Endomucosal resection (EMR) using the Transanal Endoscopic Operation (TEO®) device and the new Ligasure Advance® device

The objective of this film is to demonstrate the advantage of using the new revolving handle Ligasure Advance® device, which is, for some surgeons, more ergonomic than the first generation handle. The use of the Ligasure Advance® device proves beneficial, as it provides us with a very thin 2mm electrode, allowing for a fine dissection in the submucosal region and bipolar forceps to coagulate and seal vessels.

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Endomucosal resection (EMR) using the Transanal Endoscopic Operation (TEO®) device and the new Ligasure Advance® device

Authors

J Leroy, J Marescaux

Abstract

The objective of this film is to demonstrate the advantage of using the new revolving handle Ligasure Advance® device, which is, for some surgeons, more ergonomic than the first generation handle. The use of the Ligasure Advance® device proves beneficial, as it provides us with a very thin 2mm electrode, allowing for a fine dissection in the submucosal region and bipolar forceps to coagulate and seal vessels.

Mots-clés

TEO, TEM, rectal polyp, EMR, ESD, endomucosal resection, Ligasure Advance®

Type de vidéo

Vidéo chirurgicale

Durée

05'44''

Publication

2011-01

Popularité

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Audio

Sous-titres

E-publication

WeBSurg.com, Jan 2011;11(01).
URL: http://www.websurg.com/doi-vd01en3022.htm

Endomucosal resection (EMR) using the Transanal Endoscopic Operation (TEO®) device and the new Ligasure Advance® device

1. Introduction 00'18''

The objective of this film is to demonstrate the advantage of using the new revolving handle Ligasure Advance® device, which is, for some surgeons, more ergonomic than the first generation handle. The use of the Ligasure Advance® proves beneficial, as it provides with a very thin 2mm electrode, allowing for a fine dissection in the submucosal region and bipolar forceps to coagulate and seal vessels.

2. TEO® introduction 00'46''

The Transanal Endoscopic Operation system (TEO®), by Karl Storz, is introduced into the anal canal until getting in touch with the area to be excised. This voluminous 4cm-diameter trocar allows for the introduction of the 30-degree scope system and of several 5mm-diameter instruments.

3. Rectal insufflation 01'11''

First, the rectum is insufflated. Then, the limits of the excision area will be delimited. The objective is to carry out a complete mucosal and submucosal excision, that is, an endomucosal resection, which will allow to completely excise this flat polyp and the adjacent tissues while respecting the seromuscular limits. The Ligasure Advance® is all the more efficacious as its electrode allows for a clean resection by using Valleylab™ current. This current is a mix of cutting and coagulation at a power of 10 to 15 Watts. This power is sufficient in this case, as the electrode is quite thin.

4. Mucosal and submucosal dissection 02'20''

Mucosal and submucosal resection will be carried out in contact to the seromuscular region in order to avoid a complete excision of the rectal wall. This type of resection is beneficial, as it allows to respect the rectal wall and to avoid a complete opening of the perirectal space. Dissection is carried on. It is not necessary to infiltrate the submucosal region. This could be useful, but it would impair the action of the monopolar electrode. The mucosa can be detached from the muscular plane by exerting traction and counter-traction with the gas pressure. You can see here how to carry out the division by means of this very thin electrode, which prevents current from diffusing.

5. Mucosectomy 03'46''

Mucosectomy is carried on from caudad to cephalad. It will come to an end by dividing the upper part beyond the limits of the polyp, at least 5mm away from the flat polyp. You can see here that monopolar current with a tipped electrode can also be used. This technique gives out much more smoke than the Ligasure Advance®, as the power is higher. It is then necessary to clean the rectal cavity using ventilation. This allows to clear the operative field. Once this has been completed, this mucosal segment should be removed. It should be then subject to a histological examination.

6. Reapproximation suture of the planes 04'57''

A reapproximation suture of the two mucosal planes should then be carried out. This suture is performed by means of a reapproximation using separated PDS 2/0 stitches. The first stitch can be seen here. It allows to reapproximate the middle part of the excision area. A suture reapproximating the two mucosal margins will be carried out in a stepwise fashion by means of these two separated stitches. The use of extracorporeal stitches allows to place knots by means of a pushing knot. This has no significant difficulty, as it is quite safe. It allows to perform the suture in excellent conditions. The only problem could be the manipulation of the needle. However, with basic training, this maneuver becomes quite easy. The good quality of the anastomosis and of the whole surgical procedure can be well seen here.