title: Laparoscopy following peritoneal entry during transanal endoscopic microsurgery may increase the safety and maximize the benefits of the transanal excision.
abstract: BACKGROUND
  Peritoneal entry (PE) during transanal endoscopic microsurgery (TEM) for tumors of the upper rectum is not an uncommon complication. The suture line of the rectal defect performed for PE is not devoid of leaks. Diagnostic laparoscopy after PE enables visualization and testing of the suture line. Here, we report the outcome of patients undergoing laparoscopy for PE following TEM.
  
  
  METHODS
  Data pertaining to patients undergoing laparoscopy for PE following TEM between 2004 and 2013 were retrospectively collected.
  
  
  RESULTS
  One hundred and forty-one TEM procedures were performed, and 19 (13 %) with PE were included. The mean age was 68.1 ± 10.6 years, mean distance from the anal verge 12.5 ± 2 cm, and mean tumor size 2 cm. Lesions were located in the lateral wall (n = 14), anteriorly (n = 4), and posteriorly (n = 1). Indications for TEM were: adenoma (n = 13), indeterminate margins after polypectomy (n = 4, a submucosal lesion (n = 1), and a T1N0 adenocarcinoma (n = 1). In all patients, the rectal wall defect was closed primarily. Twelve patients underwent additional laparoscopy and suture line leak testing. In one patient, a small leak was detected which was repaired laparoscopically. In another, a hematoma of the suture line was observed and a drain was left in place. The mean operative time was 109 min (range 80-135 min) for TEM and 33 min (range 22-45 min) for laparoscopy. A diverting ileostomy was fashioned in one patient on postoperative day 3 after TEM without laparoscopy. No other major complications were observed.
  
  
  CONCLUSIONS
  Laparoscopy after PE during TEM permits visualization and testing of the suture line. It is not associated with increased morbidity, and it may increase the safety of TEM.
authors.affiliation: Departments of Surgery B, Hasharon Hospital, Rabin Medical Center, 7 Keren Kayemet St., Petah-Tikva, Israel. nidaldrissa@hotmail.com.|Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel. nidaldrissa@hotmail.com.
authors.forename: N
authors.initials: N
authors.lastname: Issa
authors.affiliation: Department of Surgery, Monmouth Medical Center, Long Branch, NJ, USA.
authors.forename: Y
authors.initials: Y
authors.lastname: Fenig
authors.affiliation: Departments of Surgery B, Hasharon Hospital, Rabin Medical Center, 7 Keren Kayemet St., Petah-Tikva, Israel.|Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.
authors.forename: M
authors.initials: M
authors.lastname: Yasin
authors.affiliation: Gastroenterology, Hasharon Hospital, Rabin Medical Center, Petach Tikva, Israel.|Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.
authors.forename: H
authors.initials: H
authors.lastname: Schmilovitz-Weiss
authors.affiliation: Department of Surgery, Rambam Health Care Campus, Haifa, Israel.
authors.forename: W
authors.initials: W
authors.lastname: Khoury
authors.affiliation: Departments of Surgery B, Hasharon Hospital, Rabin Medical Center, 7 Keren Kayemet St., Petah-Tikva, Israel.|Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.
authors.forename: E
authors.initials: E
authors.lastname: Powsner
mesh_terms: D000230:Adenocarcinoma / Q000601:surgery; D000368:Aged; D001003:Anal Canal / Q000601:surgery; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D010537:Peritoneum / Q000293:injuries* / Q000601:surgery; D011183:Postoperative Complications / Q000209:etiology / Q000517:prevention & control / Q000601:surgery*; D012004:Rectal Neoplasms / Q000601:surgery; D012007:Rectum / Q000601:surgery; D012189:Retrospective Studies; D013537:Sutures / Q000009:adverse effects; D000067369:Transanal Endoscopic Microsurgery / Q000009:adverse effects* / Q000379:methods
keywords: Laparoscopy; Perforation; Peritoneal entry; Rectal mass; Transanal endoscopic microsurgery