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Serra-Aracil et al. Mini-invasive Surg 2019;3:37 I http://dx.doi.org/10.20517/2574-1225.2019.36 Page 9 of 11

is to introduce the TEM rectoscope into the rectum without the working attachment. Then, the rectum
undergoes intensive washing to remove all the blood clots from the rectal ampulla. Subsequently, the
working attachment is introduced once more and the rectum is distended. In many cases, a rectal catheter
is inserted via the TEM to complete the aspiration of the blood clots, since the conventional TEM aspirator
is not effective. The bleeding may be as low diffuse bleeding or may start from a particular point; the
amounts are small, but constant. The inflammation of the tissues means that any sutures inserted would
tear. The most effective procedure is to perform coagulation with aspiration maintained over the point of
bleeding and the entire surface of the resection bed. Finally, new washes are performed and the defect is
left open.

Urinary complications
Some studies have reported urinary complications to be the most frequent, affecting between 5.9% and
[8,9]
10.8% of patients . In our study, 30/716 (4.2%) patients presented urinary morbidity and only 20 (2.8%)
[8]
patients had AUR, a complication which other studies (e.g., Kumar et al. ) have reported to be more
frequent. One possible explanation is that in our protocol we remove the bladder catheter at the end of the
surgery in all patients except those with a history of prostate disease; in these latter patients, the medication
against benign prostatic hyperplasia is not withdrawn and the catheter is removed early the next morning.
Another possible reason is the use of general anesthetic in 655/716 (91.4%) patients, which does not favor
AUR (unlike spinal anesthetic).

Peritoneal cavity perforation
[13]
Peritoneal cavity perforation has been considered a cause of major morbidity in some studies ; others [14,15] ,
however, have not found it to be a significant risk factor for postoperative complications. In our view, if
peritoneal perforation is detected intraoperatively and is repaired by TEO/TEM, this is considered as a
[15]
standard technical variant of the procedure .
Anterior resections with perforation in the vagina and recto-vaginal fistulas. Urethral lesions?
Special care must be taken in the resection of anterior lesions in women. The integrity of the recto-vaginal
septum should be monitored, and a vaginal examination performed in case of doubt. Vaginal perforation
should be considered an important complication; indeed, five of our 12 patients with vaginal perforations
developed recto-vaginal fistula, due to the poor vascularization of the recto-vaginal septum and the
pressure exerted on it during defecation. These fistulas constitute a rare complication (appearing in five
of our 716 (0.7%) patients), but they are difficult to treat. In most cases, they require reoperation with a
temporary stoma and subsequent repair of the fistula. We have registered no urethral injuries after TEM in
our experience.

Postoperative pneumo-retropneumoperitoneum
As shown in Figures 2 and 3, the appearance of massive pneumo- and retroperitoneum on chest
radiographs and abdominal CT is relatively common during the immediate postoperative period. Provided
that the clinical and inflammatory parameters are normal, pneumo- and retroperitoneum need not be a
matter for concern. As noted above, two patients with asymptomatic postoperative fever presented these
features and were assigned to exploratory laparotomy, which turned out to be negative in both cases.

Asymptomatic postoperative fever
Fever is defined as asymptomatic and postoperative if it appears during the first 24-48 h, without other
[6]
symptoms, hemodynamic repercussion, or any focus. Fever may be as high as 39 °C ; it is not associated
with leukocytosis or with abdominal or pelvic pain and remits with antipyretics. In our study, 59/716
(8.2%) patients presented fever, which we considered to be a normal feature of the postoperative course.
[16]
In contrast, fever associated with abdominal pain and leukocytosis is termed post-TEM syndrome .