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25 Transanal Minimally Invasive Surgery (TAMIS): Operative Technique, Pitfalls, and Tips
287
Fig. 25.6 The tumor is cauterized in the full-thickness plane. The traction applied to allow easy cauterization of the tissue is well demonstrated
Fig. 25.9 Continued full-thickness dissection on the inferior aspect of
the lesion. Notice the excellent hemostasis
Fig. 25.7 Dissection continues on the medial side. Notice the fullthickness dissection
Fig. 25.8 As the dissection continues in the full-thickness plane, traction allow excellent visualization
Specimen extraction should be performed at completion of
resection and prior to closure to maintain specimen integrity
and avoid accidental proximal migration. The specimen is
then pinned in place or marked per surgeon and pathologist
preference (Figs.
25.12 and 25.13 ). The majority of plat-
forms accommodate extraction by allowing removal of the
faceplate; however, some ports require removal of the entire
Fig. 25.10 Dissection continues in the previously marked lateral
boundary to complete the resection
Fig. 25.11 The size of the defect can be appreciated in this defect.
It was approximately 40 % of the circumference of the rectum
device with reinsertion for closure. Irrigation of the excision
bed with dilute betadine, presumably for its tumoricidal and
bactericidal effects, is a common practice. However, no evidence-based literature exists to support this technique.
For tumors that are extremely low, in the distal rectum and
even abutting the dentate line, a hybrid technique can maintain
all the benefi ts of TAMIS and facilitate a superior resection.
288
F. Quinteros et al.
Fig. 25.12 A full-thickness specimen after extraction. The mesorectal
fat is evident on the portion of the specimen that was not anterior
Fig. 25.13 Notice the perirectal fat on the posterior aspect of the tumor
to confi rm full-thickness resection
Although these can be performed with traditional anorectal
retractors to avoid additional expense, we believe that use of a
transanal port is extremely advantageous in bulky friable villous tumors, circumferential or near circumferential tumors,
or lesions that extend more proximally into the rectum. The
distal incision is made prior to port insertion with dissection
carried proximally a short distance. This is followed by port
deployment and standard excision once the mass is above the
anorectal ring, where the port will be seated.
Closure is performed by placing a suture for traction at
the midportion of the proximal rectal wall followed by port
removal and replacement with an anorectal retractor. Easy
closure is permitted with perfect alignment of the rectal wall.
There is no consensus as to whether it is necessary to close
the remaining mural defect in the rectal wall. Certainly, this
can be the most diffi cult component of the operation.
Fig. 25.14 The defect is fi rst re-approximated at the midportion using
an absorbable stitch
Extraperitoneal full-thickness resections can be left to heal
without closure of the defect. This technique almost certainly
arose from the amount of diffi culty and time it took to close
a defect with conventional transanal surgery, as well as the
common belief that wound dehiscence and abscess are a
regular occurrence. Aside from the aesthetic pleasure, the
authors recommend closure of all defects with a 2-0 or 3-0
absorbable sutures for postoperative hemostasis. In addition
to minimizing bleeding complications, the wound usually
remains closed at postoperative offi ce proctoscopy, and this
facilitates quicker healing.
Laparoscopic suturing with traditional laparoscopic needle holders is challenging due to the ergonomic diffi culties
of suturing within a confi ned space. Wound closure can
be performed using interrupted, fi gure-of-eight, or running
sutures. Initially, decreasing the insuffl ator pressure by
3–5 mmHg can “shrink” a seemingly daunting defect to one
that is more manageable. Defects should be closed from
proximal to distal and not side to side to avoid narrowing of
the lumen. Given the compliance of the rectal wall, it is
uncommon to have to mobilize the proximal rectum to
oppose the wound. Dividing the defect into two sections by
re-approximating the midportion of the defect can be helpful
(Fig. 25.14 ). Intracorporeal knot tying is time consuming
and diffi cult and can be avoided using a standard 25 cm laparoscopic knot pusher or an automated suture tying device.
Alternatively, performing a continuous sutured closure with
a barbed suture avoids the need to tie altogether. The use of
modern laparoscopic suture devices endoluminally to close
defects can dramatically shorten the learning curve and
improve precision of closure, but requires increased procedural
costs (Endostitch, Ethicon, Cincinnati, OH; LSI, Covidien,
CT). With practice, given the minimal increase in operative
time and technical diffi culty, the authors feel that closure is
warranted to minimize any complications (Fig.
25.15 ).
Entry into the peritoneal cavity is not an uncommon
occurrence with anterior-based tumors, especially in women
where the peritoneal refl ection is lower and is surrounded by
25 Transanal Minimally Invasive Surgery (TAMIS): Operative Technique, Pitfalls, and Tips
289
Fig. 25.15 The wound is shown nearly closed, with only the last suture
requiring a tie. The lumen is clearly visible and is not narrowed with the
closure
Fig. 25.16 An anterior rectal mass leading to entry into the peritoneal
cavity is shown from an abdominal perspective. The loss of pneumorectum made closure not possible transanally and required placement of
laparoscopic trocars. The peritoneal wound was closed with interrupted
sutures, and the rectum was then re-insuffl ated and closed with interrupted sutures as well
less perirectal fat (Fig. 25.16 ). This should be anticipated by
tumor localization on preoperative proctoscopic evaluation
and appropriate precautions and discussion with the patient.
During the early history of TEM, this commonly necessitated conversion to laparotomy with the need for resection
and frequently colostomy. In addition, the potential for transperitoneal seeding in the setting of malignancy was a common concern. More recently, Gavagan demonstrated this to
be a low-risk event, which does not mandate conversion [ 21 ].
Obviously, a secure closure becomes mandatory. A two- layer
closure of outer peritoneum fi rst followed by full- thickness
closure of the rectal wall is recommended. In this scenario,
some surgeons have suggested a water-soluble contrast study
the following morning prior to discharge. In our experience
with peritoneal entry during TAMIS, we have had two cases
where insuffl ation failed to maintain distention of the rectum
to permit adequate closure. In both of these instances, laparoscopy with suture closure of the peritoneal defect from the
abdominal side allowed reestablishment of the pneumorectum
Fig. 25.17 The instruments are positioned at a comfortable height
with completion of the closure endoluminally. These patients
were discharged the following day without further studies.
Minimal postoperative care with same-day discharge can
be accomplished in most patients, except those with excessive comorbidities. No postoperative antibiotics are required
and patients may resume normal diet and activity immediately. Postoperative surveillance of adenomas over the initial
postoperative year can be performed with proctoscopy at
regular intervals. Small recurrences can often be removed
with endoscopic techniques. Patients with malignancy
should be followed by standard NCCN or locoregional
guidelines with quarterly follow-up and CEA levels. Serial
MRI or endoscopic ultrasound has been advocated for early
detection of mural and mesorectal recurrences that tend to
occur following local excision; however, no standard guidelines currently exist. If “salvage” operation is required for
patients with more advanced lesions than suspected preoperatively or with later fi ndings of nodal disease, no negative
prognosis has thus far been associated with the initial TAMIS
approach followed by abdominal surgical resection in our
experience.
Pearls and Pitfalls
• Select your patients wisely, especially at the beginning.
Posterior, <3 cm, mid-rectal lesions are often the best can-
didates. Even if they can be performed by traditional
transanal methods, use TAMIS for increased visualization
and better instrumentation.
• Position the patient and set up the room to maximize
ergonomics. These are complex operations, but will only
become harder if you are uncomfortable with the instru-
mentation and straining (Figs.
25.17 , 25.18 , and 25.19 ).
290
F. Quinteros et al.
Fig. 25.18 An experienced assistant or surgeon is invaluable
• Immediately prior to transecting the fi nal attachments on
the specimen, ensure you have proper orientation prior to
removal to assist in marking the boundaries for pathology.
A grasper placed on the anterior (i.e., distal) midline facil-
itates this process.
• Attempt intracorporeal suturing in easy cases, but don’t
waste time, effort, and frustration—use one of the described
methods above to make things much easier.
• Preoperatively discuss with your patient the potential for
an inability to complete the case purely via TAMIS and
the possibility of abdominal exploration if peritoneal
entry occurs.
Conclusion
Transanal minimally invasive surgery is a feasible technique
that has maximized the advantages introduced by minimally
invasive techniques and evolving laparoscopic instrumentation. The improved access to the rectum enhances visualization, improves resection, and extends the upper limits of
resection in comparison to traditional transanal excision.
TAMIS should be a part of every colorectal specialist’s
armamentarium.
Fig. 25.19 Creating space between the different instrumentations provides clear visualization while avoiding collisions
• Ensure you have adequate margins. Marking your boundaries of resection closer to 1 cm at the onset of the case,
especially in your early experience, and ensuring you
have a full-thickness excision are imperative. Although
the defect will be slightly larger, it is better than the alternative of positive margins.
• It is imperative that your anesthesiology team has completely paralyzed the patient and continues to re-dose
during the procedure as needed. Failure to ensure this is
done will compromise your visualization.
• Take care of the troublesome bleeding right away. Don’t
let small nuisance bleeding obstruct your visualization.
• Although the lesion is fi xed, be active in changing angles
of the camera and of changing which ports your instruments and cameras use. Impossible angles typically
become very easy when the perspectives are changed.
Disclosures Dr. Quinteros and Dr. Thiruppathy have no disclosures.
Dr. Albert is a paid speaker, program director, and consultant for
Applied Medical and is a speaker for Lifecell.
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Combined Endo-Laparoscopic Surgery (CELS)
Kelly A. Garrett and Sang W. Lee
K e y P o i n t s
• The technique of combined endo-laparoscopic surgery is
for patients with benign colon polyps that cannot be
removed endoscopically.
• Colonoscopy report and pathology results should be
reviewed at initial consultation.
• CO
colonoscopy should be employed in order for this
2
technique to be more often successful.
• The polyp should be localized fi rst endoscopically and its
location marked using dilute indigo carmine solution.
• The colon wall adjacent to the polyp can be manipulated
laparoscopically to facilitate snare polypectomy.
• If a repair of the colon wall is performed, repair should be
leak-tested with the colonoscope.
• Endoscopic-assisted laparoscopic wall excision may be
necessary in some locations.
• If there are features of malignancy, the procedure can be
converted to laparoscopic colectomy.
• If CELS is successful, but fi nal pathology reveals malignancy, patients may go on to require colectomy in the
postoperative period.
Electronic supplementary material: Supplementary material is available
in the online version of this chapter at
Videos can also be accessed at
978-1-4939-1580-4
K. A. Garrett , M.D., F.A.C.S., F.A.S.C.R.S
Division of Colorectal Surgery, Department of Surgery ,
NY Presbyterian Hospital, Weill Cornell Medical College ,
525 East 68th Street , Box 172 , New York , NY 10065 , USA
S. W. Lee , M.D., F.A.C.S., F.A.S.C.R.S. (
Division of Colon and Rectal Surgery, Department of Surgery ,
Weill-Cornell Medical College, New York Presbyterian Hospital,
New York , NY , USA
sal2013@med.cornell.edu
e-mail:
.
10.1007/978-1-4939-1581-1_26 .
http://www.springerimages.com/videos/
*)
26
Background
Large colon polyps and those on or behind a haustral fold
can be very challenging to remove endoscopically. Although
endoscopic mucosal resection (EMR) and submucosal dissection (ESD) have been performed for these polyps, this
technique is not widely available and does not provide a
solution for certain polyps [ 1 , 2 ]. For this reason, the most
common recommendation for these patients who cannot
have their polyps removed through endoscopic means has
traditionally been segmental colectomy. There are many
studies that demonstrate that laparoscopic colectomy has
quicker recovery rates, faster return of bowel function, and
earlier return to normal activities in comparison with open
colectomy. However, while the laparoscopic approach can
minimize the morbidity associated with colectomy, only a
minority of the colon resections performed in the United
States are being performed laparoscopically [ 3 ].
Furthermore, even if a minimally invasive approach is
employed, it still entails a major abdominal operation with
the potential for associated morbidities. In place of resection, combined endo-laparoscopic surgery (CELS) removal
of the polyps has been described as an alternative in select
patients [ 3 – 10 ].
The technique of laparoscopic-assisted polypectomy was
fi rst described in 1993 as a means to avoid the morbidities associated with a major bowel resection [ 4 ]. Larger retrospective
studies have since been published indicating that the technique
is safe and effective [ 3 , 6 , 7 , 10 – 12 ]. The benefi ts of CELS
include mobilization of the colon to make the polyp easier to
resect with the colonoscope, the ability to directly observe the
wall of the colon laparoscopically to ensure there is not a fullthickness defect, the capacity to repair an injury if there is one,
and the option of converting directly to a laparoscopic resection
if the polyp cannot be resected endoscopically or there are fi ndings suspicious for malignancy (Fig. 26.1 ). Many different
techniques and approaches have been described including laparoscopic-assisted colonoscopic resection, endoscopic-assisted
H.M. Ross et al. (eds.), Minimally Invasive Approaches to Colon and Rectal Disease: Technique and Best Practices,
DOI 10.1007/978-1-4939-1581-1_26, © Springer Science+Business Media New York 2015
293
294
K.A. Garrett and S.W. Lee
Fig. 26.1 Combined endo-laparoscopic polypectomy. Laparoscopic manipulation of the bowel wall allows invagination of the bowel wall ( right )
facilitating polypectomy
laparoscopic wedge resection, and endoscopic-assisted
laparoscopic resection [ 13 – 15 ]. The largest study to date was
performed by Franklin et al., which included long-term follow-up of 160 patients with 209 polyps. At a median follow-up
of 65 months (range 6–196 months), there were no recurrences
of completely resected polyps [ 16 ].
Indications
Current indications for CELS include large benign colon
polyps or polyps in a diffi cult anatomic location that are
unable to be removed by colonoscopic snare polypectomy.
In addition, a similar polyp that has been incompletely
removed via traditional endoscopic techniques may be
considered for CELS. Patients should have a preoperative
colonoscopic biopsy that is benign, although polyps with
high-grade dysplasia can be included. If patients have other
polyps, they should be able to be removed colonoscopically
or with CELS technique. CELS should not be performed on
patients with a known polyposis syndrome. Finally, relative
contraindications for CELS would include a history of multiple previous abdominal surgeries or polyps that are too
close to the ileocecal valve.
elsewhere, it is important to obtain both the colonoscopy and
pathology report, and frequently the pathology slides themselves for internal review. If the polyp is on the left side, it is
often useful to evaluate the area in the offi ce with a fl exible
sigmoidoscope to determine the exact location, polyp characteristics, and feasibility of CELS.
Patients should undergo a preoperative workup as they
would for any other abdominal procedure including blood
work, electrocardiogram, and chest X-ray. Patients should
receive a full mechanical bowel preparation the day prior to
the procedure in order to aid in visualization of the polyp.
When discussing the procedure, the patient should be
informed that colonoscopic polypectomy would be
attempted; however, if the polyp cannot be resected endoscopically or if there are fi ndings suspicious for malignancy,
then laparoscopic colectomy will need to be performed. In
addition, patients should be made aware that even if CELS is
successful in completely removing the polyp, it is possible
that the fi nal pathology may reveal a malignancy and that
they may require a bowel resection at a later date.
Procedure (Video 26.1 )
Setup
Preoperative Planning
A complete history and physical examination should be done
including past medical and surgical history. If the patient has
a history of multiple abdominal operations, then CELS may
not be feasible. Generally, if the colonoscopy has been done
After the induction of general anesthesia, Venodyne boots, a
nasogastric tube, and a Foley catheter are placed. The patient
is positioned in modifi ed lithotomy, ensuring the legs are
abducted and placed in padded yellow fi n stirrups to facilitate
the insertion and manipulation of the colonoscope during the
operation. Both arms are tucked at the sides, and the hands
26 Combined Endo-Laparoscopic Surgery (CELS)
295
Table 26.1 Equipment needed for CELS
Adult or pediatric colonoscope with monitor (CO 2 insuffl ation if available)
Indigo carmine diluted 50 % with injectable saline
Endoscopic injector needle
Endoscopic snare
Endoscopic Roth net
Suction trap
Bovie cautery
Laparoscopic monitors
High-defi nition, fl exible-tip laparoscope
Trocars: 5 mm × 4, 10 mm × 1, and 12 mm × 1
Laparoscopic bowel graspers and scissors
Laparoscopic needle driver
Laparoscopic energy device (surgeon preference)
Micro-laparoscopic (3 mm) instruments if available
Laparoscopic linear stapler (with appropriate loads)
Endo Catch bag (Covidien, Norwalk, CT)
Wound protector
Polysorb or vicryl sutures
CELS combined endo-laparoscopic surgery
®
(US Endoscopy, Mentor, OH)
and wrists are padded. All equipment should be available to
perform colonoscopic polypectomy as well as laparoscopic
and open colectomy (though only opened as needed)
(Table 26.1 ). Subcutaneous heparin and intravenous antibiot-
ics are given prior to incision.
Laparoscopic monitors will be placed depending on the
location of the lesion. For right colon polyps, monitors are
placed on the patient’s right side and toward the head of
the bed (Fig. 26.2 ). For left colon lesions, the monitors are
placed at the patient’s left and toward the foot of the bed. For
transverse colon or fl exure lesions, the monitors are placed at
the head of the bed as the surgeon may stand between the
patient’s legs (as will the endoscopist).
Endoscopic equipment may vary. Surgeons may prefer
to use pediatric versus an adult colonoscope. In addition, we
feel it is a prerequisite to have CO 2 colonoscopy available in
the operating room. Simultaneous performance of laparoscopy and colonoscopy with room air can present technical
challenges. Insuffl ation using room air can signifi cantly
obscure the laparoscopic view and compromise exposure.
For institutions where this is not possible, a technique of
laparoscopically clamping the terminal ileum to minimize
bowel distention during laparoscopy has been described, but
we have found that colonic distention alone still is a major
impediment to this method [
3 , 4 ]. Since 2003, our group has
been performing colonoscopy with the use of CO 2 insuffl ation during laparoscopy. Because the bowel absorbs CO 2 gas
approximately 150 times faster than room air, there is minimal unwanted dilation of the colon and excellent simultaneous endoscopic and laparoscopic visualization. We have
previously demonstrated that intraoperative CO 2 colonoscopy is safe during laparoscopy and can be used to avoid
excessive bowel dilation during CELS procedures [ 9 , 17 ].
Therefore, if available, it is preferred to have CO
for
2
insuffl ation during colonoscopy.
Procedure Steps
Endoscopy
• After the abdomen is prepped and draped in a sterile fashion,
CO 2 colonoscopy is performed to locate the lesion (Fig. 26.3 ).
We then use dilute indigo carmine solution (50 % dilution of
indigo carmine with injectable saline solution) to mark the
area directly under and surrounding the polyp.
Port Placement
• Initial access : A periumbilical incision is made and the
fascia is entered sharply. A 5 mm port is placed and pneumoperitoneum is established. A 5 mm, high-defi nition,
fl exible-tip laparoscope is preferred for better visualization. The abdomen is explored and the site that was
previously marked is located.
• Secondary trocars : Depending on the location of the
lesion, typically two 5 mm trocars may be placed. For right
colon lesions, trocars can be placed in the left lower quadrant and suprapubically. For left colon lesions, trocars can
be placed in the right lower quadrant and suprapubically.
For transverse colon lesions, trocars can be placed on both
sides in both the lower and upper quadrants. If available,
micro-laparoscopic (3 mm) instruments are used.
• Optional trocars : A 5–12 mm port may be needed for a
stapler if a colonoscopic-assisted laparoscopic wall excision is anticipated.
• GelPort : For CELS, a hand port is not necessary. However,
if converting to a segmental or formal colectomy, then
some may elect to place a GelPort™ for hand-assisted
laparoscopy.
Mobilization
• For laparoscopic-assisted colonoscopic polypectomy, the
lesion is located by the endoscopist, and its position is
confi rmed by laparoscopic visualization with the use of
transillumination and/or by endoscopic visualization during laparoscopic manipulation of the colon (Fig. 26.4 ).
This maneuver can also expose areas that were not previously visualized because of mucosal folds or segmental
kinks of the colon. The location of the polyp in relation to
the peritoneum is important. Polyps that are located on
the retroperitoneal side or mesenteric side require lateral
mobilization of the colon for adequate exposure.
• If the polyp is in a diffi cult location (i.e., at a fl exure or
near the mesenteric border of the colon) and this area cannot be manipulated, the colon will need to be mobilized.
This is done as in any laparoscopic procedure. We prefer
to use an energy device along the line of Toldt and carried
in the native planes. Once the colon is mobilized adequately, the polyp can then be manipulated.
296
Fig. 26.2 Patient positioning and room setup for a right-sided CELS procedure
K.A. Garrett and S.W. Lee
Fig. 26.3 CO 2 colonoscopy to determine lesion location. With permission from Yuko Tonohira
Fig. 26.4 Laparoscopic manipulation of the bowel wall helps to put
the polyp in ideal position for endoscopic removal. With permission
from Yuko Tonohira
Fig. 26.5 Endoscopic snare is placed around the polyp while the wall
is invaginated laparoscopically. With permission from Yuko Tonohira
Polypectomy
• As stated previously, the polyp is lifted with dilute indigo
carmine solution. This aids in visualizing the polyp in
comparison to the normal surrounding mucosa and also
aids in seeing the location of the polyp laparoscopically.
It also provides a “buffer” zone to facilitate endoscopic
resection without causing a full-thickness injury.
• Polypectomy is performed using an electrosurgical snare.
This can be done using a single attempt or in a piecemeal
fashion. For polyps that are either fl at or situated in tough
location, laparoscopic manipulation of the polyp during
snare polypectomy can facilitate delivery of the polyp
into the snare (Fig. 26.5 ).
• During polypectomy, the serosal aspect of the colon
should be monitored closely. If there is any subtle change
to the area, this can be immediately recognized and then
26 Combined Endo-Laparoscopic Surgery (CELS)
Fig. 26.6 Laparoscopic closure
of the bowel wall. With
permission from Yuko Tonohira
297
oversewn if needed (Fig. 26.6 ). Typically, seromuscular
sutures are placed if a full-thickness thermal injury or perforation is noted. If there is some evidence of blanching or
deterioration of muscle layers, the area can also be reinforced to avoid the evolution of partial-thickness to fullthickness injuries in the postoperative period. The ability
to laparoscopically repair potential damage allows for a
more aggressive polypectomy.
Colonoscopic-Assisted Laparoscopic Wall Excision
• For polyps that are located in the cecum where the wall of
the colon is the thinnest, one may elect for a laparoscopic
sleeve excision of the polyp.
• Colonoscopy is used to locate the lesion and monitor adequate surgical margins. It should be noted if polyps are
located very close to the ileocecal valve in order to avoid
injury to this structure. This can be monitored with the
colonoscope.
• Sleeve resection is performed using a laparoscopic linear
stapler through a 12 mm port (Fig. 26.7 ). Once the speci-
men is removed, it can be placed within an Endo Catch
bag (Covidien, Norwalk, CT) and brought out through the
12 mm port site. The specimen can be opened in the operating room to make sure there is a clear margin.
• Oversewing of the staple line can be performed laparoscopically as needed.
Fig. 26.7 Sleeve resection of a polyp using CELS. With permission
from Yuko Tonohira
Leak Test
• A leak test using CO 2 insuffl ation with the colonoscope
and immersion of the bowel segment under saline (using
gravity to make the correct area dependent) should be
performed.