TEM - Transanal Endoscopic Microsurgery
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In 1983 the German Surgeon, Dr Gerhard Buess, has developed Transanal Endoscopic Microsurgery, what revolutionized the resection of rectal lesions. TEM is performed transanally with especially created microsurgical instrumentation. Thank TEM is possible to remove high inside the rectum, what before was only able by major abdominal surgery. The patients after TEM surgery recover rapidly, and the complication occurs not so often as after traditional or laparoscopic surgery. In a case of recurrence all the operation techniques can be done (TEM, laparoscopy or transabdominal surgery) However TEM has earn famous not so quickly, the main reason of that is high cost, secialized instrment needed but it is now an establlished procedure and especially useful for elderly and unfit patients. The gastroenterologists should to know about properties and indications of TCM, and remember about TCM in the time of reffering patients with ractal adenomas to surgical treatment. Open major rectal surgery may have a lot of complication, which makes the patient's life quality lower because of bladder dysfunction or erectile dysfunction. So the patient had to be warned regarding risk of this complications. In the cases of conventional rectal of laparoscopc surgery may occur risk ot a stoma, a permanent colostomy after an abdominal resection of the rectum or sometime temporary ileostomy or colostomy as a reson of an anterior resection of the rectum. In the case of temporary stoma is needed more operation to close the aperture and every surgery carries some kind of risk. Moreover the presence of a constant stoma may be hard to accept and difficult to manage for some patients. TEM requires a mnimal access surgeon who has advanced laparoscopic skills. It is a laparoscopic technique, may to be done on a much more limited area. The surgeon may fast aquire the TEM skill, because he need not too much patient cases to learn how to perform the TEM. There is much more patient's case in centrain centers, what allow the surgeon to get more experience. The special equipment for TEM consists of 4 centimeter diameter sigmoidoscope, the sterioscope, laparoscopic atraumatic forceps, laparoscopic
diathermy or vessel sealer, laparoscopic irrigation‐suction device, which are connected to a standard laparoscopic stack inclusive a gas source, a light source and a high resolution monitor. Before surgery is required full bowel preparation. The whole procedure is performed transanally in lithotomy position, unless there is a complication of intra‐abdominal perforation of the rectum. In the most of cases is used general anaesthesia although the author and others have performed cases subarachnoid anaesthesia. TEM offers, in the opposite to more radical surgery, minimally invasive solution for the excision of certain rectal polyps and early stage rectal tumors. TEM enable minimale invasive excision of large or sessile rectal adenomas. Some patients may avoid the risk and side effects of the major surgery. TEM may also be done a short stay procedure without general anasthetic, and its common complications, minimalilising morbidity and mortality. TEM may be still the first line treatment also in case of malignant transformation or recurrence since it does not preclude radical surgery.
The benefits of TEM for patients, because of avoiding of radical abdominal surgery are clear: no major surgery, no large incision, no colostomy, less pain, faster recovery and shorter hospital stay.
Chief of the Gastrointestinal Surgery Department, Hospital Clinic in Barcelona
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