The Poor Man’s Tem

Roel Hompes, MD, Frederic Ris, MD, Christopher Cunningham, FRCS, Neil Mortensen, FRCS, Ronan Cahill, FRCS. 1. department of colorectal surgery, John radcliffe hospitals, Oxford 2. Department of visceral surgery, Geneva University Hospitals, Geneva, Switzerland 3. Department of colorectal surgery, Beaumont Hospital, Dublin, Ireland

Objective: Single port laparoscopic tools and principles are transferable to transanal work. Initial experiences and small series have recently been reported with the use of commercially available singe port system. In an effort to improve on the ergonomic constraints as well as to reduce the costs associated with these commercially available ports, we have further evolved our personal experience with the glove port towards an access modality the equivalent of Transanal Endoscopic Microsurgery (TEM) for the intraluminal management of rectal disease. We here describe this new and cost-effective technique for transanal work in a short video.
Materials and Methods: The glove TEM port is constructed on table by using a circular anal dilator (CAD), wound retractor-protector (ALEXIS, Applied Medical) and standard sterile surgical glove. The wound retractor-protector is inserted through the CAD and anchors itself at the anorectal junction. Sealing the outer ring of the wound retractor with the cuff of the surgical glove creates a workspace and airtight seal. Through the fingers of the glove, standard laparoscopic trocar sleeves are inserted (along with a gas sufflation channel) through which a conventional 30-degree videoscope along with straight rigid laparoscopic instruments are inserted. Excellent views can be obtained with the regular laparoscopic optics after the creation of a stable pneumorectum of 10-15mmHg. The same principles apply for the dissection and resection as with a conventional TEM. The flexibility of the glove provides enhanced instrument maneuverability in each of the horizontal, vertical and rotational planes as well as improved tip abduction and adduction especially useful for suturing.
Results: Initial preliminary work standardised both set-up and application of the apparatus and confirmed it outperformed commercially available counterparts in this application with regard to stability, instrument maneuverability and range of movement. Thereafter, all patients eligible for TEM have been offered the option to participate in our pilot study. With this new access modality, ten consecutive patients between October 2010 and January 2011 underwent resection of benign (n=6) or malignant (n=4) rectal tumours. Only one case had to be converted to a conventional TEM procedure because anatomical features prohibited inserting the CAD high enough into the anal canal. The case we present here is a full-thickness excision of an early rectal cancer in an 87 year old female patient who was unfit for the conventional radical rectal resection.
Conclusions: The glove TEM port is a safe, cheap and readily available tool that can be used in combination with regular laparoscopic tools for transanal resection of rectal lesions. It is surgeon friendly, economically attractive and universally applicable.