TECHNICAL REPORT
Single-port Transanal Endoscopic Microsurgery: A Developing Technique Graciela Valero-Navarro, PhD, Enrique Pellicer-Franco, MD, PhD, Victor Soria-Aledo, MD, PhD, Monica Mengual-Ballester, MD, Jose A. Garcia-Marin, MD, Pilar Guillen-Paredes, MD, and Jose L. Aguayo-Albasini, MD, PhD
Introduction: Transanal endoscopic microsurgery is a widely used and valid technique with established indications. However, the cost of surgical anoscopes is not available in all centers. Many authors have described transanal resection of rectal tumors through a single laparoscopy port such as the SILS system. Materials and Methods: We analyzed 5 cases of patients undergoing transanal resection with an SILS device. The clinical, surgical, and oncological data were assessed. Results: The median distance to the anal margin was 7.2 cm (range, 5 to 10 cm) and median tumor size was 3 cm (range, 1 to 6 cm). Median operating time was 75 minutes (range, 60 to 120 min). A postsurgical rectorrhagia occurred in 1 of the case. Two cases were adenocarcinoma, 2 were adenomas, and the other was a mucosa without any tumor remnants. The margins were negative in all cases. Conclusions: Transanal resection of rectal tumors using the SILS technique is a feasible procedure. Longer series and prospective studies are necessary. Key Words: rectal tumor, single port, transanal excision
(Surg Laparosc Endosc Percutan Tech 2014;24:e143–e145)
T
ransanal endoscopic microsurgery (TEM), described by Buess et al1 in 1985, is a safe, noninvasive, and widely used technique, indicated in certain cases of benign rectal tumors or early adenocarcinomas, in which conventional surgery, apart from being unnecessary, associates significant morbidity and mortality rates together with defecatory and genitourinary sequelae. TEM enables access to more proximally located tumors that conventional transanal resection instruments cannot reach. The endoscopic technique is similar to the classical technique, just that it uses a surgical anoscope allowing the pneumo to be maintained in the rectum and special instruments to reach the tumors in the middle third and upper third of the rectum, as well as offering a better view of the injury. This means that tumors can be resected
Received for publication November 22, 2012; accepted February 27, 2013. From the Department of Surgery, Morales Meseguer University Hospital, Murcia, Spain. Supported in part by the FFIS (Foundation for Health Research and Training in the Region of Murcia, Spain, Group FFIS-008) and IMIB (Instituto Murciano de Investigacio´n Biome´dica, Murcia, Spain). The authors declare no conflicts of interest. Reprints: Graciela Valero-Navarro, PhD, Department of Surgery, Morales Meseguer University Hospital, Murcia 30120, Spain (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
in patients who would otherwise have to undergo an anterior resection or abdominoperineal amputation. Although an increasing number of early-stage tumors have been diagnosed since the introduction of colorectal cancer screening, the number of cases does not yet warrant the acquisition of a surgical endoscope and exclusive instruments for this high-cost technique. This is why various authors2–6 have described transanal rectal tumor resection using a single laparoscopy port. We report our own contribution to this new developing technique.
MATERIALS AND METHODS After giving their informed consent, 5 patients underwent surgery with rachideal anesthesia and antibiotic prophylaxis. All the cases were diagnosed by colonoscopy plus biopsy, thoracoabdominopelvic computed tomography, nuclear magnetic resonance, and rectal ultrasonography. The only access point used was a SILS Port (Covidien), which can accommodate up to 3 cannulas (2 5 and 1 1 to 2 mm, or 3 5 mm). We used conventional straight laparoscopy pincers, 5 mm and 10 mm 30-degree telescopes, and a harmonic scalpel. The patient was placed in the lithotomy position when the tumor was located on the posterior side and the jackknife position for tumors on the anterior side. The single port is placed through the anus with a small amount of lubricant and the trocars were inserted (Fig. 1). The 12-mm trocar was inserted first, followed by the two 5-mm trocars. The optical trocar was positioned in the quadrant opposite to the tumor. Pneumorectum was created through continuous CO2 insufflation at 12 to 15 mm Hg.
FIGURE 1. External view.
Volume 24, Number 4, August 2014
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Surg Laparosc Endosc Percutan Tech
Valero-Navarro et al
Volume 24, Number 4, August 2014
occurred at the lower edge of the wound. Median length of stay was 4 days. (range, 3 to 6 d). Pathologic assessment of the anatomy revealed adenocarcinoma in 2 cases (one T1 and the other, a T1 with a minimal T2 focus), adenoma with highgrade dysplasia in another 2, and mucosa without any tumor remnants in the remaining patient. The lateral and deep margins were negative in all the cases. After the patient with a T2 tumor was assessed by the multidisciplinary team, adjuvant radiotherapy and chemotherapy was indicated because of the clinical characteristics.
DISCUSSION FIGURE 2. Traction and resection.
Once the tumor was located, it was resected with a margin with a total thickness of 1 cm using a 5-mm ultrasonic energy device and traction was maintained with the 5mm straight laparoscopy forceps (Figs. 2, 3). The 10-mm telescope can be used at this time to allow better vision. The specimen was extracted through the anus with the SILS device momentarily removed. Finally, the defect was sutured using the 5-mm telescope and leaving the 12-mm trocar for inserting the suture and the Lapra-Ty device (Ethicon Endo-Surgery Inc., Cincinnati, OH).
RESULTS Four of the 5 patients were men. Their median age was 58.5 years (range, 51 to 78 y). The preoperative diagnosis using colonoscopy plus biopsy, endorectal ultrasonography, and nuclear magnetic resonance was villous adenoma in 2 cases and T1 adenocarcinoma in another 2. The remaining case was a patient undergoing endoscopic resection of rectal neoplasia with adenocarcinoma in situ and affected margins, in whom extension of the margins was indicated after endoscopic marking of the previous eschar. Location of the injuries was posterior in 4 cases and 1 on the anterior side. The median distance to the anal margin was 7.2 cm (range, 5 to 10 cm) and median tumor size was 3 cm (range, 1 to 6 cm). Median operating time was 75 minutes (range, 60 to 120 min). A postsurgical rectorrhagia occurred in 1 case, which required reoperation and suture. The suture was performed using the conventional approach because bleeding
FIGURE 3. Postresection area.
e144 | www.surgical-laparoscopy.com
In recent years, TEM has become the star method for resecting initial rectal lesions that were outside the reach of Parks conventional transanal resection instruments. It allows better vision and management of the margins and a more accurate closure of the defect. It also avoids more aggressive major surgery in patients with polyps that cannot be resected endoscopically and with initial tumors, which means far less morbidity and mortality. Paliative resections can be performed in localy adevnced tumours in patients with associated comrbidities who would not tolerate more invasive surgery.7–8 Following the same principles as the TEM approach, transanal resection has been described using a single laparoscopic port. It is a safe, easily reproducible procedure that enables middle-third and upper middle-third tumors to be resected in the absence of the TEM technique and appears to have advantages over TEM. One of the initial advantages for which it has been chosen by some teams is the cost, as in hospitals with fewer cases, it is not worthwhile acquiring an expensive TEM device together with all the specific instruments for the technique. The SILS device is fungible but cheaper; it does not require specific instruments but uses conventional straight laparoscopy materials. With a diameter of 3 cm and a soft consistency, as opposed to the TEM device, which is rigid and 4 cm in diameter, it does not present the problems of incontinence that some authors have associated with TEM. The TEM device is 4 cm in diameter, which means dilatation has to be maintained throughout the operation, which, albeit transitory, has been associated with postsurgical incontinence.9–11 The SILS device is 3 cm in diameter and being soft, it adapts to the walls of the anus, dilates less, and does not require previous anal dilatation, which means it presumably causes less injury to the sphincter. Although entry of the pneumo in the device can be substituted by a conventional laparoscopy trocar2 for the 4port technique, 3 ports are usually sufficient. However, it is interesting to have this possibility, as it might be useful on occasions. Some authors have described the technique with the three 5-mm trocars, but we believe that it is more advantageous to use a 12-mm and two 5-mm trocars. This means that we can use a 10 mm 30-degree telescope, which offers better vision at the time of excision and change it to a 5-mm telescope during synthesis and thus have the 12-mm trocar for inserting the needle and Lapra-ty device. As it has been reported, with the TEM technique, excision of the entire thickness of the rectal wall is necessary for good oncological results. Ragupathi and Haas3 recommends avoiding the use of some ultrasonic energy device because it performs an oblique resection. However, other r
2014 Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
Volume 24, Number 4, August 2014
authors12 defend the use of the ultrasonic energy versus the monopolar scalpel showing that it is safer, more accurate, and easier to use. We believe that the direction of the resection depends on the angle of traction performed with the pincers in the left hand, which means the harmonic device is a perfectly valid instrument. Even so, the pathologist must decide whether or not the resection is correct. Therefore, if the indication is adequate, the oncological results should be similar to those with TEM. Although some authors3 claim that SILS allows all patients to undergo surgery in the lithotomy position, we believe that the jack-knife position is more appropriate for tumors of the anterior side, as positioning the tumor in the lower area of the field facilitates visualization and excision. The operating time in our sample of patients was acceptable, bearing in mind that it is a new approach and requires getting used to by surgeons and other surgical team members. There are series of up to 300 TEM patients12 with a mean of 66.4 minutes and a median of 60 minutes (range, 15 to 240 min). In conclusion, transanal resection of rectal tumors using the SILS technique is a procedure with a promising future. Longer series are needed, with long-term results regarding continence and especially survival, together with prospective studies comparing the TEM and SILS techniques. REFERENCES 1. Buess G, Mentges B, Manncke K, et al. Technique and results of transanal endoscopic microsurgery in early rectal cancer. Am J Surg. 1992;163:63–69; discussion 69–70.
r
2014 Lippincott Williams & Wilkins
Single-port for Transanal Tumour Resection
2. Cantero R, Garcia JC, Gonzalez T, et al. Transanal resection using a single port trocar: a new approach to NOTES. Cir Esp. 2011;89:20–23. 3. Ragupathi M, Haas EM. Transanal endoscopic video-assisted excision: application of single-port access. JSLS. 2011;15: 53–58. 4. Atallah S, Albert M, Larach S. Transanal minimally invasive surgery: a giant leap forward. Surg Endosc. 2010;24:2200–2205. 5. Lorenz C, Nimmesgern T, Back M, et al. Transanal single port microsurgery (TSPM) as a modified technique of transanal endoscopic microsurgery. Surg In. 2010;17:160–163. 6. Dardamanis D, Theodorou D, Theodoropoulos G, et al. Transanal polypectomy using single incision laparoscopic instruments. World J Gastrointest Surg. 2011;3:56–58. 7. Allaix ME, Arezo A, Caldart M, et al. Transanal endoscopic microsurgery for rectal neoplasm: experience of 300 consecutive cases. Dis Colon Rectum. 2009;52:1831–1836. 8. Baastrup G, Breum B, Qvist N, et al. Transanal endoscopic microsurgery in 143 consecutive patients with rectal adenocarcinoma: results from Danish multicenter study. Colorectal Dis. 2009;11:270–275. 9. Banerjee AK, Jehle EC, Kreis ME, et al. Prospective study of the proctographic and functional consequences of transanal endoscopic microsurgery. Br J Surg. 1996;83:211–213. 10. Jin Z, Yin L, Xue L, et al. Anorectal functional results alter transanal endoscopic microsurgery in benign and early malignant tumors. World J Surg. 2010;34:1128–1132. 11. Mora L, Serra J, Rebasa P, et al. Anorectal disorders in the immediate and late postoperative period after transanal endoscopic microsurgery. Cir Esp. 2007;82:285–289. 12. Garcı´ a JA, Ramirez JM, Callejo D, et al. Efficiency and outcomes of harmonic device in transanal endoscopic microsurgery compared with monopolar scalpel. Surg Endosc. 2011; 25:3209–3213.
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Single-port Transanal Endoscopic Microsurgery: A Developing Technique Graciela Valero-Navarro, PhD, Enrique Pellicer-Franco, MD, PhD, Victor Soria-Aledo, MD, PhD, Monica Mengual-Ballester, MD, Jose A. Garcia-Marin, MD, Pilar Guillen-Paredes, MD, and Jose L. Aguayo-Albasini, MD, PhD
Introduction: Transanal endoscopic microsurgery is a widely used and valid technique with established indications. However, the cost of surgical anoscopes is not available in all centers. Many authors have described transanal resection of rectal tumors through a single laparoscopy port such as the SILS system. Materials and Methods: We analyzed 5 cases of patients undergoing transanal resection with an SILS device. The clinical, surgical, and oncological data were assessed. Results: The median distance to the anal margin was 7.2 cm (range, 5 to 10 cm) and median tumor size was 3 cm (range, 1 to 6 cm). Median operating time was 75 minutes (range, 60 to 120 min). A postsurgical rectorrhagia occurred in 1 of the case. Two cases were adenocarcinoma, 2 were adenomas, and the other was a mucosa without any tumor remnants. The margins were negative in all cases. Conclusions: Transanal resection of rectal tumors using the SILS technique is a feasible procedure. Longer series and prospective studies are necessary. Key Words: rectal tumor, single port, transanal excision
(Surg Laparosc Endosc Percutan Tech 2014;24:e143–e145)
T
ransanal endoscopic microsurgery (TEM), described by Buess et al1 in 1985, is a safe, noninvasive, and widely used technique, indicated in certain cases of benign rectal tumors or early adenocarcinomas, in which conventional surgery, apart from being unnecessary, associates significant morbidity and mortality rates together with defecatory and genitourinary sequelae. TEM enables access to more proximally located tumors that conventional transanal resection instruments cannot reach. The endoscopic technique is similar to the classical technique, just that it uses a surgical anoscope allowing the pneumo to be maintained in the rectum and special instruments to reach the tumors in the middle third and upper third of the rectum, as well as offering a better view of the injury. This means that tumors can be resected
Received for publication November 22, 2012; accepted February 27, 2013. From the Department of Surgery, Morales Meseguer University Hospital, Murcia, Spain. Supported in part by the FFIS (Foundation for Health Research and Training in the Region of Murcia, Spain, Group FFIS-008) and IMIB (Instituto Murciano de Investigacio´n Biome´dica, Murcia, Spain). The authors declare no conflicts of interest. Reprints: Graciela Valero-Navarro, PhD, Department of Surgery, Morales Meseguer University Hospital, Murcia 30120, Spain (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
in patients who would otherwise have to undergo an anterior resection or abdominoperineal amputation. Although an increasing number of early-stage tumors have been diagnosed since the introduction of colorectal cancer screening, the number of cases does not yet warrant the acquisition of a surgical endoscope and exclusive instruments for this high-cost technique. This is why various authors2–6 have described transanal rectal tumor resection using a single laparoscopy port. We report our own contribution to this new developing technique.
MATERIALS AND METHODS After giving their informed consent, 5 patients underwent surgery with rachideal anesthesia and antibiotic prophylaxis. All the cases were diagnosed by colonoscopy plus biopsy, thoracoabdominopelvic computed tomography, nuclear magnetic resonance, and rectal ultrasonography. The only access point used was a SILS Port (Covidien), which can accommodate up to 3 cannulas (2 5 and 1 1 to 2 mm, or 3 5 mm). We used conventional straight laparoscopy pincers, 5 mm and 10 mm 30-degree telescopes, and a harmonic scalpel. The patient was placed in the lithotomy position when the tumor was located on the posterior side and the jackknife position for tumors on the anterior side. The single port is placed through the anus with a small amount of lubricant and the trocars were inserted (Fig. 1). The 12-mm trocar was inserted first, followed by the two 5-mm trocars. The optical trocar was positioned in the quadrant opposite to the tumor. Pneumorectum was created through continuous CO2 insufflation at 12 to 15 mm Hg.
FIGURE 1. External view.
Volume 24, Number 4, August 2014
www.surgical-laparoscopy.com |
e143
Surg Laparosc Endosc Percutan Tech
Valero-Navarro et al
Volume 24, Number 4, August 2014
occurred at the lower edge of the wound. Median length of stay was 4 days. (range, 3 to 6 d). Pathologic assessment of the anatomy revealed adenocarcinoma in 2 cases (one T1 and the other, a T1 with a minimal T2 focus), adenoma with highgrade dysplasia in another 2, and mucosa without any tumor remnants in the remaining patient. The lateral and deep margins were negative in all the cases. After the patient with a T2 tumor was assessed by the multidisciplinary team, adjuvant radiotherapy and chemotherapy was indicated because of the clinical characteristics.
DISCUSSION FIGURE 2. Traction and resection.
Once the tumor was located, it was resected with a margin with a total thickness of 1 cm using a 5-mm ultrasonic energy device and traction was maintained with the 5mm straight laparoscopy forceps (Figs. 2, 3). The 10-mm telescope can be used at this time to allow better vision. The specimen was extracted through the anus with the SILS device momentarily removed. Finally, the defect was sutured using the 5-mm telescope and leaving the 12-mm trocar for inserting the suture and the Lapra-Ty device (Ethicon Endo-Surgery Inc., Cincinnati, OH).
RESULTS Four of the 5 patients were men. Their median age was 58.5 years (range, 51 to 78 y). The preoperative diagnosis using colonoscopy plus biopsy, endorectal ultrasonography, and nuclear magnetic resonance was villous adenoma in 2 cases and T1 adenocarcinoma in another 2. The remaining case was a patient undergoing endoscopic resection of rectal neoplasia with adenocarcinoma in situ and affected margins, in whom extension of the margins was indicated after endoscopic marking of the previous eschar. Location of the injuries was posterior in 4 cases and 1 on the anterior side. The median distance to the anal margin was 7.2 cm (range, 5 to 10 cm) and median tumor size was 3 cm (range, 1 to 6 cm). Median operating time was 75 minutes (range, 60 to 120 min). A postsurgical rectorrhagia occurred in 1 case, which required reoperation and suture. The suture was performed using the conventional approach because bleeding
FIGURE 3. Postresection area.
e144 | www.surgical-laparoscopy.com
In recent years, TEM has become the star method for resecting initial rectal lesions that were outside the reach of Parks conventional transanal resection instruments. It allows better vision and management of the margins and a more accurate closure of the defect. It also avoids more aggressive major surgery in patients with polyps that cannot be resected endoscopically and with initial tumors, which means far less morbidity and mortality. Paliative resections can be performed in localy adevnced tumours in patients with associated comrbidities who would not tolerate more invasive surgery.7–8 Following the same principles as the TEM approach, transanal resection has been described using a single laparoscopic port. It is a safe, easily reproducible procedure that enables middle-third and upper middle-third tumors to be resected in the absence of the TEM technique and appears to have advantages over TEM. One of the initial advantages for which it has been chosen by some teams is the cost, as in hospitals with fewer cases, it is not worthwhile acquiring an expensive TEM device together with all the specific instruments for the technique. The SILS device is fungible but cheaper; it does not require specific instruments but uses conventional straight laparoscopy materials. With a diameter of 3 cm and a soft consistency, as opposed to the TEM device, which is rigid and 4 cm in diameter, it does not present the problems of incontinence that some authors have associated with TEM. The TEM device is 4 cm in diameter, which means dilatation has to be maintained throughout the operation, which, albeit transitory, has been associated with postsurgical incontinence.9–11 The SILS device is 3 cm in diameter and being soft, it adapts to the walls of the anus, dilates less, and does not require previous anal dilatation, which means it presumably causes less injury to the sphincter. Although entry of the pneumo in the device can be substituted by a conventional laparoscopy trocar2 for the 4port technique, 3 ports are usually sufficient. However, it is interesting to have this possibility, as it might be useful on occasions. Some authors have described the technique with the three 5-mm trocars, but we believe that it is more advantageous to use a 12-mm and two 5-mm trocars. This means that we can use a 10 mm 30-degree telescope, which offers better vision at the time of excision and change it to a 5-mm telescope during synthesis and thus have the 12-mm trocar for inserting the needle and Lapra-ty device. As it has been reported, with the TEM technique, excision of the entire thickness of the rectal wall is necessary for good oncological results. Ragupathi and Haas3 recommends avoiding the use of some ultrasonic energy device because it performs an oblique resection. However, other r
2014 Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
Volume 24, Number 4, August 2014
authors12 defend the use of the ultrasonic energy versus the monopolar scalpel showing that it is safer, more accurate, and easier to use. We believe that the direction of the resection depends on the angle of traction performed with the pincers in the left hand, which means the harmonic device is a perfectly valid instrument. Even so, the pathologist must decide whether or not the resection is correct. Therefore, if the indication is adequate, the oncological results should be similar to those with TEM. Although some authors3 claim that SILS allows all patients to undergo surgery in the lithotomy position, we believe that the jack-knife position is more appropriate for tumors of the anterior side, as positioning the tumor in the lower area of the field facilitates visualization and excision. The operating time in our sample of patients was acceptable, bearing in mind that it is a new approach and requires getting used to by surgeons and other surgical team members. There are series of up to 300 TEM patients12 with a mean of 66.4 minutes and a median of 60 minutes (range, 15 to 240 min). In conclusion, transanal resection of rectal tumors using the SILS technique is a procedure with a promising future. Longer series are needed, with long-term results regarding continence and especially survival, together with prospective studies comparing the TEM and SILS techniques. REFERENCES 1. Buess G, Mentges B, Manncke K, et al. Technique and results of transanal endoscopic microsurgery in early rectal cancer. Am J Surg. 1992;163:63–69; discussion 69–70.
r
2014 Lippincott Williams & Wilkins
Single-port for Transanal Tumour Resection
2. Cantero R, Garcia JC, Gonzalez T, et al. Transanal resection using a single port trocar: a new approach to NOTES. Cir Esp. 2011;89:20–23. 3. Ragupathi M, Haas EM. Transanal endoscopic video-assisted excision: application of single-port access. JSLS. 2011;15: 53–58. 4. Atallah S, Albert M, Larach S. Transanal minimally invasive surgery: a giant leap forward. Surg Endosc. 2010;24:2200–2205. 5. Lorenz C, Nimmesgern T, Back M, et al. Transanal single port microsurgery (TSPM) as a modified technique of transanal endoscopic microsurgery. Surg In. 2010;17:160–163. 6. Dardamanis D, Theodorou D, Theodoropoulos G, et al. Transanal polypectomy using single incision laparoscopic instruments. World J Gastrointest Surg. 2011;3:56–58. 7. Allaix ME, Arezo A, Caldart M, et al. Transanal endoscopic microsurgery for rectal neoplasm: experience of 300 consecutive cases. Dis Colon Rectum. 2009;52:1831–1836. 8. Baastrup G, Breum B, Qvist N, et al. Transanal endoscopic microsurgery in 143 consecutive patients with rectal adenocarcinoma: results from Danish multicenter study. Colorectal Dis. 2009;11:270–275. 9. Banerjee AK, Jehle EC, Kreis ME, et al. Prospective study of the proctographic and functional consequences of transanal endoscopic microsurgery. Br J Surg. 1996;83:211–213. 10. Jin Z, Yin L, Xue L, et al. Anorectal functional results alter transanal endoscopic microsurgery in benign and early malignant tumors. World J Surg. 2010;34:1128–1132. 11. Mora L, Serra J, Rebasa P, et al. Anorectal disorders in the immediate and late postoperative period after transanal endoscopic microsurgery. Cir Esp. 2007;82:285–289. 12. Garcı´ a JA, Ramirez JM, Callejo D, et al. Efficiency and outcomes of harmonic device in transanal endoscopic microsurgery compared with monopolar scalpel. Surg Endosc. 2011; 25:3209–3213.
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