Difficulties and strategies of robotic natural orifice specimen extraction surgery for rectal cancer

The surgical approach to rectal cancer has evolved from traditional minimally invasive procedures toward techniques that emphasize enhanced recovery and individualized treatment. Among these, robotic surgery and natural orifice specimen extraction surgery (NOSES) have become the focal points in colorectal surgery in recent years. Robotic NOSES for rectal cancer integrates the dual advantages of robotic system and NOSES. Numerous studies have confirmed that, compared with conventional minimally invasive surgery, robotic NOSES offers comparable safety and oncologic outcomes, while demonstrating superior benefits in terms of enhanced recovery and reduced post-operative incision‑related complications. However, robotic NOSES for rectal cancer presents consider-able difficulties and challenges, as performing digestive tract reconstruction entirely under robotic assistance increasing the complexity of the procedure, opening the bowel lumen intraabdominally raising the risk of peritoneal contamination and tumor dissemination, and difficulties associated with extracting the specimen through natural orifices. Drawing upon the literature and the clinical experience, the authors summarize the difficulties and corresponding strategies associated with robotic NOSES for rectal cancer, with the aim of providing valuable reference to support the wider application of this surgical approach.