TEM for rectal tumor resection

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TEM   for   rectal   tumor   resection

Authors
N Demartines
Mots-clés
operation,rectum,transanal endoscopic microsurgery,colorectal surgery
Type de vidéo
Durée
13'00''
Publication
2004-09
Popularité
Favoris
Favorites Media
Audio
en
Sous-titres
en
E-publication
WeBSurg.com, Sept 2004;4(09).
URL: http://www.websurg.com/doi-vd01en1255e.htm

TEM   for   rectal   tumor   resection

1. Case presentation 00'25''
This is an operative rectoscope and we will introduce it into the anus of the patient. The patient must be well relaxed for easy introduction. The diameter of this tube is 4cm and the length is 12cm. the patient may be under local or regional anesthesia and usually if we proceed slowly, introduction of this device is easy. We begin with an exploratory rectoscopy with an operative rectoscope. The alternative solution will be to use a 22cm rectoscope but it is more difficult. Now we remove the window; this is the plug that closes the tube. Two lower ports will now be used but they are capped to preserve air seals after insufflation of the rectum. There are 2 working ports. The principles are the same as in laparoscopy but it is more difficult because the instruments are parallel. The tubes are installed. The principle of the system is airtight. The rectum is insufflated to obtain a working space that is wide enough. This very well designed instrument is a multifunction probe. It functions as a suction and insufflation device, plus a section needle, which is pushed out by a pressure of 5 to 7 atmospheres. Two separate tubes are used for aspiration and suction. It is very surgeon-friendly as the red ends fit on the red and the blue on the blue. This is the cable that is connected to the machine. The developers of this device have been truly surgeon-friendly as both hands are identical. We insufflate, it’s for pressure control, this is the suction tube and this is the irrigation tube. The spy is connected to this opening and the spy is the 2nd camera. And now the light cable is connected to the system. The tumor erosion can easily be identified. Its size is about 5cm and it was very well palpated during the rectal exam. Circumferential marking is done including the safety margin. We will mark all the way round the edges of the tumor at this point. It’s a small tumor. The lesion is here and this is the centre of the lesion. The suction device is working. The right aspect of the tumor is grasped and section is begun. I’m going to coagulate again and now as we continue the beginning of the section here, the muscular layer of the rectum will soon come into view. And this is the muscular layer as seen by the fibres here. Principles here are to coagulate the vessels first and then cut as we continue the dissection deeper. We are behind the rectum. You see now the perirectal fat. At this point, we know the full depth of the rectal wall has been incised. The vessels are selectively coagulated. If I cut too fast, the vessels will be encountered and bleeding will be seen, and then the vessels need to be coagulated. We start at the inferior lower part and then continue towards the left in this resection. Each time the same principle will be applied: section, then selective coagulation of vessels as they are encountered. We are now reaching the limit of the range of motion of the instruments on the left side. We now have to move the rectoscope in order to bypass this restraint on the left. And you can see now that the base of tumor is being exposed. We have a little bit of bleeding and the bleeding vessel is coagulated. It’s a matter of patience at this point. The muscular fibres are coagulated. We’re just at the edge of the rectoscope and some hemostasis can be obtained by coagulating the edge of the rectoscope. However, it becomes harder to achieve a satisfying working space because of the space of the tumor. We’re coagulating now with the blunt coagulator at first. This is then followed by the coagulation needle used to cut. Now I cut with the needle. The needle is withdrawn and the coagulation is put into place adjacent to the vessel. If the coagulation is ineffective, we can grasp with the forceps and continue with coagulation and shown here again is needle cauterization and cutting. Resection is almost complete at this point and this is the piece of the tumor. We’ll pull this portion out in just a moment. You can see the tumor resection here. Right now I’m loading the needle into the needle holder. As you can imagine, this is unlike laparoscopy in that our instruments are completely parallel due to the small working space. Go to the mucosa here and we’re positioned just superior to the dentate line, thus fairly low. There’s another bite on the mucosa superiorly and here we can achieve some re-approximation by pulling down the upper portion. Because of the low position of this tumor, we’ll have to retract the rectoscope somewhat for a better angle on the mucosa. To be perfectly honest, I’m more or less satisfied because of the proximity of the dentate line. However, I hope the patient will not feel anything postoperatively. We’re also in close contact with the sphincter as you can see. Because of this, there is an increased risk of postoperative incontinence. We do have a series of 50 patients and we’ve only had one case of postoperative incontinence. It was a case of resection for palliative reasons and the patient was incontinent preoperatively also. This will be the last stitch with this needle. We grasp the mucosa as shown. Now we keep some tension on the suture line. Because of this instrument, it is absolutely impossible to tie a knot through a 12 by 4cm tube so what we do instead is place a silver clip on the end of the running suture line as shown here in place of a knot. The suture is cut and as you can see there is good approximation. Again, the same thing is done here for the remainder of the gap. This is the last stitch for this suture line and again a silver clip will be placed in lieu of a knot. And this is the last clip.