Techniques in Coloproctology

, Volume 21, Issue 9, pp 729–736 | Cite as

Peritoneal perforation is less a complication than an expected event during transanal endoscopic microsurgery: experience from 194 consecutive cases

Original Article



Indications for transanal endoscopic microsurgery (TEM) have been extended to technically challenging tumors, which may be associated with an increased risk of peritoneal perforation (PP). The aim of the present study was to investigate the occurrence, management and outcome of PP in patients having TEM.


All the patients who had TEM for rectal adenoma or adenocarcinoma in our unit were included. Patients in whom PP occurred (Group A) were compared to those without PP (Group B).


From 2007 to 2015, 194 TEM (116 men, median age 66 [range 21–100] years) were divided into Groups A (n = 28, 14%) and B (n = 166). The latter group included four patients, in whom a laparoscopy did not confirm suspicion of PP made during TEM. In 2 of 28 patients (7%), the diagnosis of PP was made postoperatively during reoperation for peritonitis. For the 26 other patients (93%), routine exploratory laparoscopy was performed with suture of the peritoneal defect on the pouch of Douglas in 24 cases and a rectal suture alone in 2 cases. Independent predictive factors for PP were: distance from the anal verge >10 cm (OR = 3.6), circumferential tumor (OR = 3.0) and anterior location (OR = 2.7). Hospital stay was significantly longer in Group A (7.5 [3–31] days) than in Group B (4 [1–38] days; p < 0.0001), whereas there was no significant difference regarding postoperative morbidity and recurrence rate.


Our results suggested that PP is not a very rare event during TEM, especially in anterior, circumferential and/or high rectal tumors. Laparoscopic treatment of PP is feasible and safe. The occurrence of PP is not associated with poor oncologic results.


Transanal endoscopic microsurgery Peritoneal perforation Rectal adenoma Rectal adenocarcinoma 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This study was conducted according to the ethical standards of the Committee on Human Experimentation of our institution.

Informed consent

Informed consent was obtained from all the individual participants included in the study.


  1. 1.
    Demartines N, Von Flüe MO, Harder FH (2001) Transanal endoscopic microsurgical excision of rectal tumors: indications and results. World J Surg 25:870–875CrossRefPubMedGoogle Scholar
  2. 2.
    Darwood RJ, Wheeler JMD, Borley NR (2008) Transanal endoscopic microsurgery is a safe and reliable technique even for complex rectal lesions. Br J Surg 95:915–918CrossRefPubMedGoogle Scholar
  3. 3.
    Christoforidis D, Cho H-M, Dixon MR, Mellgren AF, Madoff RD, Finne CO (2009) Transanal endoscopic microsurgery versus conventional transanal excision for patients with early rectal cancer. Ann Surg 249:776–782CrossRefPubMedGoogle Scholar
  4. 4.
    Peng J, Chen W, Sheng W, Xu Y, Cai G, Huang D et al (2011) Oncological outcome of T1 rectal cancer undergoing standard resection and local excision. Colorectal Dis 13:e14–e19CrossRefPubMedGoogle Scholar
  5. 5.
    Buess G, Theiss R, Günther M, Hutterer F, Pichlmaier H (1985) Transanal endoscopic microsurgery. Leber Magen Darm 15:271–279PubMedGoogle Scholar
  6. 6.
    Moore JS, Cataldo PA, Osler T, Hyman NH (2008) Transanal endoscopic microsurgery is more effective than traditional transanal excision for resection of rectal masses. Dis Colon Rectum 51:1026–1031CrossRefPubMedGoogle Scholar
  7. 7.
    Guerrieri M, Baldarelli M, De Sanctis A, Campagnacci R, Rimini M, Lezoche E (2010) Treatment of rectal adenomas by transanal endoscopic microsurgery: 15 years’ experience. Surg Endosc 24:445–449CrossRefPubMedGoogle Scholar
  8. 8.
    Langer C, Liersch T, Süss M, Siemer A, Markus P, Ghadimi BM et al (2003) Surgical cure for early rectal carcinoma and large adenoma: transanal endoscopic microsurgery (using ultrasound or electrosurgery) compared to conventional local and radical resection. Int J Colorectal Dis 18:222–229PubMedGoogle Scholar
  9. 9.
    Saget A, Maggiori L, Petrucciani N, Petruciani N, Ferron M, Panis Y (2015) Is there a limit to transanal endoscopic surgery? a comparative study between standard and technically challenging indications among 168 consecutive patients. Colorectal Dis 17:O155–O160CrossRefPubMedGoogle Scholar
  10. 10.
    Khoury R, Duek SD, Issa N, Khoury W (2016) Transanal endoscopic microsurgery for large benign rectal tumors; where are the limits? Int J Surg 29:128–131CrossRefPubMedGoogle Scholar
  11. 11.
    Gavagan JA, Whiteford MH, Swanstrom LL (2004) Full-thickness intraperitoneal excision by transanal endoscopic microsurgery does not increase short-term complications. Am J Surg 187:630–634CrossRefPubMedGoogle Scholar
  12. 12.
    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 11:964–966CrossRefPubMedGoogle Scholar
  13. 13.
    Baatrup G, Borschitz T, Cunningham C, Qvist N (2009) Perforation into the peritoneal cavity during transanal endoscopic microsurgery for rectal cancer is not associated with major complications or oncological compromise. Surg Endosc 23:2680–2683CrossRefPubMedGoogle Scholar
  14. 14.
    Morino M, Allaix ME, Famiglietti F, Caldart M, Arezzo A (2013) Does peritoneal perforation affect short- and long-term outcomes after transanal endoscopic microsurgery? Surg Endosc 27:181–188CrossRefPubMedGoogle Scholar
  15. 15.
    Marks JH, Frenkel JL, Greenleaf CE, D’Andrea AP (2014) Transanal endoscopic microsurgery with entrance into the peritoneal cavity: is it safe? Dis Colon Rectum 57:1176–1182CrossRefPubMedGoogle Scholar
  16. 16.
    Eyvazzadeh DJ, Lee JT, Madoff RD, Mellgren AF, Finne CO (2014) Outcomes after transanal endoscopic microsurgery with intraperitoneal anastomosis. Dis Colon Rectum 57:438–441CrossRefPubMedGoogle Scholar
  17. 17.
    Maggiori L, Panis Y (2012) Transanal endoscopic microsurgery (TEM) for T1 rectal cancer. Acta Chir Iugosl 59:87–90CrossRefPubMedGoogle Scholar
  18. 18.
    Dindo D, Demartines N, Clavien P-A (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Morino M, Risio M, Bach S, Beets-Tan R, Bujko K, Panis Y et al (2015) Early rectal cancer: the European Association for Endoscopic Surgery (EAES) clinical consensus conference. Surg Endosc 29:755–773CrossRefPubMedGoogle Scholar
  20. 20.
    Von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP et al (2007) The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet 370:1453–1457CrossRefGoogle Scholar
  21. 21.
    Molina G, Bordeianou L, Shellito P, Sylla P (2016) Transanal endoscopic resection with peritoneal entry: a word of caution. Surg Endosc 30:1816–1825CrossRefPubMedGoogle Scholar
  22. 22.
    Mege D, Bridoux V, Maggiori L, Tuech JJ, Panis Y (2016) What is the best tool for transanal endoscopic microsurgery (TEM)? a case-matched study in 74 patients comparing a standard platform and a disposable material. Int J Colorectal Dis. doi: 10.0007/s00384-0162733-0 PubMedGoogle Scholar
  23. 23.
    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 52:1831–1836CrossRefPubMedGoogle Scholar
  24. 24.
    De Graaf EJR, Doornebosch PG, Tetteroo GWM, Geldof H, Hop WCJ (2009) Transanal endoscopic microsurgery is feasible for adenomas throughout the entire rectum: a prospective study. Dis Colon Rectum 52:1107–1113CrossRefPubMedGoogle Scholar
  25. 25.
    Issa N, Fenig Y, Yasin M, Schmilovitz-Weiss H, Khoury W, Powsner E (2016) Laparoscopy following peritoneal entry during transanal endoscopic microsurgery may increase the safety and maximize the benefits of the transanal excision. Tech Coloproctol 20:221–226CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  • D. Mege
    • 1
  • N. Petrucciani
    • 1
  • L. Maggiori
    • 1
  • Y. Panis
    • 1
  1. 1.Department of Colorectal Surgery, Beaujon HospitalParis UniversityClichyFrance

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