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Transanal minimally invasive full-thickness middle rectum polyp resection with the patient in a prone position

G Dapri, MD, PhD, FACS, FASMBS, Hon FPALES, Hon SPCMIN, Hon BSS, Hon CBCD, Hon CBC L Qin Yi, MD A Wong, MD P Tan Enjiu, MD S Hsien Lin, MD D Lee, MD T Kok Yang, MD S Mantoo, MBBS, MS, MMed, FRCS
Epublication WebSurg.com, Apr 2018;18(04). URL: http://websurg.com/doi/vd01en5214

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  • 2018-04-20
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Background: Nowadays, rectal preservation has gained popularity when it comes to the management of degenerated rectal polyps or early rectal cancer (1, 2). Tis/T1 rectal lesions can be safely treated without chemoradiation (3). Treatment via transanal minimally invasive surgery (TAMIS) offers more advantages than endoscopic submucosal dissection (ESD) (4). The authors report the case of a 60-year-old woman who underwent a TAMIS procedure for a large polyp located anteriorly in the middle rectum, which was 7cm away from the pectineal line and staged as uTisN0M0 preoperatively. Video: The patient was placed in a prone position with a split-leg kneeling position. A reusable transanal D-Port (Karl Storz Endoskope, Tuttlingen, Germany) was introduced into the anus together with DAPRI monocurved instruments (Figure 1). The polyp was put in evidence (Figure 2) and resection margins were defined circumferentially using the monocurved coagulating hook. A full-thickness resection was performed with a complete removal of the rectal serosa and exposure of the peritoneal cavity, due to the anatomical polyp positioning (Figure 3). The rectal opening was subsequently closed using two converging full-thickness running sutures using 3/0 V-loc™ sutures (Figure 4a). The two sutures were started laterally and joined together medially (Figure 4b). Results: Total operative time was 60 minutes whereas suturing time was 35 minutes. There was no perioperative bleeding. The postoperative course was uneventful, and the patient was discharged after 2 days. The pathological report showed a tubular adenoma with high-grade dysplasia and clear margins. Conclusions: In the presence of degenerated rectal polyps, full-thickness TAMIS is oncologically safe and feasible. The final rectal flap can be safely closed by means of laparoscopic endoluminal sutures.