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26 Zen andtheArt ofthePurse-String
Fig. 26.1 The perfect
purse-string (low)
273
274
to start the purse-string distal to the visible
tumour to ensure correct height of the suture.
Common Pitfalls
1. The “spiral”– It is not uncommon for novice
surgeons to place the suture at different levels from the anal verge. This is typically too
far proximal in the anterior aspect and often
going too distal in the posterior aspect. This
then creates a spiral or eccentrically placed
purse-string which will make for a difcult
rectotomy and the potential for uneven
length of remaining rectal tube. The surgeon
needs to be mindful of placing each suture at
an equal distance from the anal verge or anorectal junction to avoid this common
mistake.
2. The “rose petal” (Fig.26.2)– This is one of
the most feared pitfalls when performing the
purse-string. This is created by having the
suture needle taking too much of the rectal
wall circumference, i.e. taking too much tissue in one pass of the needle or simply stated,
“taking too big of a bite”. The resultant
appearance when a suture is tightened and
secured is to have an obvious segment which
lacks symmetrical radial folds. This will
become more evident once pneumorectum
has been initiated. Indeed, if the pneumorectum is allowed to continue, there is a high
probability that a gap in the mucosa and rectal wall will become apparent which may
then lead to failure of the purse-string and the
potentially catastrophic egress of bowel content or mucous in the operative eld.
Furthermore, gas can distend the entire colon
making the laparoscopic portion of the operation arduous.
3. The “overzealous”– The converse of the rose
petal is the surgeon who passes the suture
needle in and out so many times in going
around the circumference of the rectum that it
makes it very difcult to bring the tissue edges
together. This may create difculties when
tying the suture and again result in a central
gap in the purse-string.
A. R. L. Stevenson
Fig. 26.2 The “rose petal” seen here in the upper left corner of the photograph
4. The “stuck on you” (Fig. 26.3) – The ideal
depth of each suture for the purse-string
should be through mucosa and at least the circular muscle layer of the rectal wall. However,
some surgeons may become frustrated with
their initial attempts to achieve a secure pursestring that they then take very deep bites
through the rectal wall. These deep sutures
risk including adjacent tissue such as the pelvic oor muscles, vagina or prostate. Whilst
the purse-string may have appeared to be
secure, this will cause problems once the dissection has commenced and often leading the
surgeon to proceed in the incorrect plane or
causing injury to the adjacent structures.
5. The “locked” (Fig.26.4)– You’ve placed the
sutures perfectly! The sutures are at the appropriate and equal height from the anal verge or
anorectal junction, equal bites, perfectly
spaced. But, the job of achieving the pursestring is not yet over. All too commonly
observed through the workshops, the enthusiastic surgeon, eager to commence taTME dissection, will quickly throw a few knots and
often locking the second knot without properly bringing together the edges of the rectum.
It is important for the surgeon to pay careful
attention to this part of the procedure, not to
26 Zen andtheArt ofthePurse-String
Fig. 26.3 The “stuck on you”
suture inadvertently including
deeper tissues, becomes evident
after dissection has begun,
leading into deeper incorrect
planes
275
placement of the suture as the height from
the anal verge will be limited by retraction
and exposure. This may lead to an unnecessarily low anastomosis, possibly requiring a
handsewn coloanal anastomosis, leading to
potentially worse bowel function. If access
to place the purse-string is limited using
direct vision and a proctoscope, it is recommended to place the purse-string under
endoscopic guidance with pneumorectum
(such as with the TAMIS platform) to hopefully reduce the risk of an unnecessarily low
rectotomy and anastomosis.
Fig. 26.4 The “locked” suture, leading to inadequate seal
have their hands unnecessarily holding needle
holders or forceps. If a single throw is used to
tie the suture, the second throw should also be
in the same direction so as to allow the surgeon to “snug down” the knot and pulling
together the purse-string. It is often the second
throw that causes the problem if this is done in
the opposite direction to the rst throw. When
it comes time to tying a perfectly placed
purse-string, it is time for returning to your
highly focused mental state (ow), nding
your Zen.
6. The “limbo” – How low can you go?
Sometimes this is unnecessarily low, particularly in larger patients or those with a long
anal canal. This is more commonly a problem when using a proctoscope for the
Special Considerations
Whilst most purse-strings will be placed in the
“sweet spot” at about 5–6 cms proximal to the
anal verge, there may be other times when it will
need to be very low or much higher. With very
low tumours requiring an intersphincteric dissection, it may not be possible to perform a pursestring until the dissection has been initiated. In
this situation, the Lone Star retractor can be utilized to gain exposure and the dissection commence in the mid-anal canal extending into the
intersphincteric space. Once this has released the
tension on rectal tube, it may then be possible to
perform a purse-string. If a purse-string has been
placed prior to beginning the dissection, for these
very low tumours, it may be helpful to place a
further purse-string or at least gure of eight on
276
A. R. L. Stevenson
the distal rectum once the dissection has released
the tension on the tissue with dissection in the
intersphincteric plane.
When the purse-string is higher than the sweet
spot, it may become difcult to reach by surgeon’s hand to secure the knot. In this case, it will
become necessary to tighten and secure the
purse-string and tie it endoscopically. This can be
quite challenging, especially for surgeons not
familiar with intracorporeal knot tying. An endoscopic knot pusher can be employed.
Alternatively, the formation of preformed loop
can facilitate the tightening of the purse-string.
This can be readily made with the loop 12–15cms
from the needle. The “tail” should only be 3cm
long to make it easier for the surgeon to nish off
the tie.
Once tied, the ends of the purse-string suture
are often used for retraction during the initial rectotomy and dissection. The utility of holding the
tied purse-string ends can be improved by placing
multiple knots (15–20). This then creates a “handle” for the surgeon to manipulate and improve
tissue tension and retraction when performing the
next step of the operation, the rectotomy.
The rectotomy should proceed once the sur-
geon is condent that the lumen of the rectum has
been completely occluded by the creation and
tying of the perfect purse-string. This can be
tested by using a grasper or suction device, probing centrally once the pneumorectum has been
initiated. If the purse-string is tight and complete
without the formation of a “rose petal”, the surgeon may then lavage the rectum with a cytocidal
solution and proceed with the rectotomy and dissection with condence. If at any stage the pursestring should fail during the dissection, either
through technical failure, inadvertent cutting of
suture or excessive pressure on the specimen, the
surgeon needs to have appropriate skills to rescue
the situation. This again may involve placement
of further purse-string or gure eight suture
endoscopically. Other possible solutions include
using an ENDOLOOP® Ligature (Ethicon,
Somerville, NJ, USA) around the distal divided
rectum followed by copious lavage or bringing
the specimen down to the anal canal and suturing
under direct vision.
The Distal Purse-String
For the majority of patients undergoing a restorative procedure, a circular-stapled anastomosis
will be utilized. Unlike the double-stapled technique, which closes the distal rectum, by denition the taTME technique will have an open distal
rectal stump. This will then require placement of
a further purse-string which is secured to the central spike of the circular stapler. Although this
will be also addressed in the chapter on anastomotic technique, it is again another time where
the perineal surgeon needs to pay close attention
to the formation of the purse-string. This is more
commonly achieved using a handheld proctoscope under direct vision, but occasionally this
needs to be performed endoscopically if the rectotomy has been at a higher level. An 0-Prolene
or equivalent heavy-gauge monolament suture
is also used for the distal purse-string, again starting at the 3 o’clock position. The suture is placed
from the lumen through the rectal wall and continued in an over and over fashion. It may be useful to use a “boomerang” suture technique going
from outside the rectal wall into the lumen. A
“boomerang” suture is where the needle is held
by the needle holder oriented back towards the
surgeon’s hand. This will ensure a full-thickness
bite of tissue and subsequent complete doughnut
upon completion of the stapled anastomosis.
Focus, or ow, is again needed when tying this
distal purse-string around the central spike of the
circular stapler. Of course, the third time a pursestring is required in this operation is for the proximal colonic conduit for placement of the stapler
anvil.
Every step of the operation is equally important. Each subsequent step can only proceed
depending on the success of the preceding step.
The formation of a perfect purse-string in the
operation of taTME lays the foundation for a
good-quality TME and helps assure a negative
distal resection margin. It is important for the surgeon to appreciate the importance of the pursestring and to give all attention– breathe, relax,
have that special Zen moment and slow down– to
be sure to achieve your goal of achieving the perfect purse-string.
An Overview ofOperative Steps
andSurgical Technique
F.BorjadeLacy, MaríaClaraArroyave,
andAntonioM.Lacy
27
Preoperative Preparation
Preoperative evaluation by an enterostomal therapist, a trained nurse or a surgeon is highly recommended for demarcation of a potential stoma
site to avoid postoperative ostomy-related complications. Mechanical bowel preparation plus
oral antibiotics should be administered the day
before surgery; intravenous antibiotic prophylaxis against aerobic and anaerobic bacteria
should be administered 1h prior to skin incision,
as clinical evidence supports its use to reduce surgical site infections [1].
To avoid deep venous thrombosis and pulmonary thromboembolism, sequential compression
socks are recommended from the induction of
general anaesthesia and in the postoperative
period until patient mobilization is fully achieved.
During the anaesthetic period, a deep pharmacologic muscle paralysis is induced to facilitate rec-
Supported by: No sources of funding to disclose.
F. B. deLacy · A. M. Lacy (*)
Gastrointestinal Surgery Department, Hospital Clinic,
University of Barcelona, Barcelona, Spain
e-mail: bdelacy@aischannel.com;
amlacy@aischannel.com; https://www.aischannel.com
M. C. Arroyave
Department of Surgical Oncology, Clinica Somer,
Rionegro, Colombia
https://www.aischannel.com
tal distension and pneumoperitoneum. A urinary
catheter must be placed. The rectum is irrigated
thoroughly with both saline and cytocidal solutions such as povidone-iodine to remove any faecal residue that may disturb the transanal vision
or which may lead to postoperative infection.
For the transanal team, a regular laparoscopic
instrumental set and a laparoscopic unit are
required. If available, the authors recommend the
use of a 3D scope with a exible tip and a continuous insufator with smoke evacuation as
better depth perception, proper hand-eye coordination and a steady pneumorectum eld are
achieved. For the abdominal team, another regular laparoscopic instrumental set and a complete
laparoscopy unit are needed.
One Versus Two Teams
TaTME can be performed consecutively (oneteam approach) or simultaneously (two-team
approach). The latter is recommended for the following reasons: possibility to perform traction and
countertraction, visualization of the surgical plane
from two points of view and shorter operative
time. The collaboration between the two teams is a
valuable feature of this technique. If only one team
is available, it is advisable to start in the abdominal
eld and stop the dissection just before opening
the peritoneal reection and then proceed with the
© Springer Nature Switzerland AG 2019
S. Atallah (ed.), Transanal Minimally Invasive Surgery (TAMIS) and Transanal Total Mesorectal
Excision (taTME), https://doi.org/10.1007/978-3-030-11572-2_27
277
278
transanal dissection. This sequence avoids the
appearance of retropneumoperitoneum, which
makes the abdominal dissection harder due to distortion of the retroperitoneal space. Single-team
taTME is described in further detail in a chapter
dedicated to this topic.
Only case reports and small series have been
published about pure natural orice transluminal
endoscopic surgery (NOTES) taTME, and in the
meanwhile, it should only be performed as part
of an investigation protocol in highly specialized
centres [2–4].
Positioning thePatient
F. B. deLacy et al.
The patient is placed in the modied lithotomy
(Lloyd-Davies) position with adjustable boot stirrups that allow easy mobilization of the legs without compromising the sterile eld. The surgical
table must allow steep Trendelenburg inclination
when required during the procedure (Fig.27.1).
Placement of the team for the transanal phase
is with the principal surgeon and assistant
between the patient’s legs and scrub nurse in the
left lower side of the patient. For the abdominal
phase, the team is placed with the principal surgeon, second assistant and scrub nurse in the
right upper side and rst assistant in the left upper
side of the patient (Fig.27.2).
Fig. 27.1 Patient positioned in Lloyd-Davies and steep
Trendelenburg
Fig. 27.2 Abdominal and transanal teams working
together
Abdominal Approach
The abdominal approach will be described separately in a chapter dedicated to this topic. Briey,
the transabdominal phase is initiated with
12–15 mmHg pneumoperitoneum and insertion
of a 10 mm trocar above the umbilicus for the
optical instrument. Under direct vision, a 12mm
trocar is inserted in the right iliac fossa, and two
5mm ports are placed in the right and left anks.
The distal sigmoid is cross-clamped to allow construction of transanal purse-string suture without
colon distension. Once the purse string is made
and conrmed to be airtight, both teams work
synchronically.
A medial to lateral approach is advised for
cancer resections. The inferior mesenteric artery
is divided 1cm away from its origin at the aorta,
following the oncological principles of mesenteric resection with lymph nodes alongside the
vascular arcade (Fig.27.3). After exposure of the
retroperitoneal plane and identication of the left
ureter, artery ligation is performed with a vesselsealing device, a vascular stapler or using regular
clips. The inferior mesenteric vein is visualized
more caudally and laterally at the level of the
inferior border of the pancreas and is ligated in
the same fashion. Descending colon dissection is
27 An Overview ofOperative Steps andSurgical Technique
standard laparoscopic instruments. As stated previously, occlusion of the distal sigmoid by the
abdominal team is essential to minimize colonic
distention.
tumour is relatively easy as it is done under direct
vision. Distally, a purse-string suture with a
26mm needle and a size 0 polydioxanone suture
(with small equal bites at the same rectal level) is
made, to close the rectal lumen (Fig. 27.4).
Fig. 27.3 Division of the inferior mesenteric artery at its
origin
Performing a tight purse-string suture prevents
translocation of liquid stool and tumour cells,
reducing the risk of pelvic abscesses and locoregional recurrences.
continued by releasing the fusion plane along
Toldt’s fascia and mobilizing the splenic exure
when needed.
Following the posterior avascular plane, rectal
and mesorectal dissection is started. Circumferential
dissection preserving Denonvilliers’ fascia in
povidone-iodine solution, the rectotomy is started
just distal to the purse string. It is performed with
monopolar cautery in a circumferential fashion
(Fig. 27.5). The insufation pressure should be
set to ≤15mmHg.
males is continued until rendezvous with the transanal team.
along the anterior surface of the rectum, at the 12
o’clock position, and is then extended in counter-
clockwise fashion. A full-thickness dissection is
Transanal Approach
carried out until reaching the avascular “angel’s
hair” plane, sharply following the TME plane
Restorative Total Mesorectal Excision
described by Heald [5]. TaTME is not an easy
operation, and nding the correct plane may be
challenging. However, once correctly identied,
Mid andLow Tumours to2cm Above
theDentate Line
After digital rectal examination and proper irrigation, an anal retractor (Lonestar, Cooper
Surgical, Trumbull, CT, USA) is placed to efface
the anus and thereby visualize the dentate line,
followed by the introduction of the endoscopic
platform, which is xed to the perineal skin. At
our centre, a TAMIS Port (GelPOINT Path
Transanal Access Platform, Applied Medical,
Rancho Santa Margarita, CA, USA) is used.
Three cannulas are inserted into the TAMIS
Port’s gel cap, forming an inverted triangle, with
the camera lens positioned at 6 o’clock. In case of
a challenging posterior mesorectal dissection, the
camera can be switched to one of the TAMIS
Port’s lateral cannulas. The abdominal team then
clamps the distal sigmoid, the pneumorectum is
initiated, and the transanal phase is started with
Fig. 27.4 Purse-string suture to close the rectal lumen
279
With taTME, locating the distal edge of the
After washing out the closed rectal stump with
By preference, the rectotomy commences
280
Fig. 27.5 Circumferential rectotomy
Fig. 27.6 Down-to-up transanal dissection following the
“holy plane”
this technique is characterized by a more natural
dissection inside Denonvilliers’ and Waldeyer’s
fascias due to pneumatic dissection and direct line
of site visualization of, in particular, the anterior
plane in males. This leads to a potential decrease
of intraoperative complications, such as haemorrhage, and autonomic nerve injury– while maintaining the integrity of the mesorectal envelope.
The cephalad dissection is performed with
electrocautery and bipolar forceps (Fig.27.6). A
circumferential dissection is preferred by the
authors, with a focus on maintaining the envelope’s symmetry– since this medium (i.e. insufation using the TAMIS apparatus) enables
pneumatic-assisted dissection to help localize the
mesorectum’s innermost correct plane. The TME
plane is always easier to nd at the anterior and
posterior aspects; that is why connecting them
might help if any doubt arises while dissecting
the lateral boundaries. Compared to abdominal
TME, the risk of damaging the pelvic sidewall
F. B. deLacy et al.
Fig. 27.7 “Rendezvous”, meaning that both planes are
connected and both teams work together
may be increased. The improved visualization by
laparoscopic instruments may help the surgeon in
identifying the correct lateral planes and avoiding
dissecting laterally to the endopelvic fascia, in
false planes that become exposed due to pneumatic dissection during taTME.
Once at the level of the peritoneal reection,
the anterior surface is divided, and the peritoneal
cavity is entered. This is made lastly to maintain
a stable pneumopelvis. This rendezvous point in
dissection allows both teams to work synchronously until the rectosigmoid is released from its
attachment in toto (Fig.27.7).
Low Tumours, Distally to2–3cm Above
theDentate Line
The length of the TAMIS Port’s access channel
measures approximately 4.5 cm. When the
tumour is so low that its insertion is limited, an
intersphincteric dissection with conventional
open instruments may be necessary (Fig.27.8).
Rullier et al. [6] suggested that a partial intersphincteric resection might be necessary for
juxta-anal tumours (<1 cm from the anal ring)
and a total intersphincteric resection in intra-anal
tumours which do not encroach on the external
anal sphincter. One must remember that a partial
or a total intersphincteric resection is technically
feasible, but with an increased risk of postoperative poor bowel function.
27 An Overview ofOperative Steps andSurgical Technique
281
Once there is enough tissue to close the lumen,
the purse-string suture is placed to prevent spillage of liquid stool and cancer cells. It is possible
to insert the endoscopic platform afterwards, and
the transanal dissection with laparoscopic instruments can be continued as explained above.
Abdominoperineal Excision
This topic is discussed more completely in a dedicated chapter. Here, a brief description is provided. In cases of tumours invading the external
sphincter or when there is a poor bowel function
expectation after surgery, an abdominoperineal
excision is required. The abdominal approach
Fig. 27.8 Intersphincteric dissection with conventional
open instruments
should be performed in a standardized laparoscopic fashion. Once in the perineal phase, the
anus is closed with a purse-string monolament
suture, and the threads might serve as traction. A
circular perianal skin incision is made, approximately 2cm from the closed anus. The incision is
performed along the loose areolar tissue and the
anobulbar or anovulvar raphe. Posteriorly, the
incision extends to distal extent of the coccyx.
Laterally, it is dividing the fat from both ischiorectal fossae. With taTME for APR, the dissection should start posteriorly to nd the presacral
plane. Once located, our preference is to utilize
the TAMIS technique with the GelPOINT Mini
Advanced Access Platform (Applied Medical,
Rancho Santa Margarita, CA, USA). Three cannulas should be placed in an inverted triangle
position, and transanal dissection should be continued as described above (Fig.27.9).
Partial Mesorectal Excision
The surgical community has embraced taTME
mostly based on its benets when dissecting mid
and low rectal tumours. However, at our centre,
taTME is also performed for higher lesions
because with appropriate experience, these
patients may benet from shorter operative times
and lower conversion rates. In those higher
tumours in the upper rectum, it has been proven
that, although total mesorectal excision is not
necessary, mesorectal residual cancer cells can
Fig. 27.9 Transanal eld during abdominoperineal excision
282
F. B. deLacy et al.
be found 5cm below the level of the tumour [7].
This is the reason why, when a partial mesorectal
excision (PME) is intended, the transection of
the mesorectum should be at least 5 cm below
the distal edge of the tumour. After occluding the
rectal lumen with the purse string, both the rectum and mesorectum are transected perpendicularly until reaching the proper TME plane. There
is an increased risk of bleeding while dissecting
inside the mesorectum, which can be limited
using sealing devices, although this could lead to
increased procedure costs. Partial mesorectal
excision with the taTME technique is very challenging and is only recommended for experienced surgeons.
Critical Anatomic Landmarks
Through the transanal approach, the pelvic anatomy is novel even for very experienced colorectal
surgeons. TaTME carries potential pitfalls, which
could lead to a more difcult dissection or to
intra- or postoperative complications. Therefore,
early recognition of errors is crucial, to be able to
return to the correct plane [8–10].
Anteriorly, the prostate and seminal vesicles
in males can be injured [10]. In females, the
vagina can be opened, although this complication can be safely repaired intraoperatively. The
most feared complication is urethral injury, typically when an excessive lateral dissection is
made, followed by prostate mobilization and
putting the urethra at risk during the initial anterior dissection [10, 11]. If in doubt, the endo-
scopic platform should be removed, and the
surgeon should palpate the prostate and urinary
catheter.
Posteriorly, dissection must respect Waldeyer’s
fascia, avoiding the presacral venous plexus
(Fig.27.12) and minimizing the confusion about
correct versus incorrect plane of dissection when
coming along lateral and anterior sides. Moreover,
when dissecting laterally, neurovascular bundles
must be respected, to decrease the risk of impaired
bowel, urinary and sexual function.
Specimen Extraction
There exist two ways to extract the specimen:
transanally or transabdominally. The latter has the
advantage of maintaining the integrity of the
abdominal wall and reducing the risk of surgical
site infections and incisional hernias while
improving postoperative pain and cosmesis. The
size of the tumour, the mesorectum, the length of
the colon and the width of the pelvis are conditions that must be considered before a transanal
extraction is performed (Fig. 27.10). To avoid
excessive vascular tension during the specimen
retrieval, splenic exure mobilization is recommended. In case of a circular, endoluminal stapled
(double purse string) anastomosis, the purse string
on the opened distal rectal cuff should be performed before transanal extraction to prevent any
mucosal retraction that may make this step more
difcult post-extraction. For a hand-sewn coloanal anastomosis, the transanal extraction must be
performed after placing the four cardinal stitches.
Transabdominal specimen extraction is a better option than transanal extraction when facing
large tumours and bulky mesenteric envelopes–
Fig. 27.10 Transanal specimen extraction