George J Nassif, DO, Harsh Polavaropu, MD, Andres Monroy, MD, Teresa H deBeche-Adams, MD, Sergio W Larach, MD, Matthew R Albert, MD, Sam Atallah, MD
Florida Hospital Center for Colon and Rectal Surgery
Introduction: The characteristics for the ideal pelvic surgery include, minimal morbidity and mortality, minimal trauma to the patient, good optical visualization, minimal blood loss, and preservation of physiologic function. These goals become more challenging in the re-operative pelvis, the narrow male pelvis and distal rectal pathology. Our group pioneered transanal minimally invasive surgery (TAMIS), which was initially described as an advanced platform for high-quality local excision of rectal neoplasms, but we have evolved this technique to pelvic dissection which gives a excellent option for these difficult cases including total mesorectal excision. With this approach, the TAMIS platform is used to perform total mesorectal proctectomies and other pelvic resections in a “bottom up” fashion as apposed to the standard technique of “top down”.
Hypothesis: We hypothesize that TAMIS bottom up technique is a safe and effective minimally invasive option for difficult and routine pelvic resections including TME and J-pouch excision.
Methods: We retrospectively reviewed data from a prospectively maintained database of a single colorectal surgery practice to identify all patients who had transanal minimally invasive surgery (TAMIS) for total mesorectal excision, pelvic excision of ileal J-pouch and previous coloanal anastomosis. Cases were performed with standard laparoscopic instruments, cameras and single port transanal platforms. Patient data including demographics, intra-operative details, perioperative morbidity and mortality and post-operative data were examined.
Results: 9 patients (men=4) underwent TAMIS bottom up pelvic dissection (TME=6 and Pelvic excision=3). Average age was average 52yo (31-65yo). Average BMI was 26.4 (18-38.5). 6 patients were treated for malignancy (5=rectal 1=cervical), UC n=2, crohns n=1. 5 patients received concomitant preoperative 5 FU based chemotherapy and radiation. OR time was 250min (172-450*combined with gyn). Mean EBL was 224cc (100-400cc). Specimen nodal harvest average 21.5 (9-42). All 6 TME were complete. There were no mortalities. Morbidity rate was n=1 crohn’s patient with superficial wound infection. LOS 4.6days ( 2-9). Follow up is 6.8 months (1-22).
Conclusion: Advances in minimally invasive surgical procedures have led us to explore less traumatic and more effective techniques to handle difficult pelvic pathology. This review demonstrates the feasibility, accessibility, and quality outcomes for a novel minimally invasive transanal surgical technique with retrograde pelvic dissection. The TAMIS bottom up dissecting technique can be easily adapted by surgeons who are capable of advanced laparoscopic surgery to operate in the difficult pelvis. Long-term oncological and functional data will need to be examined as the increased utilization of this technique is applied. TAMIS will continue to mature as a viable option for the surgical treatment of the complex pelvis in colorectal surgery.
Program Number: P012