A combination of transanal minimally invasive surgery and transanal technique to facilitate suturing during transanal minimally invasive surgery

Introduction

Rectal cancer accounts for approximately 28% of all colorectal cancers in the United States (1). Radical proctectomy with total mesorectal excision is the standard operation for most patients with rectal cancer as it ensures removal of the lymph nodes in the mesorectum (2,3). However, this approach can be associated with high morbidity and poor functional outcomes (4).

Alternatively, local excision is an option for patients with benign, noninvasive lesions, or selected early stage rectal cancers. Transanal minimally invasive surgery (TAMIS), introduced in 2009 Dr. Albert et al., is a safe and effective option for local excision, as it provides direct visualization and precise dissection of the lesion (5-11). The use of standard or modified laparoscopic instruments along with an easy set-up has made TAMIS readily available to a wide group of surgeons (11). One of the difficulties with TAMIS is suturing the defect closed and maintaining adequate suture tension due to the small work space with limited triangulation (7,12,13). Several attempts have been made to overcome this difficulty with the use of self-locking sutures (9,10), endo-GIA staplers (11), and intracorporeal suturing with the aid of knot pushers (7,8). Nevertheless, suturing in TAMIS remains challenging.

We present a 64-year-old female with a T1N0 adenocarcinoma located anteriorly in the mid-rectum 10 cm above the anal verge (7 cm above the sphincter). This case demonstrates a transanal suturing technique which can be used with TAMIS allowing the surgeon to avoid the maneuvering difficulties encountered with laparoscopic suturing.

Patient selection and workup

A 64-year-old female was diagnosed with a 2 cm T1N0 adenocarcinoma located anteriorly in the mid-rectum 10 cm above the anal verge. The lesion was identified during a routine screening colonoscopy and confirmed on biopsy. Endorectal ultrasound revealed early submucosal invasion (sm1). Computed tomography (CT) of the chest, abdomen, and pelvis was negative for metastatic disease. An MRI of the pelvis showed no obvious mesorectal lymph node involvement. Pre-operative carcinoembryonic antigen was 0.6. Multiple surgical options were discussed with the patient; however, a TAMIS’s excision of this early stage T1 mid-rectal lesion was agreed to be the best approach.

Preoperative preparation

The patient received mechanical bowel preparation with polyethylene glycol one day prior to the procedure and was instructed to fast at least 6 hours prior to surgery. Prophylactic antibiotics (One gram of ertapenem) were administered within 30 minutes of the initial incision. The appropriate consent was obtained from the patient per the institutional protocol.

Equipment preference card

• 30 degree 5 mm laparoscopic camera;
• Maryland forceps;
• Monopolar electrocautery hook;
• Self-retaining wound retractor;
• GelPOINT Path Transanal Access Platform (Applied Medical TM, Rancho Santa Margarita, CA, USA);
• 3–0 Vicryl sutures.

Procedure

The operative procedure is demonstrated in Figure 1. After induction with general anesthesia the patient was placed in the prone jackknife position with the buttocks taped apart. The prone position was preferred in this patient because it places the anterior rectal lesion in the lower half of the visual field. The anal canal was prepped with povidone-iodine solution and the patient was draped in the usual sterile fashion. Digital rectal examination and anoscopy were performed to confirm anterior orientation of the lesion and its 10 cm distance from the anal verge.

Figure 1 Video demonstrating the hybrid laparoscopic and open approach to suturing in transanal minimally invasive surgery (TAMIS) (14). Available online: http://www.asvide.com/articles/1018

A self-retaining wound retractor was placed in the anal canal followed by a GelPOINT Path Transanal Access Platform (Applied Medical TM, Rancho Santa Margarita, CA, USA). Pneumorectum was established with CO₂ insufflation to 15 mmHg. A 5 mm camera was inserted along with two additional 5 mm instruments. In our case, the operating surgeon was positioned to the left of the patient and the assistant was positioned between the patient’s legs.

Initially, a 1 cm perimeter around the lesion was marked with electrocautery to delineate the resection margins. Subsequently, a full-thickness excision into the underlying mesorectal fat was performed. Careful dissection around the specimen was performed without direct manipulation of the tumor to avoid violation of oncological planes. Occasionally, the incision will extend into the free peritoneal space, as in this case. An adequate bowel preparation is thus essential to avoid peritoneal contamination. The specimen was then completely excised in a discoid fashion, while maintaining its orientation. It was extracted through the self-retaining wound retractor after removal of the gel-port. Gross inspection revealed a sufficient circumferential margin without tumor perforation.

At this point, we planned to close the defect transversely in two layers (peritoneum and full thickness bowel) with a hybrid TAMIS and transanal approach. We began by placing a midline stay suture across the distal and proximal edges of the defect using the TAMIS technique. Next, the GelPOINT cap was removed while the wound retractor remained in place. Using the midline stay suture, the defect was brought towards the surgeon to allow for further stepwise closure in the open technique. In our case, two layers of interrupted sutures (3–0 vicryl) were placed in a figure-of-eight fashion to close the peritoneal and bowel layers. The sutures were tied via an open technique through the wound retractor, negating the need for knot-tying devices. Upon completion of the closure, the GelPOINT device was re-inserted and the rectum insufflated to adequately visualize the closure and ensure hemostasis.

Total operative time was 91 minutes. Final pathology revealed a 0.7 cm T1 well-differentiated adenocarcinoma 0.8 cm from the closest resection margin.

Postoperative management

The patient was admitted for overnight observation post-operatively. On post-operative day 1, the patient was discharged after tolerating diet. Surveillance colonoscopy and CT of the chest, abdomen and pelvis were done at 1 year follow-up and revealed no evidence of local or systemic recurrence. The patient did not have any symptoms of incontinence or other bowel dysfunction at any time during her 24 months follow-up.

Tips, tricks, and pitfalls

• Good bowel preparation remains crucial for the prevention of intraperitoneal contamination if entrance into the peritoneal cavity occurs;
• TAMIS procedure allows for a very controlled resection of selected rectal lesions. The midline stay suture, placed in the TAMIS, allows the defect to be approximated by the surgeon through the wound retractor after removal of the gel-port;
• With the defect brought through the wound retractor, the surgeon can close the defect via the standard transanal technique;
• The open modification of the suturing technique can be easily dispersed among surgeons who are familiar with transanal approaches yet are not facile with laparoscopic/TAMIS suturing;
• Closure of the defect with interrupted sutures facilitates closure of large rectal defects.

Conclusions

TAMIS is a safe and effective option for removal of benign lesions and low grade T1 adenocarcinomas of the rectum. We have demonstrated a hybrid TAMIS and transanal approach which addresses certain challenges of laparoscopic suturing encountered in TAMIS.

Acknowledgements

None.

Footnote

Conflicts of Interest: The authors have no conflicts of interest to declare.

Informed Consent: Written informed consent was obtained from the patient for publication of this manuscript and any accompanying images.

References

1. American Cancer Society. Colorectal Cancer Facts and Figures 2014-2016. Atlanta: Ameri-can Cancer Society, 2014.
2. Monson JR, Weiser MR, Buie WD, et al. Practice parameters for the management of rectal cancer (revised). Dis Colon Rectum 2013;56:535-50. [Crossref] [PubMed]
3. Heafner TA, Glasgow SC. A critical review of the role of local excision in the treatment of early (T1 and T2) rectal tumors. J Gastrointest Oncol 2014;5:345-52. [PubMed]
4. Endreseth BH, Myrvold HE, Romundstad P, et al. Transanal excision vs. major surgery for T1 rectal cancer. Dis Colon Rectum 2005;48:1380-8. [Crossref] [PubMed]
5. Keller DS, Tahilramani RN, Flores-Gonzalez JR, et al. Transanal Minimally Invasive Surgery: Review of Indications and Outcomes from 75 Consecutive Patients. J Am Coll Surg 2016;222:814-22. [Crossref] [PubMed]
6. Martin-Perez B, Andrade-Ribeiro GD, Hunter L, et al. A systematic review of transanal min-imally invasive surgery (TAMIS) from 2010 to 2013. Tech Coloproctol 2014;18:775-88. [Crossref] [PubMed]
7. Lim SB, Seo SI, Lee JL, et al. Feasibility of transanal minimally invasive surgery for mid-rectal lesions. Surg Endosc 2012;26:3127-32. [Crossref] [PubMed]
8. McLemore EC, Weston LA, Coker AM, et al. Transanal minimally invasive surgery for be-nign and malignant rectal neoplasia. Am J Surg 2014;208:372-81. [Crossref] [PubMed]
9. Verseveld M, Barendse RM, Gosselink MP, et al. Transanal minimally invasive surgery: im-pact on quality of life and functional outcome. Surg Endosc 2016;30:1184-7. [Crossref] [PubMed]
10. Barendse RM, Doornebosch PG, Bemelman WA, et al. Transanal employment of single ac-cess ports is feasible for rectal surgery. Ann Surg 2012;256:1030-3. [Crossref] [PubMed]
11. Atallah S, Albert M, Larach S. Transanal minimally invasive surgery: a giant leap forward. Surg Endosc 2010;24:2200-5. [Crossref] [PubMed]
12. Rimonda R, Arezzo A, Arolfo S, et al. TransAnal Minimally Invasive Surgery (TAMIS) with SILS™ port versus Transanal Endoscopic Microsurgery (TEM): a comparative experimental study. Surg Endosc 2013;27:3762-8. [Crossref] [PubMed]
13. Diana M, Dhumane P, Cahill RA, et al. Minimal invasive single-site surgery in colorectal procedures: Current state of the art. J Minim Access Surg 2011;7:52-60. [PubMed]
14. Christie R, Sugrue J, Marecik S, et al. Video demonstrating the hybrid laparoscopic and open approach to suturing in transanal minimally invasive surgery (TAMIS). Asvide 2016;3:256. Available online: http://www.asvide.com/articles/1018