2016, he men-
tioned that he had started carrying out colorectal NOSES procedures in 2013. In just three
years, Prof. Wang has successfully completed more than 300 colorectal NOSES procedures.
He also had them classified and integrated to form a complete technical and theoretical system.
I was very pleasantly surprised by his achievement, which helps me gain a new understanding
of the NOSES technique.
By now, Prof. Wang Xishan has published many monographs on NOSES, which play an
important role in the promotion and development of NOSES. To facilitate the development of
NOSES in Korea, I was honored to translate Professor Wang Xishan's monograph of NOSES
for Colorectal Cancer into Korean. Since its publication, this book has been highly evaluated
in the surgical field of Korea. It has also played an important role in the standardization of
colorectal NOSES technique in Korea.
Now, I am glad to hear that Prof. Wang Xishan and dozens of international experts have
collaboratively written the second edition of English monograph of NOSES for Gastrointestinal
Cancer, which covers all NOSES techniques for gastrointestinal cancer. Many new techniques
have been launched in an innovative manner, and the previous techniques have been improved
and perfected, which injects new vitality into NOSES. I believe that the publication and distri-
bution of this edition will play a positive role in promoting the standardized development of
NOSES technique for gastrointestinal tumor in the field of minimally invasive surgery
worldwide.
Ho Kyung Chun

President, International Society of University Colon & Rectal Surgeons (ISUCRS)
President, Asia Pacific Federation of Coloproctology (APFCP)
President, Eurasian Colorectal Technologies Association (ECTA)
Introduction of Chief Editor
The Main Academic Title
The Chairman of Colorectal Cancer Committee of Chinese Medical Doctor Association; the
Chairman of Colorectal Cancer Committee of Chinese Anti-Cancer Association; the President
of International Alliance of NOSES; the President of China Alliance of NOSES; the Chairman
of Youth Committee of Colorectal Cancer Committee of Chinese Anti-Cancer Association; the
Vice Chairman of Tumor Metastasis Committee of Chinese Anti-Cancer Association; the Vice
Chairman of MDT Committee of Chinese Medical Doctor Association; the Standing Committee
of Surgeon Committee of Chinese Medical Doctor Association; the Chief Editor of Chinese
Journal of Colorectal Diseases (Electronic Edition); President of Russian-Chinese Society of
Colorectal Surgeons; Honorary Member of Russian School of Colorectal Surgery.
xv
xvi Introduction of Chief Editor
Scientific Research and Clinical Achievements
Totally, he has published 116 SCI papers; edited and participated in 18 monographs and 31
audiovisual materials related to colorectal cancer treatment; taken charge of more than 10
projects, including three projects of the National Natural Science Foundation, the National
City cancer early diagnosis and early treatment; and presided over National Major Project of
Precision Medicine titled “the application of precision medicine in colorectal cancer diagnosis
and treatment.”
Novel Techniques
He is proficient in minimally invasive surgery for colorectal cancer as well as combined organ
resection for difficult cases. Currently, he has improved the theoretical system of natural orifice
specimen extraction surgery (NOSES) in the treatment of colorectal cancer, including 10 dif-
ferent surgical procedures for colorectal cancer resection, and performed more than 500 cases
of NOSES for colorectal cancer; this number ranked first in China. He established evaluation
standard to determine low, ultra-low anastomosis surgery based on the tumor location to the
dentate line instead of the anal verge; put forward the “risk investment theory” to make sphinc-
ter preserving surgery a more scientific and standardized treatment system; carried out a vari-
ety of difficult surgeries, such as hemicolectomy combined with pancreaticoduodenectomy;
and proposed the distinction of concepts between combined organ resection and multiple
organ resection. According to the different invasion manner (cancerous invasion or inflamma-
tory invasion), he proposed refinement T4 staging recommendations. On the basis of the
expanded radical resection of rectal cancer, the selective expanded radical resection of rectal
cancer was proposed to fully retain the physiological function of patients after operation. In
addition, other new technologies also include radical rectal cancer surgery through sacrococ-
cygeal route, radical colectomy with the omentum preserved, and total colectomy with the
rectal ampulla preserved. These clinical works play an important role of improving the current
treatment status of colorectal cancer.
Student Training
At present, there are a total of 95 graduate students, including one professor, 10 associate pro-
fessors, 8 master tutors, 9 students in the national academic community as academic part-time,
and 15 students in the provincial academic community as academic part-time; some of these
students were sent abroad including Britain, the USA, and Japan, to study further.
Introduction of Associate Editor
Atsushi Nishimura
MD
Chief of Department of Surgery of Nagaoka Chuo General Hospital
Board Certified Surgeon in Japan Surgical Society
Board Certified Surgeon in Gastroenterology
Councilor of Japan Society for Endoscopic Surgery
Qualified Surgeon of Endoscopic Surgical Skill Qualification System
Cuneyt Kayaalp
Professor
Chief of Gastrointestinal Surgery Department of Inonu University
Member of Turkish Surgical Society, Society of Surgery Days, Turkish Laparoscopic
Endoscopic Surgery Association, Turkish HBP Surgery Society, Turkish Gastrointestinal
Surgery Society
Vice president of Turkish Bariatric Metabolic Surgery Association
President of MAGIC (Malatya Gastro-Intestinal Chirurgie)
xvii
xviii Introduction of Associate Editor
Joaquim Manuel da Costa Pereira

Professor
Director Surgical Service and of Colorectal Unity of Hospital de Braga.
Director of Courses of Advanced Colorectal Laparoscopic Surgery of Portuguese Society of
Minimally Invasive Surgery.
Director of Courses of Intestinal Anastomosis of Portuguese Society of Minimally Invasive Surgery.
Director of Courses of Laparoscopic Suture of Portuguese Society of Minimally Invasive Surgery.
Member of Direction of Portuguese Society of Coloproctology.
Honorary Consultant Surgeon of Vigo University Hospital
Joel Leroy
MD, FRCS, Professor of Surgery
Founder and Chairman Hanoi High Tech and Digestive Center, Saint Paul Hospital
Chairman of Colorectal Department HDC, Digestive Colorectal Surgeon
Professor Honoris Causa Hanoi Medical University
Introduction of Associate Editor xix
Petr V. Tsarkov
MD, Professor, PhD, FASCRS (Hon)
Director of Clinic of Colorectal and Minimally Invasive Surgery, Chief of Research Educational
Clinical Center of Colorectal and Endoscopic Surgery of Sechenov First Moscow Medical
State University
Founding Member of Russian Coloproctology Association
International Society of University Colorectal Surgeons (ISUCRS)
President Eurasian Colorectal Technologies Association (ECTA)
Member of European Society of Coloproctology (ESCP)
Honorary Fellow of American Society of Colon and Rectal Surgeons (ASCRS)
Member of European Association of Endoscopic Surgery (EAES)
Founding Member and Board Chairman of Russian Society of Colorectal Surgeons (RSCRS)
William Tzu-Liang Chen

MD, Associate Professor of Surgery
Vice-Superintendent of International Medicine Center, Chairman of Department of Surgery,
Director of Minimally Invasive Center of China Medical University Hospital
Member of American Society of Colon and Rectal Surgeons
Member of Society of American Gastrointestinal Endoscopic Surgeons
Board Member of Endo-laparoscopic Surgeons of Asia
Board Member of Asia-Pacific Endo-laparoscopic Surgeons
Board Member of Asian Endoscopic Task Force
Preface
At the completion of the second edition of the English book on NOSES, I am overwhelmed
with emotions. When the first edition of the Chinese book on NOSES was published, I was
very excited and wrote as follows: “NOSES is the integration of idea and technology, the col-
lision of inspiration and practice, the mutual assistance of trust and motivation, the agreement
of norms and innovation, and the progress of development and wishes.” After several years of
accumulation and development, the Chinese book on NOSES has been rapidly updated from
the first edition of NOSES for Colorectal Tumors to the third edition of NOSES for Abdominal
and Pelvic Tumors, and many foreign language translations have been published successively.
I hereby share with you some of my rational reflections on this technique.
The direction for the future development of gastrointestinal surgery must be innovation.
The revolution and innovation of medicine relies on the progress of physics, mechanical engi-
neering, material science, and other related disciplines, as well as the development of various
instruments and energy platforms such as laparoscopy and Da Vinci robot. The perfection of
the human body also makes up for the arrogance and self-righteousness of medicine. Open
surgery has been the mainstay of surgical treatment for hundreds of years. In the past 30 years,
the once controversial laparoscopic surgery has been widely accepted and popularized.
Similarly, we are making continuous progress and improvement in the development of
NOSES. At present, the techniques of laparoscopic organ resection and digestive tract recon-
struction by gastrointestinal surgeons are very mature. However, how to select a rational
approach to achieve better specimen extraction still warrants consideration. Since incisions for
specimen extraction are inevitable, why do not we choose the more concealed, scarless, and
less painful approaches. The advent of NOSES happens to meet these requirements.
With regard to NOSES, we must answer three questions: (1) What is it? (2) Why we do this?
(3) How to do this?
Firstly, we must answer “What is NOSES?.” NOSES is a kind of operation in which all
operative procedures are performed in the abdominal cavity, and the specimen is extracted
through the natural orifice. This operation can be performed on all organs in the abdomen and
pelvis. NOSES originated from the concepts of incision-free, Like-NOTES, etc. This book
illustrates the concepts of NOSES, NOTES, and taTME and their mutual relations, which
facilitates the development, improvement, and perfection of these techniques.
Secondly, we must answer “Why we do NOSES?” This should be discussed from two per-
spectives of both doctors and patients. For patients, “incision-free” is a novel idea, which can
relieve or even eliminate postoperative pain, reduce abdominal wall dysfunction, provide good
cosmetic appearance, and give them positive social psychosocial suggestions. With these
advantages, NOSES facilitates the establishment of self-confidence, accelerates postoperative
rehabilitation, and helps the patients to have a better return to society. For doctors, they should
keep “two senses and two pursuits” in the process of practicing medicine. “Two senses” are the
“sense of accomplishment” and the “sense of guilt.” “Two pursuits” of surgeons are “full
understanding of the 3D anatomical structure” and “every movement is the crystallization of
wisdom.” Doctors would feel the sense of happiness and fulfillment when their patients have
good feelings and quick recovery. Thus, NOSES has a positive impact on both doctors and
patients, which indicates that it is a better surgical procedure with good prospects.
xxi
xxii Preface
Finally, we must answer “How to do NOSES?” Surgeons should explore new clinical tech-
niques in a pragmatic manner and carry out the clinical practice of a series of procedures in a
healthy, scientific, and orderly way. The members of Chinese NOSES Alliance have done a
great deal of work for this purpose. Their hard work is far more than a mere pursuit of personal
development. At the height of industry progress and national rejuvenation, they are striving to
get the voice of Chinese surgeons heard in the global medical world. They appreciate other
people’s achievements with an open mind and critically review their own limitations. With the
broad mind and wide vision of the members of Chinese NOSES Alliance, NOSES is destined
to have the characteristics of “standardization, innovation, pragmatism, truth-seeking, and
advancing.” We have accommodated the opinions and suggestions of all aspects and recognize
NOSES as the direction and goal of future development. On this basis, NOSES has developed
rapidly and vigorously. With the increased diversity of involved tissues and organs, the number
of hospitals, specialists, and operation cases of NOSES in China is increasing year by year.
The overall complications have not been increased significantly, which sufficiently demon-
strated the safety and feasibility of NOSES.
The International NOSES Alliance has been established, and each province has set up the
secondary branch of the Alliance successively, which provides a strong organizational guaran-
tee for the healthy development of NOSES. In order to standardize the clinical development of
NOSES, with the efforts of all members of this alliance, the Chinese Consensus on NOSES and
the International Consensus on NOSES were formulated successively to make NOSES reason-
able and evidence based. In addition, a series of academic activities, such as international
NOSES academic conference, Chinese NOSES lecture tour, NOSES seminar, NOSES live
surgical demonstration, and expert symposium, have been carried out with the Chinese NOSES
Alliance and the Chinese Journal of Colorectal Diseases as the academic platform. These have
greatly promoted the clinical popularization of NOSES and benefited more patients. The suc-
cessive publications of NOSES books in English, Korean, Japanese, and Russian have signifi-
cantly promoted the international popularization and exchange of NOSES. We firmly believe
that all specialties will publish their respective NOSES monographs in the near future.
The successful publications of many NOSES monographs are not possible without the wis-
dom and hard work of all the editors and the guidance and help of Academician He Jie, Prof.
Zheng Shu, Prof. Zheng Minhua, Academician Chen Xiaoping, Academician Fan Daiming,
and Academician Guo Yinglu. It is also inseparable from the support and dedication of Prof.
Petr V. Tsarkov, Prof. Atsushi Nishimura, Prof. Cuneyt Kayaalp, Prof. Ho-Kyung Chun, Prof.
Joaquim Manuel da Costa Pereira, Prof. William Tzu-Liang Chen, and other international col-
leagues for the promotion of NOSES. I would like to extend our sincere gratitude to all of
them.
NOSES is not just a great work of doctors, but also the gospel of patients. NOSES not only
belongs to China, but also belongs to the world.
Beijing, China Xishan Wang

Contents
Part I General Statement
1 Overview of NOSES�� 3

Xishan Wang
2 Perioperative Preparation of NOSES�� 25
Xishan Wang, Yinggang Chen, Lei Yu, and Rui Huang
3 Laparoscopic Abdominal Pelvic Anatomical Landmarks and Essentials
of Surgical Exploration�� 33
Haipeng Chen, Xu Guan, and Xishan Wang
Part II NOSES for Colorectal Cancer
4 Laparoscopic Lower Rectal Cancer Resection with Transanal Specimen

Extraction (CRC-NOSES IA, IB, and IB+, Eversion Method)�� 43
Xishan Wang, Enrui Liu, and Haipeng Chen
5 Laparoscopic Ultralow Rectal Cancer Resection with Transanal Specimen
Extraction: Park Method (CRC-NOSES IC)�� 67
Xishan Wang, Yinghu Jin, and Zheng Jiang
Extraction: Intersphincteric Resection Method (CRC-NOSES ID) �� 81
Xishan Wang, Meng Wang, and Zheng Jiang
Extraction: Bacon Method (CRC-NOSES IE)�� 95
Bo Jiang and Yi Feng
8 Laparoscopic Lower Rectal Cancer Resection with Rectal Eversion
and Extra-Abdominal Resection: Tsarkov Method (CRC-NOSES IF)�� 109
Sergey Efetov, Inna Tulina, and Petr V. Tsarkov
9 Laparoscopic Middle Rectal Cancer Resection with Transanal Specimen
Extraction (CRC-NOSES II)�� 121
Xishan Wang, Ziming Yuan, and Zhixun Zhao
10 Laparoscopic Middle Rectal Cancer Resection with Transvaginal Specimen
Extraction (CRC-NOSES III)�� 139
Xishan Wang, Qian Zhang, and Haipeng Chen
11 Laparoscopic Upper Rectal Cancer Resection with Transanal Specimen
Extraction (CRC-NOSES IV) �� 157
Xishan Wang, Song Wang, and Peng Sun
xxiii
xxiv Contents
12 Laparoscopic Upper Rectal Cancer Resection with Transvaginal Specimen

Extraction (CRC-NOSES V)�� 171
Xishan Wang and Zhixun Zhao
13 Laparoscopic Left Hemicolectomy with Transanal Specimen Extraction
(CRC-NOSES VI A)�� 187
Xishan Wang and Zheng Jiang
14 Laparoscopic Left Hemicolectomy with Transrectal Specimen Extraction
(CRC-NOSES VIB)�� 205
Haipeng Chen, Zhaoxu Zheng, and Xishan Wang
15 Laparoscopic Left Hemicolectomy with Transvaginal Specimen Extraction
(CRC-NOSES VII) �� 221
Xishan Wang, Zheng Liu, and Zhao Lu
16 Laparoscopic Right Hemicolectomy with Transvaginal Specimen Extraction
(CRC-NOSES VIIIA)�� 237
Xishan Wang, Xu Guan, and Haiyang Huang
17 Laparoscopic Right Hemicolectomy with Transrectal Specimen Extraction
(CRC-NOSES VIIIB)�� 255
Xiyue Hu and Haitao Zhou
18 Laparoscopic Right Hemicolectomy with Transcolonic Specimen Extraction
(CRC-NOSES VIIIC)�� 269
Jian Peng
19 Laparoscopic Total Colectomy with Transanal Specimen Extraction
(CRC-NOSES IX)�� 283
Xishan Wang and Zheng Jiang
20 Laparoscopic Total Colectomy with Transvaginal Specimen Extraction
(CRC-NOSES X)�� 303
Xishan Wang, Zheng Jiang, and Runkun Yang
21 Transanal Total Mesorectal Excision (taTME) �� 319
Liang Kang
Part III NOSES for Gastrointestinal Cancer
22 Laparoscopic Distal Gastrectomy (Billroth I) with Transrectal Specimen

Extraction (GC-NOSES I)�� 335
Su Yan
23 Laparoscopic Distal Gastrectomy (Billroth I) with Transvaginal Specimen
Extraction (GC-NOSES II) �� 345
Su Yan
24 Laparoscopic Distal Gastrectomy (Billroth II) with Transrectal Specimen
Extraction (GC-NOSES III)�� 355
Gang Yu
25 Laparoscopic Distal Gastrectomy (Billroth II) with Transvaginal Specimen
Extraction (GC-NOSES IV)�� 369
Gang Yu
Contents xxv
26 Laparoscopic Proximal Gastrectomy with Transrectal Specimen Extraction

(GC-NOSES V)�� 387
Gang Yu
27 Laparoscopic Proximal Gastrectomy with Transvaginal Specimen Extraction
(GC-NOSES VI) �� 401
Gang Yu
28 Laparoscopic Total Gastrectomy with Transrectal Specimen Extraction
(GC-NOSES VII)�� 415
Gang Yu
29 Laparoscopic Total Gastrectomy with Transvaginal Specimen Extraction
(GC-NOSES VIII)�� 431
Gang Yu
30 Robotic Gastric Tumor Resection with Transoral Specimen Extraction
(GC-NOSES IX) �� 447
Zhiwei Jiang
31 Laparoscopic Small Intestinal Tumor Resection with Transrectal Specimen
Extraction �� 455
Haitao Zhou
32 Laparoscopic Small Intestinal Tumor Resection with Transvaginal Specimen
Extraction �� 465
Xishan Wang and Haipeng Chen
Part IV Special and Extended Resection Surgery with NOSES
33 Laparoscopic Extended Lower Rectal Cancer Resection with En Bloc Lateral

Lymph Node Dissection (Wang’s Approach) �� 475
Xishan Wang, Zhaoxu Zheng, and Haipeng Chen
34 Laparoscopic Right Hemicolectomy and Sigmoidectomy with Transvaginal
Specimen Extraction�� 491
Xishan Wang and Haipeng Chen
35 Laparoscopic Right Hemicolectomy and Rectal Cancer Resection
with Transrectal Specimen Extraction�� 507
Guiyu Wang, Tianyi Ma, and Qian Zhang
36 Laparoscopic Rectal Cancer Resection Combined with Liver Metastasis
Resection with Transanal Specimen Extraction�� 523
Chuangang Fu
37 Laparoscopic Right Hemicolectomy Combined with Pancreaticoduodenal
Resection with Natural Orifice Specimen Extraction�� 539
Gang Yu
Part V Complications and Management of NOSES
38 Complications and Management of NOSES for Gastrointestinal Tumor�� 559

Yinggang Chen, Yantao Tian, and Qian Liu
xxvi Contents
Part VI Collection of Expert Experience on NOSES
39 Experience Sharing in NOSES for Colorectal Cancer �� 567

Qingchao Tang, Haipeng Chen, and Xishan Wang
40 Totally Laparoscopic Colectomy for Colorectal Cancer with Natural
Orifice Specimen Extraction Combined with Reduced-Port Surgery:
Japanese Experience�� 587
Atsushi Nishimura, Mikako Kawahara, Yasuyuki Kawachi, Shigeto Makino,
Chie Kitami, and Keiya Nikkuni
41 Laparoscopic-Assisted Natural Orifice Specimen Extraction Colectomy
Using a Cai Tube for Left-Sided Colonic Carcinomas�� 595
Jianchun Cai and Shuzhen Xu
42 Laparoscopic Total Colectomy Combined with NOSES:
Turkish Experience�� 601
Cuneyt Kayaalp
43 Operating Points of Aseptic and Tumor-Free Operation in NOSES
for Rectal Cancer �� 605
Chuangang Fu
44 Application of Reverse Puncture Technique to Place Anvil for Laparoscopic
Colorectal Resection with NOSES�� 607
Qingsi He and Hui Qu
45 New Method of Modified NOSES I�� 615
Junhong Hu
46 Laparoscopic Resection of Tumors of Left Colon, Sigmoid Colon, and Upper
Rectum with Transanal Specimen Extraction (NOSES IV and VI): Portuguese
Experience�� 617
Joaquim Manuel da Costa Pereira and Carlos Costa Pereira
47 NOSES in Colorectal Surgery: Vietnamese Experience�� 623
Joel Leroy, Frederic Bretagnol, and Dan Nguyen
48 Robotic Radical Resection for Lower Rectal Carcinoma with Transanal
Pullout of Rectum Eversion and Extracorporeal Resection Technique�� 635
Taiyuan Li and Lei Xiong
49 Application of OrVil™ and NOSES in Total Laparoscopic Gastrectomy
for Female �� 639
Dan Ma
50 Experience Sharing of Key Points in NOSES for Colorectal Cancer�� 645
Xuejun Sun
51 Experience and Skill Sharing on NOSES in the Left and Right Colon�� 647
Guiyu Wang
52 Natural Orifice Specimen Extraction in Laparoscopic Anterior Resection
(NOSE-LAR): Taiwanese Experience�� 651
Ming Li Leonard Ho and William Tzu-Liang Chen
53 Reduced Port Laparoscopic Anterior Resection with Transrectal Specimen
Extraction and Single-Stapled Anastomosis: Taiwanese Experience�� 657
Sheng-Chi Chang, Ming Li Leonard Ho, and William Tzu-Liang Chen
Contents xxvii
54 Robotic Single Stapling Coloanal/Colorectal Anastomosis with Transanal

Specimen Extraction for Anterior Resection of Rectosigmoid Tumor�� 661
Hongliang Yao
55 Conformal Sphincter-Preserving Operation + NOSES I (CSPO + NOSES I)
for Extremely Low Rectal Cancer�� 663
Wei Zhang and Zheng Lou
56 Laparoscopic Complex NOSES Surgery of Colorectal Tumor�� 667
Yangchun Zheng and Yuanyi Rui

Appendix A: International Consensus on Natural Orifice Specimen Extraction
Surgery (NOSES) for Colorectal Cancer�� 673

Appendix B: International Consensus on Natural Orifice Specimen Extraction
Surgery (NOSES) for Gastric Cancer (2019)�� 683
Postscript�� 691
Content Summary�� 693
Contributors
Frederic Bretagnol High Tech Digestive Center, Saint Paul University Hospital, Hanoi,
Vietnam
Jianchun Cai Department of Gastrointestinal Surgery, Zhongshan Hospital of Xiamen
University, Xiamen, China
Sheng-Chi Chang Division of Colorectal Surgery, China Medical University Hospital,
Taichung, Taiwan
Haipeng Chen Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese
Academy of Medical Sciences, Beijing, China
William Tzu-Liang Chen Department of Colorectal Surgery, China Medical University
Hsinchu Hospital, Taichung, Taiwan
Yinggang Chen Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese
Academy of Medical Sciences, Shenzhen Center, Shenzhen, China
Joaquim Manuel da Costa Pereira Department of Surgery, Hospital de Braga, Braga,
Portugal
Sergey Efetov Colorectal Surgery Department, Sechenov First Moscow State Medical
University, Moscow, Russia
Yi Feng Anal and Colorectal Surgery, Shanxi Cancer Hospital, Affiliated Cancer Hospital of
Shanxi Medical University, Taiyuan, China
Chuangang Fu Department of Gastrointestinal Surgery, Shanghai East Hospital, Tongji
University School of Medicine, Shanghai, China
Xu Guan Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy
of Medical Sciences, Beijing, China
Qingsi He Department of General Surgery, Shandong University Qilu Hospital, Jinan, China
Ming Li Leonard Ho Department of General Surgery, Sengkang General Hospital, Singapore,
Singapore
Haiyang Huang Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese
Rui Huang Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of
Harbin Medical University, Harbin, China
Hanqing Hu Department of Colorectal Surgery, The Second Affiliated Hospital of Harbin
Medical University, Harbin, Heilongjiang, China
Junhong Hu Department of General Surgery, The First Affiliated Hospital of Zhengzhou
University, Zhengzhou, China
xxix
xxx Contributors
Xiyue Hu Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy
Bo Jiang Anal and Colorectal Surgery, Shanxi Cancer Hospital, Affiliated Cancer Hospital of
Shanxi Medical University, Taiyuan, China
Jun Jiang Diagnostic Imaging Department, Cancer Institute & Hospital, Chinese Academy
Zheng Jiang Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese
Zhiwei Jiang Department of General Surgery, Jiangsu Province Hospital of Traditional
Chinese Medicine, Nanjing, China
Yinghu Jin Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of
Liang Kang Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen
University, Guangzhou, China
Yasuyuki Kawachi Nagaoka Chuo General Hospital, Niigata, Japan
Mikako Kawahara Nagaoka Chuo General Hospital, Niigata, Japan
Cuneyt Kayaalp Department of Gastrointestinal Surgery, Inonu University, Malatya, Turkey
Chie Kitami Nagaoka Chuo General Hospital, Niigata, Japan
Joel Leroy High Tech Digestive Center, Saint Paul University Hospital, Hanoi, Vietnam
Taiyuan Li Department of General Surgery, The First Affiliated Hospital of Nanchang
University, Nanchang, China
Enrui Liu Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy
Hengchang Liu Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese
Qian Liu Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy
Zheng Liu Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy
Zheng Lou Department of Colorectal Surgery, Changhai Hospital, Navy Medical University,
Shanghai, China
Zhao Lu Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy
Chenxi Ma Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy
Dan Ma Department of General Surgery, Xinqiao Hospital, The Third Military Medical
University, Chongqing, China
Tianyi Ma Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of
Contributors xxxi
Xiaolong Ma Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese

Shigeto Makino Nagaoka Chuo General Hospital, Niigata, Japan
Dan Nguyen High Tech Digestive Center, Saint Paul University Hospital, Hanoi, Vietnam
Keiya Nikkuni Nagaoka Chuo General Hospital, Niigata, Japan
Atsushi Nishimura Nagaoka Chuo General Hospital, Niigata, Japan
Jian Peng Hepatobiliary and Enteric Surgery Research Center, Xiangya Hospital, Central
South University, Changsha, Hunan, China
Carlos Costa Pereira Department of Surgery, Hospital de Braga, Braga, Portugal
Tianyu Qiao Department of Pancreatic Stomach Surgery, Cancer Institute & Hospital,
Chinese Academy of Medical Sciences, Beijing, China
Hui Qu Department of General Surgery, Shandong University Qilu Hospital, Jinan, China
Jichuan Quan Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese
Yuanyi Rui Department of Gastrointestinal Surgery, Sichuan Cancer Hospital & Institute,
Sichuan Cancer Center, Cancer Hospital Affiliate to School of Medicine, UESTC, Chengdu,
China
Peng Sun Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy
of Medical Sciences, Shenzhen Center, Shenzhen, China
Xuejun Sun Department of General Surgery, First Affiliated Hospital of Xi’an Jiaotong
University, Xi’an, China
Qingchao Tang Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of
Yantao Tian Department of Colorectal Surgery, The Second Affiliated Hospital of Harbin
Medical University, Harbin, Heilongjiang, China
Petr V. Tsarkov Clinic of Colorectal and Minimally Invasive Surgery, Sechenov First Moscow
State Medical University, Moscow, Russia
Inna Tulina Clinic of Colorectal and Minimally Invasive Surgery, Sechenov First Moscow
State Medical University, Moscow, Russia
Guiyu Wang Department of Colorectal Cancer Surgery, Cancer Hospital of the University of
Chinese Academy of Sciences, Hangzhou, China
Meng Wang Department of Colorectal Cancer Surgery, Cancer Hospital of the University of
Song Wang Department of Colorectal Cancer Surgery, The First Affiliated Hospital, Zhejiang
University School of Medicine, Hangzhou, China
Xishan Wang Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese
Lei Xiong Department of General Surgery, The First Affiliated Hospital of Nanchang
University, Nanchang, China
xxxii Contributors
Shuzhen Xu Department of Gastrointestinal Surgery, Zhongshan Hospital of Xiamen

University, Xiamen, China
Ming Yang Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese Academy
Runkun Yang Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of
Su Yan Department of Gastrointestinal Surgery, Affiliated Hospital of Qinghai University,
Qinghai University, Xining, China
Hongliang Yao Department of General Surgery, The Second Xiangya Hospital, Central South
University, Changsha, Hunan, China
Gang Yu Department of General Surgery, Qilu Hospital of Shandong University (Qingdao),
Qingdao, China
Lei Yu Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of Harbin
Medical University, Harbin, China
Ziming Yuan Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of
Hongmei Zhang Diagnostic Imaging Department, Cancer Institute & Hospital, Chinese
Mingguang Zhang Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese
Qian Zhang Department of Colorectal Cancer Surgery, Cancer Hospital of the University of
Wei Zhang Department of Colorectal Surgery, Changhai Hospital, Navy Medical University,
Shanghai, China
Zhixun Zhao Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese
Yangchun Zheng Department of Gastrointestinal Surgery, Sichuan Cancer Hospital &
Institute, Sichuan Cancer Center, Cancer Hospital Affiliate to School of Medicine, UESTC,
Chengdu, China
Zhaoxu Zheng Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese
Haitao Zhou Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese
Meng Zhuang Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese
Part I
General Statement
Overview of NOSES
1
Xishan Wang
With the rapid development of surgical techniques and the 1 inimally Invasive Surgery and Surgical
M
widespread acceptance of minimal invasiveness, minimally Incisions
invasive surgery has become the focal point of new medical
technology. In most cases, laparoscopic surgery has replaced Minimally invasive surgery (MIS) is one of the most popular
the conventional open surgery as a regular treatment proce- concepts in modern surgery. However, what is the exact defi-
dure. Meanwhile, more recently, robotic surgery has been nition of minimally invasive? What does it mean to do some-
enthusiastically adopted by patients and surgeons alike. thing minimally invasive? Broadly speaking, “minimally
Moreover, natural orifice transluminal endoscopic surgery invasive” is an idea that minimizes or limits the damage to
(NOTES) has overturned the conventional concept and the tissues and organs caused by any human factors. This
pushed minimally invasive technique to the extreme of “no concept applies to all the invasive surgical operations or pro-
incision.” Furthermore, various minimally invasive tech- cedures and is central to the current era of MIS. In this con-
niques, and the evolved modalities of the surgical armamen- text, the concept of functional surgery in tumor therapy
tarium of many different laparoscopic techniques, including emerged. On the basis of radical cancer treatment, functional
3D laparoscopic surgery, single-port laparoscopic surgery, surgery of the tumor requires that the normal function of
hand-assisted laparoscopic surgery, and transanal minimally organs and tissues should be retained to the maximum extent.
invasive surgery, are widely being used in the clinical prac- It can be seen that the concept of MIS and tumor functional
tice. From here, we can see that the field of surgery has fully surgery is essentially dialectically unified, and the ultimate
entered a new era with multiple surgical techniques and a purpose of MIS, is to retain the normal function. Narrowly,
wide variety of academic perspectives. minimally invasive is a kind of surgical approach that mini-
Recently, as one of the new techniques in minimally inva- mizes the size of the surgical abdominal incision. In the past,
sive surgery, natural orifice specimen extraction surgery incision and pain were considered as the inevitable outcome
(NOSES) has gradually attracted extensive attention and of surgery; the larger the incision, the greater the surgical
heated discussion both domestically and overseas. It is well damage. Moreover, surgeons usually pay more attention to
known that NOSES is a new type of hybrid surgical proce- intra-abdominal operations, while ignoring a series of nega-
dure with the “no incision” idea of NOTES and the surgical tive physical and psychological effects of the incision on
techniques of laparoscopic surgery, to achieve better clinical patients.
and minimally invasive outcomes with satisfying safety and In fact, in NOTES, NOSES or other minimally invasive
operability. Currently, the application of NOSES is not only surgical procedures, the intra-abdominal steps are almost the
limited to the colorectal field, but has also extended gradu- same as that of traditional open surgery, consisting of tissue
ally to perform gastrointestinal, hepatobiliary, splenopancre- dissection, lesion resection, and digestive tract reconstruc-
atic, and urogynecologic surgeries, reflecting the vitality and tion. The main difference lies in the abdominal incisions.
potentiality of NOSES. In order to build a comprehensive Compared with open surgery and conventional laparoscopic
theory of NOSES, we have extended the application of surgery, the most direct advantage of the NOSES procedure
NOSES to surgeries for other abdominal and pelvic organs, is the avoidance of abdominal incision for specimen retrieval.
then present a detailed surgical monograph of NOSES. However, the necessity to avoid this small incision is a con-
ceptual problem that must be faced before starting
NOSES. Firstly, incision is the main cause of postoperative
X. Wang (*)
Department of Colorectal Surgery, Cancer Institute & Hospital, pain. The larger the incision, the greater the damage to the
Chinese Academy of Medical Sciences, Beijing, China superficial nerves, consequently, the more severe the
© People’s Medical Publishing House, PR of China 2021 3

X. Wang (ed.), Natural Orifice Specimen Extraction Surgery, https://doi.org/10.1007/978-981-15-7925-7_1
4 X. Wang
Table 1.1 Classification of incisions NOTES, like-NOTES, etc. Although the terminology is dif-
Classification Length Examples of surgery (Fig. 1.1) ferent, all techniques are aimed at achieving a common goal,
Mini <2 cm Abdominal paracentesis, incision for namely the pursuit of minimally invasive effects, avoidance
incision anvil in laparoscopic surgery, etc. of abdominal wall incisions, and reduction of abdominal
Small ≥2 cm, Appendectomy, cholecystectomy, etc. dysfunction. However, this complex nomenclature may con-
incision <5 cm
fuse literature retrieval and academic exchanges. Combining
Medium ≥5 cm, Hand-assisted laparoscopic radical
incision <10 cm surgery for sigmoid colon cancer, etc. internationally accepted presentation methods and language
Large ≥10 cm, Lower abdomen outer-transverse habits, it is recommended that the technique is named
incision <20 cm inner-longitudinal incision for extended “Natural Orifice Specimen Extraction Surgery,” the abbrevi-
radical resection of rectal cancer, etc. ation is “NOSES.” It is suggested to use this universal name
Super ≥20 cm Right hemicolectomy combined with when publishing-related papers, so as to facilitate literature
incision pancreaticoduodenectomy, etc.
retrieval and academic communication.
NOSES is defined as follows: the surgical procedures,
postoperative pain is. Wolthuis and colleagues compared the including specimen resection or reconstruction, are per-
short-term outcomes of the patients received conventional formed intracorporeally by laparoscopic, robotic device or
laparoscopic surgery and NOSES and found that the conven- flexible endoscopy, followed by specimen extraction through
tional laparoscopic surgery group showed more severe post- a natural orifice (anus, vagina, or mouth) (Guan et al. 2020).
operative pain and greater dependence on postoperative pain Compared with the conventional laparoscopic surgery,
relievers. Severe pain at or around the incision site is also an NOSES is equipped with a surgical specimen retrieval fea-
important factor affecting postoperative recovery. Secondly, ture, through a natural orifice, to avoid the abdominal inci-
abdominal incision also increases the risk of incision com- sion and yet leaving a few tiny scars on the abdominal wall
plications, including infection, incisional hernia, and even after the surgery. In addition to colorectal surgeries, the
incision site tumor implantation. During the postoperative NOSES approach is also feasible to be applied to perform
recovery period, surgical incision may bring negative moods surgeries of the other gastrointestinal, hepatobiliary, pancre-
to patients, such as panic, anxiety, irritability, etc., which aticosplenic, and urogenital organs.
could lead to a systemic state in patients and have a great Other than NOSES, NOTES and transanal total mesorec-
negative impact on postoperative recovery. Thirdly, the trac- tal excision (taTME) are also hot topics of the discussion.
tion and stimulation of the surgical scar tissue bring adverse These two techniques are closely related to “the natural ori-
psychological effects, which may remind the patient of this fice” and can easily be confused with NOSES. Knowing
painful experience over and over again. Finally, the postop- their definitions and their relationships with NOSES may
erative cosmetic appearance depends on the size of the inci- contribute to having a better understanding of NOSES.
sion, which is especially of concern to young females or NOTES is defined as a new technique for diagnosis and
patients engaged in some special professions such as dancers treatment performed intracorporeally equipped with flexible
and fitness coaches. or rigid endoscopy to access the thoracic cavity, mediasti-
Hence, the surgical incision is closely related to the post- num, and abdominal cavity through the natural orifice such
operative pain, abdominal wall dysfunction, postoperative as the mouth, esophagus, stomach, colon (rectum), vagina,
recovery, cosmetic appearance, and even the long-term psy- bladder, etc. A range of procedures can be performed this
chosocial state of the patient. The incision is a reflection of way, such as exploration and biopsy, tumor resection, diges-
the concept of minimally invasive, a representation of the tive tract reconstruction, pericardial fenestration, etc. The
endless pursuit of minimally invasive techniques by surgeons feature of NOTES is, avoiding any external incisions and
in different eras. Therefore, the author believes it is neces- performing the whole operation through natural orifices. In a
sary to classify incision according to size, so as to provide an broad sense, NOTES should be divided into no scar NOTES
objective basis for the evaluation of surgical trauma and no visible scar NOTES (Table 1.2). The former refers to
(Table 1.1). flexible endoscopic NOTES, whose operations are per-
formed through natural orifices. This is NOTES in the real
sense or pure-NOTES. The latter refers to the surgical opera-
2 Nomenclature and Definition of NOSES tion through the natural orifice with auxiliary operation
through the umbilicus, and no scar is visible on the body
In recent years, based on the introduction of natural orifice surface after operation. In 2010, our team has performed the
transluminal endoscopic surgery (NOTES), a series of con- first case of transvaginal-NOTES for rectal cancer world-
cepts related to NOTES have been gradually proposed by wide, and the patient recovered well postoperatively, without
combining different instruments and different operative recurrence and metastasis up to now (Fig. 1.2). The specific
methods, for example, pre-NOTES, pure-NOTES, hybrid- surgical procedures were presented in Chap. 39.
1 Overview of NOSES 5
a b c
d e
Fig. 1.1 Surgery incisions. (a) Mini incision (incision for anvil in inner-longitudinal incision for extended radical resection of rectal can-
NOSES surgery); (b) Small incision (appendectomy); (c) Medium inci- cer); (e) Super incision (right hemicolectomy combined with
sion (hand-assisted laparoscopic radical surgery of sigmoid colon can- pancreaticoduodenectomy)
cer); (d) Large incision (lower abdomen outer-transverse
Table 1.2 Classification of NOTES

Classification of
NOTES Operating Surgeon Instrument Operating Characteristics
No scar NOTES Gastroenterologist or Flexible endoscopy All operations are performed through natural orifices without any
endoscopist based based surgical scars on the body surface
No visible scar Surgeon-based Rigid endoscopic Surgical operation is performed through the natural orifice with
NOTES instrument based auxiliary operation through the umbilicus, and no scar is visible on the
body surface after operation.
The naming of NOTES should be standardized as well. standing. As a matter of fact, this procedure should be
Otherwise, it will harm its technical promotion and aca- referred to as Ta-NOTES, which is more in compliance with
demic exchange. According to the different surgical the actual situation.
approaches through natural orifices, NOTES is divided into In conclusion, NOSES combines the “scarless” concept
the following categories: Tg-NOTES (Transgastric-NOTES), of NOTES with the conventional laparoscopic intra-
Te-NOTES (Transesophageal-NOTES), Ta-NOTES abdominal surgical approach and making full use of the nat-
(Transanal-NOTES), Tv-NOTES (Transvaginal-NOTES), ural orifice to remove the specimen. As a result, NOSES
Tb-NOTES (Transbladder-NOTES), and Tu-NOTES shows favorable minimally invasive results and also meets
(Transumbilical-NOTES). the surgeon’s usual practice. Differently, NOTES empha-
TaTME represents a transanal endoscopic proctectomy sizes the use of natural orifice as the surgical approach to
following the principle of TME, which is based on the TEM enter the body cavity and perform various diagnostic or
or TAMIS platform and using a “down-to-up” procedure. treatment operations. This technique is a great challenge to
The access route to perform taTME is transanally and hence, the conventional surgical approach via body surface. Since
no scar is left on the abdominal wall. Actually, the current NOTES also removes the specimen through a natural orifice,
definition of taTME is quite different from general under- it therefore should be a component of NOSES. NOSES and
6 X. Wang
Transoral
Transvaginal Transanal
Fig. 1.4 Different routes for specimen extraction
Fig. 1.2 Group photo of patient and surgeons 10 years after NOTES
NOSES
NOTES
Fig. 1.5 Eversion–resection technique
TaTME
with small-sized tumors, easy to be removed via the anus. As
it has been well established that the elastic properties of the
Fig. 1.3 The relationship among NOSES, NOTES, TaTME vagina allow removal of more bulky specimens when com-
pared to proctotomy, therefore, the transvaginal specimen
NOTES are suitable for all kinds of tissues and organs, While extraction procedure is applied to the female patients with
TaTME is a concept limited in rectal surgery. TaTME empha- large-sized tumors, which are difficult to be removed transa-
sizes the transanal approach for dissection and excision of nally. In addition to these two above mentioned routes, some
mesorectum, as well as the extraction of the specimen. From surgeons have also started to operate NOSES with transoral
this perspective, TaTME belongs to NOTES as well. specimen extraction, including sleeve gastrectomy, gastric
Figure 1.3 demonstrates the relationship among these three stromal tumor resection, liver biopsy, cholecystectomy, sple-
techniques. nectomy, etc. However, considering that the esophageal is
long and narrow with low elasticity, the indications of tran-
soral specimen extraction procedure should be strict.
3 C
lassification and Surgical Procedures
of NOSES
3.2 Classification According
3.1 lassification According to the Routes
C to the Procedures for Specimen
for Specimen Extraction Extraction
According to the routes for specimen extraction, NOSES is According to the procedures of specimen extraction, NOSES
divided into three categories: transanal-, transvaginal- and can also be classified into three categories: (1) Transanal
transoral-NOSES (Fig. 1.4). The former two procedures are specimen eversion and extracorporeal resection technique
used more commonly in clinical practice, especially the (eversion-resection) (Fig. 1.5), (2) transluminal specimen
transanal specimen extraction procedure. Transanal speci- extraction and extracorporeal resection technique (extrac-
men extraction procedure is mainly applied to the patients tion–resection) (Fig. 1.6), and (3) intra-abdominal specimen
lectomy, and total colectomy. See Table 1.3 for the detailed
surgical approaches. With the deepening of the understand-
ing of NOSES, the surgical approaches for the lower rectum
have been further improved. So far, the NOSES I includes
six different methods: NOSES IA and NOSES IB are trans-
anal specimen eversion and extracorporeal resection tech-
niques, NOSES IC is Park technique, NOSES ID is
intersphincteric resection (ISR) technique, NOSES IE is
Bacon technique, NOSES IF is invented by Prof. Petr
V. Tsarkov. Moreover, the concepts of “like-NOSES” and
“passing by-NOSES” were proposed to confirm the main
concept of these techniques clinically and to standardize the
Fig. 1.6 Extraction–resection technique clinical practice of these procedures.
Each NOSES approach has its specific indications.
Therefore, in clinical practice, we need to choose the most
proper surgical approach based on the condition of the tumor
and the patient. There are several important principles that
should be followed. Firstly, surgeons should locate the tumor
accurately, especially for rectal cancer patients. Precise
tumor positioning is the basis of choosing the best surgical
approach. Secondly, the size of the specimen is a key factor
for specimen extraction. Here, the size of the specimen
mainly refers to the circumferential diameter of the speci-
men. Digital rectal examination, preoperative imaging
assessment, and intraoperative laparoscopic exploration can
help to determine the tumor location and the size of the spec-
imen. Thirdly, while transanal and transvaginal approach are
Fig. 1.7 Resection–extraction technique
both feasible for the specimen extraction, the specimen
should be removed transanally, so as to avoid unnecessary
resection and transluminal extraction technique (resection– vaginal injuries and being in line with the principle of func-
extraction) (Fig. 1.7). Different surgical procedures carry tional surgery.
different features and require specific surgical skills, how-
ever, the decisive factor in choosing an appropriate surgical
procedure is the tumor location. In colorectal NOSES, the 3.4 NOSES for Gastric Neoplasms
eversion–resection procedure is mainly used for the lower
rectal tumors, the extraction–resection procedure is mainly For gastric tumors, surgical resection procedures are differ-
used for the middle rectal tumors, and the resection–extrac- ent depending on the tumor location. Distal gastrectomy is
tion is used more widely, including for the tumors in the often used for antral tumors, subtotal gastrectomy for gastric
upper rectum, the sigmoid colon, the left half colon, the right body tumors, and total gastrectomy for gastric fundus
half colon, and the whole colon. Besides colon and rectum, tumors. Specimen extraction routes for gastric tumors
other organs follow the “resection–extraction” technique of include transvaginal, transanal, and transoral approaches.
NOSES to extract the specimen. Due to the healing ability and elasticity of the vagina, the
transvaginal extraction route is the first choice for the
removal of large gastric tumor specimens, but that procedure
3.3 NOSES for Colorectal Neoplasms is only applicable to female patients. There are risks of intes-
tinal leakage and abdominal infection associated with tran-
In the first edition of Natural Orifice Specimen Extraction— srectal specimen extraction procedure. Therefore, this
Gastrointestinal Tumor, the author summarized and approach is only applicable to patients with special needs,
described ten different NOSES approaches, from NOSES I having a strong desire to undergo the operation and can
to NOSES X. Five approaches were used for rectal resection, accept the potential risks. Technically, transrectal specimen
aiming to treat the neoplasms located in the upper, middle, extraction is also one of the approaches of NOSES. It is nec-
and lower rectum, respectively. Five approaches were used essary to know about it, but it is not recommended
for colectomy, including left hemicolectomy, right hemico- routinely.
8 X. Wang
Table 1.3 Natural orifice specimen extraction surgery (NOSES) approaches for colorectal neoplasms (Guan et al. 2020)
Abbreviations Full Name Orifice Tumor Location
CRC-NOSES I Laparoscopic lower rectal cancer resection with transanal specimen Anus Lower rectum
(A-F) extraction
CRC-NOSES II Laparoscopic middle rectal cancer resection with transanal specimen Anus Middle rectum
extraction
CRC-NOSES III Laparoscopic middle rectal cancer resection with transvaginal Vagina Middle rectum
specimen extraction
CRC-NOSES IV Laparoscopic upper rectal cancer resection with transanal specimen Anus Upper rectum/distal
extraction sigmoid colon
CRC-NOSES V Laparoscopic upper rectal cancer resection with transvaginal specimen Vagina Upper rectum/distal
CRC-NOSES VI Laparoscopic left colon cancer resection with transanal specimen Anus Left colon/ proximal
(A-B) extraction sigmoid colon
CRC-NOSES VII Laparoscopic left hemicolectomy with transvaginal specimen Vagina Left colon/ proximal
CRC-NOSES VIII A Laparoscopic right hemicolectomy with transvaginal specimen Vagina Right colon
extraction
CRC-NOSES VIII B Laparoscopic right hemicolectomy with transanal specimen extraction Anus Right colon
CRC-NOSES VIII C Laparoscopic right hemicolectomy with transcolonic specimen Colon Right colon
extraction
CRC-NOSES IX Laparoscopic total colectomy with transanal specimen extraction Anus Total colon
CRC-NOSES X Laparoscopic total colectomy with transvaginal specimen extraction Vagina Total colon
Table 1.4 NOSES approaches for gastric neoplasms

Abbreviations Full Name Orifice
GC-NOSES I Laparoscopic Distal Gastrectomy with Transanal Specimen Extraction (Billroth I) Anus
GC-NOSES II Laparoscopic Distal Gastrectomy with Transvaginal Specimen Extraction (Billroth I) Vagina
GC-NOSES III Laparoscopic Distal Gastrectomy with Transanal Specimen Extraction (Billroth II) Anus
GC-NOSES IV Laparoscopic Distal Gastrectomy with Transvaginal Specimen Extraction (Billroth II) Vagina
GC-NOSES V Laparoscopic Proximal Gastrectomy with Transanal Specimen Extraction Anus
GC-NOSES VI Laparoscopic Proximal Gastrectomy with Transvaginal Specimen Extraction Vagina
GC-NOSES VII Laparoscopic Total Gastrectomy with Transanal Specimen Extraction Anus
GC-NOSES VIII Laparoscopic Total Gastrectomy with Transvaginal Specimen Extraction Vagina
GC-NOSES IX Laparoscopic Total Gastrectomy with Transoral Specimen Extraction Mouth
Moreover, since the stomach is connected to the oral cav- tion has been used in gynecological surgery for a long time.
ity through the esophagus, a transoral specimen extraction Due to the lack of summarization, NOSES has not formed a
approach can be applied to remove small gastric tumors. systematic theoretical system in the field of gynecology.
With the application of the transoral specimen extraction Therefore, the author introduced the concept of NOSES and
approach, there is no need to open other natural orifices to related surgical operations in gynecological surgery, hoping
remove the specimen, and it is most in line with the principle to lead the application of NOSES in this field.
of “benefits damage ratio.” However, surgical indications
should be extremely strict. See Table 1.4 for the details of
surgical approaches of NOSES for gastric tumors. 4 Indications of NOSES
In clinical practice, the indication of NOSES is the first and

3.5 NOSES for Gynecological Neoplasms foremost question. Hence, the Chinese Alliance of NOSES
has published China’s first colorectal tumor NOSES expert
For gynecological surgery, the vagina is a natural way to consensus, which highlights the indication selection of
remove surgical specimens. Other than the vaginal approach, NOSES. Here, the author discusses the indication of NOSES
transrectal, or transoral sampling is not recommended for based on the specific requirements in the consensus and the
gynecological surgery. In fact, transvaginal specimen extrac- current situation of clinical practice.
Firstly, since the NOSES is performed in the laparoscopy mainly applicable for T2 and T3 tumors. In addition, the fol-
platform, the indication of NOSES should follow the indica- lowing conditions are also the indications of NOSES: benign
tion of conventional laparoscopic colorectal resection. The tumor, carcinoma in situ, large-sized T1 stage, endoscopi-
latest version of National Comprehensive Cancer Network cally unresectable tumors, or the cases with positive margin
(NCCN) Clinical Practice Guidelines points out that mini- after local resection. NOSES is not recommended for T4
mally invasive approaches may be considered based on the stage tumors. On one hand, the application of conventional
following criteria: (1) The surgeon has experience perform- laparoscopic surgery in T4 stage tumors is still controversial.
ing laparoscopically assisted colorectal operations; (2) not On the other hand, for T4 stage tumors, there is always a risk
indicated for locally advanced cancer or acute bowel obstruc- of tumor dissemination and implantation though the protec-
tion or perforation from; (3) thorough abdominal exploration tion devices are used to separate the specimen from the natu-
is required; (4) Consider preoperative marking of lesion(s). ral orifice. As a result, the consensus still does not recommend
In brief, in the application of NOSES, the basic indications the routine application of NOSES in T4 stage tumors.
of laparoscopic surgery should be met. BMI was also an important limiting factor for specimen
Besides, since the specimen extraction is performed extraction. In patients with higher BMI, the mesentery is
through natural orifices, there are corresponding require- often thicker, making it difficult to remove the specimen.
ments for the indication of NOSES. Three factors determine Therefore, NOSES is not recommended for severely obese
the feasibility of natural orifice specimen extraction, namely patients with BMI ≥ 30 kg/m2. However, in clinical prac-
specimen size, tumor invasion depth, and BMI. According to tice, we found that there are some obese patients whose
the consensus, the specific indications of NOSES for colorec- mesentery is not that thick. In these cases, the applicability
tal cancer including the depth of tumor invasion should be T2 of NOSES should be evaluated intraoperatively, based on
or T3, the CDmax of the specimen should be less than 5 cm the actual situation of bowel and mesentery. Obese patients
for transanal NOSES and 5–7 cm for transvaginal- have a higher risk of incision complications. If NOSES can
NOSES. Relative contraindications include locally advanced be applied in these patients, the risk of incisional complica-
cancer, a large size of specimen, and patients with body mass tions will be significantly reduced and benefit patients
index (BMI) more than 30 kg/m2. As it is still not clear greatly.
whether vaginal incision affects women’s reproductive func- Furthermore, in the selection of the NOSES procedure,
tion or not, transvaginal-NOSES is best to be avoided in standardization is one of the most important considerations,
young women planning for pregnancy. especially for rectal NOSES. The eversion—resection proce-
The size of the specimen is the key limiting factor that dure is mainly used in the lower rectal resection, the extrac-
determines whether the specimen can be removed through tion–resection procedure is mainly used in the middle rectal
the natural orifice or not. Here, the author focuses on the fol- resection, and the resection–extraction is used more widely,
lowing issues. Firstly, the size of the specimen is not the size including upper rectal resection and colectomy. The key
of the tumor, as some surgeons may get confused with them. point of the eversion–resection procedure is the full mobili-
Surgical specimens mainly include the tumor, resected zation of the mesorectum down to the pelvic floor, which
bowel, and mesentery. Therefore, it is necessary to consider meets the operational requirements of TME and enables the
the size of the tumor, as well as the condition of bowel and eversion and transanal removal of the tumor (Fig. 1.8a).
mesentery, while evaluating the feasibility of natural orifice However, if the eversion–resection procedure is used in sur-
specimen extraction. Secondly, to determine whether the gery of the middle and upper rectal tumors or the sigmoid
specimen can be removed through the natural orifice, or to colon tumors, the mesorectum would be overly dissected,
choose the routes for specimen extraction, the most critical which may increase the risk of pelvic plexus injury and low
determinant is the CDmax of the specimen. CDmax mainly anterior resection syndrome. That would be against the prin-
refers to the circumferential diameter of the cutting edge of ciple of functional surgery (Fig. 1.8b). Therefore, the author
the surgical specimen, which is not relevant to the length of emphasizes again that the indication and applicability of dif-
the specimen. However, the restriction of CDmax is not ferent approaches should be distinguished when selecting an
absolute. For different individuals, the anatomical structure appropriate NOSES approach, otherwise it would have
of the natural lumen may vary; for different surgeons, the adverse effects on patients.
proficiency of specimen extraction is not the same. NOSES is also a therapeutic option in colorectal cancer
Accordingly, it is hard to find a precise standard fitting all the patients with distant metastases or other lesions that require
situations. The surgeons can be flexible in determining the simultaneous surgical resection. In multiple organ resec-
applicability of NOSES, based on the actual situation of tions, the indications of NOSES should be stricter. The pri-
patients and surgical teams. mary colorectal cancer should be in an early stage, while
The depth of tumor invasion is also an important factor to other lesions should meet the indications of simultaneous
select appropriate candidates for NOSES, as NOSES is surgical resection. NOSES is not recommended for patients
10 X. Wang
a b
Fig. 1.8 Eversion of specimen. (a) Eversion of the lower rectal tumor; (b) Eversion of the upper rectal tumor
Fig. 1.9 Right hemicolectomy combined with rectal cancer resection
with locally advanced rectal cancer or with other unresect- plinary cooperation is also necessary to select the best surgi-
able lesions. Recently, several cancer centers in China have cal strategy for patients.
performed NOSES in multiple organ resections, including
right hemicolectomy combined with rectal cancer resection
with transvaginal specimen extraction (Fig. 1.9), rectal can- 5 electing Routes for Specimen Extraction
S
cer resection combined with liver metastasis resection, rectal in NOSES
cancer resection combined with uterine fibroid resection and
rectal cancer resection combined with lung metastasis resec- Although NOSES eliminates extraction site trauma by avoid-
tion (Fig. 1.10), etc. For this kind of surgery, although the ing extra-abdominal wall incision, however, whether and to
abdominal incision is small, it is still multiple organ resec- what extent the natural orifice would be injured in the pro-
tions resulting in considerable surgical damage. Therefore, it cess of specimen extraction, are the questions to be answered.
is necessary to fully evaluate the patient’s condition and the Two principles should be followed when selecting the route
organ function before surgery, so as to determine the ability for specimen extraction, namely, the principle of tumor func-
of the patient to tolerate the surgery. Besides, multidisci- tional surgery and the principle of “benefits damage ratio.”
Fig. 1.10 Rectal cancer

resection combined with lung
metastasis resection
For example, the anus is the most appropriate route to remove research, postoperative sexual dysfunction is rare, following
the specimen in colorectal surgery, the vagina is more suit- the transvaginal approach.
able for removing specimen in gynecological tumor surgery, In addition to the two common ways of specimen extrac-
while for gastric surgery the specimens are better to be tion, some surgeons have started using the transoral speci-
extracted from the mouth. men extraction approach, which is a supplement and
Whether the process of specimen extraction would injure improvement of the NOSES system. At present, some stud-
the anal sphincter and affect the postoperative defecation ies have reported the preliminary application of transoral
function of patients, are issues we need to consider. In recent specimen extraction in living animal models and clinical
years, transanal-NOSES is becoming increasingly popular, patients, including sleeve gastrectomy, liver biopsy, chole-
however, reports of postoperative anal dysfunction or sphinc- cystectomy, splenectomy, etc. Transoral-NOSES shows
ter injury are very rare. In addition, the results from a multi- promising minimally invasive results, especially for gastric
center study showed that only 1.5% of patients who tumors. However, due to the particularity of the anatomical
underwent transanal-NOSES had different degrees of post- structure of the esophagus, the surgical indications should be
operational anal dysfunctions. Therefore, the anal sphincter strict, and the technique of specimen extraction should be
injury can be prevented by following strict surgical indica- mastered.
tions, adequate anal dilation, and performing specimen
extraction more gently.
The vagina is another important route to extract speci- 6 Aseptic and Tumor-Free Technique
mens. Transvaginal specimen extraction approach also has of NOSES
significant advantages that can be used in patients with bulky
specimen that cannot be removed transanally. The author One of the main technical problems NOSES is facing, is to
suggests that the posterior fornix is the most ideal site for ensure about the aseptic and tumor-free procedures. Of
vaginal incision. In the lithotomy position, the posterior for- course, being aseptic and tumor-free is not only an issue lim-
nix is the lowest part and the most easily dilated part of the ited in NOSES but also a question worthy of consideration in
vagina, as well as the most easily exposed part in laparos- conventional open and laparoscopic surgery. It is true that
copy. In addition, the posterior fornix is deep and lacks nerve NOSES presents great challenges to aseptic and tumor-free
innervation so in most cases, postoperative sexual activity is techniques, but it does not mean that related complications
not affected. According to the follow-up data in multicenter are inevitable.
12 X. Wang
a b c d
Fig. 1.11 Abdominal wall after different surgical procedures for rectal after conventional laparoscopic radical resection of rectal cancer; (d)
cancer. (a) Abdominal wall after NOTES for rectal cancer; (b) Abdominal wall after open surgery for radical resection of recurrent
Abdominal wall after NOSES for rectal cancer; (c) Abdominal wall rectal cancer
First of all, the surgeon should have a good understanding ents a good cosmetic appearance and reduces the psycho-
of aseptic and tumor-free concepts, which is the basic prin- logical pressure caused by abdominal incision scar (Natural
ciple of any operation. The second is that the surgeon should Orifice Specimen Extraction Surgery 2018). The abdominal
be highly skilled in the NOSES technique, especially the wall after different surgical procedures for rectal cancer is
reconstruction of the digestive tract and the removal of speci- shown in Fig. 1.11.
mens, which is also necessary for high-quality NOSES. To From the perspective of surgeons, since conventional
ensure the aseptic and tumor-free operation of noses, the fol- minimally invasive surgical instruments are used in the
lowing problems should be paid attention to. Firstly, suffi- NOSES procedure, it is easier for the surgeons who are
cient preoperative bowel preparation is the basis of aseptic familiar with conventional laparoscopic surgery skills to
operation, including catharsis and enema. Secondly, the sur- master the key techniques of NOSES and adapt themselves
gical technique should be fully mastered. There are some to NOSES procedure. In addition, compared with NOTES,
special surgical steps and techniques for NOSES, including, NOSES provides more adequate surgical field exposure and
using povidone-iodine gauze laparoscopically, close coordi- more extensive operating space, thus increases the safety of
nation with suction, rectal washout with povidone-iodine surgery greatly.
solution, washing of the surgical field with povidone-iodine As an emerging minimally invasive technique, NOSES
solution, and the usage of specimen protective device. These also has some limitations, mainly including the following
techniques have been proved to be able to control the inci- aspects. First, compared with laparotomy and conventional
dence of abdominal infection and tumor implantation effec- laparoscopic surgery, the indication of NOSES is stricter,
tively. In the multicenter study the author conducted, the and it is suitable for a relatively limited group of patients.
incidence of postoperative abdominal infection was only Second, NOSES makes high demands on surgical skills,
0.8%. This result reflects that the risk of infection is control- aseptic technique, and tumor-free technique. Third, for the
lable as long as the patient is well prepared preoperatively NOSES procedures that require specimen extraction from
and the surgical steps are followed strictly. natural lumens of nonoperative organs, such as colon cancer
In order to solve the problem of being aseptic and tumor- resection with transvaginal specimen extraction and gastric
free in NOSES, members of the Chinese NOSES Alliance cancer resection with transanal specimen extraction, there is
have already made numerous explorations and attempts, and a raised risk of damaging natural lumens and postoperative
have achieved satisfying results. This book shares the experi- complications.
ence of dozens of experts, aiming to ensure aseptic and
tumor-free operation to the greatest extent possible.
8 urrent Status and Achievements
C
of NOSES in China
7 Advantages and Limitations of NOSES
In order to accelerate the promotion of NOSES and to stan-
From the perspective of patients, the auxiliary incision in the dardize the application of NOSES, the Chinese NOSES
abdominal wall could be avoided after NOSES, with reten- Alliance (Fig. 1.12) and the NOSES Subcommittee of
tion of abdominal wall function and acceleration of the Colorectal Cancer Committee of Chinese Medical Doctor
patient’s postoperative recovery. Furthermore, NOSES pres- Association (Fig. 1.13), were formally established in June
Fig. 1.12 The Chinese NOSES Alliance
Fig. 1.13 The NOSES Subcommittee of Colorectal Cancer Committee of Chinese Medical Doctor Association
2017. These two academic organizations are also working to cases nationwide. These results reveal that NOSES has been
publish Chinese NOSES researches and to improve the aca- applied on a considerable scale in China. In addition, the
demic and practical level of NOSES in China. number of NOSES cases for colorectal tumors is also increas-
In order to standardize the application of NOSES in vari- ing rapidly year by year (Fig. 1.15). This also shows the
ous regions in China, the Chinese NOSES Alliance has vitality and potential of the NOSES.
established twelve provincial-level sub-alliances, and several The reasons why NOSES can be widely applied in China
sub-alliances are actively preparing (Fig. 1.14). The estab- mainly include the following aspects. First, the laparoscopic
lishment of these sub-organizations will lead the develop- technique has been widely used as a routine treatment in
ment of NOSES in various regions to promote in-depth China, which provides the necessary basis for the promotion
communication and training of NOSES, so as to share of NOSES. Second, considering the incidence of colorectal
resource and have win-win cooperation in the region, and to tumors and the level of surgical expertise, a large proportion
aim at healthy, orderly and standardized development of of patients can benefit from NOSES. Third, limited by surgi-
NOSES. cal instruments and equipments, it is difficult for conven-
Although the Chinese NOSES Alliance has been estab- tional laparoscopic technique to have a breakthrough. The
lished for only two and a half years, over 200 medical centers invention of NOSES brings “the most minimally invasive”
all around China NOSES has started to perform NOSES, the laparoscopic surgery, which is consistent with the develop-
Chinese NOSES Alliance has more than 800 members, and mental trend of minimally invasive surgery. Forth, the
the Chinese NOSES database has collected more than 5000 NOSES technique has minimally invasive advantages,
14 X. Wang
Fig. 1.14 Twelve provincial-level sub-alliances in China
Fig. 1.15 The cases of

NOSES in China 1800
1600
1400
1200
1000
800
600
400
200
0
B2013 2013 2014 2015 2016 2017 2018
Fig. 1.16 NOSES training courses in China
including avoiding an extra incision in the abdominal wall, In August 2019, the NOSES-Abdominal Pelvic Tumors
reducing postoperative pain, retaining abdominal wall func- was published. It was an upgrade of the previous edition of
tion, and having good cosmetic results. Fifth, the establish- NOSES-Colorectal cancer > and < NOSES-Gastrointestinal
ment of the Chinese NOSES Alliance and the NOSES tumor (Fig. 1.19). This new edition collected the wisdom of
committee and the NOSES training courses and workshops nearly 100 experts in the NOSES field, summarized a large
provide an academic platform for NOSES. In addition, the number of operation experience, further improved the theo-
publication of NOSES monographs also promoted the devel- retical system of gastrointestinal NOSES, and was valuable
opment of this technique. for the learning of NOSES for abdominal pelvic tumors.
In order to promote the standardization of NOSES, the In August 2018, a series of audiovisual educational mate-
Chinese NOSES Alliance has held NOSES workshops, train- rials for 3D laparoscopic NOSES (Fig. 1.20) edited by the
ing courses, and live surgical demonstrations all around author was published. These educational materials present
China, which allows more inexperienced surgeons to grasp all the operating techniques and key points of NOSES for
the essentials of this technique (Figs. 1.16 and 1.17). colorectal cancer, which may help surgeons to learn every
The Chinese NOSES alliance has achieved many remark- detail of NOSES.
able results since it was founded. The Chinese consensus on
natural orifice specimen extraction surgery (NOSES) for
colorectal cancer (2017 edition) was published in the 9 The International NOSES Alliance
Chinese Journal of Colorectal Diseases (Electronic Edition)
(Fig. 1.18), and the new version of this consensus was In order to expand the international influence and standard-
updated in 2019. This consensus discussed and summarized ize the application of NOSES, the author led the establish-
13 topics about NOSES for colorectal cancer, including ment of the International NOSES Alliance and held the first
naming, definition, surgical instruments, technical require- International Academic Conference on NOSES in Beijing on
ments, indications and contraindication, aseptic and tumor- August 31, 2018 (Fig. 1.21). The 51 members from 12 coun-
free operation, complication prevention, and management, tries voted the author to be the first president of the
and clinical research. This consensus provided important International NOSES Alliance, and Prof. Fu Chuangang,
references for the standardization of the NOSES technique in Prof. Petr V. Tsarkov (Russia), Prof. Suk-Hwan Lee (Korean)
China. to be the vice presidents. The emblem and flag were also
16 X. Wang
Fig. 1.17 NOSES workshops in China
determined at this conference. The second Conference of the In order to strengthen the international promotion of the
International NOSES Alliance was held in Shanghai on NOSES, the author edited Natural Orifice Specimen
November 30, 2018, and co-opted Prof. Guy R. Orangio Extraction Surgery—Colorectal Cancer (English Edition),
(USA), Prof. Scott Strong (USA), and Prof. Antonio Longo published by Springer Publishing and People’s Medical
(Italy) as the new vice-presidents of the league. The interna- Publishing House. The monograph has been translated into
tional multicenter research in NOSES was launched during Japanese, Korean, and Russian languages, and has interna-
the conference (Fig. 1.22). tional influence in the field of surgery (Fig. 1.24).
All the members of the International NOSES Alliance The second Conference of the International NOSES
participated in drafting International consensus on natural Alliance was held in Moscow in June 2019, and 70 Chinese
orifice specimen extraction surgery (NOSES) for colorectal experts were invited to Moscow to attend the conference
cancer and International consensus on natural orifice speci- (Fig. 1.25). Then, the third Conference of the International
men extraction surgery (NOSES) for gastric cancer, which NOSES Alliance was held in Beijing in August 2019, and
were published in Gastroenterology Report (Fig. 1.23). In 65 experts from 16 countries gathered in Beijing to discuss
addition, the International consensus on natural orifice speci- the technical issues and challenges of NOSES (Figs. 1.26
men extraction surgery (NOSES) for colorectal cancer has and 1.27). During this conference, the launching ceremony
been translated into Russian. The publishment of this con- of < Natural Orifice Specimen Extraction Surgery—
sensus focus on the main principle and key techniques of Gastrointestinal Tumor> was held (Fig. 1.28). The estab-
NOSES on colorectal cancer and gastric cancer, which pro- lishment of the International NOSES Alliance is of great
vide the basis of the international standardization of NOSES. significance for the internationalization, communication,
Fig. 1.18 Chinese consensus

on NOSES for colorectal
cancer (2017), Chinese
consensus on NOSES for
colorectal cancer (2019), and
Chinese consensus on NOSES
for gastric cancer (2019)
and cooperation of NOSES. NOSES is also being pro- However, the laparoscopic technique developed rapidly and
moted in many countries around the world, including the has become a regular treatment procedure in just a few years.
United States, Britain, Spain, Portugal, South Korea, To see the history of surgery from the materialistic point of
Japan, etc. (Fig. 1.29). Furthermore, several international view, open surgery is still the cornerstone of surgery. In the
NOSES workshops were held in China, which invited past 30 years, with the development of electrical, optical, and
experts from more than 20 countries to study NOSES instrument technology, surgery has been moving toward the
(Fig. 1.30). direction of “non-invasive” and “minimally invasive.” With
the development and application of various equipments and
platforms, e.g., laparoscopy, concepts, and techniques of
10 Outlook on Future of NOSES surgery have changed greatly. Looking forward to the next
30–50 years, innovative minimally invasive techniques will
Nowadays, NOSES is making tremendous progress all have more advantages and wider application, which is the
around the world. However, some surgeons are still doubting general trend of development.
this technique and do not recommend it for clinical use. In When we cannot resist the trend of development, only by
the past, many surgeons were initially against the use of the changing and improving ourselves, we can truly keep up
laparoscopic technique and doubting the advantages of it. with the time. At this time, we still cannot find a perfect min-
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seminagione, il doppio alla messe, oltre gli ordinarj; trecentoventi
bovi con sessantacinque aratri alla coltura; ducencinquanta bovi
sonvi ingrassati: ottocento vacche, cento bufali e duemila pecore
pascolano nel maggese: cento cavalli servono ai sorveglianti e pei
trasporti, oltre ducencinquanta giumenti e i loro piccoli. Eppure non
si affitta che tredici franchi l’ettara.
Il sistema di far rendere senza intervento d’uomini nè spese di
coltura, contentandosi de’ prodotti spontanei, non è dunque generale
nello Stato; e la grande coltura è propria solo delle paludi e della
campagna: ma insalubrità, spopolamento, mancanza di sfoghi sono
reciprocamente cause ed effetti di danno, nè si può riparare ad uno
in particolare; e vuolsi ben altro che decreti, fossero anche ben
consigliati. Clemente XIII vietò di tagliar legnami nei possessi dei
Comuni o della Camera apostolica senza licenza; nel 1789 Pio VI
diede un buon regolamento pei boschi, e fece erigere un nuovo
catasto; colla libera asportazione de’ grani ne sollecitava la
produzione; nel conferire le doti si preferirebbero le figlie
d’agricoltori; si stabilirono premj e pene che non ottennero effetto. La
dominazione francese brevissima non ebbe tempo di spartire fra
operosi proprietarj i latifondi di manomorta che traeva al fisco; e una
commissione istituita nel 1810 per migliorare le paludi Pontine, nulla
trasse a riva. Nel 1819 una società straniera offerse di prendere in
affitto tutto l’Agro romano, retribuendo al fisco un canone annuo, e a
ciascun proprietario un fitto pari a quello che allora godeva; e dopo
cinquant’anni restituirgli i terreni migliorati: intanto la società avrebbe
dissodato il fondo, rasciutte le paludi Pontine e quelle di Macarese
ed Ostia, resi navigabili il Tevere e il Teverone per l’intero loro corso,
aprendo così una uscita ai prodotti della Sabina; costruito villaggi
con chiese, scuole, ospizj, strade; utilizzato le acque minerali e
sulfuree; piantato modelli di podere dove introdurre produzioni
nuove, l’indago, la cannamele ed altri; tutti questi lavori sarebbero
fatti da indigeni, alloggiati in situazioni salubri, congedati ne’ mesi
pestilenziali. Erano forse le solite lustre di speculatori: fatto è che la
proposizione, dal nuovo papa accolta favorevolmente, fu lasciata
cadere forse per opera di chi ne temeva scapito.
Il nuovo papa Pio VIII (Saverio Castiglioni) (1829 31 maggio), uomo
austero e dotto, lodato del far poco, dopo che Leone XII avea fatto
troppo; non arricchì parenti; usò a ministro il cardinale Albani,
impinguatosi con appalti e speculazioni, inclinato all’Austria, nè
troppo sottile in fatto di religione e amante i piaceri tanto più che non
era prete. Di corto il papa moriva (1830 30 9bre), e nell’orazione
solita recitarsi nel conclave de eligendo pontifice il dottissimo
cardinale Maj diceva ai radunati: — Dateci un papa che sia per la
fede Pietro, per costanza Cornelio, per felicità Silvestro, per
eleganza Damaso; abbia di Leone la nitida eloquenza, di Gelasio la
dottrina, di Gregorio la pietà, di Simmaco la fortezza, di Adriano
l’amicizia dei principi; sia per la concordia delle Chiese Eugenio, pel
patrocinio delle lettere Nicolò, per grandezza di consigli Giulio, per
liberalità Leone, per santità Pio, per vigore d’animo Sisto; e per non
ricorrere solo le prische età, dateci un pontefice che non manchino
nè l’erudizione di Benedetto XIV, nè la munificenza del sesto Pio, nè
la forza e benignità del settimo, nè la vigilanza di Leone XII, nè la
rettitudine di Pio VIII».
Campione della religione e dell’autorità era Francesco IV di Modena,
carattere robusto, mente estesa, operante per fredda ragione e col
profondo convincimento nelle idee patriarcali che il popolo fosse
roba del principe e da questo dovesse aspettare il bene, e il principe
fosse obbligato a farglielo. Ricchissimo di patrimonio, e più dopo che
Beatrice d’Este sua madre gli lasciò 50 milioni di lire e la signoria di
Massa e Carrara, fu il solo principe che alleggerisse le imposte; nella
fame del 1816 tirò grano dall’Ungheria e lo rivendette a basso
prezzo, oltre dar minestre gratuite; in quella del 1829 distribuì
centomila pesi di canapa da filare, duemila e cento pesi di farina per
mano de’ parroci, e cenventimila lire fra limosine e lavori straordinarj;
istituì monti frumentarj per sovvenire i piccoli possidenti e gli agricoli.
I nobili si amicò, dei perduti diritti feudali compensandoli con carte
pubbliche: ripristinò gli Ordini religiosi, e risarcì in parte la Chiesa dei
beni confiscatile. Nelle leggi mitigava i rigori della giustizia punitiva,
tutelava gl’interessi domestici, migliorava il regime delle ipoteche,
accolse la società scientifica dei Quaranta; manteneva alle
accademie forestiere giovani che si raffinassero nell’arti e nelle
scienze; raccolse libri, quadri, medagliere, museo ricchissimo.
Dotato di gran memoria, notava moltissimo; scriveva lunghe
dissertazioni, che in parte si hanno, come migliaja di suoi rescritti a
petizioni [196].
Viene il tremuoto? imperversa il cholera? esso gli annunzia come
castighi di Dio contro i riottosi; tutti i proprj atti motiva dal meglio del
popolo; ma vuole che il popolo obbedisca; e perchè la Rivoluzione
scassinò la docilità, adopera ogni mezzo per ottenerla a forza.
Tutt’occhi a vigilare gl’interessi de’ principi, per lui l’Austria venne
informata delle trame de’ Carbonari. Al congresso di Verona offrì un
lungo scritto contro le costituzioni, suggerendo come mezzi a
impedirle il favorire la religione, rialzare la nobiltà, interessandola
negli affari pubblici e alla conservazione dell’ordine; ampliare
l’esercizio dell’autorità paterna, correggere la legislazione quanto al
crimenlese, e semplificare la procedura in modo che i negativi non
isfuggano al rigore delle leggi; migliorare il sistema dell’educazione,
adattandola alle condizioni, e restringendo il numero di quelli che
applicano agli studj; s’invigilasse la stampa; insieme le imposte
fossero fisse e non vessatorie, e libera la circolazione delle derrate.
In fatti nel suo paese era gelosissima la censura, di cent’occhi la
Polizia, potenti i devoti, tollerati quei soli scrittori che si facessero
appoggio a quella che diceasi causa dei troni e degli altari. Orribil
fama avanza dei processi fatti dopo il 1821; e Giulio Besini, ministro
della Polizia che pareva inasprirli, cadde scannato (1822 17 8bre) da
un giovinetto Morandi. Il duca ne restò esacerbato, e sopra quaranta
inquisiti e sette contumaci alcuno lasciò andare a morte, fra cui il
prete Andreoli di Correggio. Altri processi tesseronsi di tempo in
tempo, e un colonnello Cavedoni se ne sottrasse uccidendosi.
Per verità l’azione delle società secrete non erasi mai rallentata; e i
vanti che se ne menarono dopo la riuscita, accertano che la
rivoluzione di Parigi nel 1830 non fu spontanea rivolta contro
ordinanze incostituzionali, ma lunga preparazione delle combriccole.
Queste aveano fila anche in Italia, onde nel 1829 il papa le colpì di
scomunica, e istituì una commissione che processò ventisei
Carbonari. Châteaubriand, allora ambasciadore a Roma, scriveva al
conte Portalis ministro a Parigi: — Leggete con cautela ciò che vi
scriveranno da Napoli e d’altrove. Si reputa cospirazione il
malcontento universale, il frutto de’ tempi, la lotta dell’antica colla
nuova società, delle istituzioni decrepite contro le giovani
generazioni, il confronto che ciascuno fa di ciò che è con ciò che
potrebb’essere. I Governi rappresentativi con Governi assoluti non
potranno durar insieme. Confini doganali possono oramai dividere la
libertà dalla schiavitù? nè un uomo essere impiccato di qua d’un
ruscello per principj che al di là sono reputati sacri? Questa, e
questa sola è la cospirazione in Italia; ma dal dì che entrerà nel
godimento de’ diritti portati dai tempi, sarà tranquilla e puramente
italiana. Non sono oscuri Carbonari che faranno sollevare questo
paese. Queste sono le condizioni dell’Italia; ma ciascuno Stato, oltre
i dolori comuni, è tormentato da qualche malattia sua particolare. Il
Piemonte in balìa d’una fazione fanatica; il Milanese divorato dagli
Austriaci; i dominj del santo padre rovinati dalla cattiva
amministrazione delle finanze, poichè l’imposta si eleva a quasi
cinquanta milioni, e non lascia al proprietario l’un per cento delle sue
rendite; le dogane non danno quasi niente, e il contrabbando è
generale. Il principe di Modena stabilì nel suo ducato (luogo di
franchigia per tutti gli antichi abusi) magazzini di merci proibite, che
nottetempo fa entrare nella legazione di Bologna. Il Governo delle
Due Sicilie è caduto nell’ultimo disprezzo: il vivere della Corte in
mezzo alle sue guardie, non offrendo altri spettacoli che cacce
ruinose e forche, rende vituperevole la monarchia agli sguardi del
popolo. La mancanza di virtù militare prolungherà l’agonia dell’Italia.
Buonaparte non ebbe il tempo di far rivivere questa virtù; le abitudini
d’una vita oziosa e i prestigi del clima contribuiscono a togliere
agl’Italiani del mezzogiorno il desiderio di agitarsi per migliorare. Le
antipatie nate dalle divisioni territoriali accrescono le difficoltà
degl’interni moti; ma se qualche impulso venisse di fuori, o se
qualche principe fra l’Alpi concedesse uno statuto a’ suoi sudditi,
avrebbe luogo una rivoluzione, a cui tutto è maturo. Di noi più felici e
della nostra esperienza istruiti, questi popoli saranno parchi de’ delitti
di cui noi femmo scialacquo».
Così, da alto ingegno e da occhio sperimentato giudicavasi la
condizione della patria nostra. Così ministri e ambasciadori possono
ingannare ed aizzare, peggio che non facciano libellisti scalmanati.
Diceasi che Sanfedisti e Concistoriali volessero anche essi
l’indipendenza, ma coll’appoggiarsi a principi nazionali, e un nuovo
riparto dell’Italia, ove al papa si attribuisse porzione della Toscana e
il Polesine di Rovigo, in compenso delle Marche, le quali coll’isola
d’Elba andrebbero al re di Napoli; al duca di Modena, parte della
Lombardia, Parma, Piacenza, il Veneto col titolo di re; il resto della
Lombardia, il Tirolo italiano, Massa, Carrara, Lucca al Piemonte.
Queste potean essere aspirazioni, e si disse che qualche capo
liberale facesse proposizioni in tal senso al duca di Modena; egli
denaroso e potente, egli avveduto e ambizioso, qualora desse mano
ad una rivolta potrebbe farsi re di tutta Italia, se non altro, del
Piemonte. Se la proposta fu fatta, se egli vi ascoltò, del che
mancano prove, fu un intrigo ignobile, dove nessuna delle parti
operava di buona fede, ma donde appare che già allora, e nei due
campi opposti, il sentimento comune era il desiderio di diventare
nazione, appena un impulso esterno desse il crollo ai principati,
destituiti del fondamento vero, l’amore dei popoli.
E parve venuto allorchè i Francesi (1830), i quali aveano una
Costituzione e tutti i mezzi legali di correggerla e svilupparla, si
precipitarono alle vie illegittime; e nelle tre giornate di luglio, con
grande sacrifizio di vite, cacciarono la dinastia de’ Borboni, e al
domani vi sostituirono quella degli Orléans. Non era però soltanto
una rivoluzione di palazzo; cambiavasi il diritto pubblico, al re
discendente da re, capo de’ nobili, largitore della libertà,
surrogandosene uno eletto da una turba parigina che intitolavasi
popolo francese; alla dinastia ripristinata dagli stranieri, una che
fondava i suoi diritti sulla rivoluzione, cioè sovra ciò che, per l’istesso
suo nome, manca di stabilità. Poichè non può scuotersi la Francia
senza che tutt’Europa se ne risenta, vi tennero dietro sollevazioni nel
Belgio, in Polonia, in Grecia, e commovimenti per tutta Europa.
La Francia sta sempre in occhio che l’Austria, sua antagonista, non
ingrandisca di troppo in Italia, solletica le aspirazioni nazionali, ostili
all’Austria: eppure ripugna dal lasciare che vi si formi uno Stato
poderoso, e noi ci diciamo traditi perchè supponiamo gratuitamente
che sia generosità disinteressata quel ch’è tornaconto nazionale. Da
un pezzo gli accorti denunziano una siffatta politica: eppure coloro
che vedono unica salvezza nelle rivoluzioni, ne considerano unica
leva la Francia, e perciò l’invocano, e dai movimenti di essa
prendono impulso e norma ai proprj; delusi cento volte, cento
ricascano, come l’amante coll’amica infedele, o come il naufrago che
s’aggrappa a qualunque corpo, foss’anche un altro naufragante.
Ora però sembrava affatto al caso nostro il simbolo della nuova
rivoluzione francese: perchè, alla Santa Alleanza, ch’erasi arrogato
d’intervenire in qualunque paese onde impedire le istituzioni
dissonanti dal sistema di lei, Francia contrapponeva il non-
intervento, cioè che nessuna nazione potesse impedire che un’altra
mutasse gli ordinamenti interni, secondo la volontà del principe o del
popolo. Chi sbandì sempre le Costituzioni d’Italia? L’Austriaco,
diceano. Ora che la magnanima Francia proclamò il non-intervento,
potranno i popoli di essa costituirsi, forse d’accordo coi re: se non
resta altra via che l’insurrezione dove mancano rappresentanza e
diritto di petizione, la Francia democratica sosterrà certo una
rivoluzione democratica; tanto più che così l’Austria sarà costretta
occupare in Italia le armi, che affilava contro la nuova rivoluzione. Il
ministro Lafitte avea dichiarato alla tribuna: — La Francia non
permetterà che il non-intervento sia violato»; e Dupin soggiunse: —
Se la Francia, rinserrandosi in un freddo egoismo, avesse detto che
non interverrà, sarebbe vigliaccheria: ma dire che non soffrirà
s’intervenga, è la più nobile attitudine che possa prendere un popolo
forte e generoso» [197].
La Santa Alleanza e i principi nostri sentirono il pericolo, e
prepararonsi: il re di Piemonte tolse le armi alla Savoja, mise le
fortezze e l’esercito in istato di guerra, ma subito stendeva la mano
al nuovo re Luigi Filippo come al solo che poteva allora salvare
l’autorità. Al contrario il duca di Modena mai nol volle riconoscere,
ebbe sempre come legittima soltanto la linea primogenita, e lasciava
che in Parlamento i Francesi minacciassero cacciarlo a colpi di
scudiscio. La situazione restava complicata dall’essere allora
appunto vacanti i troni di Piemonte, di Sicilia, di Roma.
L’interregno papale fu tumultuoso, non solo fra gli ambasciadori che
imponevano chi eleggere o no a pontefice, ma nella città dove si
tentò una sollevazione (9bre), istigandola principalmente la famiglia
Buonaparte colà ospitata; anzi Napoleone e Luigi, figli del già re di
Olanda, con alcuni Côrsi e con vecchi soldati corsero gridando Italia
e Libertà, ma non trovando consenso, andarono dispersi o furono
presi. Tra siffatte irrequietudini era elevato alla tiara Mauro
Cappellari, dotto e pio camaldolese di Belluno (1831 2 febb.); e col
nome di Gregorio XVI «si assunse liberamente in faccia all’Europa
gl’impegni che si rendeano necessarj per la durevole unione tra
gl’interessi del trono e quelli della nazione» [198].
La rivolta, che era fallita in Roma mercè l’attenzione del cardinale
Bernetti segretario di Stato, meglio riuscì in provincia. I cospiratori,
sempre tenendosi sicuri del non-intervento, divisavano far in
ciascuno Stato particolari rivoluzioni, salvo poi a fondersi in un solo
che avesse centro Bologna. I Menotti di Carpi erano ricca famiglia e
industriosa, con estesa fabbrica di cappelli di trucioli; col qual
pretesto Ciro viaggiò, ed affiatossi colla propaganda a Parigi e coi
Buonaparte a Roma. Ch’egli si facesse intermedio di questi presso il
duca di Modena, col quale era associato per negozj, e che il duca lo
lusingasse per tradirlo, è smentito da lettere; Enrico Misley riceveva
denari dal duca per ispiare i cospiratori a Parigi, mentre da questi
faceasi credere devoto alla libertà [199]. La tresca cresceva; ma di
mezzo al preparare vien arrestato Nicola Fabrizj modenese,
principalissimo fra i cospiratori, sicchè questi non potendo più
mettere indugio, raccolgonsi in numero di quindici nella casa Menotti
(3 febb.), e spacciano per sollecitare soccorsi dalla campagna e
dalle città. Il duca informatone, unisce i pochi soldati, e segnatosi,
marcia a capo di quelli, e con pochi colpi obbligatili a rendersi, li
caccia prigione, e scrive: «Mandatemi il boja». Al domani però,
udendo che anche gli Stati vicini insorgeano, egli non credesi più
sicuro, e rifugge sul Mantovano, seco traendo Ciro Menotti, che
confida ai carcerieri austriaci. Subito Modena si grida libera, e con
un atto di sole settantadue firme proclama dittatore l’avvocato Nardi
1831 con tre consoli Maranesi, Minghelli, Morano. Reggio, dove le
trame faceano capo alla Giuditta Sidoli, fece rivoluzione da sè, poi si
unì alla modenese, preponendo al governo l’insigne giureconsulto
Pellegrino Nobili; e si cominciò a disfare il vecchio, e cacciare i
Gesuiti, soliti capri emissarj.
A Parma e Piacenza l’austriaca Maria Luigia mostrava cuor buono e
generosa carità; istituì un ospizio della maternità; se, come tutti gli
Stati, contrasse debiti [200], alle scarse rendite del paese suppliva col
proprio lauto appanaggio; in occasione di feste di Corte mandava
abiti e ornamenti alle dame; arricchì d’insigni professori l’Università;
a disegno del Coconcelli fece costruire i ponti del Taro e della
Trebbia, spendendo in questo un milione, quasi due in quello; e
conservò i codici, gli ordinamenti amministrativi, la moneta di
Francia: ma l’essere austriaca e l’avere rotto fede all’ancor vivo
Napoleone screditava la duchessa, di cui solo quando morì
lasciando ben fornite le casse, confessaronsi i meriti. Regnante al
modo del secolo passato anche pei costumi, un generale austriaco
(Neipperg), poi un conte francese (Bombelles) da governatori si fece
amanti e mariti; e ad essi abbandonava il paese nelle lunghe sue
dimore ai bagni o a Vienna. Non mancarono cortigiani che
coll’avidità e l’ignoranza corruppero le benevole intenzioni di essa e
il denaro pubblico malversarono, mentre al commercio, all’industria,
alle miniere, ad ogni durevole istituto non si badava, com’era
naturale in dominio goduto a vita. E di tal condizione provvigionale
risentivansi tutte le ordinanze, oggi fatte, domani casse, e mutate le
persone. Anche la rivalità della pingue ma abbandonata Piacenza
colla preferita Parma seminava zizzania.
Nè i sudditi odiavano l’arciduchessa, bensì il ministro Werklein, in cui
tutta affidavasi dopo morto lo splendido Neipperg: ed avendo anche i
Parmigiani inalberato la bandiera italiana, ed ella dichiarato che i
suoi legami le impedivano di fare le chieste concessioni, venne
cortesemente accompagnata al confine austriaco, e istituito il
Governo con Linati, Casa, Castagnola, Sanvitale, Melegari, Ortalli,
Macedonio Melloni. Piacenza fu tenuta in fede dalla rivalità o dalla
cittadella.
Bologna compiva la sua rivoluzione, incruenta come le altre; e il
prolegato rimetteva i poteri ai cittadini che eressero un Governo
provvisorio (8 febb.). Il cardinale Benvenuti, legato a latere, fu
arrestato; e gl’insorgenti, formato un piccolo corpo sotto Armandi,
intitolatosi generale e ministro della guerra, bloccano la fortezza
d’Ancona, e l’hanno dopo pochi giorni: il colonnello Sercognani,
avendo per commissario Carlo Pepoli, avanza con duemila
cinquecento uomini nelle Marche; Perugia, Spoleto, Foligno, tutta
l’Umbria rispondono al suo appello, quasi a una festa; e
senz’opposizione del Governo, senza riazione di partiti, senz’ombra
di pericolo, la bandiera tricolore sventola fin a Orticoli, a Terni, a
Ponte Felice, insomma in vista di Roma: dappertutto istituivasi la
guardia nazionale, diminuivansi i dazj del sale e del macinato,
spandevansi proclami.
Faville che traevano importanza dalla conflagrazione di tutt’Europa.
Perocchè, sull’esempio di Francia, e forse pe’ suoi incitamenti, la
Grecia che da dodici anni combatteva per respingere la mezzaluna
dalle fronti segnate dalla croce, ripigliava spiriti alla lotta in cui
l’Europa principesca l’avea sfavorita; Spagna e Portogallo rialzavano
le abbattute bandiere costituzionali; Germania credea venuto il
tempo di ottenere ciò che le era stato promesso e mentito; la
Svizzera già prima aveva riformato i suoi statuti in senso popolare; in
Inghilterra, al grido dei radicali chiedenti libertà mesceasi terribile la
voce della plebe chiedente pane; il Belgio, a nome del cattolicismo
conculcato, ribellavasi all’Olanda; la Russia che muoveva
gl’innumerevoli suoi eserciti per rimettere la quiete in Europa, vede
la vanguardia sua rivoltarsele, cioè la Polonia, che con valore
segnalato invoca il nome di Maria e la sua nazionalità.
Tutti questi insorti fissavano gli occhi alla Francia, come a promessa
salvatrice. Di là, mezzo secolo prima, era venuta una scossa, per cui
que’ medesimi che non avevano acquistato la libertà aveano però
spezzato la servitù; era fresco il ricordo delle irresistibili vittorie di
Napoleone; la bandiera tricolore riuscirebbe meno gloriosa ora che
veniva portata, non più da un conquistatore, ma dalla libertà? non
per minacciare l’indipendenza dei popoli, ma per restituirla? Tali e
più belle speranze vagavano per le menti: ma la Francia non era
diretta da una Convenzione, bensì da un re nuovo, rinvenuto più che
cercato, accettato più che voluto, e come unica tavola in un
naufragio nel quale si temeva perisse l’ordine sociale.
Luigi Filippo, intento a farsi soffrire dagli altri re, e assodare la
propria dinastia col rispettare le altre, invece di convergere quelle
sparse resistenze ad un rimpasto europeo, s’incaricò di eliderle; e
per un pezzo vi riuscì. Casimiro Perrier, abile ministro, professa voler
fiaccare le fazioni anzichè dar mano ai sollevati, e alle turbolente
Camere (8 marzo) intimava: — Noi sosteniamo che lo straniero non
ha diritto d’intromettersi a mano armata negli affari interni; ma forse
ci terremo obbligati a portare l’armi dovunque non venga questo
dogma rispettato? Sarebbe un’intervenzione anche questa. Lo
sosterremo per via di negoziati; ma sol l’interesse o la dignità della
Francia potrebbero farci prendere le armi: il sangue de’ Francesi
appartiene solo alla Francia».
Subito si formò a Londra una conferenza di ministri che non
rappresentavano le nazioni ma i re, e che si accingeano a ripristinare
ciò che le tre giornate aveano abbattuto; e il Governo francese, che
avea favorito le sommosse finchè opportune a sviare i nemici
minaccianti, s’affrettò a comprimerle. Guglielmo Pepe, il capitano
infelice della prima rivoluzione napoletana, e che struggeasi di
condurne un’altra, erasi diretto a Lafayette, generale della guardia
nazionale e centro di tutte le cospirazioni, chiedendogli duemila
uomini, diecimila fucili e due fregate, con cui sollevare le Sicilie.
Ebbe le buone parole che colui prodigava a tutti: ma all’atto non
trovò che tergiversazioni; onde esso meditò passare in Corsica,
reclutarvi a denaro da seicento a mille di que’ robusti, e arrischiare
uno sbarco, che fra otto giorni lo renderebbe padrone di Napoli.
Tanto sono irrimediabilmente ciechi i cospiratori di professione! Ma
quand’egli, solo con due uffiziali, era per salpare, n’ebbe divieto, e fu
rimandato a Parigi ad aspettare ancora e sognare per diciassette
anni. Altrettanto erasi usato cogli Spagnuoli. L’Austria, irremovibile
nel guardare come sua propria la causa di tutti i Governi d’Italia, rise
del proclamato non-intervento, e mosse sopra i ducati insorti, o
allegando le riversibilità, o l’esservi invitata; assalirebbe anche il
Piemonte se i rivoluzionarj vi prevalessero.
La insurrezione della media Italia non era costata nè pericoli nè
sagrifizj; leggermente abbracciata, fiaccamente sostenuta, nè grandi
virtù nè grandi vizj palesò. I rappresentanti delle città di Romagna
(26 febb.) dichiarano scaduto dal dominio temporale il papa, e
stringonsi in uno Stato solo, con presidente, consiglio di ministri,
consulta legislativa [201]; si pongono a moltiplicare atti, come suole
ogni amministrazione che si sente di breve durata; e il proclama
dell’avvocato Vicini vuolsi confrontare colla dichiarazione degli Stati
Uniti per vedere quali guasti faccia tra noi la retorica. È codardo
quanto facile il calunniare la sventura, ma perchè farsene adulatore?
Certamente al popolo non si mostrò lo scopo d’un’insurrezione, a cui
non era spinto da eccesso di sofferimenti; mancarono capi che colla
risolutezza e col gran nome abbagliassero e strascinassero
gl’indifferenti, che son sempre il numero maggiore; inesperti delle
politiche cose, come gente a tutt’altro allevata, i governanti
s’impigliavano nelle minime difficoltà; onesti, leali, con quella
moderazione che onora ma che non salva, in un mondo il quale
compassiona i deboli, ma s’allea solo coi forti, esitavano per paura di
compromettere una patria che amavano, una pace di cui sentivano
la necessità; e cullandosi nel promesso non-intervento, invece di
profittare dell’impeto popolare, assalire Roma, suscitare Piemontesi,
Lombardi, Toscani, raccomandavano la quiete come garanzia
dell’inviolabilità, rimandavano a casa i campagnuoli chiedenti armi.
Nulla dirò delle gelosie rideste fra le città; nulla dei disordini
inseparabili da Governi che, nati da vittoria popolare, restano schiavi
della moltitudine, guidata da chi più grida, più esagera, più promette.
Napoleone e Luigi Buonaparte, falliti in altri tentativi di sollevare
Roma, accorsero a infervorare la rivoluzione romagnuola, e
scrissero al papa, esortandolo a deporre il temporale dominio prima
che le forze giungessero su Roma invincibili [202]. Nuovo pretesto ai
nemici di dire l’indipendenza italica minacciata da un’usurpazione
napoleonica.
Ma di pretesti non facea mestieri dove francamente era stata
dichiarata l’inimicizia. Una colonna d’Austriaci guidata da Geppert,
passato il Po, ripose in dominio il duca di Modena e Maria Luigia (9 e
13 marzo): il veterano generale Zucchi, che dal servizio dell’Austria
era disertato a comandar la rivoluzione della sua Modena [203],
ritirasi col piccolo esercito sul Bolognese; ma quel Governo,
scrupoloso al non-intervento anche quando il vede conculcato,
ricusa ricevere quei fratelli se non disarmati. Quel Gregorio, che fu
poi moda di trattar da imbecille, era stato ricevuto dalla plebe
romana con applausi strepitosissimi; ma egli da savio non
lasciossene lusingare, e «poichè rare sono le clamorose riunioni che
disgiunte vadano da qualche discordia», sapendo che allestivasi
altra festa, fece pubblicare che «non aveva egli bisogno di tali
dimostrazioni per misurare l’attaccamento che gli porta questo suo
amatissimo popolo» [204].
Al primo annunzio della sollevata Romagna, la Corte mostrossi
disposta a larghi patti, volendo il Bernetti prevenire l’invasione
austriaca; intanto erangli venute assicurazioni non solo dall’Austria
ma e dalla Francia, dove quel non-intervento che offriva il tema di
mille variazioni alla tribuna parigina ed ai giornali, due campi
dell’eroismo parolajo, or sottoponeasi ad interpretazioni da casisti:
che l’imperatore d’Austria poteva bene prender parte alle vicende
della duchessa di Parma sua figlia; anche a quelle di Modena,
ducato a sè riversibile; ma quanto alla Romagna, mai non gli si
permetterebbe. Per verità, se i Francesi non ajutavano la Polonia col
pretesto della lontananza, per l’Italia sarebbe bastato affacciarsi al
ciglio delle Alpi. Ma Metternich, che vedeva pericolare o le provincie
austriache o l’ingerenza sul bel paese, negò alla Francia il diritto
d’impedirgli di ripristinare il dominio papale; — Se si ha a morire,
tanto vale un’apoplessia, quanto la lenta soffogazione: faremo la
guerra»; ed entrò sul territorio pontifizio. Allora la fragorosa Francia a
gridare vilipesa la dignità nazionale e traditi i patrioti, e volersene
vendetta; l’ambasciadore Maison da Roma incalzava a gettar il
fodero, e spedire un esercito in Piemonte: ma il casismo soccorse di
nuovo mostrando che l’Austria non v’interveniva per proprio conto,
sibbene a richiesta del papa; e che del resto, guaj a lei se pensasse
invadere il Piemonte [205], il quale in fatto non n’avea bisogno.
L’ardore esalò in magnanime ciancie, e i Romagnoli videro non poter
sostenersi che da sè. «Italiani, all’armi! chi ha un fucile, una spada,
una falce, la prenda e venga con noi, che la vittoria non ci può
fallire»; ebbero raccozzato un esercito di circa settemila uomini; ma
vedendo presa Bologna, si ritirarono innanzi agli Austriaci, che
procedeano a passo di carica sulla via Emilia: a Rimini tennero testa
(25 marzo) quel tanto che bastasse perchè la loro bandiera fosse
vinta, non macchiata; e avendo con quel fatto protetta la ritirata
sopra Ancona, lasciato molti morti sul campo e trasportatine i feriti, si
rassegnarono ad evitare una resistenza disastrosa quanto inutile.
Il Governo, ridottosi in Ancona, dichiarando non essersi mosso se
non per fiducia del non intervento, dai Francesi proclamato in
pubblico e promesso in particolare, rimette in libertà il legato
Benvenuti; il quale promette l’oblio di qualunque atto della
rivoluzione, e firma il passaporto de’ capi. Questi s’imbarcano;
Ancona è resa pacificamente dal generale Armandi (29 marzo): ma
la convenzione viene dichiarata nulla a Roma, giacchè il Benvenuti
avea cessato dalla sua carica col divenire prigioniero; s’istituisce
processo contro quelli che avessero firmato l’atto di decadenza, o
violato il giuramento militare, o pubblicato scritti empj o sediziosi; agli
altri intero perdono. Il colonnello Sercognani, ch’era proceduto fin a
Rieti, udito quel rovinío, volta per la Toscana, e ben accolto dal
popolo e soccorso dal Governo rifugge in Francia. Tre navi portarono
altri profughi in Francia, in Inghilterra, a Corfù; ma una fu arrestata
da due golette austriache, e ventun pontifizj e sessantasette
modenesi che vi stavano furono gettati nelle prigioni di Venezia.
Poco poi i pontifizj, più tardi i modenesi furono rimessi in libertà;
processati gli austriaci, e Zucchi, come disertore, sottoposto a
giudizio militare e condannato in fortezza per tutta la vita. Paolo
Costa di sessant’anni e malato della pietra, andò a Corfù ad
insegnare filosofia, come l’archeologo Orioli; Pellegrino Nobili di
settantasei anni, dopo una fuga piena di pericoli, raggiunse in
Francia suo figlio, insigne fisico fuggente anch’esso, sinchè
ottennero di ricoverarsi in Toscana. Questi e il filosofo Mamiani, i
fisici Amici e Melloni, il medico Sterbini, il poeta Pepoli ed altri colla
loro civiltà e sapienza cresceano la pietà per le sventure d’Italia in
quella Francia dove i nostri ricevettero ospitalità benevola, stentati
sussidj e fallaci promesse [206]. Napoleone Buonaparte era finito di
morte violenta: suo fratello Luigi dall’amorevole madre Ortensia fu
campato a preparar nuove trame, che doveano portarlo alla prigionia
poi al trono. Gli Austriaci tennero occupati i ducati della media Italia
e le Legazioni; in Lombardia spaventarono con processi rigorosi,
pure mondi di sangue; e Metternich fu decorato dall’imperatore
d’Austria «per aver tanto contribuito a mantenere l’indipendenza
degli Stati italiani».
Maria Luigia, non avendo destinato alcuno a governare in sua vece,
non poteva far colpa a chi erasi assunto gli affari; tornata a Parma,
presto bandì generale perdono, eccettuandone ventun profughi.
L’odio concentravasi sul Mistrali ministro, più ambizioso che
tristo [207], sul Sartorio, capo della polizia, che poi fu accoltellato; sui
Gesuiti annidati nel collegio di Piacenza, e contro i quali si fece poi
una chiassosa dimostrazione; mentre l’arciduchessa pensava a
goder la vita, e i resti d’un corpo ch’era stato di Napoleone diede al
conte di Bombelles che la ridusse e parca e devota.
Francesco di Modena, più irritato perchè avea previsto eppur non
ovviato, e persuaso che «i settarj si ostinano a voler abbattere altari
e troni, e che un sovrano è responsabile in faccia a Dio se tollera il
trionfo dell’irreligione» mandò al supplizio Vincenzo Borelli e Ciro
Menotti, il quale salì al patibolo esclamando — Italiani, non
lusingatevi a promessa di stranieri» [208]. Coll’editto 18 aprile 1832
sopprimeva le formole giuridiche contro i rei di Stato,
abbandonandoli agli sgherri e alle spie; e sparsasi voce d’un
attentato contro la vita di esso, i soldati giuravano, «Se l’inferno
vomitasse un’anima capace di rinnovare le ribellioni, noi renderemo i
concittadini responsali sulla vita loro della sicurezza di Francesco IV
con giustizia militare pronta sicura». Da tremilacinquecento volontarj
estensi rimanevano alle proprie case ma in armi, vigilando alla
pubblica tranquillità, e pronti ad accorrere quando bisognasse. Il
duca non curossi che Francia e Inghilterra interrompessero le
relazioni diplomatiche con lui, lasciava stampare contro di esse e
contro il liberalismo, e francamente si collocava campione de’
Governi assoluti, alla riazione pretendendo imprimere il carattere
religioso e patriarcale, dopo sei anni di processi, furono condannate
a gravissime pene cenquattro persone, ma tutte contumaci e due
morte; e quelle pene stesse ebbero mitigazione. Giuseppe Ricci,
guardia nobile del duca, al quale era rimasto fedele nei movimenti
del 1831, e che passava pel favorito di esso, accusato che
cospirasse ad assassinarlo, fu fucilato: vittima forse d’una ingiustizia,
ma non eroe politico.
Quel Canosa, che, parendo eccessivo a Napoli, n’era stato rinviato
con doni e mortificazioni, viveva oscuro a Genova, allorchè il duca di
Modena lo chiamò a capo della sua Polizia, dove per molti anni fu lo
spauracchio de’ liberali di tutta Italia. Più tardi ritiratosi a Nizza, si
congratulava seco «d’aver processato, imprigionato, frustato, ma
non impiccato; d’aver prevenuto le colpe collo sbigottire, ma non
ucciso un solo per crimenlese nè stando governatore militare a
Ponsa, nè ministro di polizia a Napoli; mentre dappoi abbondarono
congiure, sêtte, mandati di morte, e in conseguenza commissioni
militari, e un numero estesissimo di esiliati, vera e bestiale misura
per chi conosce il mestiere» [209].
In Piemonte Carlo Felice poco avea fatto per rimarginar le piaghe del
suo paese; pieno di sè, nè cerimonie volea nè malinconie, ripetendo
— Non son re per essere seccato». Ad un capitano di bastimento
che avea durato fatica nel salvarlo in una procella, volea dare
qualche centinajo di scudi, ma il ministro gli suggerì avrebbe meglio
aggradito la croce di san Maurizio e Lazzaro. — Oh che zugo!
(esclamò) dategliela subito». Intanto la giustizia era pessimamente
amministrata [210], sospetti i pensatori, mesto il paese pei tanti
profughi e per gli arbitrj della Polizia. Il re, disgustato di Torino come
covile di faziosi, sene teneva lontano; non raccoglieva regolarmente i
consigli di Stato, puzzandogli di costituzione, e lasciava far ai ministri
e principalmente al Latour. Avrebbe rinnegato la tradizione di tutta la
sua stirpe se si fosse accordato coll’Austria, delle cui spoglie par
destinata a ingrandire: onde avendogli questa offerto soccorsi contro
i faziosi, egli ricusò risoluto, e represse qualche tentativo de’
Savojardi.
Non ebbe figli, e con lui terminato (1831 27 aprile) il ramo
primogenito di casa di Savoja, appunto nel bollore delle sommosse
gli sottentrava il ramo cadetto di Carignano [211] nella persona di
Carlalberto, quel desso che vedemmo nella rivoluzione del 1821.
Giovane, allevato in mezzo alle armi, partecipe delle speranze se
non delle trame liberali, avea subíto gl’insulti dell’Austria, che
diceano si fosse adoperata a farlo credere indegno del trono per le
macchie del 21, mal lavate al Trocadero, e surrogargli il duca di
Modena. Tanto bastava perchè, dimenticando il passato, sopra di lui
si fissassero le speranze de’ Liberali, e girò l’indirizzo di un Italiano
(Mazzini), il quale gli mostrava come non gli restasse che essere
tiranno ed esecrato, o farsi costituzionale e italiano francamente
rompendola coi potentati; parziali riforme gli nimicherebbero l’Austria
senza amicargli i popoli, mentre con una parola libera e sincera
potea ricreare l’Italia, riunirne le membra sparte, e se pronunziasse,
«È mia tutta e felice», venti milioni d’uomini esclamerebbero, «Dio è
nel cielo, e Carlalberto sulla terra! — Respingete l’Austria, lasciate
addietro la Francia, e stringetevi a lega l’Italia; ponetevi alla testa
della nazione, e scrivete sulla vostra bandiera, Unione, Libertà,
Indipendenza! proclamate la santità del pensiero, liberate l’Italia dai
barbari, date il vostro nome ad un secolo, siate il Napoleone della
libertà italiana. Or che temete? il Tedesco? gridategli guerra, ardite
guardar da vicino questo colosso eterogeneo, forte solo perchè altri
è debole. Una voce ai vostri, una voce alla Lombardia, e avanti. Là,
nella terra lombarda hanno a decidersi i fati dell’Italia ed i vostri;
nella terra lombarda, che non aspetta se non un reggimento ed una
bandiera per levarsi in massa: ma siate forte e deciso; rinnegate i
calcoli diplomatici, gl’intrighi de’ gabinetti, le frodi dei patti. La salute
per voi sta sulla punta della vostra spada... Se voi non fate, altri
faranno, e senza voi e contro voi...».
Carlalberto re vedeva altrimenti che l’antico granmastro d’artiglieria,
e conobbe che un movimento avrebbe posta in compromesso
l’indipendenza del suo paese, determinando una nuova invasione
austriaca. Nonchè parlare di costituzione, nemmeno l’amnistia
concesse; nominò un consiglio di Stato, esprimendo che volea fare
miglioramenti, ma «senza scostarsi dagli esempj lasciati da’ suoi
maggiori», e «conservando inalterata la dignità della Corona». Si
disperò dunque anche di lui; onde molti s’affrettarono a ricoprire la
polvere di carbone colla polvere delle anticamere, altri si annoiarono
nelle società secrete.
Perocchè, mentre le rivoluzioni del 31 eransi fatte a pieno giorno
confidando nell’iniziamento del Governo francese, allora i novatori si
ridussero a trame sotterranee; e appoggiatisi ai radicali, meditarono
sommosse invece dell’insurrezione. Giuseppe Mazzini, nato a
Genova nel 1808, ivi fondò l’Indicatore genovese; soppresso questo
giornale, andò a piantare l’Indicatore livornese; poi a Genova
processato nel 30 e sbandito, ricoverò a Marsiglia, e con Bianchi
piemontese e Santi di Rimini istituì la società della Giovane Italia.
Suo simbolo un ramo di cipresso; parola d’ordine Ora e sempre.
Direttosi a «tutti quelli che sentivano la potenza del nome italiano e
la vergogna di non poterlo portare francamente», escludeva ogni
uom maturo; confidava nell’insurrezione armata; accennava anche
ad una religione da surrogare al cattolicismo, di cui dicea finito il
tempo; e d’accordo coi Carbonari nel volere sbrattar la patria dai
forestieri, ne discordava nel non chiedere più costituzione ma
repubblica, abbattere ogni privilegio, confidare nel popolo a cui quelli
non erano ricorsi. Venne sistemata a modo delle guerriglie, giacchè
derivava dalla solita fonte; e la dirigevano da Londra Mazzini, da
Malta i modenesi Giovanni e Nicola Fabrizj; stampava le sue
declamazioni e i suoi intenti; e fin dai primordj apparve una sentenza
di morte, eseguita col pugnale contro un preteso traditore.
Anche questa società parve più diretta a generare martiri che ad
assicurare la vittoria, mostrando perseveranza di moto più che
evidenza di meta. Il primo atto importante ne fu la spedizione di
Savoja. I nostri rifuggiti comprarono una mano di que’ Polacchi che
erano scampati dalla loro patria quando fu anch’essa abbandonata e
vinta, e sotto al generale Ramorino, genovese che avea combattuto
in Polonia, mossero dal lago di Ginevra e da Grenoble verso la
Savoja (1834 gennajo). I proclami dicevano, dovunque è
despotismo, essere sacro dovere l’insurrezione; delitto il non seguire
la bandiera di questa allorchè il momento sia giunto; non concepire
essi l’Italia che repubblicana, una dall’Alpi al Faro, non federativa;
aspirare a fondare una Roma del popolo, centro d’una grande e
libera unità religiosa, politica, sociale.
Ma parte furono arrestati sul territorio svizzero; alcuni entrati in
Savoja non incontrarono il minimo assenso nel popolo, nè disertori
dalla truppa, e pochi gendarmi li dissiparono. Malissimo concepita,
peggio condotta; pure volle spiegarsi colla solita bubbola del
tradimento, affisso al Ramorino.
Carlalberto avea già prima istituito corti marziali sotto di uffiziali
inesorabili, come il generale Galateri governatore d’Alessandria e il
Cimella nizzardo, e di cavillosi curiali; processati sessantasette
militari dal sergente in giù, dodici furono fucilati, anche alle spalle,
trenta alle galere «per aver avuto notizia della congiura, per aver
letto o fatto circolare un libro contrario ai principj della monarchia».
Coll’avvocato Andrea Vochieri d’Alessandria il Galateri insisteva
perchè rivelasse, promettendogli grazia; ed esso gli rispose: — La
sola grazia che desidero è che mi liberiate della vostra presenza». Il
generale gli dà un calcio nella pancia, e l’inquisito gli sputa in viso.
Galateri esacerbò la morte di lui facendolo traversar le vie dove
abitava, sicchè la moglie e i figliuoli lo vedessero, e alla fucilazione
assistette in grand’uniforme, pippando appoggiato a un
cannone [212]. Giacomo Ruffini genovese si ammazzò in prigione:
suo fratello fuggì in tempo per narrare, più tardi e ricreduto, le trame
e le speranze. E molti furono gli esigliati [213], molti i dolenti, molte le
decorazioni al Galateri e ad altri zelanti.
Dopo la spedizione di Savoja furono fucilati Volonteri e Borrel caduti
prigionieri in quella, ed altri processati; e il non sospetto Gualterio
assicura che Carlalberto ne provasse poi dolore e rimorso, e dal
bisogno d’espiazione cominciasse la sua vita ascetica. Certo quel re
assentiva ai concetti e ai comporti del duca di Modena [214], e lasciò
rinnovarsi l’onnipotenza della Polizia: in conseguenza tornò odioso ai
Liberali, che gl’imputavano di favorire a Gesuiti e missionarj, aver
cercato la beatificazione d’Umberto di Savoja e di Bonifazio
arcivescovo, dato ricetto a un prelato Pacca, già direttore della
Polizia di Roma, poi scacciatone per sozzure; favoreggiato alla
fazione che in Ispagna ed altrove contraddiva alle costituzioni:
garantito un prestito di seicentomila lire fatto dai Pallavicini di
Genova alla duchessa di Berry per tentare una controrivoluzione in
Francia, dove su bastimento genovese sbarcò infelicemente [215]:
sicchè Carlalberto fu denunziato per sanfedista con tanta giustizia,
quanto una volta per Carbonaro.
Anche l’Austria cominciò processi, dove il tirolese Zajotti, già
partecipe alle cospirazioni o alle speranze italiche, nel 1815, fu
chiamato a tradurre in requisitorie criminali i suoi epigrammi da sala
e le sue critiche di giornale: molti furono condannati a morte, a tutti
commutata in carcere temporario, poi nella deportazione in America.
E di nuovo ne usciva un effetto opposto di quel che i Liberali aveano
sperato, crescendo l’influenza dell’Austria sulla penisola. Che essa
mirasse a ingrandire di territorio è una baja, accettata da quella
credulità ch’è propria de’ tempi di rivoluzione; ma è vero che, sentita
necessaria dai principi, e ai popoli non suoi men odiosa, che i
principi proprj, essa poteva dirsi arbitra dell’italiche sorti. Nesselrode,
Fiquelmont, Ancillon, rappresentanti della Russia, dell’Austria, della
Prussia, a Berlino convenivano che i loro sovrani cercherebbero far
adottare, che un principe, nel cui dominio scoppiasse una rivolta, ha
diritto di chiamar in soccorso il sovrano vicino che sia in grado
d’ajutarlo a ristabilire la tranquillità, senza che verun altro Governo
possa opporvisi o rimostrare. Francia dichiarò non lascerebbe
applicare questo dogma di diritto pubblico al Belgio, alla Svizzera, al
Piemonte, ma Metternich incaricava il conte Appony, ambasciadore
austriaco a Parigi, di chiarire quel ministero che il suo imperatore era
risoluto di portar soccorsi anche al re di Sardegna qualora li
domandasse, quand’anche dovesse seguirne una guerra. A ciò
risolveasi il proclamato non-intervento.
Che che ne blatterino i caffè, la politica pontifizia fu sempre gelosa
del predominio austriaco; Leone XII non meno che Pio VII ne
stettero in guardia; molto più il cardinale Bernetti, segretario di Stato
di Gregorio XVI. S’adoprò egli vivamente perchè gli Austriaci
uscissero al più presto: e di fatti non rimasero in Bologna che fino al
15 luglio 1831, quando le varie potenze si furono obbligate a
conservare il dominio temporale della santa Sede. Ma persuase che
non si otterrebbe mai tranquillità se non adattando il Governo ai
tempi, chiesero al papa v’istituisse assemblee comunali e provinciali
di elezione popolare; una giunta centrale sindacasse gli uffizj
amministrativi; secolarizzate le cariche pubbliche; con cittadini
notabili si componesse un consiglio di Stato [216].
Tali promesse arrisero ai Romagnuoli, e confidarono nell’êra nuova
che il Bernetti aveva preconizzata pubblicamente: ma ben presto fu
disdetta, e negate le riforme che era bello attuare quando non
avevano aria d’essere strappate a forza. L’editto del 5 luglio 1831 la
nomina de’ consigli comunali e provinciali attribuiva non al popolo,
ma al preside di ciascuna provincia; esclusi i secolari dal Governo
delle Legazioni; nè consentito d’aggiungere un Consiglio di Stato
laico al sacro Collegio [217]. Prendeasi paura de’ moderati quanto de’
sommovitori, e forse più, perchè contro loro non si poteva invocare
gli Austriaci.
Si dovettero aggravare le imposte, giacchè in que’ tre anni lo Stato
ebbe a spendere otto milioni cennovantottomila scudi più
dell’entrata: si comprarono due reggimenti svizzeri, il cui impianto
costò cinquecentomila scudi, e trecensessantamila l’annuo
mantenimento: si ordinò il disarmo delle Legazioni, alle guardie
urbane surrogando corpi di volontarj, cerniti alla peggio, che
diventarono tiranni e ladri atroci. Inveleniti gli animi, si ripigliarono le
coccarde tricolori; la guardia urbana si fece deliberatrice, e

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Natural Orifice Specimen Extraction

Surgery Gastrointestinal Tumor 2nd

Mesenteric Principles of Gastrointestinal Surgery:

Atlas of Robotic Upper Gastrointestinal Surgery 1st

Oxford Handbook of Gastrointestinal Nursing 2nd Edition

Business Database Technology 2nd Edition Shouhong Wang

The Handbook of Natural Resources Second Edition Six

Agricultural Land Use and Natural Gas Extraction

Circulating Tumor Cells Advances in Liquid Biopsy

Atlas of upper gastrointestinal and hepato pancreato

Natural Orifice Specimen

ISBN 978-981-15-7924-0 ISBN 978-981-15-7925-7 (eBook)

© People’s Medical Publishing House, PR of China 2021

Be appreciative of others’ achievements;

The courage to question oneself makes one a real surgeon.

On the basis of conventional laparoscopic surgical techniques, NOSES combines the

Ho Kyung Chun

The Main Academic Title

Scientific Research and Clinical Achievements

Joaquim Manuel da Costa Pereira

William Tzu-Liang Chen

Beijing, China Xishan Wang

Part I General Statement

Part II NOSES for Colorectal Cancer

4 Laparoscopic Lower Rectal Cancer Resection with Transanal Specimen

12 Laparoscopic Upper Rectal Cancer Resection with Transvaginal Specimen

Part III NOSES for Gastrointestinal Cancer

22 Laparoscopic Distal Gastrectomy (Billroth I) with Transrectal Specimen

26 Laparoscopic Proximal Gastrectomy with Transrectal Specimen Extraction

Part IV Special and Extended Resection Surgery with NOSES

33 Laparoscopic Extended Lower Rectal Cancer Resection with En Bloc Lateral

Part V Complications and Management of NOSES

38 Complications and Management of NOSES for Gastrointestinal Tumor������������� 559

Part VI Collection of Expert Experience on NOSES

39 Experience Sharing in NOSES for Colorectal Cancer ������������������������������������������� 567

54 Robotic Single Stapling Coloanal/Colorectal Anastomosis with Transanal

Xiaolong Ma Department of Colorectal Surgery, Cancer Institute & Hospital, Chinese

Shuzhen Xu Department of Gastrointestinal Surgery, Zhongshan Hospital of Xiamen

© People’s Medical Publishing House, PR of China 2021 3

Table 1.2 Classification of NOTES

Fig. 1.4 Different routes for specimen extraction

Fig. 1.5 Eversion–resection technique

Table 1.4 NOSES approaches for gastric neoplasms

In clinical practice, the indication of NOSES is the first and

Fig. 1.9 Right hemicolectomy combined with rectal cancer resection

Fig. 1.10 Rectal cancer

Fig. 1.12 The Chinese NOSES Alliance

Fig. 1.14 Twelve provincial-level sub-alliances in China

Fig. 1.15 The cases of

Fig. 1.16 NOSES training courses in China

Fig. 1.17 NOSES workshops in China

Fig. 1.18 Chinese consensus

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Ho Kyung Chun

The Main Academic Title

Scientific Research and Clinical Achievements

Beijing, China Xishan Wang

Part I General Statement

Part II NOSES for Colorectal Cancer

4 Laparoscopic Lower Rectal Cancer Resection with Transanal Specimen

12 Laparoscopic Upper Rectal Cancer Resection with Transvaginal Specimen

Part III NOSES for Gastrointestinal Cancer

22 Laparoscopic Distal Gastrectomy (Billroth I) with Transrectal Specimen

26 Laparoscopic Proximal Gastrectomy with Transrectal Specimen Extraction

Part IV Special and Extended Resection Surgery with NOSES

33 Laparoscopic Extended Lower Rectal Cancer Resection with En Bloc Lateral

Part V Complications and Management of NOSES

38 Complications and Management of NOSES for Gastrointestinal Tumor�� 559

Part VI Collection of Expert Experience on NOSES

39 Experience Sharing in NOSES for Colorectal Cancer �� 567

54 Robotic Single Stapling Coloanal/Colorectal Anastomosis with Transanal