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 ¤  Abstract
 ¤ Introduction
 ¤ Technique
 ¤ Histopathology
 ¤ Discussion
 ¤  References
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HOW I DO IT DIFFERENTLY?
Year : 2014  |  Volume : 10  |  Issue : 2  |  Page : 99-101
 

Single incision laparoscopic surgery - trans anal endoscopic microsurgery: A technological innovation


Department of Surgery, Lifeline Multispeciality Hospitals, Perungudi, Chennai, Tamil Nadu, India

Date of Submission07-Dec-2011
Date of Acceptance28-Jan-2013
Date of Web Publication7-Apr-2014

Correspondence Address:
Neha Shah
Department of Surgery, Lifeline Multispeciality Hospitals, 5,639 Rajiv Gandhi Salai, Perungudi, Chennai - 600 096, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-9941.129970

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 ¤ Abstract 

Trans anal endoscopic microsurgery (TEM) first burst upon the scene several decades ago and then underwent a period of immersion. We have herein reported our experience in two cases who underwent TEM using laparoscopic techniques. The advent of single incision laparoscopic surgery (SILS) has made great inroads into various fields of general and gastrointestinal (GI) surgery. We decided to make use of the same technique in TEM for two patients who had large sessile villous adenomas of the rectum. We used this port and fixed it transanally to the edge of the anus. Carbon dioxide used for insufflation in laparoscopic surgery was used through one of the ports, and a telescope was inserted to the larger port. We made sure that the entire polyp was cut out completely until the circular muscle of the internal sphincter was clearly exposed. Next, the cut edges of the rectum were undermined between the mucosa and the circular muscles in order to bring the cut edges closer together. We were able to perform this SILS TEM in two cases. In both the cases, well differentiated villous adenoma (colonoscopically, biopsy proven before surgery) was confirmed after excision. The question has been raised whether TEM is the new laparoscopy for anorectal surgery. Increasingly, several reports are showing promise for treatment for early stage cancers and large rectal adenomas using TEM. Adoption of our technique using the SILS port that has not been previously described in medical literature, seems to be a promising tool for the future.
TEM first burst upon the scene several decades ago and then under went a period of immersion. In recent years, with the onset of laparoscopic surgery, the thoughts and the ideas of using a laparoscopic surgical technique have invaded the area of colorectal cancer as well. We have herein reported our experience in two cases who underwent TEM using laparoscopic techniques.


Keywords: Anal canal, single incision laparoscopic surgery, trans anal endoscopic microsurgery, villous adenoma


How to cite this article:
Shah N, Sasikumar P, Rajkumar JS. Single incision laparoscopic surgery - trans anal endoscopic microsurgery: A technological innovation. J Min Access Surg 2014;10:99-101

How to cite this URL:
Shah N, Sasikumar P, Rajkumar JS. Single incision laparoscopic surgery - trans anal endoscopic microsurgery: A technological innovation. J Min Access Surg [serial online] 2014 [cited 2020 Feb 24];10:99-101. Available from: http://www.journalofmas.com/text.asp?2014/10/2/99/129970



 ¤ Introduction Top


The advent of single incision laparoscopic surgery (SILS) has made great inroads into various fields of general and gastrointestinal (GI) surgery. Over the last 20 months, in our unit, we performed several SILSs cholecystectomy, appendicitis, hernia, fundoplication, and SILS sleeve gastrectomy. We decided to make use of the same technique in trans anal endoscopic microsurgery (TEM) for 2 patients who had large sessile villous adenomas of the rectum.


 ¤ Technique Top


The SILS port (Covidien) is a blue PVC port that has an entry port for gas and three other trocars. We utilized this port and fixed it transanally to the edge of the anus [Figure 1]. The carbon dioxide that used for insufflation in laparoscopic surgery was used through one of the ports and a telescope was inserted to the larger port. The other two ports were used for right hand and left hand working instrument and we utilized the harmonic shears (Ultrasision, Ethicon) to completely excise the villous adenoma with a 0.5 cm border of the mucosa [Figure 2]. During the procedure, we maintained the carbon dioxide insufflation pressure of 80 ml of mercury. We made sure that the entire polyp was cut out completely until the circular muscle of the internal sphincter was clearly exposed. Next, the cut edges of the rectum were undermined between the mucosa and the circular muscles in order to bring the cut edges closer together. Deploying a Maryland dissector with the left hand working port and an endo stitch (Covidien) on the right side, we were able to close the mucosa by a running suture using 30 polysorb (polyglactin 910) [Figure 3]. The running suture was completed starting from proximal, working down distally, and the procedure was completed. We were able to perform this SILS TEM in 2 cases.
Figure 1: Insertion of SILS port in anus

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Figure 2: Resection of villous adenoma using harmonic scalpel

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Figure 3: Suturing of defect

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 ¤ Histopathology Top


In both cases, well-differentiated villous adenoma (colonoscopically, biopsy proven before surgery) was confirmed after excision. Both patients are being followed-up post operation for 1 and 3 months, respectively, and, at this point of time, they are free of recurrence. The postoperative period was uncomplicated in both the cases with no bleeding, infection, or any other local or systemic complications.


 ¤ Discussion Top


The advent of SILS permits the surgeon to pass in two instruments and perform complicated surgery like fundoplication and bariatric surgery. Applying the same physics through the rectum, we felt that continuous insufflation of the rectum with carbon dioxide through a side port would give us an adequate working space for operations, and utilization of higher energy sources like the ultrasation will make surgery swift and bloodless. In order to secure the edges of the mucosa, we initially tried using standard suturing instruments like the regular needle holder and the Cambridge endo riveted needle holder. We found both of them to be associated with much ergonomic difficulties in the performance of suturing. Therefore, we decided to use the endo stitch that we have been using for quite some time in regular laparoscopy and intra abdominal SILS surgeries. We found that utilization of the endostitch was the most important time framing factor in the performance of the SILS TEM. We strongly recommend that any group planning to performing a SILS TEM acquaint themselves with operating with endostitch in order to perform the surgeries completely.

The question that has been raised is whether TEM is the new laparoscopy for anorectal surgery. Increasingly, several reports are showing promising results for the treatment of early stage cancers and large rectal adenomas using TEM. The study by de Graaf et al., [1] from The Netherlands is one of the largest studies because it represents 353 TEM procedures. Opening of the peritoneum occurred as a complication in only 9% of cases with the conversion just short of 10% either for this reason or because of the failure of completion of the procedure. The margins were complete in 85% with a recurrence rate of 9%. It was stressed in the earlier paper too that, not only is colorectal surgical training important to complete these procedures but also adequate general surgical training is important in order to excise lesions in a piece and to get a proper margin with least recurrence and complications like operation. Toward this end, adoption of our technique using the SILS port, which has not been previously described in medical literature, seems to be a promising tool for the future.

 
 ¤ References Top

1.de Graaf EJ, Doornebosch PG, Tetteroo GW, Geldof H, Hop WC. Transanal endoscopic microsurgery is feasible for adenomas throughout the entire rectum: A prospective study. Dis Colon Rectum 2009;52:1107-13.  Back to cited text no. 1
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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