A New Reusable Platform for TransAnal Minimally Invasive ... … · innovation in conventional...

IIntroduction: TransAnal Minimally Invasive Surgery (TAMIS) has generated interest and attracted research

in the last decade. This approach is used to treat primary benign and malignant diseases, but it can also be

adopted to resolve colorectal complications, such as leak and fistula, bleeding and stenosis. A new reusable

transanal platform formed by a new port and monocurved instruments has been invented and here presented.

Materials and Methods: The first experience included 13 patients submitted to TAMIS for rectal

adenocarcinoma (8), immediate colorectal leak (1), early rectovaginal fistula (1), late colorectal fistula (1),

immediate colorectal bleeding (1), and benign stenosis (1). Mean age was 62.3 years (38-74), and mean BMI

was 25.2 kg/m2 (20.5-32.1).

A New Reusable Platform for TransAnalMinimally Invasive Surgery:

First ExperienceGIOVANNI DAPRI, MD, PHD, FACS

PROFESSOR OF SURGERY

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ABSTRACT

General SurgerySURGICAL TECHNOLOGY INTERNATIONAL XXVIII

DANIEL GUTA, MDFELLOW

LUCA CARDINALI, MDFELLOW

CLAUDIA MAZZETTI, MDFELLOW

ANNY CADENAS FEBRES, MDFELLOW

KONSTANTIN GROZDEV, MDFELLOW

SIXTE-HENRY SONDJI, MDASSISTANT

ION SURDEANU, MDASSISTANT

GUY-BERNARD CADIÈRE, MD, PHD PROFESSOR OF SURGERY & DIRECTOR

DEPARTMENT OF GASTROINTESTINAL SURGERYEUROPEAN SCHOOL OF LAPAROSCOPIC SURGERY

SAINT-PIERRE UNIVERSITY HOSPITALBRUSSELS, BELGIUM

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In the last decade thanks to the Nat-ural Orifice Translumenal EndoscopicSurgery (NOTES), laparoscopic surgerythrough the anus has drawn attentionand investment in both surgical and

research endeavors. Because the anus isa natural orifice, it has already beenused to extract specimens from theabdominal cavity, a procedure thatavoids enlarging the abdominal trocarscar or performing a supplementaryabdominal incision.1,2 Consequently,this approach reduces abdominal trauma

and the risk of postoperative incisionalhernias. TransAnal Minimally Invasive

Surgery (TAMIS) represents a recentinnovation in conventional laparoscopy,one which adopts the instrumentsand scopes of general abdominallaparoscopy for procedures performed

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A New Reusable Platform for TransAnal Minimally Invasive Surgery: First ExperienceDAPRI/GUTA/CARDINALI/MAZZETTI/FEBRES/GROZDEV/SONDJI/SURDEANU/CADIÈRE

INTRODUCTION

Results: Mean operative time for transanal total mesorectal excision (TME) was 149.2 minutes (96-193) and for

the other procedures 80.6 minutes (15-163). Mean operative bleeding was 51.1 cc (0-450). Mean hospital stay

was 5.0 days (2-8). The 3 patients with coloanal anastomosis presented diarrhea postoperatively. No other

early postoperative complications were registered. Pathologic report in the oncologic diseases showed that a

mean number of 14.7 nodes (16-20) were removed. After a mean follow-up of 8 months (1-14), there were no

late complications in any of the 13 patients treated.

Conclusion: TAMIS is a feasible alternative approach to treat rectal cancer and a completely new technique

to manage colorectal complications. Moreover, this new transanal platform offers surgeons a satisfactory

working ergonomy, with no increase in cost of the procedures, because entirely reusable materials are

adopted.

Table I

ONCOLOGIC

PATIENTS SexAge(years)

BMI (kg/m2)Anal margindistance (cm)

Neoadjuvant chemoradiation

Post-therapyTNM stade

Protectivestoma

Anastomosistype

1 F 69 24.6 10 yes T2N1M0 No ColoRectal

2 M 65 23.6 4 yes T3N1M0 Yes ColoRectal

3 M 58 22.8 2 yes T3N0M0 No ColoAnal

4 F 58 21.4 10 yes T3N1M0 No ColoRectal



7 M 64 20.5 6 yes T2N0M0 Yes ColoRectal

8 F 69 27.3 5.5 yes T2N0M0 Yes ColoRectal

NON-ONCOLOGIC

PATIENTS SexAge(years)

BMI (kg/m2)Anal margindistance (cm)

Disease Radius (cm)Protectivestoma

9 F 50 27.6 4intraoperative

anastomotic leak0.5 Yes

10 F 74 22.3 12 early anastomotic fistula 2.0 Yes

11 M 65 32.1 11 late anastomotic fistula 1.0 Yes

12 M 38 27.1 2.5 stenotic ulcer 0.8 No

13 F 69 27.3 2.5intraoperative

anastomotic bleeding0.5 Yes

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through the anus. This approach allowsthe surgeon to perform the totalmesorectal excision (TME) with auto-nomic nerve preservation through a dif-ferent and new route called“down-to-up” TME.3 TAMIS is advanta-geous because it pinpoints the exactlocation of the rectal lesion and initiatesdissection just below it, to reveal the so-called “holy plane” with a magnificationof the operative field’s exposure. Magni-fied exposure reveals a bloodless planeof dissection with more evidence of thelateral sacral nerves, thereby avoidingfirings of the stapler to transect the rec-tum. The specimen can then beremoved transanally. On the otherhand, a high learning curve is required,as has been the case with TransanalEndoscopic Microsurgery (TEM).4Additional applications of TAMIS

include the resection of endoluminalbenign rectal lesions or early stage rec-tal adenocarcinoma,5,6 and treatmentof complications such as leak andfistula,7 bleeding,8 and stenosis.9TAMIS can be performed using

disposable ports developed for SingleIncision Laparoscopy (SIL), such as theflexible SILS Port (Covidien, NewHaven, Connecticut), the flexible Gel-POINT Path (Applied Medical, RanchoSanta Margarita, California), the flexi-ble KeyPort (Richard Wolf GmbH,Knittlingen, Germany), the flexibleTriPort (Advanced Surgical Concepts,Wicklow, Ireland), the flexible LapDisc Mini (HAKKO Group, Nagano,Japan), the r ig id Endorec (AspideMedical, Saint-Étienne, France), therigid Single Site Laparoscopy (SSL)Access System (Ethicon Endo-Surgery,Cincinnati, Ohio); or reusable plat-forms developed for TEM, such as therigid Transanal Endoscopic Operation(TEO) System (Karl Storz -Endoskope, Tuttlingen, Germany) orthe rigid Wolf TEM System (RichardWolf GmbH, Knittlingen, Germany).Finally, the instruments implementedthrough the transanal port can be dedi-cated instruments for transanal plat-forms, SIL-dedicated instruments, orconventional instruments for generallaparoscopy. A new reusable transanal platform

consisting of a new port and mono-curved instruments has been inventedand is here presented. The first expe-rience of transanal rectal resection andmanagement of colorectal complica-tions is described as well.

Materials and Methods

PatientsBetween February 2015 and January

2016, 13 patients underwent TAMIS.Eight patients were affected with rectaladenocarcinoma (Table I), 1 patient pre-sented with an immediate colorectalanastomotic leak at leak test after laparo-scopic anterior rectal resection (LARR),1 patient presented with an early recto-vaginal fistula after 3 weeks of LARR plushysterectomy, 1 patient presented with alate colorectal fistula after 4 weeks ofLARR, 1 patient presented an immediate

colorectal anastomotic bleeding after cir-cular mechanical anastomosis, and 1patient presented with a benign circum-ferential stenosis due to rectal ulcer. Thefollowing procedures were performed: 8transanal TME, 3 leak/fistula repairs, 1bleeding repair, and 1 total mucosectomy.If the outcome of a procedure

required it, a temporary protective stomawas created by ileostomy. The mean age of the patients was

62.3 years (38-74), and mean BMI was25.2 kg/m2 (20.5-32.1). The patientswith rectal adenocarcinoma and pre-operative TNM stage > T2N0 under-went neo-adjuvant chemoradiation.

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Figures 2a-g. Monocurved reusable instruments according to DAPRI (Karl Storz - Endoskope, Tuttlingen,Germany): grasping forceps (a), anvil grasping forceps (b), needle holder (c), scissors (d), coagulatinghook (e), bipolar forceps (f), bipolar scissors (g).

MATERIALS AND METHODS

Figure 1. Transanal reusable DAPRI Port or D-Port (Karl Storz - Endoskope, Tuttlingen, Germany).

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During the transanal TME, abdominallaparoscopy (for the vascular dissection,sigmoid and left colons mobilization,splenic flexure download) was per-formed before the transanal dissection. Operative time was measured in

minutes, between insertion of the D-Portand its removal at the end of the proce-dure. Operative bleeding was observed atthe end of the transanal approach.

Transanal port and instrumentsThe transanal platform is formed by

the reusable DAPRI Port or D-Port (KarlStorz - Endoskope, Tuttlingen, Germany)(Fig.1) and the DAPRI monocurvedreusable instruments (Figs. 2a-g) (KarlStorz - Endoskope, Tuttlingen, Ger-many). The components of the D-Port are

completely reusable; as a result, the pro-cedure does not increase cost. The D-Port consists of 3 parts:

1.Tube (Fig. 3): 30 mm diameter and7.5 cm length, facilitating its intro-duction through the anal verge with-out any anal dilatation. It allows theuse of a 10-mm scope and two5-mm instruments, without anyclushing of the two instruments’ tipsduring dissection, resection andsuturing. It permits contemporaryinsufflation and desufflation of CO2,evacuating the smoke created duringthe dissection. It is supported by 4oval holes, which allow the port torotate if necessary. Finally, 4 cardinalpoints are marked inside the tube toorientate the surgeon during theoperation.

2.Obturator (Fig. 4): used for theintroduction of the tube through theanal verge. It is removed before thesilicon cap is placed.

3.Silicon cap (Fig. 5): formed by 3orifices (6-mm, 11-mm, 6-mm)aligned on the same horizontal line.It permits the instruments to movefreely outside the port. The orificespermit the introduction of the10-mm scope in the middle and ofthe two ancillary 5-mm tools onboth sides. This disposition followsthe principle of conventionallaparoscopy, which is to maintain theoptical system in the center as thebisector of the working triangulationformed by two ancillary tools.10

The monocurved reusable instru-ments are similar in shape and allow a

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Figure 5. Parts of the D-Port: silicon cap.

Figure 3. Parts of the D-Port: tube.

Figure 4. Parts of the D-Port: obturator.

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certain degree of freedom in intralumi-nal work, thereby providing anergonomic benefit to the surgeon.

Transanal TME with colorectalanastomosisThis procedure is initiated with a

laparoscopic approach through theabdomen, permitting vascular dissection(inferior mesenteric vein and artery),sigmoid and left colons mobilization, andsplenic flexure download. The abdomi-nal laparoscopy ends when the dissectionreaches the promontory. Then TMEbegins with the insertion of the transanalD-Port through the anus (Fig. 6a). Theport is fixed to the skin by four sutures.A 10-mm, 30º scope is inserted in themiddle opening of the D-Port. The rec-tal lumen is checked to identify the rec-tal tumor. A gauze is pushed beyond therectal tumor, to prevent the stools fromflowing out. The monocurved graspingforceps (Fig. 2a) and the anvil graspingforceps (at the end of the procedure)

(Fig. 2b) are inserted at the 9 o’clockorifice of the D-Port (Fig. 6b). Theother instruments, like the monocurvedneedle holder (Fig. 2c), the monocurvedscissors (Fig. 2d), the monocurvedcoagulating hook (Fig. 2e), the mono-curved bipolar forceps (Fig. 2f) and scis-sors (Fig. 2g), are inserted at the 3o’clock orifice of the D-Port (Fig. 6c). A safe margin, distally from the

tumor, is chosen and a purse-stringsuture using Prolene 2/0 is placed intothe rectal mucosa and submucosa, usingthe monocurved grasping forceps andthe monocurved needle holder (Fig. 7).Then the mucosa directly under thepurse-string suture is incised until theentire rectal wall is perforated, reachingthe perirectal fatty tissue. The TME isperformed from bottom-to-top, first

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Figures 6a-c. Insertion of the D-Port into the anal canal (a); insertion of the monocurved instruments at 9 (b) and 3 o’clock opening of the D-Port (c).

Figure 7. Intraluminal purse-string suture into therectal mucosa and submucosa, distally to thetumor.

Figures 8a-d. TME performed first going posteriorly and respecting the presacral fascia (a); then on theleft side (of the patient) (b); then on the right side (of the patient) (c); finally anteriorly between therectum and the prostate (male) or the vagina (female) (d).

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proceeding posteriorly and respectingthe presacral fascia (Fig. 8a). Then theTME is completed laterally, on the leftside of the patient (Fig. 8b), and on theright side of the patient (Fig. 8c). Thedissection is finally performed anteriorly,taking care to dissect the correct planebetween the rectum and the prostate(male) or the vagina (female) (Fig. 8d).The dissection continues upward,respecting the presacral fascia, reachingthe seminal vesicles (male) or the uterinecervix (female), using both mono-curved coagulating hook and mono-curved bipolar scissors. Finally, thetransanal dissection joins the previousdissection performed by abdominallaparoscopy (Fig. 8d). The rectal-sigmoid colon is encircled

by a plastic protection and removedtransanally, after the D-Port is removed(Fig. 9). The level of the colic transec-tion is found, the left colon is sectioned,and the specimen is sent for pathologyexamination. The anvil of the circular

stapler is introduced into the lumen.The colic lumen is closed by a Prolene2/0 purse-string suture. The colon andanvil are pushed into the pelvis and theD-Port is repositioned. The rectalstump is closed transanally by a Prolene2/0 purse-string suture, using themonocurved grasping forceps and themonocurved needle holder (Fig.10a).The monocurved anvil grasping for-ceps is introduced to grasp the anvil(Fig.10b) before pushing the rectalknot. Then, the suture is cut and theD-Port is removed. The circular stapleris introduced transanally, and the anvil isattached to it, through the monocurvedanvil grasping forceps. The anastomosisis performed under abdominal laparo-scopic view (Fig.10c).Through the abdomen, the pelvis is

immersed under physiologic solution,and the anastomotic leak test is per-formed.

Transanal TME with coloanalanastomosisThis procedure is initiated with a

laparoscopic approach through theabdomen, permitting vascular dissection(inferior mesenteric vein and artery),sigmoid and left colons mobilization,and splenic flexure download. Theabdominal laparoscopy ends when thedissection reaches the promontory.Then TME is begun. A gauze is insertedinto the anal canal, to avoid potentialfecal contamination. The Lone Starretractor (Cooper Surgical, Trumbull,Connecticut) is positioned, and the analmucosa is injected with lidocaine 1%.The pectineal line is incised by monopo-lar electrode (Fig.11a). Once freed cir-cumferentially, the anal mucosa is closed

by a 0 silk purse-string suture (Fig.11b)and pushed into the pelvis. The D-Port is inserted into the anus

and fixed to the skin by four sutures.The scope and instruments are insertedas described above in “Transanal TMEwith colorectal anastomosis”. The anal canal is mobilized circum-

ferentially from down-to-up, proce-eding first posteriorly, to the left sideof the patient, to the right side of thepatient, and finally anteriorly. In addi-tion, the lower rectum is mobilizedcircumferentially from bottom-to-top,first proceeding posteriorly, to the leftside, then to the right side, and finallyanter iorly, using the monocurvedcoagulating hook and the monocurvedgrasping forceps. The dissection is per-formed poster iorly taking care torespect the presacral fascia, and ante-r iorly searching the correct planebetween the rectum and the prostate(male) or the vagina (female). The middle rectum is freed, taking

care to respect the presacral fascia poste-riorly, and the correct plane betweenthe rectum and the seminal vesicles(male) or uterine cervix (female) ante-riorly. Either the monocurved coagu-lating hook or monocurved bipolarscissors can be used. Finally, thetransanal dissection joins the previousdissection performed by abdominallaparoscopy.The rectal-sigmoid colon is encir-

cled by a plastic protection, andremoved transanally, after the D-Porthas been removed. The level of thecolic transection is found and the leftcolon is sectioned, removing the speci-men. The coloanal anastomosis is per-formed (Fig.11c).

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Figure 10a-c. Closure of the rectal stump transanally by a purse-string suture (a); attachment of the anvil to the circular stapler by the monocurved anvil graspingforceps (b); successive colorectal anastomosis (c).

Figure 9. Removal of rectal-sigmoid colontransanally.

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Repair of immediate colorectalleak At the end of the rectal resection

operation, the colorectal anastomosisis tested. If the leak test appears posi-tive, immediate repair can be per-formed using the transanal approach.Hence the D-Port is inserted into theanus and fixed to the skin. The colo-rectal leak is made evident; in the casereported, the leak was located 4 cmfrom the anal margin. The repair was

performed using the monocurvedgrasping forceps and the monocurvedneedle holder (Fig.12a). During theentire procedure the surgeon workedunder sat is factory ergonomy(Fig.12b).

Repair of early rectovaginalfistula Once the defect is diagnosed,

transanal repair can be proposed to thepatient. The D-Port is inserted into the

anus, and the rectal lumen is explored,making evident the level of the fistula;in the case reported, the fistula waslocated 12 cm from the anal margin(Fig.13a). Local debr idement andlavage were then performed. Differentabsorbable figure of 8 sutures (usingVicryl 2/0) were placed to close thedefect (Figs.13b,c), and the surgeonworked ergonomically with mono-curved grasping forceps and mono-curved needle holder.

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Figures 11a-c. Incision of the pectineal line by monopolar electrode (a); closure of the anal mucosa by purse-string suture (b); final coloanal anastomosis (c).

Figures 12a,b. Endoluminal colorectal leak’s suture (a); extracorporeal surgeon’s ergonomy (b).

Figures 13a-c. Endoluminal rectovaginal fistula’s exposure (a) and suture (b,c).

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Repair of late colorectal fistulaThe D-Port is inserted into the anus

and fixed to the skin. The previouscolorectal anastomosis is localized andthe defect is revealed; in the casereported, the defect was located 11 cmfrom the anal margin (Fig.14a). Localdebridement and lavage were per-formed. The repair was performedusing the monocurved grasping forcepsand the monocurved needle holder.Different figure of 8 sutures usingVicryl 2/0 were positioned (Figs.14b,c).

Repair of immediate colorectalbleeding If a bleeding is apparent after a cir-

cular colorectal mechanical anastomo-sis, the D-Port is inserted into the anusand fixed to the skin. The anastomosisis inspected; in the case reported, thebleeding was located anteriorly on thestaple line at 2.5 cm from the analmargin (Fig.15a). The blood was aspi-rated and the repair was performed,using the monocurved grasping forcepsand the monocurved needle holder,with intracorporeal knotting technique(Figs. 15b,c).

Total mucosectomyThe D-Port is introduced into the

anus and fixed to the skin. The circum-ferential rectal stenosis is identified; inthe case reported it was at 2.5 cmfrom the anal margin (Fig.16a). Themucosectomy was initiated, with thedissection first proceeding posteriorly,then laterally and finally anteriorly,taking care to respect the muscolarfibers (Fig.16b). Once the stenosis wascompletely removed, the superior andthe inferior mucosal edges were joinedby separated Vicryl 2/0 sutures(Figs.16c-f).

Results

The results are summarized inTable II.Mean operative time for transanal

TME was 149.2 minutes (96-193) andfor the other procedures 80.6 minutes(15-163). Mean operative bleeding was51.1 cc (0-450). Mean hospital stay was5.0 days (2-8). In all oncologic patients, the speci-

men’s quality was complete, the circum-

ferential resection margin was clear aswell as the distal or proximal margins.The anastomosis performed was colo-rectal in 5 patients, and coloanal in theremaining 3 patients.In non-oncologic patients, TAMIS was

applied for a defect or lesion distant fromthe anal margin by 2.5 cm to 12 cm.Temporary protective ileostomy was

performed in 3 of the 8 oncologicpatients and in all patients with a leak.Only one early postoperative compli-

cation was registered and it was diarrheain the 3 patients submitted to coloanalanastomosis. Medical therapy togetherwith perineal kinesitherapy improvedthis complication.Pathologic report on the 8 oncologic

diseases showed a mean number of 14.7nodes (16-20) removed. The radiologic (gastrograffin enema)

or the colonoscopic control at 2 monthsof the patients submitted to leak orfistula repair showed complete healing ofall the defects. At this time, the patientsunderwent reversal of the protectivestoma procedure. After a mean follow-up of 8 months

(1-14), there were no late complicationsin any of the 13 patients.

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RESULTS

Figures 15a-c. Endoluminal colorectal anastomotic bleeding exposure (a) and suture (b,c).

Figures 14a-c. Endoluminal colorectal fistula’s exposure (a) and suture (b,c).

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Discussion

Colorectal diseases treated bytransanal laparoscopy were introducedby Buess et al. in 1983 with the TEM.11With the advent of NOTES thisapproach, using a natural orifice, hasbeen re-evaluated and has generatedinterest and attracted research, therebyinaugurating a new era in laparoscopycalled TAMIS.12 The anus has not onlybeen used as the natural orifice for theremoval of a specimen from theabdomen,1,2 but it has also become theaccess site to create retropneumorec-tum and to perform laparoscopy. Major operations such as rectal

resection with TME,13 besides theresection of benign and early malignantrectal tumors,14 began to be performedwith this new approach. In general,TAMIS is a potentially beneficial treat-ment for the following conditions:

�benign lesions located intraluminallyin the low, middle and high rectum;

�malignant lesions in the low, middleand high rectum;

�leaks at colorectal anastomosis, loca-ted from 2 cm to 15 cm from the analmargin;

�bleeding of colorectal anastomosis inthe low, middle and high rectum;

�benign stenosis in the low, middle andhigh rectum.

In addition, in patients for whomconventional abdominal laparoscopymay be difficult (for instance, malepatients, obese patients, or patients withnarrow pelvic bones and a bulkymesorectum), this procedure may bemore easily implemented. During rectal resection with TME,

the main advantages of TAMIS over con-ventional abdominal laparoscopy includethe possibility of localizing the positionof the lesion intraluminally and initia-ting rectal resection a few centimetersdown; easier opening of the “holyplane”; clearer exposure of the opera-tive field; increased exposure of thelateral sacral nerves to be preserved;bloodless presacral dissection; a fewernumber of firings of the stapler used tosection the rectum; and finally thespecimen’s removal through the anus,thereby avoiding a mini-laparotomy. Sofar, in our preliminary experience, weencountered no difficulties finding agood plane of dissection, and we clearly

identified the lateral sacral nerves. Inonly one case did we encounter opera-tive bleeding of >50 cc, probably due tothe short break-time between the endof the neoadjuvant therapy and the rec-tal resection operation. In one malepatient with narrow pelvic bones, thetransanal TME was performed underworking conditions and exposure thatwere better than would have been thecase under conventional abdominallaparoscopy. The mean number of 14.7 nodes

removed may appear low, but all ouroncologic patients receive neoadjuvantchemoradiation; therefore the numberof nodes can be further reduced.Our mean operative time of 149.2

minutes for transanal TME, as well asour mean hospital stay of 5 days, areboth comparable to the times reportedin the literature.15 However, operativetime can be reduced if transanal TME isperformed simultaneously with theabdominal laparoscopic steps.16

The registered early complication ofdiarrhea, solved during follow-up,probably stemmed from the pre-operative sphincter function than fromthe pure TAMIS technique.17Patients undergoing rectal resection

with TME can be at risk of anastomoticleakage for several reasons. Amongthem, preoperative chemoradiation,weak quality of the tissues, presence ofco-morbidities such as diabetes, vasculardeficiences, obesity, and anatomical dif-ficulties due to the narrow pelvic space,have an important impact. Hotta et al.reported that the colorectal anastomoticleak rate varied between 0 and 23%.18This perioperative complication can berepaired during the procedure of rectalresection using the transanal platform,as we did with one of our patients. Thisstrategy enabled us to avoid a poormanagement of colorectal leaks.19As was true of another patient of the

series, a symptomatic late colorectalfistula can be repaired by TAMIS as

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Figures 16a-f. Circular benign rectal stenosis at 2.5 cm from the anal verge (a); mucosectomy by coagu-lating hook (b); endoluminal suture (c-e); final result (f).

DISCUSSION

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well. This option confirms thattransanal repair of a persistent lowcolorectal anastomotic leakage is feasi-ble in selected cases, even whenchemoradiation has been performed.20Rectovaginal fistula has been repor-

ted as solved using the TEM plat-form.21 In our series, the new reusableplatform allowed the fistula to beclosed by suturing up into the rectum(12 cm).In our 3 cases of rectal leaks, a tem-

porary protective stoma was performedand closed 2 months later. However,this procedure requires further investi-gation, because other authors havereported that the rectal fistula healedwithout the protective stoma.22 In ourexperience, this strategy allowed us todischarge patients with rectal fistulawithin a reasonable time of hospital stay,thereby avoiding long hospitalization ortakedown of the anastomosis and perma-nent colostomy or tentative suturingrepair from the abdomen with proximaldiversion.23Furthermore, this new transanal plat-

form can be regularly adopted at the endof each rectal resection performed alsothrough conventional multitrocarlaparoscopy or SIL. This platform thusallows each colorectal anastomosis to beinspected, as is done with intraoperativecolonoscopy, but allows possible peri-operative problems to be correctedimmediately. One patient of this prelimi-nary series presented an immediatebleeding at the control of the circularmechanical colorectal anastomosis loca-ted at 2.5 cm from the anus. The repairwas performed transanally without anysequelae.Other potential complications or

diseases such as stenosis, can beapproached transanally, as it was for oneof our patients presenting a benignstenosis at 2.5 cm from the anal margin.Transanal mucosectomy offered goodresults comparable to those reportedwith the technique of TEM.9The use of the D-Port together with

the monocurved instruments, originallydeveloped for SIL.24 constitutes a newreusable transanal platform that allows

surgeons to work under satisfactoryergonomic conditions. This feature dif-ferentiates this platform from others,reported in the literature, which are lessergonomically satisfactory; for under thelatter conditions, which tend to be lessflexible, conflict usually arises betweenthe surgeon’s hands and the hands of thecamera assistant.25On the other hand, as was the case for

TEM,4 one of the disadvantages ofTAMIS is that it entails a steep learningcurve for the surgeon, because the sur-geon needs time to adjust to workingthrough a unique entry point and with alimited endoscopic space.Another general disadvantage of

TAMIS lies in its increased cost, anincrease that arises from the adoption ofthe disposable anal port and instru-ments.15 However, this new platformavoids supplementary costs because theport and the instruments used arereusable.Finally from a technical point of view,

the structure of the D-Port is characteri-zed by the following TAMIS features:

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Table II

ONCOLOGIC

PATIENTSOperative time

(min)Operative bleeding

(cc)Hospital stay

(days)Pathologic report

Follow-up(months)

1 114 0 8 pT2N0 (13 nodes) 14

2 145 50 5 pT2N0 (15 nodes) 14

3 96 10 8 pT3N0 (18 nodes) 11

4 182 10 5 pT3N0 (12 nodes) 10

5 193 450 6 pT3N0 (12 nodes) 5

6 180 10 6 pT3N0 (20 nodes) 4

7 160 50 3 pT2N0 (12 nodes) 3

8 124 50 5 pT1N0 (16 nodes) 1

NON-ONCOLOGIC

PATIENTSOperative time

(min)Operative bleeding

(cc)Hospital stay

(days)Pathologic report

Follow-up(months)

9 60 0 5 / 14

10 120 5 6 / 3

11 45 5 2 / 12

12 163 5 2 benign stenosis 12

13 15 20 5 / 1

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�The diameter is 3 cm, avoiding anytype of anal dilatation, and smallerthan platforms that are more rigid.

�The length is 7.5 cm, which allowsTAMIS to treat lesions located close tothe anal margin as well as distal intothe rectum, because a stable pneu-morectum is maintained when theport is retracted or pushed maximally.

�The cap is made of silicon, whichallows the instruments to be flexiblymoved both extracorporeally andintraluminally.

�The cap has a thickness of 1 cm and 3orifices arranged at 6-mm, 11-mm,and 6-mm, and accomodating two5-mm laparoscopic instruments andone 10-mm optical system.Moreover,the central orifice also allows theintroduction of a linear staplerthrough a change of the 11-mm orificeinto a 13-mm.

�One principle of general laparoscopy isrespected: the optical system is situat-ed in the middle of the two workingancillary tools.10

�The components include two lockconnectors, which allow the insuffla-tion of CO2 with the simultaneousevacuation of the smoke createdduring the dissection.

�The 4 holes out of the tube allow theport to be fixated to the skin, butcapable of rotating during some stepsof the procedure.

�The 4 cardinal points inside the tubeoffer the surgeon a reliable orientationduring the procedure.

�The absence of an articulated armholder to secure the system to theoperating table, allows the surgeonmore liberty of movement.

Conclusion

TAMIS is a feasible alternativeapproach to treat rectal cancer and acompletely new technique to managecolorectal complications. Moreover, thisnew transanal platform offers surgeonsa satisfactory working ergonomy, withno increase in cost of the procedures,because entirely reusable materials areadopted.

Authors’ Disclosures

Doctor Dapri is a consultant for KarlStorz - Endoskope,Tuttlingen, Germany. Doctors Guta, Cardinali, Mazzetti,

Febres, Grozdev, Sondji, Surdeanu andCadiere have declared no actual orpotential conflict of interest in connec-tion with this paper.

References

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