Transanal Video Assisted Surgery Using Single Access Port-initial Experience and Lessons Learned

Irene J Lo, MD, Paul Suding, MD, Giovanni Begossi, MD, Rupert Horoupian, MD, Ajay K Upadhyay, MD. Alta Bates Summit Medical Center (Oakland and Berkeley, California), St. Rose Hospital (Hayward, California).

Transanal endoscopic microsurgery (TEM) was initially developed in the early 1980s as a minimally invasive option for the surgical management of rectal neoplasms and has been reported as a safe, effective, and more efficient alternative to traditional surgical techniques. However, the instrumentation and equipment is not readily available and requires a capital set up cost. Recently, utilization of laparoendoscopic single site (LESS) port devices for transanal video assisted excision of middle and upper rectum lesions have been reported by several authors. However, the use of video assisted single site port instrumentation requires some adjustment and getting used to as well as a willingness to experiment with different devices and instrumentation. In this presentation, we report our early experience and the lessons learned from using a variety of single site ports, instrumentation, suture devices, different laparoscopic lenses, and high definition video.

Our center maintains a database of prospectively collected patient information. Using this database, we identified patients who underwent Transanal Video Assisted Surgery. Indications were adenoma, carcinoid, early carcinoma, and rectovaginal fistula.

From December 2011 to May 2013, ten patients underwent a total of eleven Transanal Video Assisted Surgeries. These procedures were performed by both attending surgeons as well as minimally invasive surgery fellows. Single access ports were used, including the SILS port (Covidien, Inc, Westbury, MA). For these procedures, a variety of laparoscopic lenses were utilized, including flexible tip cameras, standard length lenses, bariatric length lenses, and the Endochameleon lens (Karl Storz, Tuttlingen Germany). Suturing techniques for closure of the defect, if suturing was performed, were performed with Endostitch (Covidien, Inc, North Haven, CT) or direct suturing techniques. One patient required a second procedure in order to obtain adequate deep margins. One patient required diagnostic laparoscopy in order to ensure that the lesion of interest was below the peritoneal reflection. During our early experience with transanal video assisted surgery, closure of the defect was not performed. However, with one of our patients developing post-operative bleeding and pelvic sepsis, all defects subsequent to this were closed. All patients were discharged on the same hospital day as their procedure. One patient required re-admission due to the development of pelvic sepsis, deep vein thrombosis, and pulmonary embolism, which was later determined to be secondary to a Protein S deficiency.

Transanal excision of mid and upper rectal lesions can easily be performed using laparoscopic instrumentation and laparoendoscopic single site (LESS) port devices that are readily available. This transanal video assisted surgery, from our experience, can be easily taught as our procedures have been performed by both minimally invasive surgery fellows in training as well as attending surgeons. We have found that, for lesions located in different quadrants of the rectum, utilizing different camera tips and lenses can be very helpful. We have also found that employing different suturing techniques can also aid in closure of the defects that remain after excision.

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