Transanal endoscopic video-assisted excision: application of single-port access

Transanal Minimally-Invasive Surgery (TAMIS): Experience with No Closure of the Rectal Defect

Background In transanal minimally-invasive surgery (TAMIS), the closure of the rectal defect is controversial, and endoluminal suture is one of the most challenging aspects. The goal of the present study is to evaluate the short- and medium-term complications of a consecutive series of patients with extraperitoneal rectal injuries who underwent TAMIS without closure of the rectal defect.

Materials and Methods A prospective, longitudinal, descriptive study conducted between August 2013 and July 2019 in which all patients with extraperitoneal rectal lesions, who were operated on using the TAMIS technique, were consecutively included. The lesions were: benign lesions ≥ 3 cm; neuroendocrine tumors ≤ 2 cm; adenocarcinomas in stage T1N0; and adenocarcinomas in stage T2N0, with high surgical risk, or with the patients reluctant to undergo radical surgery, and others with doubts about complete remission after the neoadjuvant therapy. Bleeding, infectious complications, rectal stenosis, perforations, and death were evaluated.

Results A total of 35 patients were treated using TAMIS without closure of the defect. The average size of the lesions was of 3.68 ± 2.1 cm (95% confidence interval [95%CI]: 0.7 cm to 9 cm), their average distance from the anal margin was of 5.7 ± 1.48 cm, and the average operative time was of 39.2 ± 20.5 minutes, with a minimum postoperative follow-up of 1 year. As for the pathologies, they were: 15 adenomas; 3 carcinoid tumors; and 17 adenocarcinomas. In all cases, the rectal defect was left open.

The overall morbidity was of 14.2%. Two patients (grade II in the Clavien-Dindo classification) were readmitted for pain treatment, and three patients (grade III in the Clavien-Dindo classification) were assisted due to postoperative bleeding, one of whom required reoperation.

Conclusion The TAMIS technique without closure of the rectal defect yields good results, and present a high feasibility and low complication rate.

TAMIS is a valuable alternative to TEM for resection of intraluminal rectal tumors

BACKGROUND

The aim of this study was to compare the short-term outcome after Transanal Endoscopic Microsurgery (TEM) and Transanal Minimally Invasive Surgery (TAMIS) for intraluminal rectal lesions.

METHODS

Retrospective analysis of a prospectively maintained database of all TEM and TAMIS procedures performed at a single institution by one surgeon between March 2009 and September 2017 was conducted. Primary outcome was operating time. Secondary outcomes were blood loss, pathological outcome, length of hospital stay, 30-day readmission and mortality.

RESULTS

Fifty-three patients underwent TEM procedure and 68 patients underwent TAMIS. Operating time was significantly shorter for TAMIS compared with TEM (median 45 vs 65 min, p < 0.0001). Blood loss was negligible for both TEM and TAMIS. Resection margins, lesion grade and invasion depth were comparable for both approaches. A significantly higher postoperative readmission rate was observed in the TEM group (17% vs 4.4%, p = 0.031). Mortality was zero in both groups.

CONCLUSIONS

TAMIS is a valuable alternative to TEM, leading to decreased operating times, because all resections can be done in lithotomy position.

Transluminal Cancer Surgery

Transluminal surgery, also known as natural orifices endoluminal surgery, can be considered the most minimally invasive approach of gaining access to an organ. Although some approaches, such as transgastric or transvaginal cholecystectomy, have remained experimental, peroral endoscopic myotomy to treat achalasia and transanal total mesorectal excision to treat low rectal cancer have become accepted, safe, and feasible approaches by trained surgeons for selected patients. This article recapitulates the development of transluminal surgery from its experimental beginnings to the validated procedure it has become today.

Should the rectal defect be closed following transanal local excision of rectal tumors? A systematic review and meta-analysis

BACKGROUND

Transanal local excision (TLE) has become the treatment of choice for benign and early-stage selected malignant tumors. However, closure of the rectal wall defect remains a controversial point and the available literature still remains unclear. Our aim was to determine through a systematic review of the literature and a meta-analysis of relevant studies whether or not the wall defect following TLE of rectal tumors should be closed.

METHODS

Medline and the Cochrane Trials Register were searched for trials published up to December 2016 comparing open versus closed management of the surgical rectal defect after TLE of rectal tumors. Meta-analysis was performed using Review Manager 5.0.

RESULTS

Four studies were analyzed, yielding 489 patients (317 in the closed group and 182 in the open group). Meta-analysis showed no significant difference between the closed and open groups regarding the overall morbidity rate (OR 1.26; 95% CI 0.32-4.91; p = 0.74), postoperative local infection rate (OR 0.62; 95% CI 0.23-1.62; p = 0.33), postoperative bleeding rate (OR 0.83; 95% CI 0.29-1.77; p = 0.63), and postoperative reintervention rate (OR 2.21; 95% CI 0.52-9.47; p = 0.29).

CONCLUSIONS

This review and meta-analysis suggest that there is no difference between closure or non-closure of wall defects after TLE.

What is the best tool for transanal endoscopic microsurgery (TEM)? A case-matched study in 74 patients comparing a standard platform and a disposable material

PURPOSE

Transanal endoscopic microsurgery (TEM) is the gold standard for local excision of rectal lesions, but no study exists concerning the best material. The objective was to compare TEM using a disposable material vs a standard platform through a case-matched study.

METHODS

Patients who underwent TEM for rectal neoplasms were identified from prospective databases in two tertiary referral centers and matched according to four criteria (sex, tumor location, size, distance from the anal verge): TEM using a disposable material (GelPoint Applied®; group A) and TEM using a standard TEO® platform (Karl Storz, Tuttlingen, Germany; group B).

RESULTS

A total of 74 patients were included and divided into group A (n = 33) and group B (n = 41). Full-thickness resection was less frequent in group A (85%) than B (100%; p = 0.01). Adenocarcinoma was less frequent in group A than B: 27 vs 42% (p = 0.03). No difference was noted regarding median operative time (53 vs 53 min; p = 0.6) and a peritoneal perforation rate (6 vs 20%; p = 0.17). Median length of stay was shorter in group A than B (4 vs 5 days; p < 0.008). No significant difference was noted for major morbidity (12 vs 10%; p = 0.66), R1 resection (21 vs 10%; p = 0.2), and recurrence rates (8 vs 7%; p = 0.62). No difference was noted for rectal stenosis (3 vs 12%; p = 0.22) and transit disorder rates (12 vs 17%; p = 0.74).

CONCLUSIONS

Our study suggested that TEM can be performed using either a TEO® platform or a disposable material, with similar surgical results. The TEO® platform seems to be superior to obtain full-thickness and R0 resection.

Future of Minimally Invasive Colorectal Surgery

Minimally invasive surgery is slowly taking over as the preferred operative approach for colorectal diseases. However, many of the procedures remain technically difficult. This article will give an overview of the state of minimally invasive surgery and the many advances that have been made over the last two decades. Specifically, we discuss the introduction of the robotic platform and some of its benefits and limitations. We also describe some newer techniques related to robotics.

TAMIS for rectal tumors: advancements of a new approach

TAMIS allows transanal excision of rectal lesions by the means of a single-incision access port and traditional laparoscopic instruments. This technique represents a promising treatment of rectal neoplasms since it guarantees precise dissection and reproducible approaches. From May 2010 to September 2015, we performed excisions of rectal lesions in 55 patients using a SILS port. The pre-operative diagnosis was 26 tumours, 26 low and high grade displasias and 3 other benign neoplasias. 11 patients had a neoadjuvant treatment. Pneumorectum was established at a pressure of 15-20 mmHg CO2 with continuous insufflation, and ordinary laparoscopic instruments were used to perform full thickness resection of rectal neoplasm with a conventional 5-mm 30° laparoscopic camera. The average operative time was 78 min. Postoperative recovery was uneventful in 53 cases: in one case a Hartmann procedure was necessary at two postoperative days due to an intraoperative intraperitoneal perforation; in another case, a diverting colostomy was required at the five postoperative days due to an intraoperative perforation of the vaginal wall. Unclear resection margins were detected in six patients: thereafter five patients underwent radical surgery; the other patient was unfit for radical surgery, but is actually alive and well. Patients were discharged after a median of 3 days. Transanal minimally invasive surgery is an advanced transanal platform that provides a safe and effective method for low rectal tumors. The feasibility of TAMIS also for malignant lesions treated in a neoadjuvant setting could be cautiously evaluated in the future.

Anorectal function and outcomes after transanal minimally invasive surgery for rectal tumors

BACKGROUND:

Transanal endoscopic microsurgery is a minimally invasive technique that allows full-thickness resection and suture closure of the defect for large rectal adenomas, selected low-risk rectal cancers, or small cancers in patients who have a high risk for major surgery. Our aim, in the given prospective study was to report our initial clinical experience with TAMIS, and to evaluate its effects on postoperative anorectal functions.

MATERIALS AND METHODS:

In 10 patients treated with TAMIS for benign and malignant rectal tumors, preoperative and postoperative anorectal function was evaluated with anorectal manometry and Cleveland Clinic Incontinence Score.

RESULTS:

The mean distance of the tumors from the anal verge was 5.6 cm, and mean tumor diameter was 2.6 cm. All resection margins were tumor free. There was no difference in preoperative and 3-week postoperative anorectalmanometry findings; only mean minimum rectal sensory volume was lower at 3 weeks after surgery. The Cleveland Clinic Incontinence Score was normal in all patients except one which resolved by 6 weeks after surgery.The mean postoperative follow-up was 28 weeks without any recurrences.

CONCLUSION:

Transanal minimally invasive surgery is a safe and effective procedure for treatment of rectal tumors and can be performed without impairing anorectal functions.

Transanal Minimally Invasive Surgery

Transanal minimally invasive surgery (TAMIS) was first described in 2010 as a crossover between single-incision laparoscopic surgery and transanal endoscopic microsurgery (TEM) to allow access to the proximal and mid-rectum for resection of benign and early-stage malignant rectal lesions. The TAMIS technique can also be used for noncurative intent surgery of more advanced lesions in patients who are not candidates for radical surgery. Proper workup and staging should be done before surgical decision-making. In addition to the TAMIS port, instrumentation and set up include readily available equipment found in most operating suites. TAMIS has proven its usefulness in a wide range of applications outside of local excision, including repair of rectourethral fistula, removal of rectal foreign body, control of rectal hemorrhage, and as an adjunct in total mesorectal excision for rectal cancer. TAMIS is an easily accessible, technically feasible, and cost-effective alternative to TEM.

Transanal minimally invasive surgery (TAMIS): new treatment for early rectal cancer and large rectal polyps—experience of an Italian center

Transanal endoscopic microsurgery (TEM) is a minimally invasive technique for excision of rectal tumors that avoids conventional pelvic resectional surgery along with its risks and side effects. Although appealing, the associated cost and complex learning curve limit TEM use by colorectal surgeons. Transanal minimally invasive surgery (TAMIS) has emerged as an alternative to TEM. This platform uses ordinary laparoscopic instruments to achieve high-quality local excision. The aim of the study is to assess reliability of the technique. From July 2012 to August 2013, 15 consecutive patients with rectal pathology underwent TAMIS. After a single-incision laparoscopic surgery port was introduced into the anal canal, a pneumorectum was established with a laparoscopic device followed by transanal excision with conventional laparoscopic instruments, including graspers, electrocautery, and needle drivers. Patient demographics, operative data, and pathologic data were recorded. Of the 15 patients, 10 had rectal cancers (six T1 lesions and four T2 after preoperative chemoradiotherapy). The remainder of patients had a local excision for voluminous benign rectal adenomas. The median length of the lesions from the anal verge was 7 cm (range, 4 to 20 cm). The median operating time was 86 minutes (range, 33 to 160 minutes). There was no surgical morbidity or mortality. The median postoperative hospital stay was two days (range, 1 to 4 days). TAMIS seems to be a feasible and safe treatment option for early rectal cancer. We believe that this new technique is easy to perform, cost-effective, and less traumatic to the anal sphincter compared with traditional TEM.

Transanal minimal invasive surgery for rectal lesions: should the defect be closed?

AIM

Transanal minimal invasive surgery (TAMIS) of rectal lesions is increasingly being used, but the technique is not yet standardized. The aims of this study were to evaluate peri-operative complications and long-term functional outcome of the technique and to analyse whether or not the rectal defect needs to be closed.

METHOD

Consecutive patients undergoing TAMIS using the SILS port (Covidien) and standard laparoscopic instruments were studied.

RESULTS

Seventy-five patients (68% male) of mean age 67 (± 15) years underwent single-port transanal surgery at three different centres for 37 benign lesions and 38 low-risk cancers located at a mean of 6.4 ± 2.3 cm from the anal verge. The median operating time was 77 (25-245) min including a median time for resection of 36 (15-75) min and for closure of the rectal defect of 38 (9-105) min. The defect was closed in 53% using interrupted (75%) or a running suture (25%). Intra-operative complications occurred in six (8%) patients and postoperative morbidity was 19% with only one patient requiring reoperation for Grade IIIb local infection. There was no difference in the incidence of complications whether the rectal defect was closed or left open. Patients were discharged after 3.4 (1-21) days. At a median follow-up of 12.8 (2-29) months, the continence was normal (Vaizey score of 1.5; 0-16).

CONCLUSION

Transanal rectal resection can be safely and efficiently performed by means of a SILS port and standard laparoscopic instruments. The rectal defect may be left open and at 1 year continence is not compromised.

Colonic Foreign Body Retrieval Using a Modified TAMIS Technique with Standard Instruments and Trocars

Background. Reports of retained colorectal foreign bodies (CFBs) are no longer considered uncommon. We present a case where a retained CFB was retrieved using a modified TAMIS technique using standard instruments and trocars. Case Report. A 52-year-old man presented with a CFB. We report our technique of extraction with standard laparoscopic instruments without specialized access platforms. Conclusions. This modified TAMIS technique is well suited for resource poor environments because it requires no specialized equipment, platforms, or additional skill sets compared to conventional laparoscopy.

Transanal endoscopic microsurgery (TEM) facilitated by video-assistance and anal insertion of a single-incision laparoscopic surgery (SILS(®))-port: preliminary experience

OBJECTIVE

Transanal endoscopic microsurgery (TEM) is an established method for the resection of benign and early malignant rectal lesions. Very recently, TEM via an anally inserted single incision laparoscopic surgery (SILS(®))-port has been proposed to overcome remaining obstacles of the classical TEM equipment.

METHODS

Nine patients with a total of 12 benign or early stage malignant rectal polyps were operated using the SILS(®)-port for TEM. Patients' and polyps' characteristics, perioperative and postoperative complications, as well as operating and hospitalization time were recorded.

RESULTS

All 12 polyps (ten low-grade adenoma, one high-grade adenoma, one pT2 carcinoma [preoperatively staged as T1]) were resected. Local full-thickness bowel wall resection was performed for three lesions and submucosal resection for nine lesions. Median operating time was 64 (range 30-180) min. No conversion to laparoscopic or open techniques was necessary. The median maximum diameter of the specimen was 25 (range 3-60) mm, fragmentation of polyps was avoidable in 11 of 12 (92 %) lesions, and resection margins were histologically clear in 11 of 12 (92 %) polyps. Only one patient, in whom three lesions were resected, experienced a complication as postoperative hemorrhage. No mortality occurred. Median hospitalization time was four (range 1-14) days.

CONCLUSIONS

SILS(®)-TEM is a feasible and safe method, providing numerous advantages in application, handling, and economy compared with the classical TEM technique. SILS(®)-TEM might become a promising alternative to classical TEM. Randomized, controlled trials comparing safety and efficacy of both instrumental settings will be needed in the future.

Clinical competence in the surgery of rectal cancer: the Italian Consensus Conference

BACKGROUND AND AIM

The literature continues to emphasize the advantages of treating patients in "high volume" units by "expert" surgeons, but there is no agreed definition of what is meant by either term. In September 2012, a Consensus Conference on Clinical Competence was organized in Rome as part of the meeting of the National Congress of Italian Surgery (I Congresso Nazionale della Chirurgia Italiana: Unità e valore della chirurgia italiana). The aims were to provide a definition of "expert surgeon" and "high-volume facility" in rectal cancer surgery and to assess their influence on patient outcome.

METHOD

An Organizing Committee (OC), a Scientific Committee (SC), a Group of Experts (E) and a Panel/Jury (P) were set up for the conduct of the Consensus Conference. Review of the literature focused on three main questions including training, "measuring" of quality and to what extent hospital and surgeon volume affects sphincter-preserving procedures, local recurrence, 30-day morbidity and mortality, survival, function, choice of laparoscopic approach and the choice of transanal endoscopic microsurgery (TEM).

RESULTS AND CONCLUSION

The difficulties encountered in defining competence in rectal surgery arise from the great heterogeneity of the parameters described in the literature to quantify it. Acquisition of data is difficult as many articles were published many years ago. Even with a focus on surgeon and hospital volume, it is difficult to define their role owing to the variability and the quality of the relevant studies.

Complications of transvaginal natural orifice transluminal endoscopic surgery: a series of 102 patients

OBJECTIVE

To review the complications encountered in our facility and in previously published studies of transvaginal (TV) natural orifice transluminal endoscopic surgery (NOTES) to date.

BACKGROUND

TV NOTES is currently observed with critical eyes from the surgical community, despite encouraging data to suggest improved short-term recovery and pain.

METHODS

All TV NOTES procedures performed in female patients between 18 and 65 years of age were included. The median follow-up was 90 days. The TV appendectomies and ventral hernia repairs were pure NOTES, through a SILS port in the vagina, whereas TV cholecystectomies were hybrid procedures with the addition of a 5-mm port in the umbilicus.

RESULTS

A total of 102 TV NOTES procedures, including 72 TV cholecystectomies, 24 TV appendectomies, and 6 TV ventral hernia repairs, were performed. The average age was 37 years old and body mass index was 29 kg/m. Three major and 7 minor complications occurred. The first major complication was a rectal injury during a TV access port insertion. The second major complication was an omental vessel bleed after a TV cholecystectomy. The third complication was an intra-abdominal abscess after a TV appendectomy. Seven minor complications were urinary retention (4), transient brachial plexus injury, dislodgement of an intrauterine device, and vaginal granulation tissue.

CONCLUSIONS

As techniques in TV surgery are adopted, inevitably, complications may occur due to the inherent learning curve. Laparoscopic instruments, although adaptable to TV approaches, have yet to be optimized. A high index of suspicion is necessary to identify complications and optimize outcomes for patients.

Single-port transanal endoscopic microsurgery: a developing technique

INTRODUCTION

Transanal endoscopic microsurgery is a widely used and valid technique with established indications. However, the cost of surgical anoscopes is not available in all centers. Many authors have described transanal resection of rectal tumors through a single laparoscopy port such as the SILS system.

MATERIALS AND METHODS

We analyzed 5 cases of patients undergoing transanal resection with an SILS device. The clinical, surgical, and oncological data were assessed.

RESULTS

The median distance to the anal margin was 7.2 cm (range, 5 to 10 cm) and median tumor size was 3 cm (range, 1 to 6 cm). Median operating time was 75 minutes (range, 60 to 120 min). A postsurgical rectorrhagia occurred in 1 of the case. Two cases were adenocarcinoma, 2 were adenomas, and the other was a mucosa without any tumor remnants. The margins were negative in all cases.

CONCLUSIONS

Transanal resection of rectal tumors using the SILS technique is a feasible procedure. Longer series and prospective studies are necessary.

Which treatment for large rectal adenoma? Preoperative assessment and therapeutic strategy

In the present review the authors discuss the standard ways of preoperative work-up for a suspected large rectal non-invasive lesion, comparing East and West different attitudes both in staging and treatment. Looking at the literature and analyzing recent personal data, neither pit-pattern classification, nor EUS, nor biopsy histology, nor lifting sign verification, nor digital examination allow a specificity of more than three fourth of such cases. The authors disquisition about which optimal treatment excludes a role for EMR for the impossibility to obtain a single en-bloc specimen, minimum requirement for a correct lateral and vertical margin assessment. For the same reason ESD should be preferred, although a recent meta-analysis of the literature defined that one fourth of patients undergoing ESD for a preoperatively assessed non-invasive large rectal lesion fail to receive an R0 en-bloc resection. This forces about 10% of patients treated by flexible endoscopy to undergo abdominal surgery, which is about fourfold higher than TEM. While awaiting further implementation of modern technologies both to improve staging and to reduce invasiveness, a full-thickness excision of the rectal wall by TEM still represents the standard treatment even for suspected benign diseases.

Transanal minimally invasive surgery for total mesorectal excision

Transanal TME is a new and important application for TAMIS. It allows for resection and mobilization of the rectum while preserving the quality of the mesorectal envelop. This new approach has gained considerable interest not only because of its minimally invasive nature, but because TAMIS-TME offers a solution to one of the most difficult problems in rectal cancer surgery: Specifically, access to the distal rectum in obese male patients with a narrow pelvis. Recently, transanal TME has become one of the most rapidly expanding areas in rectal cancer surgery. Interestingly, the origin and inception of this approach began decades ago. The evolution of transanal TME with a historical perspective is described.

TransAnal Minimally Invasive Surgery (TAMIS) with SILS™ port versus Transanal Endoscopic Microsurgery (TEM): a comparative experimental study

BACKGROUND

TransAnal Minimally Invasive Surgery (TAMIS) has been proposed as an alternative to Transanal Endoscopic Microsurgery (TEM) for resection of benign polyps and early cancers of rectum. Since clinical application has begun in the absence of any experimental validation, we assessed its feasibility and efficacy ex vivo in a pilot study.

METHODS

In a dedicated trainer box for transanal procedures, 10 surgeons with no experience in transanal surgery were asked to perform a dissection/suture task using both TAMIS and TEM in randomly allocated order. Surgeons were asked to dissect two identically drawn lesions of ~3 cm in larger diameter. Precision of dissection was assessed using a quantitative photographic method, while the time needed for dissection and suturing was considered a measure of quantitative evaluation. Each participant expressed a subjective opinion regarding difficulty with dissection, difficulty with suturing, vision quality, and conflict between instruments on a scale from 1 to 5.

RESULTS

No difference was observed between the two techniques regarding the accuracy of dissection as the margin was interrupted along 4.1 % of the circumference in the TEM group compared with 2.48 % in the SILS group (P = 0.271). Dissection and suturing were significantly quicker in the TEM group [04:30 vs. 06:35 min (P = 0.049) and 14:34 versus 19:18 min (P = 0.003)]. In three cases in the SILS group, completing the suture was not considered possible, and the procedures were terminated by TEM. Subjective evaluation revealed a better appreciation of TEM in all proposed comparisons: dissection (2.6 vs. 3.5, P = 0.004), suturing difficulty (3.1 vs. 4.6, P < 0.001), quality of vision (2.3 vs. 2.8, P = 0.18), and instrument conflicts (3.1 vs. 4.0, P = 0.054).

CONCLUSIONS

In the ex vivo setting, both techniques were comparable for achieving a good dissection, although TAMIS failed to prove effective in suturing the rectal wall. Moreover, TEM was significantly quicker despite the small groups and was better appreciated by the surgeons.

Transanal minimally invasive surgery (TAMIS) for local excision of benign neoplasms and early-stage rectal cancer: efficacy and outcomes in the first 50 patients

BACKGROUND

Since its inception in 2009, transanal minimally invasive surgery has been used increasingly in the United States and internationally as an alternative to local excision and transanal endoscopic microsurgery for local excision of neoplasms in the distal and mid rectum. Despite its increasing acceptance, the clinical benefits of transanal minimally invasive surgery have not yet been validated.

OBJECTIVE

The aim of this study is to assess the adequacy of transanal minimally invasive surgery for the local excision of benign and malignant lesions of the rectum.

DESIGN

This is a retrospective analysis of consecutive patients who underwent transanal minimally invasive surgery for local excision of neoplasms at a single institution.

SETTINGS

The study was conducted by a single group of colorectal surgeons at a tertiary referral center.

PATIENTS

Eligible patients with early-stage rectal cancer and benign neoplasms were offered transanal minimally invasive surgery as a means for local excision. Data from these patients were collected prospectively in a registry.

MAIN OUTCOME MEASURES

The primary outcome measures included the feasibility of transanal minimally invasive surgery for local excision, resection quality, and short-term clinical results.

RESULTS

: Fifty patients underwent transanal minimally invasive surgery between July 2009 and December 2011. Twenty-five benign neoplasms, 23 malignant lesions, and 2 neuroendocrine tumors were excised. All lesions were excised using transanal minimally invasive surgery without conversion to an alternate transanal platform. The average length of stay was 0.6 days (range, 0-6), and 68% of patients were discharged on the day of surgery. The average distance from the anal verge was 8.1 cm (range, 3-14 cm). All lesions were excised completely with only 2 fragmented specimens (4%). All specimens were removed with grossly negative margins, although 3 (6%) were found to have microscopically positive margins on final pathology. There were 2 recurrences (4%) at 6- and 18-month follow-up. Early complications occurred in 3 patients (6%). No long-term complications were observed at a median follow-up of 20 months.

LIMITATIONS

The study was limited by its retrospective nature and midterm follow-up.

CONCLUSIONS

Transanal minimally invasive surgery is an advanced transanal platform that provides a safe and effective method for resecting benign neoplasms, as well as carefully selected, early-stage malignancies of the mid and distal rectum.

Robotic transanal access surgery

Transanal use of laparoscopic instrumentation has been described in several case reports as an alternative to transanal endoscopic microsurgery (TEM). Both of these techniques have significant technical limitations due to anatomical constrictions. Robotic technology with articulating instruments has been effectively used in many areas with anatomic limitations similar to the intraluminal use within the rectum. We present the technique of a full-thickness transanal resection of a rectal polyp with endorectal suturing using a robotic platform. Larger case series and trials are needed to compare outcome and cost with TEM. Alternative robotic platforms and instrumentation may be further developed for different and more advanced indications of transanal access surgery.

Transanal minimally invasive surgery (TAMIS): applications beyond local excision

Transanal minimally invasive surgery (TAMIS) is a new technique for the local excision of rectal neoplasia. This platform employs ordinary laparoscopic instruments to achieve high-quality local excision. The TAMIS platform, however, is quite versatile. Described here are applications of TAMIS beyond local excision, ranging from repair of a rectourethral fistula to reverse proctectomy.

Current status of robotic rectal cancer surgery

SUMMARY After the introduction of robotic surgery for rectal cancer, the safety and feasibility of robotic rectal cancer surgery was demonstrated. However, early comparative studies between laparoscopic and robotic surgery did not show a significant postoperative benefit. Recently, it was reported that robotic rectal surgery showed better postoperative outcomes than laparoscopic surgery with regard to postoperative recovery, pain and function preservation. In addition, robotic transanal specimen extraction was safely performed while maintaining a lower level of postoperative pain and recovery time. All of these findings should be validated with well-designed comparative studies. As robotic technology advances and continues to be studied, the use of robotic surgical systems will become more common among colorectal surgeons.

Transanal endoscopic video-assisted (TEVA) excision

BACKGROUND

Transanal endoscopic video-assisted (TEVA) excision represents an alternative approach for the surgical treatment of middle and upper rectal lesions not amenable to colonoscopic removal. Utilizing principles of single-incision laparoscopic surgery, this novel minimally invasive approach optimizes access for safe and complete removal of these lesions without the need for a formal rectal resection. We describe our technique and early outcomes with TEVA excision.

METHODS

Between March 2010 and September 2011, TEVA excision was performed for patients presenting for management of rectal lesions not amenable to colonoscopic or standard transanal removal. Patients were selected if they presented with benign disease or superficial adenocarcinoma, and the proximal extent of the lesion extended beyond 8 cm from the anal verge. Demographic, intraoperative, and postoperative data were assessed. A SILS™ port was placed in the anal canal for access in all cases. Standard laparoscopic instruments were utilized for visualization, full-thickness transanal excision, and primary closure.

RESULTS

Twenty patients (50% male) with a mean age of 64.6 ± 10.9 years, mean body mass index of 28.2 ± 4.9 kg/m(2), and median American Society of Anesthesiologist score of 2 underwent TEVA excision. Fourteen patients (70%) presented with benign disease and six patients (30%) presented with malignant disease. The mean size of the lesions was 3.0 ± 1.4 cm, and the mean distance from the anal verge was 10.6 ± 2.4 cm. All excisions were successfully completed with a mean operative time of 79.8 ± 25.1 (range, 45-135) min. The mean length of hospital stay was 1.1 ± 0.7 (range, 0-3) days.

CONCLUSIONS

TEVA excision is a safe and feasible approach for local excision of rectal lesions not otherwise amenable to standard techniques. Continued investigation and development will be important to establish its role in minimally invasive colorectal surgery.

Feasibility of transanal minimally invasive surgery for mid-rectal lesions

BACKGROUND

Transanal minimally invasive surgery (TAMIS) has emerged as an alternative to transanal endoscopic microsurgery. We assessed the feasibility of TAMIS for lesions located in the mid rectum.

METHODS

From July 2010 to October 2011, 16 consecutive patients with rectal pathology underwent TAMIS. After a single-incision laparoscopic surgery port was introduced into the anal canal, pneumorectum was established with a laparoscopic device, followed by transanal excision with conventional laparoscopic instruments, including graspers, monopolar electrocautery, and needle drivers. Clinicopathological findings, surgical procedure results, and perioperative outcomes were determined prospectively.

RESULTS

Of the 16 patients, 11 had rectal cancers (3 T1 lesions and 8 after preoperative chemoradiotherapy), 4 had neuroendocrine tumors, and 1 had a mucocele. The median length of the lesions from anal verge was 7.5 cm (range 4-10 cm). All procedures were completed laparoscopically without conversion to conventional transanal approach. The median operating time was 86 min (range 33-160 min), and the median estimated blood loss was 15 ml (range 0-150 ml) with no patient requiring intraoperative transfusions. There was no surgical morbidity or mortality, but one patient died during follow-up due to synchronous advanced gastric cancer. The median postoperative hospital stay was 3 days (range 2-6 days).

CONCLUSIONS

TAMIS seems to be a feasible and safe treatment option for lesions located in the mid rectum.

Feasibility of transanal minimally invasive surgery for mid-rectal lesions

BACKGROUND

Transanal minimally invasive surgery (TAMIS) has emerged as an alternative to transanal endoscopic microsurgery. We assessed the feasibility of TAMIS for lesions located in the mid rectum.

METHODS

From July 2010 to October 2011, 16 consecutive patients with rectal pathology underwent TAMIS. After a single-incision laparoscopic surgery port was introduced into the anal canal, pneumorectum was established with a laparoscopic device, followed by transanal excision with conventional laparoscopic instruments, including graspers, monopolar electrocautery, and needle drivers. Clinicopathological findings, surgical procedure results, and perioperative outcomes were determined prospectively.

RESULTS

Of the 16 patients, 11 had rectal cancers (3 T1 lesions and 8 after preoperative chemoradiotherapy), 4 had neuroendocrine tumors, and 1 had a mucocele. The median length of the lesions from anal verge was 7.5 cm (range 4-10 cm). All procedures were completed laparoscopically without conversion to conventional transanal approach. The median operating time was 86 min (range 33-160 min), and the median estimated blood loss was 15 ml (range 0-150 ml) with no patient requiring intraoperative transfusions. There was no surgical morbidity or mortality, but one patient died during follow-up due to synchronous advanced gastric cancer. The median postoperative hospital stay was 3 days (range 2-6 days).

CONCLUSIONS

TAMIS seems to be a feasible and safe treatment option for lesions located in the mid rectum.

A novel approach for the treatment of pelvic abscess: transrectal endoscopic drainage facilitated by transanal endoscopic microsurgery access

BACKGROUND

Postoperative pelvic abscesses in patients submitted to colorectal surgery are challenging. The surgical approach may be too risky, and image-guided drainage often is difficult due to the complex anatomy of the pelvis. This article describes novel access for drainage of a pelvic collection using a minimally invasive natural orifice approach.

METHODS

A 37 year-old man presented with sepsis due to a pelvic abscess during the second postoperative week after a Hartmann procedure due to perforated rectal cancer. Percutaneous drainage was determined by computed tomography to be unsuccessful, and another operation was considered to be hazardous. Because the pelvic fluid was very close to the rectal stump, transrectal drainage was planned. The rectal stump was opened using transanal endoscopic microsurgery (TEM) instruments. The endoscope was advanced through the TEM working channel and the rectal stump opening, accessing the abdominal cavity and pelvic collection.

RESULTS

The pelvic collection was endoscopically drained and the local cavity washed with saline through the scope channel. A Foley catheter was placed in the rectal stump. The patient's recovery after the procedure was successful, without the need for further intervention.

CONCLUSIONS

Transrectal endoscopic drainage may be an option for selected cases of pelvic fluid collection in patients submitted to Hartmann's procedure. The technique allows not only fluid drainage but also visualization of the local cavity, cleavage of multiloculated abscesses, and saline irrigation if necessary. The use of TEM instrumentation allows safe access to the peritoneal cavity.