Training Transanal Endoscopic Microsurgery (tem): Feasibility of a New Simple and Economic Surgical Simulator.

Gustavo L Carvalho, MD PhD, Marcos Lyra, MD, Sergio E Araujo, MD PhD, Eduardo A Bonin, MD MSc, Diego L Lima, Student. Oswaldo Cruz University Hospital and UNIPECLIN, Faculty of Medical Sciences, University of Pernambuco – Recife, Brazil.


BACKGROUND: TEM is a safe, feasible and efficacious minimally invasive surgical approach for the treatment of benign adenomas and early-stage carcinomas of the rectum. TEM enables proper en bloc tumor resection while providing enhanced visualization. TEM results in reduced hospital stay and morbidity when compared to anterior resection or abdominoperineal operation. Although advantageous in many ways, TEM techniques are not yet performed in a widespread fashion as expected at many institutions, since it is still considered a technically demanding procedure . Extensive training is deemed required to master the technique. Cadaveric and live animal models represent the current available options for simulation. However, they might be considered laborious and raise ethical concern. Furthermore, these models are expensive and require complex settings which are not easily accessible in all institutions. In order to overcome these limitations, a newly developed, simple and user friendly surgical TEM simulator model using an artificial low cost synthetic tissue called Neoderma is presented.

METHOD: Neoderma is a material that offers color, touch, consistency and texture similar to the Human tissues. A TEM Neoderma trainer was engineered to simulate a pathologic rectum with several sessil tumors. Every TEM trainer is a cylinder 30 cm- long, 4cm-wide, naturally self-expanded and closed at one end, simulating a gas-insufflated rectum. It simulates all rectum wall layers including mucosa, muscularis propria and the surrounding fat tissue (mesorectum). Each layer was engineered in a different color and this resource is used to help the identification of surgical dissection plans. The actual surgical model is manufactured with 3 polypoid 2 cm-sized tumors . The TEO device is firmly inserted in the open end of the model keeping it securely attached. A 5mm laparoscope and usual 5mm grasping forceps, scissors and needle holder completes the setting. The device was used by two experienced surgeons for performing endoluminal full-thickness resection of polypoid tumors to evaluate its feasibility.

RESULTS: Preliminary results with the use of the simulator indicate that it is a reliable tool. Experienced surgeons demonstrated a good acceptance by successfully completing the proposed tasks. A total of 3 polypectomies and 5 endoluminal sutures were performed. Apart from usual TEM instruments, a harmonic scalpel device was successfully used. Both surgeons agreed that the TEO simulator offers a good model for mastering transanal resection and suturing superficial rectal tumors.

CONCLUSIONS: TEM Neoderma trainer offers a simple, practical and cost effective solution for training the surgeon to perform the complex TEM procedures. The number of lesions to be resected with this model to master the ex-vivo technique and its correlation with in vivo procedures is currently under evaluation. Due to exemption of human cadavers and laboratory animals, significant cost saving associated to TEM pre clinical practice may be anticipated.

Session Number: Poster – Poster Presentations
Program Number: P156
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