Transanal Endoscopic Microsurgery

 

TEM is emerged as an trans anal alternative to more radical abdominal surgery, Transanal Endoscopic Microsurgery (TEM) offers a minimally invasive solution for the excision of certain rectal polyps and early stage rectal tumors. Pioneered in 1983 by German surgeon, Dr. Gerhard Buess, TEM has revolutionized the resection of rectal lesions. Performed transanally with specially designed microsurgical instrumentation, TEM has made it possible to excise lesions high inside the rectum that otherwise would be accessible only by major abdominal surgery. The patient benefits of TEM as compared to radical abdominal surgery are clear: no major surgery, no large incision, no colostomy, less pain, faster recovery and shorter hospital stay.

In response to the technical limitations of conventional Transanal resection, in 1980 Professor Gerhard Buess from Germany, started to advance the method of Transanal Endoscopic Microsurgery (TEM). In collaboration with Richard Wolf in Germany, Dr. Buess has developed the expertise needed to perform Transanal endoscopic surgery instruments. TEM was introduced into clinical practice in 1983 and is gradually carried out in several European countries, and possibly introduced in North America and Asia.

Indications for TEM

Current indications for TEM are extended to the treatment of early stage Gastric adenocarcinoma, as well as mitigation in cases of patients with advanced cancer of the rectum radical excision or those who are good candidates for surgery to refuse. Patients with cancer of the following polypectomy accessories suitable candidates for TEM especially in the context of sessile polyps or if you are concerned about margin positivity. For possibly healing resection of malignant lesions, preoperative assessment is paramount, so that only the lesions with the lowest probability of metastases in the lymph nodes selected for TEM. Endo-rectal ultrasound or MRI may be used to determine the penetration depth of the lesion and to assess mesorectum for metastatic disease.

TEM Equipment

TEM software can be divided into two main components: operating and 2) instruments Endosurgical unit 1). Operating instruments are manipulated by the surgeon during the procedure, including: operating rectoscopes, the stereoscope and long-handled instruments for dissection, cutting and end. Endosurgical unit provides carbon dioxide (CO2) insufflation, suction, irrigation and control within the rectal pressure. Operating rectoscopes is about 4 cm in diameter and 12 cm long and 20 cm, with a straight face or beveled end. So that the surgeon has a front air enclosure with 4 port sealed with rubber sleeve covered through which the optical stereoscope, suction and two operating instruments are inserted for long shaft. The surgeon sees the field through the binocular stereoscopic eyepiece, offering a view of the 3 precise dimensions of the operating area with up to 6-fold increase from the surgical field. Stereoscopic eyepiece contains two lenses, channel irrigator target insufflation and operated by the pedal. Monocular field of accessory is connected to the video screen to allow the surgical team to view the procedure. All instruments are operating diameter of 5 mm, and include tweezers, scissors, knife high frequency driver and a staple needle. More of the apex angle of the instrument. Pliers are on both curves to the right or to the left. In rectoscopes and its annexes are attached to the operating table with a clamp Multilink, Martina hand.

Surgical Technique

Rectal cleaning is essential for a good visualization of the rectum and light injuries. This can be done either by mechanical abrasion or hoses alternatively the patient regular bowel enemas. Intravenous antibiotics are used selectively. TEM procedures usually performed under general anesthesia, a Foley catheter is used to decompress the bladder. Preoperative tumor localization is achieved by rigid sigmoidoscopy in a clinical setting to determine the quadrant of the lesion and the patient positioning surgical plan to allow the lesion of interest to the service position six. Patients with a previous injury is based are found in the abdominal position stabbing (legs apart and hands attached plate), while those with a back injury put the lie. Side localized lesions better with the corresponding lateral decubitus position to solve patients.

The operation begins with mild dilation of the anus with two fingers and insert rectoscopes, rectal under air insufflation and positioning rectoscopes manuals for optimal visualization of the lesion. Sigmoidoscope then attached to the operating table by Martin hands. During resection, frequent moving scope is often necessary to maintain optimal operating field in view. Optical and surgical instruments are inserted and the unit is activated Endosurgical provided insufflation, suction, irrigation and pressure control. Using the numbness, the surgeon first makes margin desired game. This margin should be 5 mm from the periphery of the gross tumor and 10 mm cases of invasive cancer. For intraperitoneal adenoma located in the colon, it is mucosectomy taken to prevent injury to the peritoneum with the following loss of rectal distension. For extraperitoneal adenomas found and for all invasive cancers, full thickness resection is the standard. The periphery of the lower half-plane and adenomas can be resected as the whole depth of comprehensive components, followed by the end to end anastomosis. Invasive cancer on the back or side position can be resected with little perirectal fat, which can often give 1 or 2 adjacent lymph nodes, which are considered to metastasis.

The resection bed lesions below the peritoneal reflection can be opened or closed with a continuous suture with 3-0 polydioxanone suture (PDS) in a small-half (SA). Tying use TEM team is very difficult and instead is achieved by using money clips that are attached to the seam. In the abdominal cavity closure of all defects is required and must be carried out in two layers with a separate closure of the peritoneum, if entered.

Complications

The overall rate of complications TEM benign and malignant lesions have been reported to range from 6% to 31%. Perioperative complications are bleeding and peritoneal entry, which may require conversion to laparotomy. Intraperitoneal drilling rate in the range of 0% to 9%. However, drilling in the peritoneal cavity does not require conversion to open laparotomy. In a series of 144 patients with Ganai and colleagues, 9 patients (6%) had peritoneal entry, but they were all led by primary closure of the defect in order to avoid the conversion of open anterior resection. In addition, the retrospective study 34 patients, Gavagan and colleagues did not give raise more or less complications and a significant increase in the length of hospital stays for people with peritoneal perforation compared with those without them.

Postoperative bleeding was observed in 1% to 13% of patients. Most resolve spontaneously or with conservative transfusion. Very few patients require surgery. Line wound dehiscence, perirectal abscess and rectal stricture are also described. In most cases, dehiscence suture line is conservative and treated with therapy and topical antibiotics.

The physiological effect of TEM in postoperative anal sphincter function was studied and demonstrated anorcktalna pressure gauge reduced TEM followed by rest. Kennedy and his colleagues conducted preoperative anorcktalna physiological studies and 6 weeks after surgery in 18 consecutive patients with TEM. A significant reduction in the maximum resting anal pressure observed in correlation with the duration of the procedure. However, there is no important change was noted in the level of restraint and pudendal nerve terminal motor latency, rectal mucosa and EHS compliance has not changed significantly. No deterioration in continence in 37% of patients after TEM study Daphnis and colleagues and again associated with extended operating time, but is not associated with patient age or gender was observed.

Cataldo and colleagues evaluated the role of base and anorectal postoperative period in 37 patients undergoing TEM using tools functional assessment confirmed the severity of faecal incontinence (FISI) and fecal incontinence quality of life (FIQL respectively) and no concrete changes were noted among the basic and post-operative assessment ASRA and FIQL respectively. Similarly, a study comparing the quality of life in patients undergoing TEM and patients undergoing total removal mesorectum (TEM) found that the quality of life in general was similar between the 2 groups after surgery, or TEM patients had fewer problems with defecation that TEM patients.

Conclusion

Since 1983, TEM is effectively used for the treatment of benign rectal lesions and early stage rectal cancer. TEM allows the surgeon to fight too hard to solve with common injuries Transanal resection with immediate improvement of parameters (margin positivity and fragmentation pattern) and lower recurrence rates long term. More than two decades of scientific data support the use of TEM as an alternative to essential removal of the rectum with less illness, quicker recovery and potential cost savings when conducted in specialized centers. Functional impairment of restraint occurs in a minority of patients.

The role of TEM in patients with T2N0 and T3N0 is still under discussion and further research. Currently TEM should be limited in these cases, patients who refuse or are too risky for transabdominal radical excision. In such circumstances, should be seriously considered for aid or neoadjuvant chemoradiation to reduce the risk of local recurrence.