title: Transanal endoscopic microsurgery: a new technique for completion proctectomy.
abstract: OBJECTIVE
  Following subtotal colectomy, the retained rectal stump is a potential source of morbidity. Although restorative ileal pouch-anal anastomosis is the gold standard for ulcerative colitis, up to 14% of patients will opt for a permanent ileostomy and undergo completion proctectomy, traditionally by an abdomino-perineal approach, which itself carries significant morbidity. We describe a new technique of perineal proctectomy using transanal endoscopic microsurgery (TEMS) equipment. To our knowledge, this technique has not previously been described in the literature.
  
  
  METHODS
  Twelve patients, mean (SD) age 66 (±13) years, underwent TEMS proctectomy, performed by a single surgeon between January 2007 and October 2011. Excision began with an intersphincteric dissection following which the TEMS (WOLF) proctoscope was inserted and close rectal dissection was performed, entering the peritoneal cavity (if the top of the stump was intraperitoneal). Following perineal extraction of the specimen, the external sphincter and skin were closed with an absorbable suture.
  
  
  RESULTS
  Nine patients had inflammatory bowel disease, two had neoplasia and one had intractable radiation proctitis. The mean (SD) rectal stump length was 17.8 (±6.1) cm and the peritoneal cavity was entered in nine patients, with no small-bowel injury. The median postoperative hospital stay was 5.5 days. In four patients there was delayed healing of the perineal wound. There was no perioperative mortality.
  
  
  CONCLUSIONS
  TEMS perineal proctectomy is a novel, but safe, technique that may avoid the need for a traditional abdominoperineal approach in selected patients.
authors.affiliation: St Richards Hospital, Chichester, West Sussex, UK.
authors.forename: C
authors.initials: C
authors.lastname: Liyanage
authors.forename: A
authors.initials: A
authors.lastname: Ramwell
authors.forename: G J
authors.initials: GJ
authors.lastname: Harris
authors.forename: B F
authors.initials: BF
authors.lastname: Levy
authors.forename: J N L
authors.initials: JN
authors.lastname: Simson
mesh_terms: D000236:Adenoma / Q000601:surgery; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003082:Colectomy; D013505:Digestive System Surgical Procedures; D005260:Female; D006801:Humans; D007081:Ileostomy; D015212:Inflammatory Bowel Diseases / Q000601:surgery*; D008297:Male; D008866:Microsurgery / Q000379:methods*; D008875:Middle Aged; D011349:Proctitis / Q000601:surgery; D011351:Proctoscopy / Q000379:methods*; D011832:Radiation Injuries / Q000601:surgery; D012002:Rectal Diseases / Q000601:surgery*; D012004:Rectal Neoplasms / Q000601:surgery; D012007:Rectum / Q000601:surgery*
keywords: TEMS; completion proctectomy; inflammatory bowel disease