Transanal minimally invasive surgery using laparoscopic instruments of the rectum:A review

Transanal minimally invasive surgery(TAMIS)was first described in 2010 as an alternative to transanal endoscopic microsurgery(TEM).The TAMIS technique can be access to the proximal and mid-rectum for resection of benign and earlystage malignant rectal lesions and also used for noncurative intent surgery of more advanced lesions in patients who are not candidates for radical surgery.TAMIS has a shorter learning curve,reduced device setup time,flexibility in instrument use,and versatility in application than TEM.Also,TAMIS shows similar results in a view of the operation time,conversion rate,reoperation rate,and complication to TEM.For these reasons,TAMIS is an easily accessible,technically feasible,and cost-effective alternative to TEM.Overall,TAMIS has enabled the performance of high-quality local excision of rectal lesions by many colorectal surgeons.As TAMIS becomes more broadly utilized such as pelvic abscess drainage,rectal stenosis,and treatment of anastomotic dehiscence,the acquisition of appropriate training must be ensured,and the continued assessment and assurance of outcome must be maintained.

Transanal minimally invasive surgery to rescue anastomosis following leak after low anterior resection: A case report

Restorative low anterior resection(LAR)for rectal cancer carries a significant risk of anastomotic leak:One of the most feared complications in colorectal surgery.Operative management may include takedown of the anastomosis and end colostomy which,in some cases,is permanent.Other contemporary operative measures include over the scope clips and Endosponge.Recently,there have been case reports and a Society of American Endoscopic and Gastrointestinal Surgeons video on the novel use of transanal minimally invasive surgery(TAMIS)in the management of anastomotic leak.We present a 59-year-old female who underwent LAR after declining radiotherapy for a bulky 9 cm rectal tumour 9-10 cm from the anal verge.Following clinical deterioration,computed tomography demonstrated an anastomotic leak communicating with a 5-cm pelvic collection containing gas.At laparoscopy,pus and faeculent material were washed from the pelvic cavity and drains were placed.Intra-operative endoscopy demonstrated a 7-8 mm dehiscence at the anastomosis.The defect(approximately 7 cm from the anal verge)was successfully closed using TAMIS and a running V-lock suture.The patient recovered well and was discharged home on post-operative day 20.In this case,a low colorectal anastomotic leak was successfully rescued with TAMIS.This novel technique may be useful in the armamentarium of colorectal surgeons experienced in TAMIS.

Role of minimally invasive surgery for rectal cancer

Rectal cancer is one of the most common malignancies worldwide.Surgical resection for rectal cancer usually requires a proctectomy with respective lymphadenectomy(total mesorectal excision).This has traditionally been performed transabdominally through an open incision.Over the last thirty years,minimally invasive surgery platforms have rapidly evolved with the goal to accomplish the same quality rectal resection through a less invasive approach.There are currently three resective modalities that complement the traditional open operation:(1)Laparoscopic surgery;(2)Robotic surgery;and(3)Transanal total mesorectal excision.In addition,there are several platforms to carry out transluminal local excisions(without lymphadenectomy).Evidence on the various modalities is of mixed to moderate quality.It is unreasonable to expect a randomized comparison of all options in a single trial.This review aims at reviewing in detail the various techniques in regard to intra-/perioperative benchmarks,recovery and complications,oncological and functional outcomes.

Recent advances in the management of rectal cancer: No surgery, minimal surgery or minimally invasive surgery

Over the last decade,with the acceptance of the need for improvements in the outcome of patients affected with rectal cancer,there has been a significant increase in the literature regarding treatment options available to patients affected by this disease.That treatment related decisions should be made at a high volume multidisciplinary tumor board,after pre-operative rectal magnetic resonance imaging and the importance of total mesorectal excision(TME)are accepted standard of care.More controversial is the emerging role for watchful waiting rather than radical surgery in complete pathologic responders,which may be appropriate in 20%of patients.Patients with early T1 rectal cancers and favorable pathologic features can be cured with local excision only,with transanal minimal invasive surgery(TAMIS)because of its versatility and almost universal availability of the necessary equipment and skillset in the average laparoscopic surgeon,emerging as the leading option.Recent trials have raised concerns about the oncologic outcomes of the standard"top-down"TME hence transanal TME(Ta TME"bottom-up")approach has gained popularity as an alternative.The challenges are many,with a dearth of evidence of the oncologic superiority in the long-term for any given option.However,this review highlights recent advances in the role of chemoradiation only for complete pathologic responders,TAMIS for highly selected early rectal cancer patients and Ta TME as options to improve cure rates whilst maintaining quality of life in these patients,while we await the results of further definitive trials being currently conducted.

Use of transanal minimally invasive surgery for endoscopic resection of rectal tumour:a technical note

Background:The aim of this article is to report and discuss a case of lower rectal cancer undergoing endoscopic transanal resection of tumour(ETART)using a transanal minimally invasive surgery(TAMIS)approach.Methods:A technical note on a case report.An innovative approach for ETART using TAMIS.Results:This is the first-ever case report of lower rectal cancer treated by ETART using a TAMIS approach.The procedure was completed successfully without any operative or peri-operative complication.Peri-operative flexible sigmoidoscopy confirmed a wide and patent rectal lumen.Conclusion:Use of a TAMIS approach for ETART to remove lower rectal cancer for palliation can be technically very effective compared with conventional ETART,due to the potential advantages of avoiding contaminant fluid spillage,easy access,better visualization compared with conventional ETART,and being user-friendly.The results from larger cohorts of patients undergoing TAMIS ETART are required before recommending the routine use of this technique.However,until then,this approach may be considered as an alternative to conventional ETART.

Laparoscopic natural orifice specimen extraction-colectomy: A systematic review

Over the last 20 years, laparoscopic colorectal surgery has shown equal efficacy for benign and malignant colorectal diseases when compared to open surgery. However, a laparoscopic approach reduces postoperative morbidity and shortens hospital stay. In the quest to optimize outcomes after laparoscopic colorectal surgery, reduction of access trauma could be a way to improve recovery. To date, one method to reduce access trauma is natural orifice specimen extraction(NOSE). NOSE aims to reduce access trauma in laparoscopic colorectal surgery. The specimen is delivered via a natural orifice and the anastomosis is created intracorporeally. Different methods are used to extract the specimen and to create a bowel anastomosis. Currently, specimens are delivered transcolonically, transrectally, transanally, or transvaginally. Each of these NOSEprocedures raises specific issues with regard to operative technique and application. The presumed benefits of NOSE-procedures are less pain, lower analgesia requirements, faster recovery, shorter hospital stay, better cosmetic results, and lower incisional hernia rates. Avoidance of extraction site laparotomy is the most important characteristic of NOSE. Concerns associated with the NOSE-technique include bacterial contamination of the peritoneal cavity, inflammatory response, and postoperative outcomes, including postoperative pain and the functional and oncologic outcomes. These issues need to be studied in prospective randomized controlled trials. The aim of this systematic review is to describe the role of NOSE in minimally invasive colorectal surgery.

Management of early rectal cancer;current surgical options and future direction

Rectal cancer is the second commonest cause of cancer death within the United Kingdom.Utilization of national screening programmes have resulted in a greater proportion of patients presenting with early-stage disease.The technique of transanal endoscopic microsurgery was first described in 1984 following which further options for local excision have emerged with transanal endoscopic operation and,more recently,transanal minimally invasive surgery.Owing to the risks of local recurrence,the current role of minimally invasive techniques for local excision in the management of rectal cancer is limited to the treatment of pre-invasive disease and low risk early-stage rectal cancer(T1N0M0 disease).The roles of chemotherapy and radiotherapy for the management of early rectal cancer are yet to be fully established.However,results of high-quality research such as the GRECCAR II,TESAR and STAR-TREC randomised control trials may highlight a wider role for local excision surgery in the future,when used in combination with oncological therapies.The aim of our review is to provide an overview in the current management of early rectal cancer,the surgical options available for local excision and the future multimodal direction of early rectal cancer treatment.