Fig. 2

Procedures for laparoscopic anterior resection of upper RC with trans-rectal specimen extraction (NOSES). Laparoscopic surgeries were performed with general anesthesia and reverse Trendelenburg position was indicated. The standard surgical procedure for high RC mainly included high ligation of the inferior mesenteric artery, D3 lymphadenectomy, mobilization of sigmoid and rectum, dissection and retrieval of specimen and intracorporal anastomosis. As for laparoscopic anterior resection of high RC with trans-rectal specimen extraction (NOSES), proximal colon was dissected at approximately 10 cm away from the tumor followed by ligation of the distal rectum using silk ribbon (blue) at least 1 to 2 cm from the lower edge of the tumor (A) after being naked. The distal rectum was then dissected by ultrasound knife (B). Next, a plastic specimen protection bag was introduced into the pelvis through trocar at the right lower quadrant and trans-anal insertion of a Kocher’s clamp though the distal rectal stump was performed to grasp and pull the bottom half of the bag out of the body after four finger anal dilation (C). The anvil was placed in the cavity through the bag (D) and the specimen was dragged out thereafter (E). Intracorporal anastomosis with circular stapler (F)