144

5utti..l

Procedures hlcluding Minimol Access Procedures

Gostrointestinol Surgery

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Video monitors (2) VCR

Light source (e.g., Xenon 300 W)

Mavigraph (video printer, optional) CO' insufflator Me[hylene blue dYe Skin closure striPs (oPtional) Silastic tubing

SpeciolNotes After the patient is in the room, position and connect

the monitors. Position electrosurgical unit' l"ff"*i"g a"aping,- the scrub person- passes off-the *ift" cabie, light cord, and Silastic tubing' "rl"tu .i*"iitoi adjusts the insufflator:-first low flow ftetween 5 and 7 mm Hg), then higher flow according io the surgeon's instructions' -Co""".t"u"d turn on the light source and white bal'
ance camera. --il" rechecks the position of monitors' remaining items: .it*t"tor iii" "i"."tator then connebts all and so

r""Jio" tubing, electrosurgical cord, --aif ^on' i".i""ttidnts (nondiiosable) mav be flash-steril
ized. '--iltk scope(s) and

light cord(s) in Steris solution af-

ter thorough cleansing.

The cirJulator turis the lights on and off as reqrr"lt"a. O"" Iight will remain on for the scrub person'
TRANSANAL ENDOSCOPIC
MICROSUROERY

Definition

Application of endoscopic surgical techniques via

transanally Placed rectoscoPe.
Discussion

by the operator and assistant. A unit is utilized thai continuously monitors intrarectal pressure and insufflates with carbon dioxide to mainiain an appropriate pressure to keep the recturrr distended, thus permitting visualization and responding to the introduction of inl struments and need for suctioning blood or fumes as well. Visualization is by means of binocular stereo_ scopic optics to which a side arm or teaching attachment or video monitor can be adapted. An irrigating de_ vice to cleanse the lens is also a part of the Jystem. A Morton arm retractor stabilizes the scope after it is positioned transanally. Most often this technique is em_ ployed for sessile lesions too large to be safely and/or adequately excised or electrofulgLrated via a standard sigmoidoscope. Benign and limiled nralignancies may be so treated. Preoperative evaluation may, i., addition to biopsy, include transrectal ultrasonography to determine the depth of mural invasion and lymph nodal involvement, which would influence the operati.,re approach. The position of the lesion will also influence the ,positioning ofthe patient for ease of access (i.e., prone, Fthqtgr-nyl or lateral). Transanal endoscopic rectopexy in which the posterior rectal wall is incised and the rectrm fixed to the presacral ligaments has been desribed. In most instances wlien violation of a fullSickhess. segment of rectal wall is anticipated, lneoperative preparation and postoperative cire is *imilar t-o that for a formal colon-surgery. If during the Gou{fe of the procedure the peritoneum is entered, im_ lediate repair is performed. Procedure

or for a lesion not technically feasible to be adequately treated by the usual transanal exposure, .p""i"t irrstrumentation has been devised permitting the use of endoscopic surgical instruments- in a wef-visualized gas-distended operative field. Up to four instruments may-be manipulated in parallel fashion simultaneously

Ihis procedure would

For rectal and rectosigmoid lesions to the level of20 cm ;;;;it";l t; th" trr.rr,"*hi.h otherwise would be excised iy op"r, (transperitoneal or transsacral) approach'

be performed on a patient with a fransanal sessile tumor of the midrectum. After inducbn of anesthesia, the patient is positioned to best visualize the lesion with respect to the operative field (e.g.,

"r,