TAMIS resection of a large colonic polyp 20 cm from the anal verge: could endo-stapling be the solution to peritoneal entry?

Abstract

Transanal minimally invasive surgery (TAMIS) has been used for the treatment of rectal neoplasms such as benign polyps and early rectal cancer [1,2]. After early experience, other applications have appeared and the use of TAMIS approaches has expanded [3,4]. Transanal endoscopic microsurgery (TEM) and transanal endoscopic operation (TEO) resection for lesions above the rectosigmoid junction have been described [5], but TAMIS resection of these lesions is usually not considered feasible.We present the case of a 68-year-old male patient with large polyp located 20 cm from the anal verge, measuring 5 × 8 cm with a thick pedicle, which could not be resected with an endoscopic approach. After pre-operative examination as well as a computed tomography (CT) scan and magnetic resonance imaging (MRI) were performed, the patient underwent TAMIS as shown in the attached video.A long Gel Point Path (4 × 9 cm) was placed, and a conventional insufflator was used. Resection of the polyp was performed with a laparoscopic linear stapler (EndoGIA, Covidien) and conventional laparoscopic materials. Total resection of the polyp with free margins was possible. With the stapler, it was possible to excise the tumor, while sealing the suture line, minimizing the risk of entering the peritoneal cavity.The post-operative pathology report confirmed a tubulo-villous adenoma with high grade dysplasia and a free margin. The patient was discharged 24 h after surgery and remains asymptomatic after 5 months of follow-up. TAMIS resection of tumours located above the rectosigmoid junction may be a safe and feasible technique, but careful selection of patients, in terms of anatomy and tumor characteristics, is mandatory.