Transanal Endoscopic Microsurgery (TEM) and Transanal Minimally Invasive Surgery (TAMIS) Periprocedural Care

Updated: Jun 20, 2016
  • Author: David E Stein, MD; Chief Editor: Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS  more...
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Periprocedural Care

Equipment

Equipment used for transanal endoscopic microsurgery (TEM) (Buess et al/Richard Wolf TEM instrument system) includes the following:

  • Operating sigmoidoscope, 12 or 20 cm in length and 4 cm in outer diameter with binocular optical system
  • Rectoscope tube
  • Grasping forceps, monopolar
  • Scissors
  • Knife, monopolar
  • Needle holders
  • Suture clip forceps
  • Suction tube
  • Retractable needle
  • U-shaped support arm
  • TEM combination system

Equipment used for transanal endoscopic operation with a Storz rectoscope (Karl Storz, Tuettlingen, Germany) includes the following:

  • Operating rectoscope, 40 mm in diameter, with a working length of 15 cm, a handle and a luer-lock connector for smoke evacuation
  • Obturator for use with the operating rectoscope tube during its insertion
  • Working attachment for the operating rectoscope tube, with fixation for the telescope and channels (one 5- to 12-mm and two 5-mm) for instruments, including a silicone leaflet, the operating rectoscope tube, a handle, valve, sealing caps, and a Luer-Lok connector for insufflation
  • Forward oblique 30° telescope, 5 mm in diameter and 21 cm in length, provided with a 45° angled eyepiece and incorporated fiberoptic light transmission
  • Holding device to fix the operating rectoscope with a mounted video camera to the operating table
  • Laparoscopic energy dissector of the surgeon's choice
  • Laparoscopic grasping forceps
  • Needle holders
  • Suction tube
  • Scissors

Equipment used for transanal minimal invasive surgery (TAMIS; laparoscopic gel point technique) includes the following:

  • Access channel with introducer
  • Gel seal cap with insufflation port
  • Self-retaining ports (5-10 mm)
  • Angulated laparoscope (30°)
  • At least two video monitors
  • Laparoscopic tissue grasper
  • Laparoscopic energy dissector of the surgeon's choice (the authors prefer a Harmonic device from Ethicon Endo-Surgery, Cincinnati, OH)
  • Laparoscopic clip applier (5 mm)
  • Scissors
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Patient Preparation

Anesthesia

The authors prefer general anesthesia, but no paralysis is required. Local anesthesia with sedation and spinal anesthesia are acceptable alternatives.

Positioning

Positioning the patient for TEM in either the lithotomy or the prone jackknife position depends on the location of the tumor and the distance from the anal verge. A lesion located on the anterior wall of the rectum requires the patient to be in the prone position, whereas a lesion on the posterior wall can be reached with the patient in the lithotomy position. Some patients need to be placed in the lateral position.

For TAMIS, most surgeons prefer lithotomy regardless of the location of the lesion; accordingly, the patient is placed in the lithotomy position with legs elevated in the Lloyd-Davies position. In contrast to TEM, the laparoscopic instruments are not attached to the operating table; this allows more freedom in movement.

The authors prefer to position the patient in accordance with the location of the tumor.

Studies show that the lithotomy position decreases the risk of position-related nerve injuries [36, 37] and loss of airway control [38]  as compared with the prone position.

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Monitoring and Follow-up

Patients are admitted for observation and maintained on antibiotics. Oral nutrition is commenced immediately, and the patient's diet is advanced as tolerated. The patient is discharged on postoperative day 1 if he or she is tolerating a diet.

Patients should undergo routine surveillance endoscopy every 3 months for the first 2 years postoperatively to monitor for any signs of tumor recurrence.

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