Transanal Endoscopic Operation (TEO) for rectal polyp: first step for NOTES colorectal procedure?

Transanal Endoscopic Microsurgery (TEM) is a minimally invasive technique for the resection of adenomas and early rectal carcinomas unsuitable for local or colonoscopic excision, which would otherwise necessitate major surgery. The objective of this film is to demonstrate the transanal resection of an endorectal polyp using the TEO, a Karl Storz system, according to the TEM principles as was first described by Gerhard Buess in 1983 (and published in the literature in 1984).

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Transanal Endoscopic Operation (TEO) for rectal polyp: first step for NOTES colorectal procedure?

Authors

J Leroy, J Marescaux

Abstract

Transanal Endoscopic Microsurgery (TEM) is a minimally invasive technique for the resection of adenomas and early rectal carcinomas unsuitable for local or colonoscopic excision, which would otherwise necessitate major surgery. The objective of this film is to demonstrate the transanal resection of an endorectal polyp using the TEO, a Karl Storz system, according to the TEM principles as was first described by Gerhard Buess in 1983 (and published in the literature in 1984).

Classification

tips and tricks

Keywords

Transanal Endoscopic Operation, TEO, rectal polyp, NOTES colorectal procedure, villous tumor

Media type

Surgical video

Duration

05'53''

Publication

2009-07

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E-publication

WeBSurg.com, Jul 2009;9(07).
URL: http://www.websurg.com/doi-vd01en2420.htm

Transanal Endoscopic Operation (TEO) for rectal polyp: first step for NOTES colorectal procedure?

1. Introduction 00'08''

The objective of this film is to demonstrate the transanal resection of an endorectal polyp using the TEO, a Karl Storz system, according to the Transanal Endoscopic Microsurgery (TEM) principles as was first described by Gerhard Buess in 1983 (and published in the literature in 1984).

2. Description of technical principle 00'29''

The principle consists in the transanal introduction of a rigid tube (such as a port with multiple openings). This allows for the placement of an optical system and diverse instruments of varied shapes, which will be used to resect polyps in the rectal lumen. Curved tip instruments but also straight instruments (such as the Ligasure device) can be used. Monopolar hooks (either straight or curved with an angled tip) are used here. Smoke is extracted thanks to a stopcock present on the system introduced through the anus.

3. Resection 01'19''

The principles of local resection are respected in the presence of benign tumors by removing the entire rectal wall, also called full-thickness excision. This allows for a wide resection distal from tumoral tissues. Resection is performed through a careful hemostasis thanks to the use of monopolar, sometimes bipolar current (the one used in the Ligasure device). As soon as the resection is complete, the specimen is extracted and control of hemostasis is achieved before suturing the edges of the rectal mucosa and the posterior rectal wall in the present case.

4. Endosuture stitches placement 02'33''

Once the operative area has been thoroughly washed, and contrarily to what Gerhard Buess recommended, PDS 2/0 or 3/0 interrupted stitches are used and not a running suture. The Endosuture system allows to easily perform stitches with extracorporeal knots, each half-hitch being pushed as would be done through an abdominal incision. The instrument is used as a knot-pusher extending the extremity of the forefinger. Manipulation of the needle is done easily and thanks to both the orientation of the needle in the needle holder and the rotation of the needle holder, an interrupted suture can be carried out. This helps to safely re-approximate the edges of the resection margins. Thanks to the rotation movement, using a caudad to cephalad closure or a cranial to caudal re-approximation, progress is made into the right side of the incision to end with the left side always through interrupted stitches. This helps to prevent any suture break in case of leakage. This type of suturing may be performed very cranially beyond the Douglas’ pouch. Partial segmental resections of the rectosigmoid junction or of the lower portion of the sigmoid colon can then be achieved. A side-to-side anastomosis is performed and secured by stitches. The difficulty lies in the good orientation of the needle in the needle holder and the rotation movement of the needle holder (which is the most precise and easiest to reproduce at the level of the needle holder’s handle). Thanks to the thread-integrated knot-pusher ESS®, Endo Suture System® by Ethicon, a knot and suture can be achieved easily. Once the anastomosis has been performed, the gauze placed in the upper rectum to avoid the flow of faeces is removed.