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Ex-Vivo Feasibility Testing of Transanal Specimen Extraction During Colon Resection Using a Transanal Endoscopic Surgery (Tes) Proctoscope
Ezra N. Teitelbaum*, Fahd O. Arafat, Amy L. Halverson, Michael F. Mcgee, Kyle H. Mueller, Anne Marie Boller
Northwestern University, Chicago, IL
INTRODUCTION: Laparoscopic-assisted colon resection traditionally requires creation of a small laparotomy for specimen extraction. Transanal extraction of the specimen obviates the need for such an incision, and several studies have described the use of a transanal endoscopic surgery (TES) proctoscope to serve as a conduit for this technique. In this study, we performed an ex-vivo experiment to determine the feasibility of extracting resected colon segments through a TES proctoscope.
METHODS: Patients undergoing elective colon resections for both benign and malignant disease were studied under an IRB-approved protocol. After the colon segment was resected in the normal fashion (either laparoscopically or open), it was passed off the operative field for testing. We then attempted to pass the specimen through a commercially-available TES proctoscope with a 4 cm inner diameter and 15 cm length using a laparoscopic grasper. If resistance was encountered during passage, the test was considered a failure. To test the feasibility of using variably sized extraction tubes, the specimen was also passed through 15 cm long PVC-tubing segments with 1.25 inch (3.1 cm) and 2 inch (5.1 cm) diameters. Associations between patient variables and ability of the specimen to pass through the TES proctoscope were tested using a bivariate Pearson's correlation.
RESULTS: Extraction tests were performed on 21 resected colon specimens. Indication for resection was colon cancer or polyps in 10 cases, recurrent diverticulitis in 9 cases, Crohn's disease in 1 case, and ulcerative colitis in 1 case. The anatomy of the resection was the sigmoid colon in 13 cases, a hemicolectomy in 5 cases, a total proctocolectomy in 2 cases, and a proctectomy in 1 case. Mean patient age was 55 ±14, BMI was 26 ±6 kg/m2, 13 (62%) were female, and 15 (71%) had received preoperative mechanical bowel preparation. Mean colon specimen length was 30 ±33 (range 10-150) cm and mean width (including mesentery) was 5.6 ±1.9 (range 3-9) cm. Nine (43%) specimens were able to pass through the 4 cm diameter TES proctoscope without significant resistance. Six (29%) were able to pass through the 3.1 cm diameter tube, while 14 (67%) passed through the 5.1 cm diameter tube. Specimens from patients with higher BMIs were less likely to pass through the TES proctoscope (r =-.48, p=.03) and wider specimens were also less likely to pass (r = -.51, p=.03). Longer specimens were less likely to pass successfully at a trend level (r = -.39, p=.08).
CONCLUSIONS: In an ex-vivo experiment, less than 50% of colon specimens were able to be passed through a standard TES proctoscope. Increased specimen width and length, as well as patient BMI, were predictive of passage failure. Use of a TES proctoscope to facilitate transanal specimen extraction may not be a feasible technique for the majority of colon resections.
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