Sections

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

Sections Transanal Endoscopic Microsurgery (TEM) and Transanal Minimally Invasive Surgery (TAMIS)
Overview
Periprocedural Care
Technique
References

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-Lok 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 5-12 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

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^{[51, 52]}and loss of airway control^[53] as compared with the prone position.

Monitoring & 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.

Technique

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Williams NS, Durdey P, Johnston D. The outcome following sphincter-saving resection and abdominoperineal resection for low rectal cancer. Br J Surg. 1985 Aug. 72 (8):595-8. [QxMD MEDLINE Link].
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Lee W, Lee D, Choi S, Chun H. Transanal endoscopic microsurgery and radical surgery for T1 and T2 rectal cancer. Surg Endosc. 2003 Aug. 17 (8):1283-7. [QxMD MEDLINE Link].
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Garcia-Aguilar J, Mellgren A, Sirivongs P, Buie D, Madoff RD, Rothenberger DA. Local excision of rectal cancer without adjuvant therapy: a word of caution. Ann Surg. 2000 Mar. 231 (3):345-51. [QxMD MEDLINE Link]. [Full Text].
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Author

David E Stein, MD, MHCM Regional Chief of Surgery, Baltimore MedStar Health

David E Stein, MD, MHCM is a member of the following medical societies: American College of Surgeons, American Society of Colon and Rectal Surgeons, Crohn's and Colitis Foundation of America, Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Coauthor(s)

Harkanwar S Gill, MBBS Resident Physician, Department of General Surgery, Hahnemann University Hospital

Disclosure: Nothing to disclose.

Juan L Poggio, MD, MS, FACS, FASCRS Professor of Surgery, Department of Surgery, Lewis Katz School of Medicine at Temple University; Colon and Rectal Surgeon, Department of Surgery, Cancer Treatment Centers of America; Colon and Rectal Surgeon and General Surgeon, Division of Colon and Rectal Surgery, Department of Surgery, Temple University Hospital and Jeanes Hospital

Juan L Poggio, MD, MS, FACS, FASCRS is a member of the following medical societies: American College of Surgeons, American Society of Colon and Rectal Surgeons, Association for Academic Surgery, Pennsylvania Society of Colon and Rectal Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FFST(Ed), FIMSA, MAMS, MASCRS Dean (Academic) and Professor of General and Gastrointestinal Surgery and Senior Consultant Surgeon, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), India

Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FFST(Ed), FIMSA, MAMS, MASCRS is a member of the following medical societies: American College of Gastroenterology, American College of Surgeons, American Society of Colon and Rectal Surgeons, Fellow of the Faculty of Surgical Trainers (RCSEd), Royal College of Physicians and Surgeons of Glasgow, Royal College of Surgeons of Edinburgh, Royal College of Surgeons of England, Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Acknowledgements

The Chief Editor would like to acknowledge the assistance of Dr Gurushankari Balakrishnan, Junior Resident, Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Pondicherry, India, in updating the review of this article.

Sections Transanal Endoscopic Microsurgery (TEM) and Transanal Minimally Invasive Surgery (TAMIS)
Overview
Periprocedural Care
Technique
References

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

Equipment

Patient Preparation

Anesthesia

Positioning

Monitoring & Follow-up

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

Equipment

Patient Preparation

Anesthesia

Positioning

Monitoring & Follow-up

References

Tables

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