Page 168 - Read Online

Page 4 of 9 Adegbola et al. Mini-invasive Surg 2018;2:40 I http://dx.doi.org/10.20517/2574-1225.2018.55

[34]
proach results in fewer scars with improved cosmetic results . In 2017, a retrospective comparative study
assessing ta-IPAA (n = 97 patients) vs. transabdominal minimally invasive (completion) proctectomy with
[37]
IPAA (119 patients) assessed 90-day morbidity between the two groups . They demonstrated safety of the
ta-IPAA approach in patients with UC, with decreasing rates of postoperative morbidity, lower conversion
[37]
rate and shorter postoperative length of stay . An analysis of the benign cases extracted from the TaTME
International registry reported leak rates of less than 5% in the first 69 Ta-IPAA patients included, with
[38]
23% overall complication rates (most of them grade I-II Clavien-Dindo) . Similarly, analyses of the entire
cohort of patients with inflammatory bowel disease who underwent TAMIS proctectomy with or without
[39]
restoration of the continuity confirmed the safety of the technique . Four percent experienced Clavien-
Dindo III complications; surgery was, however, technically more demanding in Crohn’s disease with in-
[39]
ability to proceed with TAMIS in 20% of patients and more frequent wound complications .

The techniques employed offer an added advantage as a form of natural orifice transanal endoscopic sur-
gery with laparoscopic/SILS assistance and is potentially a well suited technique for inflammatory bowel
[42]
disease [33,36,40,41] . Recent European guidelines on surgery in UC acknowledge these new variants of natu-
ral orifice surgery (i.e., TAMIS for proctectomy with or without an anastomosis). However, in view of their
an early development stage, it is noted that future prospective (and comparative) studies would be required
[42]
to assess benefit in terms of functional outcomes and their role in management of patients with UC .
Redo pelvic surgery
[43]
In 2016 Borstlap et al. shared their experience of TAMIS in redo pelvic surgery addressing complica-
tions or necessity for surgery following rectal resections and primary anastomosis and also in the context
of pouch surgery. In a series of 17 patients, they described TAMIS use for redo anastomotic surgery in 13
and pouch problems in the remaining four. A majority of patients had chronic presacral sinus due to prior
anastomotic dehiscence after low anterior resection, and pouch problems were due to efferent loop syn-
drome, obstructive pouch polyp, voiding disorder, recurrent cuffitis. Using a hybrid technique of transanal/
transabdominal approach for most (15/17), feasibility was defined as the ability to complete rendezvous
from transanal to transabdominal level (at seminal vesicles/anterior curvature of neorectum in women)
[43]
beyond the anastomosis . Whereas for those with sole TAMIS procedures (2/17) feasibility was defined as
the ability to perform safer dissection with better visualisation of the dehisced anastomosis. This increased
visibility is proposed to be one of the likely benefits of the TAMIS approach in redo pelvic surgery, with
[43]
supposed lower risk of neurovascular injury, however this remains yet to be proven . The authors pro-
posed the merits of TAMIS in the context of redo surgery of the above nature to be judged on feasibility
and complication rate, in view of the absence of oncological issues. Another potential anastomotic problem
that can be addressed by this platform is the treatment of completely occluded anastomotic strictures, with
[44]
incision of the blind end with electrocautery following confirmation of proximal lumen with contrast .

Pelvic exenterative surgery
The TAMIS platform has been applied to exenterative surgery in the context of advanced rectal cancer,
with case reports by two groups of authors, both from Japan [45-47] . The technique described involves a hy-
brid transabdominal/transanal approach with the use of TAMIS access port following incision of the peri-
anal skin incision and subsequent perirectal tissue and muscles dissection until the abdominal cavity is en-
[45]
countered . The platform is proposed to facilitate the pelvic dissection with removal of the pelvic organs
[46]
within the visceral pelvic fascia . Clearly, evidence is very limited at this stage, however, there may well be
future adoption of this technique in view of the proposed advantages of increased visibility, reduced blood
[46]
loss and smaller perineal wounds with the TAMIS approach . As the series are small and assessing feasi-
bility there is no formal comparison available with the conventional open technique, and the oncological
outcomes and long term safety of this technique will need to be evaluated in future studies.