The emergence and evolution of natural orifice specimen extraction surgery (NOSES) in colorectal oncology marks a significant milestone in the journey toward scarless surgery. Since Professor Xishan Wang’s team first pioneered this technique in China in 2010, NOSES has not only bridged the gap from laparoscopic-assisted incisions to natural orifice specimen extraction but has also redefined surgical paradigms with its "scarless" concept.At the recently concluded 9th Annual Meeting of the Chinese Medical Doctor Association’s Colorectal Oncology Committee, Dr. Taiyuan Li from The First Affiliated Hospital of Nanchang University delivered a compelling presentation titled "The Current State and Future Prospects of NOSES Surgery in Colorectal Oncology—A Revolutionary Shift from Minimally Invasive to Scarless Surgery." His in-depth analysis covered the evolution, current advancements, and future directions of NOSES surgery. Below is a summary of the key insights from his report.The Rise of NOSES Surgery: From Concept to Clinical Transformation
NOSES (Natural Orifice Specimen Extraction Surgery) was first proposed as a surgical concept by Professor Xishan Wang in China. After progressing through its early exploratory, initial application, and development phases, NOSES has now entered a stage of maturity and widespread adoption.
The exploration of NOSES in China began in 2007. By 2009, Dr. Taiyuan Li had already performed five cases using the NOSES-IF technique, publishing the results in 2010 in the Chinese-German Journal of Clinical Oncology. While some teams may have attempted NOSES earlier, no reports were available at the time. The true breakthrough came in 2010, when Professor Xishan Wang’s team in China successfully performed a totally laparoscopic, natural orifice specimen extraction rectal cancer resection via transanal extraction. Their research was published in 2013 in the Chinese Journal of Gastrointestinal Surgery, marking a pivotal transition from minimally invasive to scarless surgery. NOSES eliminates auxiliary abdominal incisions by retrieving specimens through natural orifices (such as the anus or vagina), significantly enhancing postoperative aesthetics and improving patients’ quality of life.
Following this milestone, NOSES entered a phase of rapid development. In 2017, Professor Xishan Wang led the creation of the first Expert Consensus on NOSES for Colorectal Cancer, establishing a standardized classification system and surgical protocols that laid the groundwork for international adoption. The English-language guidelines, followed by translations into Korean, Russian, and French, further promoted global dissemination. By 2019, the consensus document had been cited over 100 times, while international consensus guidelines were referenced 149 times, solidifying NOSES as a standardized surgical approach.
In recent years, NOSES has transitioned into a widespread application and dissemination phase. In China, a “point-line-surface” strategy has expanded its reach to over 20 provinces and cities, including Chongqing, Guangdong, and Shanghai. Through academic conferences, live surgical demonstrations, and multicenter clinical research, NOSES adoption has accelerated. Multiple studies confirm its oncologic safety, low postoperative complication rates, and faster patient recovery, making it an increasingly preferred choice in colorectal cancer surgery.
Current Challenges and Future Directions in NOSES Surgery
With standardized surgical protocols now in place, numerous global studies have validated the safety and efficacy of NOSES. The 2019 expert consensus and international guidelines continue to gain citations, further cementing NOSES’ role in colorectal surgery. However, its widespread adoption still faces several challenges.
One of the primary obstacles is the technical complexity of NOSES procedures. The surgery requires a high level of proficiency in laparoscopic techniques and an advanced understanding of natural orifice anatomy, resulting in a steep learning curve. This has limited NOSES adoption in non-specialist hospitals, where laparoscopic expertise is less developed.
Another challenge is instrumentation. Many current surgical tools are not specifically designed for natural orifice procedures, leading to limitations in maneuverability and visualization. The development of dedicated NOSES instruments is crucial to overcoming these constraints.
The narrow range of indications is also a significant bottleneck. NOSES is currently best suited for patients with small, well-positioned tumors. For patients with larger tumors, obesity, advanced-stage disease, or locally invasive tumors, careful patient selection remains essential.
Additionally, ethical and psychological concerns surrounding certain NOSES techniques, such as transvaginal specimen extraction, have led to hesitation among both patients and surgeons. While clinical outcomes demonstrate the safety and feasibility of this approach, cultural and ethical considerations continue to influence its acceptance.
Although NOSES has a low rate of postoperative complications, risks such as infection and anastomotic leakage remain areas for further improvement. Continued technical innovations and refinements in postoperative management will be key to further reducing these risks and expanding NOSES’ applicability.
Moving forward, enhanced training programs, dedicated surgical tools, and ongoing research into expanding NOSES indications will be critical in overcoming these barriers and bringing the benefits of scarless surgery to a broader range of colorectal cancer patients worldwide.
Charting the Future: Strategic Roadmap and Innovations in NOSES Surgery
To overcome current limitations, future advancements in NOSES surgery will require a multidimensional approach encompassing technological dissemination, scientific research, patient education, and policy support.
In terms of technical training, a tiered system will be established. Junior surgeons will acquire fundamental skills through virtual reality simulators, while senior surgeons will refine their expertise through animal models and mentorship-based clinical training. Additionally, international collaboration will be strengthened by partnering with global academic organizations to facilitate knowledge exchange and establish a worldwide training network.
In the scientific research domain, efforts will focus on multicenter prospective studies to expand NOSES indications, particularly for locally advanced tumors. Medical-engineering collaboration will drive the development of next-generation anastomotic devices, such as biodegradable materials and magnetic anastomosis technology, which could simplify bowel reconstruction and reduce the risk of anastomotic leakage. Furthermore, the integration of artificial intelligence (AI) in surgical decision-making will enhance intraoperative precision, and novel techniques, such as stent-assisted bowel diversion, will be explored to further optimize NOSES procedures.
Patient education is a crucial component of NOSES’ widespread adoption. Public awareness campaigns will leverage new media platforms to disseminate educational content, clarifying the benefits and indications of NOSES while addressing common concerns about natural orifice specimen extraction. Simultaneously, a national surgical database will be established to develop standardized quality assessment metrics, ensuring comprehensive monitoring from preoperative planning to postoperative follow-up.
On the policy front, efforts will focus on expanding insurance coverage and standardizing reimbursement structures to improve the accessibility of NOSES. A multidisciplinary expert panel will be convened to develop standardized surgical guidelines, ensuring procedure safety and uniformity across institutions, thereby providing a strong regulatory framework for NOSES adoption.
Looking ahead, NOSES surgery is poised to advance toward greater precision and personalization. The deep integration of AI and radiomics will enhance precise patient selection and provide real-time intraoperative guidance, improving surgical accuracy. Meanwhile, biodegradable materials and magnetic anastomosis technology will streamline bowel reconstruction and minimize anastomotic leakage risks. Advances in chemoradiotherapy and immunotherapy will further expand NOSES eligibility to a broader range of locally advanced colorectal cancer patients. Additionally, the incorporation of genomic profiling will enable personalized treatment strategies, optimizing patient outcomes.
From an evidence-based medicine perspective, large-scale clinical studies will continue to strengthen NOSES’ scientific foundation, ultimately supporting its inclusion in international treatment guidelines. The establishment of a global collaborative network will accelerate NOSES innovation by facilitating cross-border data sharing and knowledge exchange, driving continuous surgical advancements in colorectal oncology.
In summary, NOSES surgery is reshaping the landscape of colorectal cancer treatment, transitioning from minimally invasive to scarless procedures. Its successful integration into mainstream clinical practice depends not only on technical expertise but also on interdisciplinary collaboration, policy reinforcement, and patient trust. Only by uniting stakeholders across multiple domains can we break technological barriers and truly achieve a patient-centered medical vision.
Expert Profile: Dr. Taiyuan Li
Affiliation: The First Affiliated Hospital of Nanchang University
Position: Vice President, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University
- Chief of General Surgery, Director of Surgical Affairs, and Deputy Director of Health Insurance & Medical Services
- Professor, Chief Physician, MD, PhD Supervisor, and recognized as an Outstanding Young and Middle-Aged Expert by the Jiangxi Provincial Health Commission
Professor Li holds multiple national and international leadership positions, including:
- Standing Member, Second Committee of the Chinese Medical Doctor Association’s Colorectal Oncology Committee
- Standing Member, Colorectal Surgeon Committee of the Chinese Medical Doctor Association
- Chair, NOSES Surgery Group, Second Committee of the Chinese Medical Doctor Association’s Colorectal Oncology Committee
- Standing Member, Robotic Surgery Committee, Chinese Medical Doctor Association
- Vice Chair, Robotic Surgery Group, Chinese Medical Doctor Association’s Colorectal Oncology Committee
- Chair, Surgery Section, Jiangxi Medical Association
- Vice Chair, Second Committee of the Chinese Research Hospital Association’s Robotic and Laparoscopic Surgery Group
- Chair, Jiangxi Provincial Medical Doctor Association’s Colorectal Oncology Committee
- Vice President, Jiangxi Provincial Medical Doctor Association’s Surgery Division
- Chair, Jiangxi Provincial Integrated Medicine Association’s Surgery Committee
- Member, International and Chinese NOSES Alliances, President of Jiangxi NOSES Alliance
- Member, Chinese Medical Association’s Colorectal Surgery Section and Experimental Surgery Section
Professor Li has led nine major research projects, including two grants from the National Natural Science Foundation of China. He has published over 50 SCI-indexed papers, with his highest impact factor reaching 45.042 (2022). He has authored four books, serving as the chief editor for one, published by People’s Medical Publishing House. His work has earned him four third-place Jiangxi Provincial Science and Technology Progress Awards and one first-place Huaxia Medical Science and Technology Award. He has spearheaded the development of one national expert consensus and contributed to nine others. Among his many accolades, he was honored as one of Jiangxi’s “Most Distinguished Physicians” by the Jiangxi Provincial Health Commission.
