In this video we will present some surgical scenarios showing the most common problems related with the pneumorectum that can arise when performing the Transanal TME.
Transanal access platform set up:
The first issue that may be found is that it is impossible to introduce the transanal access platform. This can happen because of a narrow or long anal canal, a hypertonic sphincter, or lack of relaxation. The use of a Lone Star retractor to expose the anus, good lubrication of the device and the use of dilators could decrease the situation.
In addition, close interaction with the anesthesiologists is necessary, as this technique requires intense neuromuscular blockage to diminish sphincter pressure.
Undesired effects of the pneumorrectum:
Once the procedure has begun, we should take into account the effect of the transanal pneumorectum on the abdominal field. A retropneumoperitoneum can be generated, impairing the transabdominal team’s work. We strongly recommend that both teams work simultaneously (the Cecil approach). If only one team is available, the abdominal field should be performed prior to using the pneumorectum through the anus.
The transanal pneumorectum can also insufflate the proximal colon, making the sigmoid resection difficult. To avoid this, the surgeon on the abdomen should clamp the distal sigmoid colon until the purse string is closed. If clamping the colon is not possible or has failed, the solution is deflating it using a rectal tube.
Lack of rectal distention:
Another common problem is the lack of correct distension of the rectal lumen when a pursestring has to be created or even during the dissection. The reason could be again incorrect neuromuscular blockage to avoid the effect of the surgical stimulus on the rectal wall and pelvic floor muscles. Another reason is high pressure from the abdomen.
Try to reduce the CO2 on the abdomen by increasing pneumorectum pressure, until both sides are connected and pressure is equal again.
Proper closure of the pursestring is essential to build a sealed cavity and achieve the exposure to work properly. A mistake during this step can create CO2 leakage in the rectal lumen giving rise to contamination and tumor spillage. Moreover, the proximal lumen will be insufflated which will hinder performance of the sigmoidectomy.
To perform this step correctly we recommend making a tight knot, without the transanal access platform cap, ensuring a sealed cavity. If the error persists you should make a new suture or another stitch before moving on to the next step. Take care not to cut the suture due to too close rectal transection.
Another important issue to be concerned with is the kind of the device we use to provide the CO2 and evacuate the smoke. The conventional insufflator works in a pulsating manner, which increases rectum movement. In addition, every time we open a valve to evacuate the smoke, this modifies intraluminal pressure, resulting in significant pumping of the rectal tissue. All these factors hinder the procedure and tire out the surgeon so the procedure takes longer and the quality of the dissection may be compromised.
Another type of insufflation device works by maintaining constant pressure on the pelvic cavity with a permanent smoke evacuation. Thanks to this device you can achieve a stable working field with a clear view.
Which problems do you recognize on the next video? Exactly, we had problems with rectum distension as well as with smoke. What did we do? We achieved correct patient relaxation, low pressure in the abdominal cavity, and introduced CO2 insufflators that were able to maintain constant lumen cavity pressure.
To sum up, with these easy tips and tricks you can solve some frequent problems that surgeons can find during the TaTME procedure.