Fistula in ano and TEM痔疮肛门和TEM瘘课件.pptVIP

Combination of techniques used for conventional transanal excision with laparoscopic technology and instrumentation: endorectal system to create pneumorectum for optimal exposure and endoscopic magnification for excellent visualization Indications and contraindications are the same as for conventional transanal excision, except that higher lesions up to 12–14 cm can be targeted. Very low lesions are not amenable and are better treated with a conventional transanal excision. Polyp or other pathology (eg, ulcer) between 3 and 12(14) cm: No absolute size limit (less than hemicircumference) as long as tissue adequate, eg, sufficiently pliable for defect closure. Rectal cancer T1N0 lesion (invades submucosa). 4 cm largest diameter (less than one-third of circumference) Well or moderately differentiated histology No evidence of poor prognostic indicators, eg, lymphatic/vascular invasion. having significant comorbidities or extensive metastasis but locally highly symptomatic Full colonic evaluation and histologic documentation. Rigid sigmoidoscopy: determination of level above anal verge and exact location on circumference are very important for correct patient positioning Staging: ERUS. Bowel cleansing: full bowel cleansing. Prophylactic antibiotics 1. Patient positioning: the lesion has to be down! ie, posterior lesion lithotomy; left lesion left lateral; right lesion right lateral; anterior lesion prone jackknife position with legs spread apart (for access). 2. Pudendal/perianal nerve block with 15–20 cc of a local anesthetic in addition to general anesthesia to improve relaxation of anal sphincter muscles. 3. Insertion of 4-cm operating rectoscope/obturator and fixation to supporting arm, insertion of main body with sealing working and gas ports, stereotactic telescope with connection to video system. 4. Exposure of lesion. 5. Using combination instruments (coagulation/suction) and graspers, a dotted line (high-frequency knife, electrocautery) is marked