Lee E. Smith, M.D., Editor

Transanal Endoscopic Microsurgery Theodore J. Saclarides, M.D.,* Lee Smith, M.D.,~- Sung-Tao Ko, M.D.,* Bruce Orkin, M.D.,-~ Professor Gerhard Buess, M.D. + From the *Department of General Surgery, Section of Colon and Rectal Surgery, Rush-PresbyterianSt. Luke's Medical Center, Chicago, Illinois, the ~Section of Colon and RectaL Surgery, George Washington University, Washington, D. C, and +Eberhard-Karls Universitaet, Tubingen, Germany Transanal endoscopic microsurgery (TEM) has emerged as a minimally invasive means of resecting rectal tumors. Developed in Germany and now being used with increasing frequency in the United States, TEM utilizes a 40-mm operating rectoscope, which is sealed with an airtight facepiece. Carbon dioxide is constantly infused, thereby distending the rectum and maintaining visibility. A variety of instruments, such as tissue graspers, a high-frequency knife, suction, and needle holders, are inserted through the facepiece. Adenomas that are small, large, or even circumferential, as well as selected carcinomas up to 24 cm, can be removed with TEM instrumentation. The optics provide sixfold magnification, and this, combined with the constantly distended operative field, allows for a precise excision of the tumor as well as closure of the wound. For lesions in the mid and upper rectum, TEM is an alternative to a transsacral or transabdominal approach, with subsequently shorter hospital stay and fewer complications. [Key words: Transanal resection; Minimally invasive; Rectal neoplasms] Saclarides TJ, Smith L, Ko S-T, Orkin B, Buess G. Transanal endoscopic microsurgery. Dis Colon Rectum 1992; 35:1183-1191. inimal-access surgery has b e e n thrust into p r o m i n e n c e largely b e c a u s e of the success of laparoscopic c h o l e c y s t e c t o m y and its m a n y advantages. Transanal e n d o s c o p i c m i c r o s u r g e r y (TEM) is a n o t h e r o u t g r o w t h of minimal-access surgery. The instrumentation and t e c h n i q u e w e r e dev e l o p e d b y Professor G e r h a r d Buess et al. 1 in Germany; o n l y recently has interest increased in the United States. TEM has e v o l v e d on a p r e m i s e similar to other minimal-access p r o c e d u r e s , namely, an operative a p p r o a c h to rectal p a t h o l o g y that has significantly less m o r b i d i t y than the m o r e involved, traditional operations. A d e n o m a s and p r o p e r l y s e l e c t e d carcinomas that are located u p to 20 cm f r o m the anal


v e r g e m a y be excised b y a mucosal or full-thickness dissection f o l l o w e d by direct suture closure of the defect. Circumferential lesions m a y b e excised segmentally, with intestinal continuity re-established by the transanal p e r f o r m a n c e of a sutured end-toe n d anastomosis. If located in the u p p e r rectum, resection of such lesions has h e r e t o f o r e r e q u i r e d l a p a r o t o m y and low anterior resection with reanastomosis. While lesions in the distal r e c t u m can be excised b y conventional transanal techniques, TEM provides an alternative a p p r o a c h with imp r o v e d e x p o s u r e and a m o r e precise closure. In addition to its utility in the excision of neoplasms, TEM can be u s e d to p e r f o r m transanal r e c t o p e x y for rectal p r o l a p s e and also to correct anastomotic strictures refractory to c o n v e n t i o n a l m e t h o d s of dilatation. As with other minimal-access p r o c e d u r e s , recovery following these procedures is hastened, hospital stay is shortened, and m o r b i d i t y is lessened. TEM distinguishes itself f r o m other e n d o s c o p i c and minimal-access p r o c e d u r e s in several ways. First, the visual i m a g e is a c h i e v e d t h r o u g h a binocular s t e r e o s c o p e , w h i c h delivers a p e r c e p t i b l y u n i q u e d e p t h of field unlike the i m a g e a c h i e v e d by m o n o c u l a r instruments or v i d e o cameras. Second, the dissecting instruments are inserted and m a n i p u l a t e d in parallel planes, in contrast to laparoscopic surgery, w h e r e o p p o s i n g portals aid in e x p o s i n g tissue. As a result, traction and countertraction m a y be difficult to achieve, and brisk b l e e d i n g and h e m o r r h a g e , w h i c h m a y b e encountered during mucosal or full-thickness excisions, can b e difficult to isolate and control. Lastly, the conditions treated b y TEM, n a m e l y a d e n o m a s , carcinomas, and procidentia, are e n c o u n t e r e d far less f r e q u e n t l y than those a d d r e s s e d laparoscopically. As a c o n s e q u e n c e of this i n f r e q u e n c y and the con-

Address reprint requests to Dr. Saclarides: Section of Colon and Rectal Surgery, Department of General Surgery, Rush-Presbyterian-St. Luke's Medical Center, 1653 West Congress Parkway, Chicago, Illinois 60612. 1183



siderable skill necessary to perform these procedures, they have, for the present, become the providence of a few surgeons. They are unquestionably, however, spearheading what will surely become an alternative and perhaps indispensable operative approach for appropriate rectal lesions. EQUIPMENT TEM utilizes a rectoscope that is 40 mm in diameter and available in lengths of 12 and 20 cm (Fig. 1). After insertion, the rectoscope is advanced under direct vision to the desired location in the rectum; a rubber hose attachment allows for manual insufflation of air while the rectoscope is being positioned. The rectoscope can be locked into position by a supporting device (Richard Wolf, Rosemont, IL) that is attached to the operating table. This device must be draped within the sterile field to permit the frequent repositioning of the rectoscope necessary during the operation. An airtight faceplate, which locks onto the end of the rectoscope, contains four ports that are sealed by capped rubber sleeves; through these ports are inserted the dissecting instruments. The stereoscope is inserted via a fifth port. The rubber caps prohibit leakage of CO2 insufflated during the operation to keep the rectum distended and open, thereby maintaining visibility (Fig. 2). Suction, CO2 insufflation, and irrigation are regulated by a single monitoring unit that also monitors and regulates intrarectal pressure (Fig. 3). Insufflation of

Dis Colon Rectum, December 1992

CO 2 can be adjusted up to a rate of 6 1/min to maintain intrarectal pressure between 12 and 15 mmHg. Failure to achieve this pressure should alert the physician to check for an adequate CO2 supply, breaks in the rubber seals or caps, or an improperly fitting facepiece. The rate of suction is engineered to be less than the rate of CO2 insufflation so that rectal distention is maintained. A standard electrical coagulation source is needed. A variety of instruments necessary for microsurgery can be inserted through the sealed rectoscope. These instruments are used in parallel through a field of vision of approximately 72 ~ from the end of the stereoscope. An accessory monocular scope is inserted through the facepiece. This second optic can be utilized by an assistant or connected to a video unit (Fig. 4). Proper placement of the accessory scope through the facepiece is important to avoid leakage of CO2. Other instruments include: tissue graspers and scissors, both angulated to the left and right; needle holders; a suction coagulator; and a needle-tip high-frequency knife. The tissue graspers, knife, and suction device may be connected to the electrocautery source (Figs. 5A and B).

PATIENT SELECTION Adenomas and properly selected carcinomas up to 20 cm from the anal verge may be removed with TEM.

Figure 1. Rectoscope: 12 and 20 cm long, 40 mm wide.

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Figure 2. Rectoscope with facepiece and capped rubber sleeves through which the instruments and optics are inserted.

Figure 3. The combined endosurgical unit that regulates C02 insufflation, irrigation, and suction.

Cancers It is essential that the rectal cancer be e x a m i n e d by endorectal ultrasound to d e t e r m i n e depth of penetration into the rectal wall and the p r e s e n c e of lymph n o d e metastases. Endorectal ultrasound is approximately 75 to 90 p e r c e n t accurate in determining the d e p t h of penetration; it has b e e n less so in detecting lymph n o d e metastases. 2-4 If sonography demonstrates d e e p penetration of the muscularis propria or extension to the perirectal fat, making local excision for cure unlikely, then a radical resection may be preferable. Contrariwise,

if other studies reveal distant metastases and if these are unresectable, TEM may be used to excise the rectal cancer regardl'ess of its d e p t h of penetration. Adenomas Adenomas should be e x a m i n e d sonographically to rule out an occult invasive cancer. If confined to the mucosa, t h e n the lesion can be r e m o v e d by dissecting within the submucosal space. Since, however, up to 30 to 50 p e r c e n t of large sessile adenomas harbor an occult cancer, 5 a full-thickness



Dis Colon Rectum, December 1992

Figure 4. Top. Binocular stereoscopic eyepiece. Bottom. Accessory monocular eyepiece. excision is sometimes preferable for large lesions so as to assess depth of penetration and margins of resection. Full-thickness excision is also less likely to cause tissue fragmentation during the dissection, thus enabling the pathologist to more accurately assess margins. If histologic examination of the excised villous adenoma reveals an unsuspected cancer that is well differentiated and completely excised and that has minimal invasion of the rectal wall, then perhaps no further treatment is necessary.

Distal Lesions Lesions located just above the dentate line are more difficult to remove by TEM, because the insufflated CO2 frequently escapes and the operative field collapses. Also, distal lesions such as these have a tendency to bleed more during the course of dissection because of proximity to the hemorrhoidal vessels. For these reasons, conventional transanal techniques for the most distally located lesions may be preferable. Lesions located in the distal rectum, however, provide an opportunity to acquire technical expertise; if TEM does not proceed as planned, then excision can be performed with conventional methods. PATIENT PREPARATION Bowel Preparation The bowel is prepared as for a formal laparotomy; this can be accomplished by enemas, cathar-

tics, or lavage. Colonoscopy or a barium enema should be performed during the preoperative period to examine for the presence of synchronous lesions.

Anesthesia The operation may be performed with either a regional or general anesthetic. Until one is skilled with the TEM instrumentation, general anesthesia is preferable in that there are no time limitations during which the operation must be completed.

Position Positioning the patient is dependent upon the location of the tumor. The bevel of the rectoscope must face downward, and patient position therefore depends on the location of the lesion within the rectum: for a posterior lesion, the patient must be placed in the lithotomy position; for laterally based lesions, the patient is placed in a lateral position; for anterior lesions, the patient is placed prone with the legs spread apart and the foot of the operating table dropped to allow space for the surgeon to sit between the patient's legs.

Consent In addition to transanal excision of the tumor, consent should also be obtained for possible laparotomy if unforeseen operative events occur. This would apply in those cases of uncontrollable hemorrhage Or technical difficulty. Inadvertent entry

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Figure 5. A. Needle holder; shot applier; scissors angulated to the right; scissors angulated to the left. B. Tissue graspers angulated to the right; tissue graspers angulated to the left; High-frequency cautery knife.

into the peritoneal cavity can be repaired with TEM techniques; however, the adequacy of the repair may need to be assessed by laparotomy (or laparoscopy). TECHNIQUE After the induction of anesthesia, the patient is positioned and the rectoscope is inserted and clamped into position. The faceplate is placed on the rectoscope as well as the capped rubber sleeves. The optics are inserted, and the CO2 insufflation, irrigation, suction, and pressure moni-

toring lines are attached. Through the rubber caps, the instruments are inserted and dissection begins.

Mucosectomy villous lesions may be removed by dissecting within the submucosal plane. The needle-tip cautery is used to circumferentially outline a 5-ram margin of normal mucosa. The mucosa is elevated by a tissue grasper, and the high-frequency knife is used to perform the mucosectomy (Fig. 6). Even large lesions encompassing the entire rectal circumference may be removed in this fashion. Since



Dis Colon Rectum, December 1992

Figure 6. Excision of lesion.

the chance of invasive carcinoma is higher within larger villous lesions, a full-thickness technique is sometimes preferable. When dissecting anteriorly, care must be taken not to enter the abdominal cavity, especially in women, where the peritoneal reflection is low and not consistent in its location. If there is inadvertent entry into the peritoneum, suture closure can be performed and the operation continued as planned. Inadvertent entry into the vagina is also possible when dissecting in the anterior aspect of the rectum. The operative field is kept clean and dry with liberal use of irrigation and suction. Frequent repositioning of the scope is necessary to keep the operative field in view. The

defect following partial or circumferential resection is closed with a running 3-0 monofilament suture of either nonabsorbable or long-lasting absorbable material using a tapered gastrointestinal needle. It is important to employ suture material of not more than 6 cm in length so that tension on the suture line may be maintained within the operative field. Each suture is started and finished with a malleable silver shot, which acts as a knot and anchors the suture in place (Fig. 7). A special clip applier is used to attach the shots. For large defects, wound closure may be facilitated by placing stay sutures, which will align the mucosal edges for the subsequent running suture.

Figure 7. Direct suture closure of wound.

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Full-Thickness Resection Carcinomas and some large adenomas are removed in this fashion. The incision is extended transmurally until the perirectal fat is encountered. Care must be taken when dissecting anteriorly because the peritoneal cavity or vagina may be entered. If this happens, the defect must be closed as described above.

Rectopexy Rectal prolapse is accompanied by redundancy of the rectosigmoid, lack of sacral fixation, and lengthening of the mesorectum. TEM has been employed in a small number of patients to fix the posterior wall of the rectum to the presacral tissue, theoretically to hold the rectum in its proper position. The patient is placed in the lithotomy position, and a transverse full-thickness incision is made in the posterior rectal wall. The perirectal fat is gently spread and dissected proximally, revealing the presacral fascia. The rectum is then anchored to the presacral tissue with interrupted sutures. The wound is closed in a transverse manner.

Rectal Stricture Anastomotic strictures following low anterior resection may occur after suture line disruption with subsequent fibrosis. If within reach of the examining finger, digital dilatation may be performed, or dilators can be inserted transanally. Endoscopic balloon dilatation may be tried as well. Strictures may persist and cause symptoms despite these measures, and, in such cases, TEM may provide a means of correcting the stricture. The patient is positioned in the lithotomy position for access to the posterior rectal wall. Using electrocautery, a longitudinal incision into the stricture is performed in the lateral and posterior positions. The anterior midline should be avoided. Postoperative balloon dilatation may be necessary to maintain anastomotic patency. TECHNICAL CONSIDERATIONS Some technical points that aid in performing the dissection have been learned. It is important to maintain control of the needle at all times; otherwise it is difficult to retrieve and reposition the needle onto the needle holder. The needle should be passed from instrument to instrument but only

when operating in parallel; i.e., crossover of instruments should be avoided. Cutting and sewing are easier when working from right to left. As one proceeds, frequent repositioning of the scope is necessary to keep the operative field in view. To facilitate the resection at the left corner of the wound, the tissue grasper may be inserted through a right-sided port and the knife switched to a left-sided port. The suture is started and finished with a malleable silver shot, which anchors the thread. At the completion of the suture, the thread should be grasped 1 cm from its exit from the tissue and pulled tautly. In this way, the mucosal edges are brought together. To end the suture, the shot applicator may be inserted through a right-sided or left-sided port; with the latter option, a crossover of instruments may be avoided. RESULTS Published results reflect the experience gained at the Universities of Cologne and Mainz by Professor Buess and staff.l' s, 7 Experience in this country is increasing but, as of yet, unpublished. The majority of lesions addressed by Professor Buess have been adenomas. Most of those carcinomas that he treated were discovered incidentally during the excision of large adenomas, and, therefore, the majority are T1 cancers. Of the adenomas removed using TEM instrumentation, 25 percent were in the lower rectum, 47 percent were in the mid rectum, 18 percent were in the upper rectum, and 9 percent were in the lower sigmoid colon. Of the cancers treated, 18 percent were in the lower rectum, 45 percent were in the mid rectum, 31 percent were in the upper rectum, and 6 percent were in the lower rectum. A total of 137 adenomas and 49 carcinomas were treated up to 1990. Forty carcinomas were T1 lesions, seven were T2 lesions, and two were T3 carcinomas. The average length of surgery was 84 minutes, with a range of 30 to 215 minutes. Segmental resections took approximately twice as long to complete. Complications of adenoma and carcinoma excision using TEM instrumentation are shown in Tables 1 and 2, respectively. Recurrence following excision of adenomas was found in 7 of 137 patients (5 percent). Of these patients, five were treated with simple endoscopic snare or cautery and only one required another TEM procedure. Thirteen patients developed pol-



Table 1. Complications of TEM (Adenomas; n = 137) Complication Treatment Peritoneal entry Pulmonary embolism Suture dehiscence Small bowel fistula Temporary bladder dysfunction Rectal stenosis Bleeding

1 1 2 1 5 5 3

Conversion to laparotomy Conservative

None Catheterization Bougienage Surgery in two

Table 2. Complications of TEM (Carcinomas; n = 49) Complication Treatment Suture dehiscence Rectovaginal fistula

2 Colostomy 2 Colostomy

1 1 Bleeding 1 Endoscopic coagulation 1 Stenosis 2 Bougienage 2 Permanent incontinence 1

yps at different locations within the rectum during the period of follow-up. Of these 13 patients, 12 were treated with simple endoscopic snare or cautery. The carcinomas were further categorized on the basis of histologic and morphologic features, such as degree of differentiation and the presence of venous or lymphatic invasion. A tumor was classified as being low risk for lymph node metastases if it was well differentiated and showed no signs of venous or lymphatic invasion. Similarly, a lesion was classified as high risk if it manifested these ominous features. Of the 25 low-risk T1 cancers available for follow-up, one developed a recurrence. On a retrospective review of the initial resection, the authors concluded that the lesion was incompletely excised at the first TEM procedure. There were three high-risk T1 carcinomas available for follow-up, of which two recurred. There were five low-risk T2 carcinomas available for follow-up, of which one recurred. One T3 carcinoma treated subsequently by local excision also recurred. Based on these results, the authors r e c o m m e n d local excision with TEM instrumentation for all T1 carcinomas. The decision as to whether T2 carcinomas are suitable for TEM excision must be made on an individual basis, taking into consideration the overall medical condition of the patient and whether the patient will consent to a more radical procedure.

Dis Colon Rectum, December 1992 SUMMARY

Traditional methods of locally excising adenomas and selected carcinomas of the distal rectum provide adequate exposure and an acceptable cure rate. The transanal excision of adenomas with traditional means, however, has a recurrence rate of 12 to 25 percent, 8-1~ possibly because the limited exposure has led to less than adequate resection margins. The accessibility of mid and upper rectal lesions is poor, and such lesions not amenable to endoscopic or transanal removal have frequently required either a transsacral excision or a formal laparotomy and low anterior resection. Both of these operations are accompanied by a lengthy hospital stay and potential morbidity. TEM has been performed extensively in Germany, successfully and with few complications.i, 6, 7, ~>i3 This technique offers substantial improvement over traditional methods of transanal surgery since larger lesions can be removed and in a more precise fashion. Tumors up to 20 cm from the anal verge can be removed, thus avoiding a low anterior resection. As a result, TEM offers the potential for shortened hospital stay and less morbidity. Furthermore, the improved exposure provided by TEM may lead to a more precise resection and closure and consequently lower recurrence rates. When considering excising rectal carcinomas by TEM, proper patient selection cannot be overemphasized. Rectal ultrasonography can help to determine depth of penetration, and TEM can be employed with curative intent for those lesions with minimal involvement of the rectal wall. TEM may also be used to excise tumors if there is widely disseminated metastatic disease yet there is the need to excise the primary lesion for palliation with the least morbidity and mortality. Minimal-access procedures are being used with increasing frequency. TEM will surely gain wide acceptance in this domain, marking a new technique for the treatment of a number of rectal conditions. REFERENCES 1. Buess G, Kipfmfiller K, Ibald R, et al. Clinical results of transanal endoscopic microsurgery. Surg Endosc 1988;2:245-50. 2. Waizer A, Zitron S, Ben-Baruch D, Baniel J, Wolloch Y, Dintsman M. Comparative study for preoperative staging of rectal cancer. Dis Colon Rectum 1989; 32:53-6.

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3. Yamashita Y, MachiJ, Shirouzu K, Morotomi T, Isomoto H, Kakegawa T. Evaluation of endorectal ultrasound for the assessment of wall invasion of rectal cancer: report of a case. Dis Colon Rectum 1988; 31:617-23. 4. Zainea GC, Lee F, McLeary RD, Siders DB, Thieme ET. Transrectal ultrasonography in the evaluation of rectal and extrarectal disease. Surg Gynecol Obstet 1989;169:153-6. 5. Muto T, Bussey HJ, Morson BC. The evolution of cancer of the colon and rectum. Cancer 1975; 36:2251-70. 6. Mentges B, Buess G. Transanal endoscopic microsurgery in the treatment of rectal tumors. Perspect Colon Rectal Surg 1991;4:265-79. 7. Buess G, Mentges B, Manncke K, Starlinger M, Becker HD. Technique and results of transanal endoscopic microsurgery in early rectal cancer. Am J


Surg 1992;163:63-70. 8. Chiu YS, Spencer RJ. Villous lesions of the colon. Dis Colon Rectum 1978;21:493-5. 9. Quan SH, Castro EB. Papillary adenomas (villous tumors): a review of 215 cases. Dis Colon Rectum 1971;14:267-80. 10. Jahadi MR, Bailey W. Papillary adenomas of the colon and rectum: a twelve-year review. Dis Colon Rectum 1975;18:249-53. 11. Kipfmtiller K, Buess G, Naruhn M, Junginger T. Training program for transanal endoscopic microsurgery. Surg Endosc 1988;2:24-7. 12. Buess G, Kipfm{iller K, Mack D, GrOsner R, Heintz A, Junginger T. Technique of transanal endoscopic microsurgery. Surg Endosc 1988;2:71-5. 13. Buess G, Theiss R, Gtinther M, Hutterer F, Pichlmaier H. Endoscopic surgery in the rectum. Endoscopy 1985;17:31-5.

Transanal endoscopic microsurgery.

Transanal endoscopic microsurgery (TEM) has emerged as a minimally invasive means of resecting rectal tumors. Developed in Germany and now being used ...
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