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Transanal Minimally Invasive Surgery: A Multi-Purpose Operation.

BACKGROUND
Minimally Invasive Colorectal Surgery (MICS) is continually evolving. The recognition of the anus as a natural orifice to perform MICS has contributed to the development of a new philosophy of treatment called TransAnal Minimally Invasive Surgery (TAMIS). Transanal total mesorectal excision (TaTME) is one of the most common forms of TAMIS. Other indications include benign diseases and early malignant rectal adenocarcinoma. This report presents the author's experience with TAMIS as a multi-purpose operation.


PATIENTS AND METHODS
Between January 2015 and May 2019, 36 patients underwent TAMIS for benign and early malignant diseases (group 1) and 30 patients underwent TaTME (group 2). The mean ± SD age was 60.2 ± 13.9 years (range 28-84) (group 1) and 63.7 ± 8.6 years (47-87) (group 2). The mean ± SD BMI was 26.7 ± 5.2 kg/m2 (19.3-42.9) (group 1) and 25.7 ± 5.9 kg/m2 (17.3-50.7) (group 2). The conditions in group 1 consisted of anastomotic leakage (n=20), benign rectal stenosis (2), anastomotic exploration with lavage and drainage (2), salvage of abdominal dissection (1), rectal ulcus (1), rectal intussusception (1), and removal of early malignant rectal polyps (9). The conditions in group 2 consisted of TaTME associated with single-incision abdominal laparoscopy (19) and conventional abdominal laparoscopy (11).


RESULTS
In group 1, the mean operative time was 38.2 ± 19.2 min (range 20-89) for immediate anastomotic leak repair, 90.2 ± 30.4 min (41-120) for early leak repair, 85 ± 67.4 min (30-180) for late leak repair, 45-163 min for rectal stenosis, 25-30 min for pelvic lavage and drainage, 180 min for difficult pelvic dissection, 57 min for rectal ulcus, 127 min for rectal intussusception, and 84.3 ± 28.0 min (50-131) for early malignant rectal polyps. In group 2, the mean operative time was 197.1 ± 63.3 min (96-399). The mean operative bleeding was 14.3 ± 24.7 ml (0-100) in group 1 and 57.0 ± 102.5 ml (0-450) in group 2. In group 1, the mean hospital stay was 11.6 ± 7.2 days (5-27) for immediate leak, 20.7 ± 14.7 days (6-42) for early leak, 2.6 ± 1.6 days (1-5) for late leak, 2-5 days for rectal stenosis, 4-7 days for pelvic lavage and drainage, 17 days for difficult pelvic dissection, 2 days for rectal ulcus, 1 day for rectal intussusception, and 1.3 ± 0.4 days (1-2) for early malignant rectal polyps. In group 2, the mean hospital stay was 11.4 ± 10.0 days (3-49). The early complication rate was 27.7% in group 1 and 40% in group 2. The late complication rate was 8.3% in group 1 and 10% in group 2.


CONCLUSIONS
TAMIS is an innovative technique that may be considered for the treatment of benign diseases like anastomotic complications, benign rectal stenosis, anastomotic explorations with lavage and drainage, rectal ulcus, and rectal intussusception. It can be used to search for a good plane of dissection, which cannot be found through the abdominal anterior approach. It can also be adopted for removal of early malignant rectal polyps and for TaTME. The technique described here allows the surgeons to work under ergonomic conditions, with completely reusable materials, and with a magnified view of the operative field, allowing intraluminal surgical sutures.