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Transanal Endoscopic Microsurgery ACCESS RECTAL SURGERY
Lynne M. Zuro, RN; Cheryl D. Terry, RN, Theodore J. Saclarides, MD
ransanal endoscopic microsurgery (TEM) is a procedure that permits the removal of adenomas or early carcinomas from the rectum or rectosigmoid colon. The surgeon uses endoscopy and a local surgical resection of the transanal lesion that results in lower morbidity and shorter hospital stays than with conventional methods. Transanal endoscopic microsurgery was developed in the early 1980s by Gerhard Buess, MD.’
Lynne M. Zuro
By July 1983, German surgeons had used TEM in the operating room, and published results indicated that this new procedure was successful.* Transanal endoscopic microsurgery still is a relatively new surgical procedure in the United States and is performed by only a few surgeons. Conventional techniques for removing rectal polyps and selected cancers vary depending on the size, shape, and location of the lesion. A rectal polyp may be transanally excised, but the
Cheryl D. Terry
Theodore J. Saclarides
Lynne M. Zuro, RN, BSN, is a general surgery staflnurse, operating room, Rush-PresbyterianSt Luke’s Medical Center, Chicago. She earned her BS in nursing f r o m Northwestern University, Chicago.
Theodore J. Saclarides, MD, is an associate professor of surgery, Rush-Presbyterian-St Luke’s Medical Center, Chicago. He earned his MD from the University of Miami School of Medicine.
Cheryl D. Terry, RN, MSN, is unit leader of urologylendoscopy,Rush-Presbyterian-StLuke’s Medical Center, Chicago. She earned her BS in nursing from Southern Illinois University, Edwardsville, and her MS in nursing administrationfrom St Xavier College, Chicago.
The authors would like to thank Joan Uebele, RN, MSN, teacher practitioner, and Eileen Pehanich, secretary, general surgery department, both at Rush-Presbyterian-St Luke’s Medical Center, Chicago, for their assistance in the preparation of this article.
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limited exposure provided by transanal retractors may confine the surgeon to the lower portion of the patient’s rectum. A cancer can he removed in a similar fashion if it is small and well-differentiated and exhibits minimal invasion of the rectal wall. Polyps and selected cancers in the middle and upper rectum are less accessible using conventional transanal techniques, and attempts bq the surgeon to excise the tumor in this way ma) be hindered by poor exposure and visibility. The surgeon may not be able to remove the tumor with a sufficient border of surrounding rectal mucosa. Consequently, there is a high rate of recurrence of benign adenomas (ie. 30%) associated with conventional methods (. which has led some surgeons to recommend laparotomy for middle and upper rectal lesions. Laparotomy and anterior resection may be performed for tumors in the upper two-thirds 01 the rectum or rectosigmoid region. This conventional approach is costly and has significant morbidity and a lengthy hospital stay. Recover! also is more painful than with other methods. Transanal endoscopic microsurgery is an effective alternative to conventional methods. It provides the surgeon with improved exposure to the lesion and allows a more precise excision and wound closure. It also enhances patient recovery and decreases the length of the patient’s hospital stay. (See “Advantages o f Transanal Endoscopic Microsurgery.”)
hat are the criteria for TEM patient selection, and how does the surgeon determine whether a patient satisfies the criteria? Several factors are taken into consideration, including the location and size of the lesion, the degree of rectal wall invasion. and the degree of lymph node involvement. Lesions nearest the rectum are more difficult to remove using TEM; bleeding may be brisk. and CO, may leak and cause the rectum to collapse. For these reasons, traditional methods of transanal excision may be preferable for lesion\ in the distal rectum. Adenomas and selected
Advantages of Transanal Endoscopic Microstsrgery Less invasive than conventional procedures Enhanced patient recovery (eg, less Decreased hospital stay Overall cost savings More tissue preserving than conventional procedures Greater depth perception than with conventional scopes Transanal access to proximal rectal lesions that previously required excision by laparotomy
carcinomas that are located within 20 cm of the anal verge usually can be removed by TEM without CO, leakage. Large, circumferential adenomas also can be excised with TEM. Preoperative endorectal ultrasound is essential to determine the degree of rectal wall penetration. Excision by TEM may be contraindicated for a lesion that demonstrates deep penetration of the rectal wall. A more radical surgical approach may be necessary. Endorectal ultrasound may detect metastatic lymph nodes as well. The surgeon should order a barium enema or perform a colonoscopy to rule out the presence of more than one tumor and orders an electrocardiogram for patients over 40 years of age. The patient enters the hospital the day before the procedure, and the medical team should assess the patient’s fluid and electrolyte balance to ensure that imbalances, if present, are corrected. The physician places the patient on a liquid diet, and after midnight, the patient is not allowed oral intake. The surgeon may order prophylactic oral or IV antibiotics. Proper bowel preparation is necessary to ensure that the surgeon has an adequate view of the tumor during surgery. Bowel preparation is the same as for a formal laparotomy and bowel resection and may include enemas, oral cathartics, or lavage. Bowel preparation must begin early so
that complete results are achieved before surgery. The perioperative nurse visits the patient preoperatively. Because TEM is a relatively new procedure, the patient probably will have many questions or concerns regarding the surgery or the OR suite. Some patients will experience more anxiety than others, so information imparted to the patient by the perioperative nurse should help promote the patient’s comfort. Patient teaching may include informing the patient of the time of surgery, the time when family members should arrive, and the events that will occur in the holding area and during the surgery. The nurse also may address the use of antiembolism stockings and sequential-decompression apparatus. The nurse should assess for patient mobility and flexibility that might make positioning difficult. The patient’s skin condition and nutritional status should be assessed to address areas of possible pressure and the need for padding and careful positioning. The nurse also should assess the patient for allergies and medical conditions that could affect intraoperative care. The rectoscope is available in 12- or 20-cm lengths. Which length the surgeon uses depends on the location of the tumor. The surgeon introduces the rectoscope into the rectum and advances it to the lesion under direct vision. For the surgeon to view the tumor, the beveled tip of the rectoscope must point downward. The binocular stereoscope, which contains two integrated optics to provide greater depth perception, is inserted through the rectoscope. Rubber hoses connect the rectoscope to the various parts of the endosurgical unit. As the surgeon inserts the rectoscope into the rectum, he or she insufflates the operative site with CO, gas for constant distention. The rate of CO, gas insufflation must be greater than the rate of suction to keep the rectum from collapsing. The rectoscope must be stabilized, but it also must be repositioned several times during the procedure to maintain the surgeon’s view of the tumor. The surgeon stabilizes the rectoscope using a special bar with a double ball-and-socket joint. This bar is attached to the OR bed and is draped into the sterile field (Fig 1). 468
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To prevent the loss of CO, and to provide the surgeon with a means for inserting the TEM instruments, a face piece is placed over the rectoscope. Pliable, leak-proof, rubber caps are secured over the entry ports of the face piece (Fig 2). Instruments are inserted through the face piece and manipulated in a parallel fashion. A teaching scope, which may be hand-held or connected to a video monitoring system, also is available. This allows the surgical assistant and other members of the surgical team to view the procedure. The optical end of the binocular stereoscope may require frequent cleansing. A rinsing channel has been integrated into the stereoscope to allow automatic flow of saline for this purpose. A standard electrocautery unit is the coagulation source for TEM. Equipment and operating room readiness include proper sterilization and meticulous care of TEM instrumentation. The TEM procedure is a clean technique; however, because of the limited amount of instrumentation available in the United States, proper disinfection and meticulous care andhandling of this equipment is crucial and is a primary responsibility of the OR nursing staff. Equipment and instrumentation should be cleaned, maintained, and stored according to manufacturers’ suggestions. The circulating nurse initiates the cleaning process, which includes soaking the rectoscope, the teaching scope, and the binocular stereoscope in a cold disinfectant for 20 minutes. Eyepieces from the teaching scope and the binocular portion of the stereoscope must not be submerged in fluid. Because submerging the eyepieces in fluid can cause severe damage to the optic bundles, a small rack is available to keep the eyepieces out of the solution. The small, silver shots used to secure sutures also need to be cleaned in the disinfectant solution. After 20 minutes, the scrub nurse places this equipment in sterile water for rinsing. The tissue graspers, scissors, needle holders, and needle-tip coagulators or knife may be gas sterilized. In addition, the rubber caps, rubber sealers, rubber hose attachments may be gas sterilized.
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Fig 1. Rectoscope secured in place by the special bar attachment. The gas lines and stereoscope have been inserted.
Fig 2. Face piece sealing the end of the rectoscope. Rubber caps and seals are in place. 470
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A patient undergoing TEM may receive general or spinal anesthetic based on the surgeon’s and the anesthesiologist’s assessments. Another option for cleansing the TEM instruments is in a computer-controlled sterilizer that contains warm water and panacetic acid. The same items that can be gas sterilized can be placed in this unit. This type of sterilizer can complete a cycle in approximately 25 minutes. Autoclaving the specialized TEM instruments is not recommended because the intense heat may cause metal degeneration and shorten the life expectancy of the instruments; however. the light handles and the special bar with the double ball-and-socket joint are autoclaved for 10 minutes. During the preparation of the sterile field, the surgeon covers the eyepieces with a sterile glove and cuts holes in two of the glove fingers so he or she can view the rectum. Placing the glove on the eyepieces is an extra precaution to protect the eyepieces from blood or other waste products during the procedure. It helps keep the eyepieces clean and dry. At the end of the case, the circulating nurse carefully cleans the eyepieces with 70% alcohol. While the scopes and silver shots are being sterilized, the scrub nurse prepares the sterile back table, which includes a laparotomy sheet, leggings, three packs of sterile towels, three paper gowns, appropriate gloves, metalware (eg, basins), sponges, a magnetic needle board, suture material, prepping items, and the TEM instruments, which are housed in a well-padded tray for added protection. Other equipment includes the rubber hoses, rubber caps, and rubber sealers. A basic rectal tray is opened on a separate table and contains Mayo scissor\, curved six-inch clamps, and towel clips. This tray is kept sterile in case TEM is abandoned for an alternative approach. The circulating nurse gathers other necessary equipment, including a proctoscope and a light source. The endosurgical unit is brought into the OR, and the nurse checks the CO, pressure
gauge to ensure that there is gas in the tank. A patient undergoing TEM may receive general or spinal anesthetic based on the surgeon’s and the anesthesiologist’s assessments. After the patient has been anesthetized, the surgical team positions him or her for the procedure. For a lesion on the lateral aspect of the rectal wall, the surgical team positions the patient in the lateral position. If the lesion is located on the anterior aspect of the rectal wall, the patient is in the prone position. If the prone position is used, the transport cart must remain in the operating room. In case of an emergency, the surgical team can move the patient quickly from prone to supine position. For a lesion on the posterior wall, the lithotomy position is used. The nurse or resident inserts a Foley catheter, pads pressure points, such as knees and elbows, ensures the patient’s good body alignment, and places the electrosurgical dispersive pad. The electrosurgical dispersive pad must be strategically placed to ensure safety. Placement of the pad depends on the patient’s position during the procedure; however, the lateral, anterior, and posterior regions of the thigh are the placement areas of choice. After the patient is positioned, the operative field is prepared. The circulating nurse cleanses the patient’s skin around the anal region with povidone-iodine. The surgeon and scrub team aseptically place sterile towels and towel clips and a laparotomy sheet on the patient. If the patient is in the prone or lithotomy position. the team places sterile leggings on the patient’s legs. Because the operating field encompasses a small area, placement of cords and tubing is challenging. The rubber hose attachments have male and female metal end components; it is important that the proper ends be passed to the circulating nurse. There are four rubber hoses 471
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that can be attached to the endosurgical unit, each of which has distinct grooved markings on the metal component end for proper port placement. The circulating nurse attaches the hoses to appropriate ports, and the scrub nurse anchors them to the sterile field with curved clamps. The circulating nurse positions another ruhber hose around the suction roller pump o n the endosurgical unit. He or she places the free end of this hose in a fluid-collection container. The connecting ends of cords for the light source and electrocautery unit are passed off of the sterile field to the circulating nurse, who attaches them to the appropriate sources. Anesthesia staff members place a solution of 1 g cephalosporin in 1,000 mL of normal saline in a pressure bag. The scrub nurse gives an irrigatingtaspirating device to the surgeon, who secures it to the irrigating port of the rectoscope. The other end is passed off of the sterile field to anesthesia personnel, who place it in the prehsure bag of antibiotic irrigation solution. Thi\ solution is used intermittently throughout the TEM procedure. If a video system is to be used. the video equipment cabinet is situated in the OR per the surgeon’s preference.
Fig 3 . Special TEM instruments. (Top) needle holder: (Bottom wM~,frornleft) two scissors, two tissue graspers, needle holder, needle, high-frequency knife, suction coagulator.
tion. and intrarectal pressure monitoring (Fig 4). The surgeon inserts the rectoscope into the patient’s rectum and secures it using the special positioning bar. He or she places the face piece on the rectoscope and secures the rubber caps over the various ports. The goal of the surgeon usin? TEM is to remove the tumor and a border of surrounding tissue in one complete piece. After the specimen is removed, the surgeon \tretches it and secures it to a piece of nonad-
he surgeon views the rectum through a 40-mm-diameter rectoscope with binocular stereoscopic vision using constant CO, gas insufflation of the rectum. The surgeon can excise the lesion and close the wound transanally using specialized instruments that include left- and right-angled scissors and tissue graspers with electrocautery capability, needle-tip coagulator or knife, suction coagulator, and needle holders (Fig 3). The TEM system includes a combined endosurgical unit that performs a variety of functions, including automatic CO, gas Fig 4 . Combined endosurgical unit that performs a variety of funcinsufflation, irrigation, SUC- tions, including insufflation of CO,, irrigation, and aspiration.
herent guaze pad or similar material. Handling the specimen this way ensures that photographic documentation and exact macroscopic and microscopic evaluations can be done.
Surgical Technique ere are two excision techniquesfor TEM. mucosectomy and full-thickness. The surgeon's choice of technique depends on the type,size, and depth of the tumor. Small, sessile, benign adenomas and selected cancers on the anterior wall of the middle rectum should be excised using a mucosectomy technique, in which the surgeon removes a 5-mm margin of normal mucosa surroundingthe tumor. Large, sessile adenomas or proven carcinomas on the lateral or posterior rectal walls should be removed using the full-thickness technique, in which the surgeon removes a 10-mm margin of normal mucosa surrounding the tumor.
Fig 5. Using the high-frequency knife, the surgeon maps out a margin of normal mucosa around the lesion. 474
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When the surgeon can see the tumor, he or she marks the healthy tissue margin using the high-frequency needle tip coagulator or knife (Fig 5). The surgeon uses a tissue grasper to lift the tumor while he or she excises it with the needle-tip coagulator or knife. For both surgical techniques, the rectoscope must be adjusted several times to maintain the surgeon's view of the operative site. Bleeding is controlled using a combination of coagulation, irrigation, and suction. In the mucosectomy technique, the muscularis propria remains intact, and, after ensuring that the wound is clean and dry, the surgeon sutures the defect. In the full-thickness technique, dissection is performed until the perirectal fat is visualized. The surgeon removes the tumor and sutures the defect. The surgeon closes the wound transanally by end-to-end anastomosis of the wound edges. Closing a mucosectomy or full-thickness
Fig 6. Wound closure with running mono-filament suture. The closure is started with a silver shot.
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defect involves using either slow-dissolving absorbable or nonabsorbable 3-0 monofilament suture material. Small silver shots are used in place of knots; one silver shot is placed on either side of the suture to secure it (Fig 6 ) . Tension on the suture line is important. Short pieces of suture material (ie, not more than 4 cm long) are used. For closing larger defects, several silver shots can be used to align wound edges and reduce stress on the suture line. The silver shots remain in place until the suture dissolves and are then passed in the patient’s stool. After the surgeon closes the wound, the patient is prepared for transport to the postanesthesia care unit (PACU). He or she is returned to the supine position and extubated when appropriate. The Foley catheter can be removed in the OR or in the PACU. After extubation, the surgical team transfers the patient to the transport cart and covers him or her with warm blankets. The patient is then taken to the PACU.
he patient spends approximately one and a half hours in the PACU to ensure that his or her vital signs are normal and that he or she sufficiently awakens from anesthesia. If necessary, the PACU nurse administers analgesics. A patient usually spends 1 to 2 days in the hospital following a TEM procedure. The patient ambulates on the first postoperative evening and is allowed to resume a normal diet as tolerated. The physician orders analgesics as needed, but postoperative patient pain usually is not a problem. .~~ ~~
Notes 1. G Buess et al, “Endoskopishe operationem zur polypabtragung im rektum,” C o l o - p r o t o l o p 5 (1984) 254-261; G Buess et al, “Technique of
Pregnant Women Favor Cystic Fibrosis Screening A high percentage of pregnant women believe carrier screening for cystic fibrosis (CF) should be offered to women who are thinking of becoming pregnant, according to an article in the May 1992 issue of the American Journal of Public Health. In a pilot study, researchers surveyed 306 pregnant Caucasian women from a variety of demographic and socioeconomic backgrounds who were less than 18 weeks pregnant. Of the 214 respondents, 98% believe that screening should be available to women before pregnancy, 84% would have been personally interested in CF testing before pregnancy, and 69% said they would undergo screening during pregnancy. In terms of confidentiality, 99% of the women indicated that they would share test results with family members. In addition, 80% believe the test should not be required by law, and 60% believe their physicians should not be compelled by law to divulge results without patient consent. Researchers also found that women who are more informed about CF are less interested in testing. Reproductive choice also was surveyed, and 67% of respondents were interested in knowing their carrier status if they were at risk for CF. This percentage fell to 29%, however, when women were asked if they would prevent the birth of a child who was determined to have CF. The article states that although pregnant women are interested in screening, interest in terminating a pregnancy because of screening results may be minimal. Cystic fibrosis is the most common lethal genetic disease in Caucasians, and it affects one out of every 2,500 infants.
transanal endoscopic microsurgery,” Surgiccrl Endoscopy 2 no 2 (1988) 71-75. 2. Ibid. 3. G Buess et al, “Clinical results of transanal endoscopic microsurgery,” Surgical Endoscopy 2 no 4 (1988) 245-250. 475