Advanced Techniques for Transanal Excision of Rectal Tumors
Advanced Techniques for Transanal Excision of Rectal Tumors
Advanced Techniques for Transanal Excision of Rectal Tumors
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<strong>Advanced</strong> <strong>Techniques</strong><br />
<strong>for</strong> <strong>Transanal</strong> <strong>Excision</strong><br />
<strong>of</strong> <strong>Rectal</strong> <strong>Tumors</strong><br />
Jennifer M. Ayscue, MD, FACS, FASCRS<br />
Washington Hospital Center<br />
Assistant Pr<strong>of</strong>essor, Surgery<br />
Georgetown University
<strong>Transanal</strong> Options<br />
• Straight transanal excision<br />
• Sutured (clip, tie, v-loc)<br />
• Stapled<br />
• With transacral manipulation<br />
• <strong>Transanal</strong> endoscopic microsurgery<br />
• <strong>Transanal</strong> minimally invasive surgery<br />
• Transacral excision
Patient Selection<br />
• Below the rectosigmoid junction<br />
• Accessible with planned technique<br />
• Tumor characteristics:<br />
• Benign lesions<br />
• Early stage tumors with appropriate features<br />
• Definitive diagnosis needed (Biopsy)<br />
• Patient characteristics
“Straight” <strong>Transanal</strong> <strong>Excision</strong><br />
• Approximately 0-10cm from the anal verge<br />
• Able to control and visualize the upper margin<br />
• May be used with large or circumferential lesions<br />
• Sutured vs Stapled
Measuring Lesion From the<br />
Anal Verge<br />
8cm<br />
10cm
Straight <strong>Transanal</strong> <strong>Excision</strong><br />
“The Lone Star”<br />
Anal<br />
Verge<br />
Dentate<br />
Line
<strong>Transanal</strong> <strong>Excision</strong>
<strong>Transanal</strong> <strong>Excision</strong>:<br />
• Visualization may be<br />
difficult<br />
• Restricted space<br />
• Appropriate margins<br />
(proximal)<br />
• Complete excision<br />
without<br />
fragmentation if<br />
possible<br />
Concerns
<strong>Transanal</strong> <strong>Excision</strong> with Transsacral<br />
<strong>Rectal</strong> Manipulation
• Since 1990<br />
<strong>Transanal</strong> Endoscopic<br />
• Improved visualization<br />
• 3D in binocular scope<br />
• Adequate margins- better<br />
proximal margin<br />
• Specialized equipment<br />
(expensive)<br />
• Learning curve<br />
Microsurgery
<strong>Transanal</strong> Endoscopic<br />
• Positioning important<br />
• Dependent on tumor<br />
location<br />
• Anatomic restrictions <strong>of</strong><br />
rectum and sigmoid<br />
Microsurgery
<strong>Transanal</strong> Endoscopic<br />
1. Outline the lesion<br />
Microsurgery<br />
2. Excise the lesion
<strong>Transanal</strong> Endoscopic<br />
3. Large defect<br />
Microsurgery<br />
4. Close defect
TEM: <strong>Excision</strong> <strong>Rectal</strong> Adenoma
Pitfalls
<strong>Transanal</strong> Minimally Invasive<br />
• First tried around 2009<br />
• Adaptation <strong>of</strong> laparoscopic<br />
equipment <strong>for</strong> transanal<br />
excision<br />
• May be used by any center<br />
who has laparoscopic<br />
capabilities<br />
• Learning curve<br />
• Visualization better with<br />
articulating-tip camera<br />
Surgery (TAMIS)
TAMIS
TAMIS
Robotic-assisted <strong>Transanal</strong> Endoscopic<br />
Minimally Invasive Surgery<br />
• Joins together articulating<br />
instrument capabilities into<br />
a small space<br />
Best <strong>of</strong> Both Worlds!
Robotic-assisted <strong>Transanal</strong> Endoscopic<br />
Minimally Invasive Surgery<br />
• 1 st procedure done in January 2012, Orlando FL<br />
<strong>Excision</strong> <strong>of</strong> a rectal neoplasm using robotic transanal surgery (RTS): a description <strong>of</strong> the<br />
technique ; S. Atallah, E. Parra-Davila, T. deBeche-Adams, M. Albert, S. Larach
Trans-sacral <strong>Excision</strong><br />
• Below S2 generally<br />
• Repeat operations, anal stenosis<br />
• Submucosal or retrorectal masses<br />
• Large posterior tumor with poor visualization<br />
transanally
Trans-sacral <strong>Excision</strong><br />
Presacral/Retrorectal Mass
Trans-sacral <strong>Excision</strong><br />
Presacral/Retrorectal Mass
Trans-sacral <strong>Excision</strong><br />
<strong>Rectal</strong> Mass
Trans-sacral <strong>Excision</strong><br />
<strong>Rectal</strong> Mass
Conclusions<br />
• Little significant change in the last 20-25 years<br />
regarding transanal excision<br />
• Robotic excision will likely be the gold standard<br />
when more technically user friendly in the future<br />
• May be bridge to NOTES as instrumentation<br />
improves.
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