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20-25%. This result leads to the conclusion that only patients Aim
with stages (Tis and T1N0) can undergo transanal excision.
Despite all of the above, it is safest to target lesions that are This study aims to present our initial experiences gai-
not located within the intraperitoneal part of the rectum: up ned during the introduction of this method into everyday
to 20 cm from the anocutaneous line posteriorly, 15 cm la- surgical practice and to compare them with the previously
terally, and 12 cm anteriorly to the transverse line. In additi- applied local technique of transanal excision. Additionally,
on to the mentioned advantages, there are also drawbacks, it aims to highlight the advantages and disadvantages of
and the main shortcomings of TEMS are the high cost of specific local surgical approaches to rectal pathological
equipment, technically demanding surgeon training, the changes.
need for highly specialized instruments, the requirement
for general anesthesia, and a lower degree of anal inconti-
nence. In the last decade, there has been the development Material and method
of robotic surgery in performing TEMS, with comparative Our study analyzed two groups of patients. The first
analyses between traditional and robotic TEMS being con- group of patients with rectal pathological lesions was trea-
6-9
ducted, highlighting the advantages of robotic surgery over ted with local transanal excision, while the second group of
traditional endoscopic surgery due to greater precision and patients was treated with the newly introduced technique
fewer complications. Another relatively new technique in of transanal minimally invasive surgery. From September
transanal local rectal surgery performed with the assistance 2021 to March 2023, a total of 12 patients underwent the
of robotic surgery is TAMIS. TAMIS procedure and 15 patients underwent the TAE tech-
Transanal minimal invasive surgery (TAMIS) is a relative- nique for various rectal pathological changes at the Clinic
ly new diagnostic and therapeutic procedure used by sur- for Surgery, Clinical Center of Belgrade Zemun. All patients
geons to treat pathological lesions of the middle and distal were diagnosed with benign adenomas of varying degrees
thirds of the rectum. TAMIS was introduced in 2010 based of dysplasia and early rectal carcinoma through histopatho-
on the rapid technological advancement of equipment for logical analysis. Preoperatively, all patients underwent stan-
laparoscopic surgery, which is utilized during this procedu- dard preparation, including basic laboratory tests (blood
re . The easy availability of laparoscopic equipment and the type, complete blood count, biochemistry, coagulation sta-
10
low costs associated with this procedure have made it domi- tus), colonoscopic examination with histopathological verifi-
nant compared to transanal endoscopic microsurgery. Due cation of the pathological changes, abdominal and pelvic CT
to the need to acquire entirely new endoscopic equipment scan, as well as pelvic magnetic resonance imaging, along
and the lengthy training process, TEMS has never been im- with anesthesiological evaluation and, if necessary, cardio-
plemented in our hospitals. logical evaluation. The indication for TAMIS in all cases was
the inability to excise the pathological lesion endoscopically
In everyday practice, we witness technical limitations due to its size or location. In the TAMIS group, all patients
and the inability to remove large polypoid lesions and early had lesions localized in the rectum ranging from 5 to 14
malignancies of the rectum (T in situ and T1) using conven- cm from the anal verge, while in the TAE group, the lesions
tional endoscopic methods . If the location of these lesions were located 0 to 6 cm from the anal verge. The pathological
11
is 5-15 cm from the anocutaneous line, patients were pre- changes could not be resected by endoscopic polypectomy.
viously typically treated with conventional or laparoscopic As part of the immediate preoperative preparation, patients
surgeries, which carry a significant rate of morbidity and underwent colon cleansing the day before the operation,
mortality. On the other hand, TAMIS is a minimally invasi- along with antibiotic prophylaxis. All patients were infor-
ve procedure which, according to current results, has low med of the possibility that if TAMIS or TAE procedures were
rates of morbidity and mortality 12, 13 . The average length technically not feasible, they could undergo laparoscopic or
of postoperative hospitalization ranges from 1-2 days. The conventional surgical rectal resection. During the study, we
thoroughness and presence of negative margins during the examined the following parameters: feasibility of the pro-
execution of this procedure are high, exceeding 90% . To cedure, margin negativity, length of hospital stay, and early
14
perform the procedure, a GelPort (a trocar with a gelatinous complications. The histological outcome of the procedure
membrane through which 10 mm plastic trocars for optics was assessed through a microscopic evaluation of the rese-
and instruments are inserted) is required to provide access ction margin status.
to the pathological lesion. The GelPort is connected to an
AirSeal insufflator that maintains a constant intraluminal Our TAMIS technique is based on the original technique
10
pressure of 14 mmHg, ensuring good visualization of the described by Attalah in 2010 . The operation is performed
rectal pathological changes. Taking all this into account, by two surgeons under general endotracheal anesthesia.
we have also started applying the TAMIS technique for re- The patient is positioned in the gynecological, Trendelen-
section of large polyps and early malignant lesions of the burg, or lateral (left or right) decubitus position if the lesions
rectum 14-16 . are located on the lateral wall at 6 o'clock. In this procedu-
re, we use standard laparoscopic instruments and GelPort
(Applied Medical), which is inserted transanally. The GelPort

ORIGINAL PAPER Galenika Medical Journal, 2024; 3(9):11-18. 13