TEM for a dysplastic polyp of the rectum

WeBSurg est une université virtuelle accessible mondialement sur Internet. Notre objectif est de fournir aux chirurgiens, aux sociétés savantes et au secteur médical un enseignement médico-chirurgical de pointe en ligne en chirurgie mini-invasive et toute information concernant les dernières avancées en chirurgie laparoscopique, dont notamment la Chirurgie Endoscopique Transluminale par les Voies Naturelles (NOTES) et la chirurgie assistée par robot.

Naviguez dans
l'Université Virtuelle
Français ▼

TEM   for   a   dysplastic   polyp   of   the   rectum

Authors
N Demartines
Type de vidéo
Durée
13'40''
Publication
2005-02
Popularité
Favoris
Favorites Media
Audio
en
Sous-titres
en
E-publication
WeBSurg.com, Feb 2005;5(02).
URL: http://www.websurg.com/doi-vd01en1734.htm

TEM   for   a   dysplastic   polyp   of   the   rectum

1. Instruments 00'10''
To perform a trans-anal endoscopic microsurgery, we basically use very few instruments as you can see on the tray here. The number one is the working operating rectoscope. This material by Karl Storz is available in 2 different shapes: the 7cm and the 15cm ones. You put this operating rectoscope inside with this guide. You go very gently through the anus. Once installed, you can work with this instrument; this is the entry for the camera and 3 working channels. The benefit of this is that the guide for the optic is very short and is only 5mm so in this working channel, you lose less space. You have a very nice small optic, also 5mm, in which one you will put the camera and so once your system is connected, you have the operating rectoscope with your 15cm, the place for the insufflation, then your working channels for placement of the instruments I’ll show you in a moment. You have the place to put the cold light and you will put the camera in this place. Basically the instrument we use is a grasper. You see that the instruments are shaped, angulated so that you can take your tissue without improving your view. There is one grasper with small teeth so that you can have a firm grasping of your tissue. You have the scissors: you can cut and coagulate and now the grasper, which is a little smaller; you can use it also as a dissector. Then if you decide to make a suture, you can use this needle holder, which is functioning easily and very similarly to the needle holder we use for laparoscopic surgery. And last but not least, we have a strong angulated suction device with a metallic tip, which also allows us to coagulate. You have here the connection so that you can clean with water and make your aspiration. So the trans-anal endoscopic microsurgery is performed with these few instruments and the Harmonic scalpel, which allows for coagulation and section as you will see shortly.
3. Resection 04'30''
Now we will put this inside. It works like a conventional rectoscope and we make the insufflation as soon as we’re done. Now we remove this. As you saw, we have located the tumor depending on the respiratory insufflation for the anesthesia and from the insufflation through the anus, you see that the tumor is moving all the time. This is coming because this system is a one-way system, you don’t have the pressure regulation. We’ll go inside with the grasper on the left side. The objective is to take the tumor at its base. The tumor is relatively large but if you’re looking at the base, you can see sufficiently. With this technique, you can remove all around the rectum. Here you have the tumor inside the operative rectoscope. With this system, we have enough distance to have a nice demonstration of this large tubulovillous adenoma. I don’t want to touch it too much since they usually bleed. You can have cancer with this large tumor in about 20 to 30% of cases. Now we’ll approach the tumor at its base and we’ll try to perform a full-thickness resection. We still are not through the whole rectal wall. Now we see very well in this particular place. We are in the perirectal fatty tissue and we probably have enough. I feel here some induration, which indicates that we‘re just down to the tumor. So we open on the left and right side. To close and suture the defect or not is still under debate. There is currently one single prospective randomized study demonstrating in the outcome and complication rate with absolutely no differences if you close or not the hole in the rectal wall. Now I’ll try to go on the other side. Probably here inside we have a vessel and in this kind of operation, a nice hemostasis is a major issue. Otherwise with blood, you won’t see anything since it will become red and dark. We started here down on the right side and pass down on the left side and we still are in the healthy tissue in order to have a few centimetres as a safety margin. We are working in a parallel tube of 20cm in length. I’ll take the next bite with some safety margins. The major issue in this kind of operation, especially if the tumor is becoming larger, is not to lose the 3D orientation, which is probably easier if you work with a conventional 3D. You see immediately when I’m using scissors, it’s bleeding. This is to demonstrate that the Ligasure is a great instrument.