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Transanal Endoscopic Surgery for Rectal Cancer

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Abstract

The resection of the rectum and its mesorectal envelope, an operation known as total mesorectal excision (TME), is the optimal surgical treatment for most rectal cancer patients. However, this procedure is associated with multiple complications and high rates of bowel and genitourinary alterations that significantly impact quality of life. In addition, some patients with early tumors that have not penetrated the rectal wall or reached the mesorectal lymph nodes may not benefit from TME. Some of these tumors, particularly those invading the submucosa but not beyond, can be treated by means of local excision (LE).

Transanal endoscopic microsurgery (TEM) was developed in the 1980s as a way to improve the outcomes of LE and expand the possibility of organ preservation for tumors located up to 20 cm from the anal verge. The TEM equipment provides direct vision through a stereoscopic rectoscope and allows precise excision and suturing with the help of specially designed instrumentation. Transanal endoscopic operation (TEO), which uses standard laparoscopic instrumention and insufflation, emerged later as a simplification of TEM.

In this chapter we offer a step-by-step description of the standard TEM/TEO technique, outline the different types of equipment used in TEM and TEO, and examine the technical limitations. We also provide an overview of the pre- and postoperative management and discuss outcomes.

Keywords

  • Transanal endoscopic microsurgery (TEM)
  • Transanal endoscopic operation (TEO)
  • Transanal endoscopic surgery
  • Local rectal excision
  • Rectal adenomas
  • Rectal cancer
  • Rectal adenocarcinoma

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Correspondence to Xavier Serra-Aracil M.D. .

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In this video, the surgeon demonstrates his approach to transanal endoscopic surgery (TEM). (MP4 149228 kb)

Key Operative Steps

  1. 1.

    Place Foley catheter and decompress the bladder.

  2. 2.

    Position the patient according to the location of the tumor.

  3. 3.

    Place the rectoscope over the lesion to gain access to the entire perimeter.

  4. 4.

    Initiate dissection by marking a circumferential dotted line 10–15 mm from the tumor.

  5. 5.

    Perform a full-thickness wall excision.

  6. 6.

    After completing excision, irrigate with povidone-iodine solution to induce cytolysis.

  7. 7.

    After completing excision, mark and orient the specimen to ensure all margins are appropriately analyzed by pathology.

  8. 8.

    Close the rectal mucosal defect with technique to avoid stenosis of the lumen.

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Serra-Aracil, X., Mora-Lopez, L. (2015). Transanal Endoscopic Surgery for Rectal Cancer. In: Kim, J., Garcia-Aguilar, J. (eds) Surgery for Cancers of the Gastrointestinal Tract. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-1893-5_28

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  • DOI: https://doi.org/10.1007/978-1-4939-1893-5_28

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