P. SYLLA Totally transanal endoscopic surgery: the step forward in no scar colorectal surgery

Oh, good morning. Sorry for the delay, but you know Professor Leroy, and so you can understand.

So thank you so much for being here this morning.

And Patricia Silla is in Boston.

She's a professor at Harvard University, and she's really one of the pioneers of the transanal approach for colorectal diseases.

and you will see a completely different approach to deal with with notes because

she's using a rigid platform that seems much more surgical platform and so for

sure we will learn many many things from her so thank you so much and please

start your presentation thank you very much for the opportunity I want to thank

Thank you, and Professor Palazzini, for the invitation.

Transanally, so here we grab the specimen and pull it out

and remove the TEM platform,

and you'll see the length of rectosigmoid that we can dissect is variable

based on how well we could mobilize proximally.

But here this is an example of how much colon you can get.

But what impressed us the most with this procedure

is that you can really achieve a very nice mesorectal dissection

pretty much in every cadaver,

And we've done over 15 human cadavers.

We haven't published our work yet, but that will be published shortly.

But we were able to very reproducibly resect the rectum with intact mesorectum.

So as I said, we have performed this in over 15 cadavers by now.

This is the range of colon that we could mobilize anywhere between 23 and 75 centimeters.

We did have two bowel perforations during some of the endoscopic mobilization.

and we find that the factors that are associated with a difficult dissection is definitely obesity,

especially as we enter the abdomen, it becomes much harder in an obese cadaver to retract the

bowel sufficiently. And we find that obviously adhesions also is an issue and the instrumentation

is limited because it's not long and not flexible enough. Now, so what about a clinical application

of this procedure, especially for rectal resection? The question is, should we continue our work

using transgastric, hybrid transgastric and transrectal approach? Or should we focus more

on a pure transanal endoscopic approach? And I think that's unfortunately until our gastronomy

closure becomes better and until we have a substantial improvement in our instrumentation.

I think for now, these two approaches are relatively unsafe. I think to start, we should

definitely consider using a laparoscopic hybrid approach, combining laparoscopy, transabdominal

laparoscopy as well as transanal endoscopic approach to perform these procedures. And that's

precisely what we did just over a year ago. We were very fortunate to be able to collaborate

with Dr. Lacey at the Hospital Clinic of Barcelona and had a patient, and this was a IRB-approved

experimental procedure in a 76-year-old female who had a T2N1 preoperatively staged anterior

rectal cancer six centimeters from the anal verge. She was an ideal surgical candidate in that she

She was very small.

Her BMI was only 20.

She had no previous major pelvic surgery before, and she underwent standard preoperative chemoradiation

for her rectal cancer.

Now, the goal was to first access her abdomen for laparoscopy for visualization and assistance,

and we did this using a total of three ports.

We had two needle-scopic ports, as well as a 5-millimeter port through the planned stoma

site in the right lower quadrant.

The exciting part about this procedure is that we were able to perform the entire rectal

dissection, including the total mesorectal excision, endoscopically through the TEM

platform, and we used the laparoscopic approach to retract the sigmoid and help with the sigmoid

mobilization.

And we then extracted the specimen trans-anally, performed a standard hand-sewn coloanal J-pouch

anastomosis, and then we diverted the patient with a standard loop oleostomy, which would

have been done regardless.

godless. So I will show you a very quick version of that procedure. Here you will see first how we

obtain laparoscopic access to the abdomen. So anyways, essentially the steps were identical

to the cadaver model. The only difference is obviously that we were able to, we used a

laparoscopic approach to identify the left uter and really help retract the sigmoid colon while

while we did our mesenteric transection of the IMA pedicle.

The patient did very well and actually had her ileostomy closed.

Her final pathology demonstrated a T1N0 tumor with 23 negative nodes.

So, so far, there's been two published reports of this human experience

using a combined trans-anal and laparoscopic approach.

Besides our group, we also have, there's also a recent publication.

So, I think this is definitely a technique that is easily reproducible.

I don't think it's very complicated to perform, especially with TEM experience.

And I think this is something that we'll see a lot more of in the future.

Now here at MGH, we are very excited to start a study that's been already IRB approved,

so we are recruiting patients.

And the indications for this procedure will be high-risk T1 cancers, T2 and T3, no negative

rectal cancers by pelvic MRI, which are located 4 to 12 centimeters from the anal verge.

Our primary endpoint will be the adequacy of our mesorectal excision, and we also will

be looking for our secondary endpoints at perioperative outcomes.

So we're very excited to start to look at this in an IRB-supervised fashion and hope

that soon we'll be able to participate with other centers to do this on a bigger scale.

So, thank you very much for your attention and I apologize again for not being able to

show the human video.

Thank you very much, Patricia.

It's a very nice experience that you have done and I'm pretty sure that this approach

is more familiar for surgeons, so we'll get more, let's say, success among the surgical

community.

I don't know if, I know, you know Marko Liric, he's one of the first sergeants to describe

the use of the ultrasonic shears

by the TEM approach. He worked with

the Buess at the beginning of his

experience, so for sure he has a question for you.

Hi, Dr. Silla.

This is Marco Lirici. I did enjoy your

presentation. I did it

even, too, as mentioned

by Antonello. I was

used to work with Geha Buess for a long

time in the early 90s.

So

it's a great approach,

but let me ask a question what about the tissue traction because I think the very big issue in

this kind of procedure should be how to retract the viscous in the abdominal cavity so do you

think that it will be only perform as an hybrid procedure or there will be some some chances in

in the future with the new technology to have a pure

transcendental approach to major colorectal resections?

I can tell you that right now it's absolutely unsafe

to do this purely transcendentally because

of the issue, the very issue of retraction

once you get into the abdomen.

It's just impossible.

With the equipment that we have right now,

it's not long enough.

It's not flexible enough.

So right now, as it stands, it's not safe.

I mean, we're still doing a lot of work in the lab trying different other prototypes,

different other instrumentation to do this, but it's still the biggest problem right now

is that it's just not safe in every cadaver.

So some cadavers that are very thin with a very, you know, redundant colon, it's feasible

to go all the way to the splenic flexure using the flexible instrumentation that we have

right now, but in bigger pelvises with more adhesions, it's just impossible.

So, I'm hoping and I'm hopeful that industry will really come forward and help design more equipment that is more adapted for these procedures.

And I hope that as a group, we can really inspire them to design instrumentation that could be used for a pure transcendental approach.

But the big question is going to be, what type of instrumentation do we need to get those procedures done purely transcendently?

And we need help from industry to help us with that.

I have a question for you, Patricia, related to the use of the TEM platform for indication that before you considered the limit or borderline, especially related to the hate of the tumor, maybe at the retosigmoid junction.

you know because of this experience I expect that in the next future surgeons

will be more keen to operate the lesions that before there would be more suitable

for laparoscopic approach or because you didn't feel so confident to open the the

full thickness excision so which is your impression do you think that this would

be a trend for the future I think so I think the big problem that we have right

right now is, I mean, this procedure is ideal for rectal lesions all the way to the recto-sigmoid.

But the big thing, and that's what Professor Leroy is working on now, is you can't justify

this procedure that I'm describing for sigmoid lesions, because we're starting the dissection,

you know, at four centimeters. So you are going to remove the entire rectum. So you can't really

justify removing the rectum for a sigmoid, you know, cancer or a sigmoid lesion. So, you know,

the procedure is easy to perform because you're starting so low right above the sphincter complex.

But right now, it's much more difficult to start your dissection higher up. And we don't have the

really the tools yet. And I mean, you saw from Dr. Leroy's videos, you know, he's describing

starting the dissection for segmental colonic resections. But the technique is very complicated

and very difficult with many, many steps that are difficult to reproduce. So until again,

until the technology gets better, I think what I'm describing here with the TM platform is really

best suited for rectal pathology. I don't think we're ready to use this

or justify this using, you know, for more proximal lesions.