To date, a variety of transrectal NOSE techniques have been described by different authors (Table21.1). There is heterogeneity among studies with regard to the number of operating ports, the use of rectal sleeves for extraction, and anastomotic technique (dou­ble stapled versus tripled stapled). The main advantage of the present technique is the extraction of a colonic specimen in a longitudinal way via a protected rectum. In con­trast, in a specimen-retrieval pouch, the specimen will form into a ball by winding, which could hamper extraction. Although the current technique can be used in patients with the same clinical characteristics as those who had laparoscopic NOSE colectomy with a specimen retrieval pouch, it remains to be shown that it is appropriate for use in left-sided colonic disease [15]. Compared to conventional laparoscopic colectomy, one study failed to show any benet from transrectal NOSE [17], while there was a signi­cantly lower analgesic requirement in the transrectal NOSE colectomy groups in two other papers [13, 18]. Moreover, a signicantly shorter operative time was observed when comparing transrectal NOSE colectomy with conventional laparoscopic colec­tomy [13]. Presumed advantages such as less postoperative pain and improved cosmetic outcome have also been evaluated [19, 20]. A single-blind randomized controlled trial showed a signicant difference in morphine analogue requirements: 5% in the NOSE group versus 50% in the conventional group (P=0.003) [19]. The strength of this study is that randomization was done during the operation as close to the time of the interven­tion as possible to reduce the chance that the allocated intervention would not have been delivered [21]. A case-matched study comparing conventional laparoscopic colectomy with laparoscopic NOSE colectomy could demonstrate better cosmetic outcome in the NOSE group [20]. Possible drawback of this technique is the intraperitoneal opening of both the colon and rectum, which could potentially increase infectious complications. Another disadvantage is that it cannot be implemented in the general population. Indeed, patient selection is key for this procedure. Factors limiting the applicability of this tech­nique are patients with a BMI >35kg/m tumors >4cm, the presence of a rectal stricture, and proximal diverticulosis. Because the colorectal anastomosis is created using a triple-stapling technique, diverticular disease present on the proximal colon could possibly lead to an anastomotic leak, due to inad­vertent diverticulum cross stapling.