Patricia Sylla (Associate professor of colorectal surgery)
Beatriz Martin-Perez (Gastrointestinal surgery specialist)
Gabriel Diaz del Gobbo (Gastrointestinal surgery specialist)
Mount Sinai, New York – USA
Hospital Clínic, Barcelona – Spain
This is a 68 year-old male who on screening colonoscopy was found to have a 4 cm villous polyp of the low anterior rectum, extending from the dentate line. There was no evidence of high grade dysplasia or malignancy on biopsy and the patient was taken to the OR for planned transanal endoscopic resection.
The patient underwent full-mechanical bowel preparation with 2 enemas given the night before surgery. Routine parenteral antibiotic prophylaxis was provided.
The patient was placed supine on the table and following anesthesia, he was placed in high lithotomy position with stirrups. Following an anal block with local anesthetic, anoscopy was performed and the low rectal villous polyp could already be visualized along the anterior rectal wall starting just at the level of dentate line and extending by 3-4 cm into the rectum.
The anus was carefully dilated and the short beveled TEO platform ® (Karl Storz). was inserted transanally.
The platform was sealed with the faceplate and CO2 was insufflated to a pressure of 12-15mmHg. After achieving excellent distention and visualization of the low rectum, the lesion was scored circumferentially with cautery with a 0.5-1 cm margin starting at the level of the dentate line and extending superiorly into the proximal rectum. The distal aspect of the lesion was mobilized along the submucosal plane using monopolar cautery, making every effort to avoid injury to the underlying anal sphincter muscle. As this dissection was extended superiorly, this dissection plane was extended deeper through the rectal wall using monopolar cautery. The lesion was entirely excised, exteriorized transanally and oriented with sutures for pathology.
The rectal wall defect was closed using interrupted 2-0 vicryl sutures using the EndoStich device®. Then the TEO platform was removed and the distal-most aspect of the anorectal defect was closed with 2-0 vicryl sutures using an anoscope. After confirming complete closure of the defect, additional local anesthesia was administered, and the patient was extubated and transferred to the recovery room.
The procedure was performed as an ambulatory (same-day) procedure. The OR time was 85 minutes and the patient was discharged home on the same day. The pathology demonstrated a 2.5 cm tubulovillous adenoma with no neoplasia and negative margins. The patient is scheduled for flexible sigmoidoscopy for 6 months following this procedure.
TEO platform is one of the multiple options available for transanal resection of anorectal lesions, with good surgical outcomes as it maintains the same surgical principles.