Single port transanal surgery vs. transanal endoscopic microsurgery
for rectal tumours: a case-control study.
RM Barendse1, WA Bemelman2, P Doornebosch3, P Fockens1, E Dekker1 and EJR de Graaf3
Dept. Of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam
Of Surgery, Academic Medical Center, Amsterdam
3 Dept. Of Surgery, IJsselland Hospital, Capelle aan den IJssel
1
2 Dept.
Single port transanal surgery (SPTS) is a novel technique for the resection of rectal
lesions, which are eligible for Transanal Endoscopic Microsurgery (TEM). Instrumental
simplicity, similarity to laparoscopy and standard lithotomy positioning in SPTS may
reduce patients’ stay in the operating theatre, thereby improving cost-effectiveness of
the procedure. We aimed to compare the in-theatre stay of patients undergoing SPTS
and TEM during the initial clinical utilization of SPTS.
Consecutive candidates for TEM who presented between April and September 2011
were operated via SPTS, using the SSL Access System (Ethicon Endo-surgery, Cincinnati,
OH, USA) and standard laparoscopic instruments. Patients undergoing SPTS were
matched with patients who had undergone TEM from 2006 – 2010 (using a rigid
rectoscope with stereoscopic view and dedicated instruments (Wolf GmbH, Knittlingen,
Germany)) in a 1:2 ratio. Controls were matched for lesion size (<20 vs. ≥20 cm2),
distance ab ano (<7.5 vs. ≥7.5 cm), rectal quadrant (posterior vs. non-posterior) and
benign vs. malignant disease. All procedures were performed by a single surgeon with
limited expertise in SPTS (13 cases) and extensive experience in TEM (>500 cases).
Primary outcome was in-theatre stay including anesthesia induction, instrument
preparation and patient positioning. Secondary outcomes included procedure time and
conversion rate.
Twenty-two patients (mean age 72 ± 12 years; 15 (68%) males) undergoing SPTS were
included. Rectal lesions (55% adenoma, 18% polypectomy scar, 5% rectal stenosis, 14%
T1 carcinoma, 9% T2) were located at a mean distance of 7.7 ± 4.5 cm ab ano and on the
anterior, posterior, left lateral, right lateral and circumferential rectal walls in 36, 9, 14,
36 and 5% respectively. Median surface of resection specimens was 11 cm2 (IQR 7-33
cm2). Patients were matched to 44 controls who underwent TEM. Median in-theatre
time was 76 minutes (IQR 57 – 106) in SPTS and 71 minutes (IQR 60 – 91) in TEM
(p=.923). Median procedure time was 35 minutes (IQR 22-59) for SPTS and 33 minutes
(IQR 23 – 49) for TEM (p=.698). Three SPTS procedures (14%) were converted to
conventional TEM due to port dislodgement; 1 to anterior resection because of
oncological considerations and 1 to transanal excision because of tumour prolapse. No
conversion occurred in TEM procedures (P=.003).
SPTS was technically feasible in 86% of patients who presented with lesions otherwise
eligible for TEM. Efficiency was similar despite the limited experience with SPTS. For
surgeons who routinely perform conventional TEM, SPTS might prove a technically
simpler and more cost-effective technique.