Techniques in Coloproctology

, Volume 17, Supplement 1, pp 55–61 | Cite as

Transanal endoscopic microsurgery

  • M. MorinoEmail author
  • A. Arezzo
  • M. E. Allaix
How I Do It


The aim of oncologic surgery is radical cancer treatment with preservation of function and quality of life. Almost 30 years ago, transanal endoscopic microsurgery (TEM) revolutionised the technique and outcomes of transanal surgery, first becoming the standard of treatment for large rectal adenomas, then offering a possibly curative treatment for early rectal cancer, and finally generating discussion on its potential role in combination with neoadjuvant therapies for the treatment of more invasive cancer. TEM afforded the advantage of combining a less invasive transanal approach with low recurrence rates thanks to enhanced visualization of the surgical field, which allows more precise dissection. We describe the current indications, the preoperative work-up, the surgical technique (with the aid of a video), postoperative management and results obtained in an over 20-year-long experience. Designed as an accurate means to allow excision of benign rectal neoplasms with a very low morbidity rate, TEM today is indicated as a curative treatment of malignant neoplasms that are histologically confirmed as pT1 sm1 carcinomas. T1 sm2-3 and T2 lesions should at present be included in prospective trials. Accurate preoperative staging is essential for optimal selection of patients. Patients with clear indication for TEM should be referred to specialized medical centres experienced with the technique.


Transanal endoscopic microsurgery Full thickness excision  Rectal adenoma Adenocarcinoma 



We would like to thank Ivo Pollastri for the invaluable contribution in implementing Transanal Endoscopic Microsurgery at our institution.

Conflict of interest


Supplementary material

Supplementary material 1 (WMV 173598 kb)

Supplementary material 2 (WMV 86247 kb)


  1. 1.
    Kapiteijn E, Marijnen CA, Nagtegaal ID et al (2001) Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med 345:638–646PubMedCrossRefGoogle Scholar
  2. 2.
    Wong RK, Tandan V, De Silva S, Figueredo A (2007) Pre-operative radiotherapy and curative surgery for the management of localized rectal carcinoma. Cochrane Database Syst Rev 18(2):CD002102. ReviewGoogle Scholar
  3. 3.
    Habr-Gama A, Perez RO (2009) Non-operative management of rectal cancer after neoadjuvant chemoradiation. Br J Surg 96:125–127PubMedCrossRefGoogle Scholar
  4. 4.
    Morino M, Parini U, Allaix ME, Monasterolo G, Brachet Contul R, Garrone C (2009) Male sexual and urinary function after laparoscopic total mesorectal excision. Surg Endosc 23:233–240CrossRefGoogle Scholar
  5. 5.
    Marijnen CAM, Kapiteijn E, van de Velde CJH et al (2002) Acute side effects and complications after short-term preoperative radiotherapy combined with total mesorectal excision in primary rectal cancer: report of a multicenter randomized trial. J Clin Oncol 20:817–825PubMedCrossRefGoogle Scholar
  6. 6.
    Wallner C, Lange MM, Bonsing BA et al (2008) Causes of fecal and urinary incontinence after total mesorectal excision for rectal cancer based on cadaveric surgery: a study from the Cooperative Clinical Investigators of the Dutch total mesorectal excision trial. J Clin Oncol 26:4466–4472PubMedCrossRefGoogle Scholar
  7. 7.
    Hendren SK, O’Connor BI, Liu M et al (2005) Prevalence of male and female sexual dysfunction is high following surgery for rectal cancer. Ann Surg 242:212–223PubMedCrossRefGoogle Scholar
  8. 8.
    Morino M, Parini U, Giraudo G, Salval M, Brachet Contul R, Garrone C (2003) Laparoscopic total mesorectal excision: a consecutive series of 100 patients. Ann Surg 237:335–342PubMedGoogle Scholar
  9. 9.
    Ho P, Law WL, Chan SC, Lam CK, Chu KW (2003) Functional outcome following low anterior resection with total mesorectal excision in the elderly. Int J Colorectal Dis 18:230–233PubMedGoogle Scholar
  10. 10.
    Williams NS, Johnston D (1983) The quality of life after rectal excision for low rectal cancer. Br J Surg 70:460–462PubMedCrossRefGoogle Scholar
  11. 11.
    Sakamoto GD, MacKeigan JM, Senagore AJ (1991) Transanal excision of large, rectal villous adenomas. Dis Colon Rectum 34:880–885PubMedCrossRefGoogle Scholar
  12. 12.
    Mellgren A, Sirivongs P, Rothenberger DA, Madoff RD, García-Aguilar J (2000) Is local excision adequate therapy for early rectal cancer? Dis Colon Rectum 43:1064–1074PubMedCrossRefGoogle Scholar
  13. 13.
    Parks AG, Stuart AE (1973) The management of villous tumours of the large bowel. Br J Surg 60:688–695PubMedCrossRefGoogle Scholar
  14. 14.
    Nivatvongs S, Balcos EG, Schottler JL, Goldberg SM (1973) Surgical management of large villous tumors of the rectum. Dis Colon Rectum 16:508–514PubMedCrossRefGoogle Scholar
  15. 15.
    Buess G, Hutterer F, Theiss J, Böbel M, Isselhard W, Pichlmaier H (1984) A system for a transanal endoscopic rectum operation. Chirurg 55:677–680PubMedGoogle Scholar
  16. 16.
    Røkke O, Iversen KB, Øvrebø K, Maartmann-Moe H, Skarstein A, Halvorsen JF (2005) Local resection of rectal tumors by transanal endoscopic microsurgery: experience with the first 70 cases. Dig Surg 22:182–190PubMedCrossRefGoogle Scholar
  17. 17.
    Dias AR, Nahas CS, Marques CF, Nahas SC, Cecconello I (2009) Transanal endoscopic microsurgery: indications, results and controversies. Tech Coloproctol 13:105–111PubMedCrossRefGoogle Scholar
  18. 18.
    Cook TA, Mortensen NJ (2000) Local methods of treatment of rectal cancer. Colorectal Dis 2:252–263CrossRefGoogle Scholar
  19. 19.
    Endreseth BH, Myrvold HE, Romundstad P, Hestvik UE, Bjerkeset T, Wibe A, Norwegian Rectal Cancer Group (2005) Transanal excision vs. major surgery for T1 rectal cancer. Dis Colon Rectum 48:1380–1388PubMedCrossRefGoogle Scholar
  20. 20.
    Lezoche E, Guerrieri M, Paganini AM, Feliciotti F (2002) Long-term results of patients with pT2 rectal cancer treated with radiotherapy and transanal endoscopic microsurgical excision. World J Surg 26:1170–1174PubMedCrossRefGoogle Scholar
  21. 21.
    Lezoche E, Guerrieri M, Paganini AM, Baldarelli M, De Sanctis A, Lezoche G (2005) Long-term results in patients with T2–3 N0 distal rectal cancer undergoing radiotherapy before transanal endoscopic microsurgery. Br J Surg 92:1546–1552PubMedCrossRefGoogle Scholar
  22. 22.
    Duek SD, Issa N, Hershko DD, Krausz MM (2008) Outcome of transanal endoscopic microsurgery and adjuvant radiotherapy in patients with T2 rectal cancer. Dis Colon Rectum 51:379–384PubMedCrossRefGoogle Scholar
  23. 23.
    Borschitz T, Heintz A, Junginger T (2007) Transanal endoscopic microsurgical excision of pT2 rectal cancer: results and possible indications. Dis Colon Rectum 50:292–301PubMedCrossRefGoogle Scholar
  24. 24.
    Ramwell A, Evans J, Bignell M, Mathias J, Simson J (2009) The creation of a peritoneal defect in transanal endoscopic microsurgery does not increase complications. Colorectal Dis 11:964–966PubMedCrossRefGoogle Scholar
  25. 25.
    Mentges B, Buess G, Raestrup H, Manncke K, Becker HD (1994) TEM results of the Tuebingen group. Endosc Surg Allied Technol 2:247–250PubMedGoogle Scholar
  26. 26.
    Stipa F, Lucandri G, Ferri M, Casula G, Ziparo V (2004) Local excision of rectal cancer with transanal endoscopic microsurgery (TEM). Anticancer Res 24:1167–1172PubMedGoogle Scholar
  27. 27.
    Lezoche E, Guerrieri M, Paganini AM, Feliciotti F, Pietrantoni F (1996) Is transanal endoscopic microsurgery (TEM) a valid treatment for rectal tumors? Surg Endosc 10:736–741PubMedCrossRefGoogle Scholar
  28. 28.
    Heintz A, Morshel M, Junginger T (1998) Comparison of results after transanal endoscopic microsurgery and radical resection for T1 carcinoma of the rectum. Surg Endosc 12:1145–1148PubMedCrossRefGoogle Scholar
  29. 29.
    Middleton PF, Sutherland LM, Maddern GJ (2005) Transanal endoscopic microsurgery: a systematic review. Dis Colon Rectum 48:270–284PubMedCrossRefGoogle Scholar
  30. 30.
    Allaix ME, Arezzo A, Caldart M, Festa F, Morino M (2009) Transanal endoscopic microsurgery for rectal neoplasms: experience of 300 consecutive cases. Dis Colon Rectum 52:1831–1836PubMedCrossRefGoogle Scholar
  31. 31.
    Casadesus D (2009) Surgical resection of rectal adenoma: a rapid review. World J Gastroenterol 15:3851–3854PubMedCrossRefGoogle Scholar
  32. 32.
    Katti G (2004) An evaluation of transanal endoscopic microsurgery for rectal adenoma and carcinoma. JSLS 8:123–126PubMedGoogle Scholar
  33. 33.
    Vorobiev GI, Tsarkov PV, Sorokin EV (2006) Gasless transanal endoscopic surgery for rectal adenomas and early carcinomas. Tech Coloproctol 10:277–281PubMedCrossRefGoogle Scholar
  34. 34.
    Guerrieri M, Baldarelli M, Morino M et al (2006) Transanal endoscopic microsurgery in rectal adenomas: experience of six Italian centres. Dig Liver Dis 38:202–207PubMedCrossRefGoogle Scholar
  35. 35.
    McCloud JM, Waymont N, Pahwa N et al (2006) Factors predicting early recurrence after transanal endoscopic microsurgery excision for rectal adenoma. Colorectal Dis 8:581–585PubMedCrossRefGoogle Scholar
  36. 36.
    Platell C, Denholm E, Makin G (2004) Efficacy of transanal endoscopic microsurgery in the management of rectal polyps. J Gastroenterol Hepatol 19:767–772PubMedCrossRefGoogle Scholar
  37. 37.
    Sengupta S, Tjandra JJ (2001) Local excision of rectal cancer: what is the evidence? Dis Colon Rectum 44:1345–1361PubMedCrossRefGoogle Scholar
  38. 38.
    Gavagan JA, Whiteford MH, Swanstrom LL (2004) Full-thickness intraperitoneal excision by transanal endoscopic microsurgery does not increase short-term complications. Am J Surg 187:630–634PubMedCrossRefGoogle Scholar
  39. 39.
    Steele RJ, Hershman MJ, Mortensen NJ, Armitage NC, Scholefield JH (1996) Transanal endoscopic microsurgery: initial experience from three centres in the United Kingdom. Br J Surg 83:207–210PubMedCrossRefGoogle Scholar
  40. 40.
    van Koesveld JJ, Tetteroo GW, de Graaf EJ (2003) Use of head-mounted display in transanal endoscopic microsurgery. Surg Endosc 17:943–946PubMedCrossRefGoogle Scholar
  41. 41.
    Jung KW, Lee OJ (2002) Extensive spontaneous submucosal dissection of the esophagus: long-term sequential endoscopic observation and treatment. Gastrointest Endosc 55:262–265PubMedCrossRefGoogle Scholar
  42. 42.
    Fujishiro M, Yahagi N, Nakamura M et al (2006) Endoscopic submucosal dissection for rectal epithelial neoplasia. Endoscopy 38:493–497PubMedCrossRefGoogle Scholar
  43. 43.
    Onozato Y, Kakizaki S, Ishihara H et al (2007) Endoscopic submucosal dissection for rectal tumors. Endoscopy 39:423–427PubMedCrossRefGoogle Scholar
  44. 44.
    Guerrieri M, Baldarelli M, de Sanctis A, Campagnacci R, Rimini M, Lezoche E (2009) Treatment of rectal adenomas by transanal endoscopic microsurgery: 15 years’ experience. Surg Endosc 24:445–449PubMedCrossRefGoogle Scholar
  45. 45.
    Puli SR, Reddy JB, Bechtold ML, Choudhary A, Antillon MR, Brugge WR (2009) Accuracy of endoscopic ultrasound to diagnose nodal invasion by rectal cancers: a meta-analysis and systematic review. Ann Surg Oncol 16:1255–1265PubMedCrossRefGoogle Scholar
  46. 46.
    Bach SP, Hill J, Monson JR, Simson JN, Association of Coloproctology of Great Britain and Ireland Transanal Endoscopic Microsurgery (TEM) Collaboration et al (2009) A predictive model for local recurrence after transanal endoscopic microsurgery for rectal cancer. Br J Surg 96:280–290PubMedCrossRefGoogle Scholar
  47. 47.
    Lebedyev A, Tulchinsky H, Rabau M, Klausner JM, Krausz M, Duek SD (2009) Long-term results of local excision for T1 rectal carcinoma: the experience of two colorectal units. Tech Coloproctol 13:231–236PubMedCrossRefGoogle Scholar
  48. 48.
    Morino M, Allaix ME, Caldart M, Scozzari G, Arezzo A (2011) Risk factors for recurrence after transanal endoscopic microsurgery for rectal malignant neoplasm. Surg Endosc 25:3683–3690PubMedCrossRefGoogle Scholar
  49. 49.
    Zhou PH, Yao LQ, Zhong YS, He GJ, Xu MD, Qin XY (2004) Role of endoscopic miniprobe ultrasonography in diagnosis of submucosal tumor of large intestine. World J Gastroenterol 10:2444–2446PubMedGoogle Scholar
  50. 50.
    Winde G, Nottberg H, Keller R, Schmid KW, Bunte H (1996) Surgical cure for early rectal carcinomas (T1). Transanal endoscopic microsurgery vs. anterior resection. Dis Colon Rectum 39:969–976PubMedCrossRefGoogle Scholar
  51. 51.
    Lezoche G, Baldarelli M, Guerrieri M et al (2008) A prospective randomized study with a 5-year minimum follow-up evaluation of transanal endoscopic microsurgery versus laparoscopic total mesorectal excision after neoadjuvant therapy. Surg Endosc 22:352–358PubMedCrossRefGoogle Scholar
  52. 52.
    Doornebosch PG, Tollenaar RAEM, Gosselink MP et al (2007) Quality of life after transanal endoscopic microsurgery and total mesorectal excision in early rectal cancer. Colorectal Dis 9:553–558PubMedCrossRefGoogle Scholar
  53. 53.
    Doornebosch PG, Gosselink MP, Neijenhuis PA, Schouten WR, Tollenaar RAEM, de Graaf EJR (2008) Impact of transanal endoscopic microsurgery on functional outcome and quality of life. Int J Colorectal Dis 23:709–713PubMedCrossRefGoogle Scholar
  54. 54.
    Kennedy ML, Lubowski DZ, King DW (2002) Transanal endoscopic microsurgery. Is anorectal function compromised? Dis Colon Rectum 45:601–604PubMedCrossRefGoogle Scholar
  55. 55.
    Kreis ME, Jehle EC, Haug V et al (1996) Functional results after transanal endoscopic microsurgery. Dis Colon Rectum 39:1116–1121PubMedCrossRefGoogle Scholar
  56. 56.
    Herman RM, Richter P, Walega P, Popiela T (2001) Anorectal sphincter function and rectal barostat study in patients following transanal endoscopic microsurgery. Int J Colorectal Dis 16:370–376PubMedCrossRefGoogle Scholar
  57. 57.
    Cataldo PA, O’Brien S, Osler T (2005) Transanal endoscopic microsurgery: a prospective evaluation of functional results. Dis Colon Rectum 48:1366–1371PubMedCrossRefGoogle Scholar
  58. 58.
    Allaix ME, Rebecchi F, Giaccone C, Mistrangelo M, Morino M (2011) Long-term functional results and quality of life after transanal endoscopic microsurgery. Br J Surg 98:1635–1643PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Italia 2013

Authors and Affiliations

  1. 1.Digestive, Colorectal, Oncologic and Minimally Invasive Surgery, Department of Surgical SciencesUniversity of TurinTurinItaly

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