Sam B Atallah, MD, FACS, FASCRS, Matthew R Albert, MD, FACS, FASCRS. Florida Hospital
Since the inception of laparoscopy, there has been considerable development in instrumentation, cameras, and lens quality. Nearly all aspects of laparoscopy have seen advancement, except for insufflation, which has remained essentially unchanged over the past three decades. However, as surgeons are performing more challenging procedures, a need for improving the existing platforms has become necessary. Transanal minimally invasive surgery (TAMIS) has allowed surgeons to perform advanced transanal procedures, from local excision to (more recently) transanal total mesorectal excision (TME). While TAMIS for local excision and TME can be successfully performed with the existing CO2 insufflators used for laparoscopy, bellowing of the rectal lumen and pelvis as well as excessive smoke accumulation are often observed limiting visibility and thereby increasing operative time. However, a valveless trocar system can deliver stable pneumatics by using a specialized trocar, tubing, and insufflation machine. By separately regulating smoke evacuation, gas inflow, and pressure parameters, stable pneumatics are achieved and the end results is the near complete absence of smoke and bellowing during TAMIS procedures. This video demonstrates the potential benefits of the valveless trocar system when it is used with TAMIS for local excision and transanal TME.