Transendoscopic Microsurgery/ Transendoscopic Operation

TEM

achalasia surgery

Despite recent advances in chemo-radiotherapy, surgery still plays an important role in the curative treatment for rectal cancers. The choice of surgical intervention depends on the location of the tumor, depth of rectal wall invasion, as well as clinical stage of the disease. Surgical options include local excision such as transanal excision and transanal endoscopic microsurgery (TEM), and radical resection such as low anterior resection, extended low anterior resection with colo-anal anastomosis, abdomino-perineal resection (APR), as well as pelvic exenteration. If the cancer is found in a polyp, a polypectomy can be performed. Many considerations (e.g., morbidity, sexual and urinary dysfunction, and/or risk of definitive stoma) have led to the increased popularity of local excision in the management of patients with rectal cancer. However, its role as a curative treatment is still controversial with oncological long-term results lower than those obtained by radical resection.
Currently, TEM is the only endoscopic technique that uses a natural opening to reach the target organ, and is a valuable surgical technique with a low complication rate for patients with early rectal cancer. The main advantage of TEM is preservation of the rectum. Other advantages include better exposure, magnified stereoscopic view, and greater reach into the middle and upper rectum. This procedure was introduced in the early 1980s; its first indication was excision of rectal adenomas. Indication for TEM was later extended to low-risk rectal cancer. Many studies reported that TEM is the optimal procedure to avoid complications for patients with rectal polyps and low-risk pathological T1 (pT1) rectal tumors.
achalasia surgery The equipment necessary for TEMS is shown in Picture 1. This consists of the operating 4 centimetres diameter sigmoidoscope, the 0 degree telescope, laparoscopic atraumatic forceps, laparoscopic diathermy or vessel sealer, laparoscopic irrigation-suction device. The above instruments are connected to a standard laparoscopic "stack" incorporating a gas source, a light source and a high resolution monitor.
Full bowel preparation is required pre-operatively. The patient is put in lithotomy position and the whole procedure is performed transanally unless there is a (rare) complication of intra-abdominal perforation of the rectum. General anaesthetic is used mostly although the author and others have performed cases under spinal anaesthesia. The duration of the procedure depends on a number of technical factors such as size and height of the lesion as well as factors to do with the equipment and can vary from 30 minutes to 3 hours. After the operation the patient can drink and eat immediately and can receive oral analgesia without the need for pareneteral opiates. In most cases discharge is within 24 hours. Temporary minor urgency incontinence may occasionally occur for a few days, and although laboratory measurements of anorectal function are altered short term, in all so far reported series there is no problem of long term incontinence.