teo –– transanal endoscopic operations · 2018-10-30 · teo® – transanal endoscopic...

Georg KÄHLER Lutz MEYER

TEO® –– TRANSANAL ENDOSCOPIC OPERATIONSMinimally Invasive Transanal Full Thickness

Resection of Early Rectal Tumors

®

TEO® –– TRANSANAL ENDOSCOPIC OPERATIONSMinimally Invasive Transanal Full Thickness

Resection of Early Rectal Tumors

Prof. Georg KÄHLER M.D.1 Lutz MEYER, M.D.2

1) Head of Department of Central Interdiscip+linary Endoscopy – Mannheim University Hospitals, Surgical Clinic, Germany

2) Head of Surgical Clinic · HELIOS Vogtland Hospital Plauen, Germany

®

TEO® – Transanal Endoscopic Operations Minimally Invasive Transanal Full Thickness Resection of Early Rectal Tumors4

TEO® – Transanal Endoscopic Operations Minimally Invasive Transanal Full Thickness Resection of Early Rectal TumorsProf. Georg Kähler, M.D.1 and Lutz Meyer, M.D.2

1) Head of Department of Central Interdisciplinary Endoscopy - Mannheim University Hospitals, Surgical Clinic, Germany

2) Head of Surgical Clinic | HELIOS Vogtland Hospital | Plauen, Germany

Correspondence address of the author: Prof. Georg Kähler Leiter der Zentralen Interdisziplinären Endoskopie Universitätsklinikum Mannheim Theodor-Kutzer-Ufer 1–3 68167 Mannheim, Germany Phone: +49 (0)621/3832647 Fax: +49 (0)621/3833825 Internet: www.umm.de E-mail: [email protected]

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TEO® – Transanal Endoscopic Operations Minimally Invasive Transanal Full Thickness Resection of Early Rectal Tumors 5

Contents

1.0 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61.1 Adenoma-Carcinoma Sequence . . . . . . . . . . . . . . . . . . . . . . 61.2 Incidence and Prognosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

2.0 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82.1 Differentiation between Adenoma and Carcinoma . . . . . . . 82.2 Local Staging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82.3 Indications for Local Procedures. . . . . . . . . . . . . . . . . . . . . . 92.4 Comparison of Local Procedures . . . . . . . . . . . . . . . . . . . . . 10

3.0 Instrumentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

4.0 Preoperative Preparations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134.1 Patient Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134.2 Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154.3 Sphincter Dilation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

5.0 Steps in the Operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165.1 Insertion of the Operating Rectoscope. . . . . . . . . . . . . . . . . 165.2 Visualization of the Operative Site . . . . . . . . . . . . . . . . . . . . . 175.3 Introduction of the Instruments . . . . . . . . . . . . . . . . . . . . . . . 185.4 Equipment Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185.5 Marking the Resection Plane . . . . . . . . . . . . . . . . . . . . . . . . . 195.6 Full-Thickness Wall Resection . . . . . . . . . . . . . . . . . . . . . . . . 205.7 Hemostasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215.8 Removing the Surgical Specimen . . . . . . . . . . . . . . . . . . . . . 215.9 Suture Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

6.0 Postoperative Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236.1 Early Postoperative Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236.2 Oncologic Follow-Up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Instrument Set for TEO® – Transanal Endoscopic Operations . . . . . 28


1.0 Epidemiology

1.1 Adenoma-Carcinoma SequenceThe pathogenesis of colorectal carcinoma has been relatively well investigated. The adenoma-carcinoma sequence, called also the Vogelstein hypothesis, forms the basis for our current understanding of colorectal carcinogenesis. Building upon previously known macroscopic and micro-scopic observations, Vogelstein and Fearon advanced a molecular concept in 1988 that explained the process of colon carcinogenesis at a molecular genetic level1. According to this concept, colon carcinoma is the result of a series of somatic mutations that block or activate certain intracellular signal pathways. By identifying the specific changes that take place at different stages in the evolution of colorectal carcinoma (normal mucosa – early adenoma – intermediate adenoma – large adenoma – carcinoma), it was possible to determine the temporal sequence of the mutations that culminate in invasive cancer.

Besides genetic changes in cells, recent studies have shown that the ability of tumor cells to adapt to the extracellular milieu is of key importance in the origination and growth of tumors. For example, it has been found that dedifferentiated cells possessing the malignant properties of invasion and migration are particularly abundant in the transition zone from normal epithelium to tumor tissue2.

1.2 Incidence and PrognosisApproximately 60,000 new cases of colorectal cancer are diagnosed in Germany each year. The annual death toll is approximately 30,000, and the incidence is rising3. Based on representative surveys, rectal cancers account for approximately 35% of the total incidence of colorectal carcinoma – a percentage that has remained stable over the years. Approximately 25–29% of rectal carcinomas are at UICC* stage I when diagnosed. T1 carcinomas account for approximately one-third of UICC I cases, with low-risk T1 tumors comprising about 75% of T1 carcinomas in general4.

*) Union Internationale Contre le Cancer (UICC)


Tab. 1: UICC stage distribution of rectal cancers in Germanyfrom 2000 to 2005

2000 2001 2002 2003 2004 2005

UICC 0 0.7% 1.7% 1.5% 1.9% 2.7% 2.4%

UICC I 26.0% 27.2% 25.3% 28.4% 28.6% 28.9%

UICC II 21.9% 21.8% 22.6% 21.7% 22.8% 22.3%

UICC III 29.3% 28.1% 28.7% 29.5% 28.3% 29.2%

UICC IV 16.0% 16.1% 16.1% 14.2% 13.0% 16.3%

Unknown 6.1% 5.1% 5.7% 4.4% 4.5% 0.9%

(Institute for Quality Assurance in Operative Medicine GmbH, Otto von Guericke University, Magdeburg, Germany. H. Ptok, personal communication)

Rectal carcinoma has a relatively good long-term oncologic prognosis following primary treatment with curative intent. The disease-free 5-year survival rate is 73% in all patients with UICC stage I–III tumors. The disease-free 5-year survival rate is highly stage-dependent, however, with respective figures of 82%, 76% and 61% for stage I, II and III lesions5.

Despite the relative good prognosis compared with other solid tumors, these survival rates can be substantially improved. In the United States, where epidemiologic conditions are comparable to those in Germany, it has been possible to lower the mortality rate to approximately 30% in recent years.

Besides improvements in surgical techniques, (neo)adjuvant therapies, and the more active treatment of recurrent and metastatic disease, the improved prognosis of colorectal tumors is most likely a result of earlier detection. It is hoped that colorectal tumors in the German population will be diagnosed and treated at an earlier stage than has traditionally been the case, but unfortunately the public campaign for screening colonoscopy has not significantly altered the stage distribution of treated rectal cancers (Table 1). This is due mainly to a lack of acceptance of colorectal cancer screening among the target population.


2.0 Indications

2.1 Differentiation between Adenoma and CarcinomaThe diagnosis and treatment of rectal tumors are more closely interrelated than in most other clinical scenarios. This is because the adenoma-carci-noma sequence represents a virtual continuum from adenomatous lesions to various degrees of dysplasia and finally to invasive cancer. As a result, preoperative diagnosis is particularly important in planning and carrying out the local excision of a rectal tumor. Gross evaluation of the lesion by an experienced endoscopist and clinical evaluation by digital rectal examination (Mason clinical staging) continue to be reliable and proven criteria.

By definition, invasive cancer is present only if the adenomatous lesion has infiltrated the muscularis propria layer of the mucosa. This question can be definitively answered only by a complete histopathologic workup of the entire tumor. Thus, the complete removal of a tumor by excisional biopsy is both a diagnostic and therapeutic necessity. Determining the depth of tumor penetration with endorectal ultrasound has assumed a particularly important role in the preoperative diagnosis of rectal tumors. While endorectal ultrasound cannot supply a direct histologic diagnosis, it can predict local tumor resectability with a very high degree of confidence.

2.2 Local StagingBesides efforts to make a benign-malignant differentiation, patient selection and planning for the local excision of a rectal tumor require an accurate preoperative assessment of local tumor extent. This includes determining the distance of the upper and lower tumor margins from the anocutaneous line, the distance of the tumor from the pectinate line (measured by rigid rectoscopy), the degree of circumferential wall involvement, and the degree of stenosis.

Local staging by endorectal ultrasound should be an essential prelude to the local excision of rectal tumors6–9. Endorectal probes are available from numerous ultrasound manufacturers. Highly experienced examiners can achieve well above 90% accuracy in the T-staging of rectal tumors, depending on the tumor stage. However, if we look at the published results of uni- and multicenter studies of endosonographic staging in large groups of patients, we find an overall agreement of 65–70% between sonography and histology in the T-staging of these tumors. T3 tumors show the highest agreement (73–86%), T4 tumors the lowest (31–44%). T1 tumors, which are of greatest interest here, are correctly staged in 50–59% of cases10–12.

Lymph node evaluation with endorectal ultrasound continues to pose a methodologic problem. While it is possible to measure the size of activated lymph nodes, we are still unable to determine whether lymph node enlargement is due to nonspecific activation or tumor infiltration.

Magnetic resonance imaging (MRI) is assuming an increasing role in the pretherapeutic diagnosis of rectal carcinoma. This modality appears to be particularly useful in evaluating the potential circumferential resection


margins for locally advanced tumors. Based on current data including meta-analyses, MRI is as accurate as endosonography in differentiating between T1 tumors (confined to the mucosa and submucosa) and T2 tumors (invasion of the muscularis propria)15,16.

2.3 Indications for Local ProceduresThere is no question that adenomatous tumors of the rectum should be completely removed, both to permit a definitive diagnosis and to prevent the development of rectal carcinoma. In the case of rectal carcinoma, all local therapeutic procedures should be measured against the oncologic standard of total mesorectal excision. According to histopathologic studies, only T1(m) rectal carcinomas of the low-risk histologic type (G1–G2, no lymphatic invasion) are suitable for curative local excision17–11. Additional criteria that should be considered for a possible local excision are tumor size (3 cm) and gross tumor morphology (polypoid, nonulcerated)8, 9, 19, 23, 24. Local excision is an adequate oncologic treatment for these lesions, as many authors have been able to confirm based on clinical experience25. In recent years, several reviews have shown that the risk of lymph node metastasis from various gastrointestinal tumors including rectal carcinoma is markedly increased if depth of infiltration reaches only as far as the lamina submucosa. In view of this finding, even T1 carcinomas now mandate a differentiated evaluation. Oncological follow-up resection should be offered to patients with sm2 infiltration and recommended to those with sm3 infiltration because these cases were found to have an elevated risk of lymph node metastasis ranging above 20%, even in well-differentiated carcinoma. (Reference: Br J Surg. 2008 Apr; 95(4):409-23.Management of early rectal cancer. Tytherleigh MG, Warren BF, Mortensen NJ.).

If the definitive workup of the surgical specimen indicates a high-risk histologic type and/or stage T2 disease or higher, it is necessary to proceed with a radical procedure consisting of abdominoperineal excision of the rectum (APER) or a low anterior rectal resection. Aside from oncologic requirements, however, factors such as age, comorbidity, and tolerance for loss of anal continence should also be considered in formulating an individual treatment plan. The surgical mortality associated with abdominoperineal excision or low anterior resection is comparable to that of a T1 low-risk carcinoma that has already undergone nodal metastasis (approximately 3–7%). Thus, in cases where a local R0 resection is technically feasible for a T1 low-risk carcinoma, it is important that these risks be individually considered in every patient.

Another key consideration is the fact that a local recurrence develops in up to 20% of cases following the local R0 resection of a T1 low-risk carcinoma with curative intent6, 8, 23, 26, 27, 28. This underscores the need for close-interval follow-ups in these patients. When local recurrences are detected in time, they can be adequately resected with a favorable overall prognosis22, 29, 30. This also applies to reexcisions in cases where the postoperative histologic workup reveals a less favorable tumor stage than was indicated by preope rative diagnosis.


Numerous individual case reports have been published on T2 and T3 tumors in patients who, for various reasons, were not managed by radical surgery. There have been increasing reports in recent years on acceptable oncologic results of neoadjuvant and adjuvant radiochemotherapeutic regimens combined with local excision24, 31–39. It is also interesting to consider studies on the risk of residual lymph node metastasis in patients with ypT0 and ypT1 tumors following neoadjuvant radiochemotherapy40–42. An initial randomized prospective study in a very limited number of patients has documented identical long-term results in cases where neoadjuvant radiochemotherapy was followed by laparoscopic or transanal endoscopic resection.43 While these treatment concepts would expand the indications for transanal endoscopic operations (TEO®), they have not yet been established as standard regimens and require further evaluation.

2.4 Comparison of Local ProceduresThe local excision of rectal tumors has a long tradition. The low extrarectal approaches described by Mason (anterolateral) and Kraska (posterior) are of purely historical interest today. Various self-retaining retractors (Parks, etc.) are available for transanal procedures that afford a satisfactory view of the rectal wall, especially in the lower third of the rectum.

During the 1980s, Prof. Gerhard Buess developed a technique for full-thick-ness wall resection using an operating rectoscope and a specially modified instrument set44.

The TEO® set manufactured by KARL STORZ was designed with the goal of utilizing as many existing standard instruments for laparoscopic surgery as possible while also combining the advantages of well-established endoscopic techniques. A particular benefit is that surgeons already experienced in laparoscopic techniques can apply their experience to TEO®. Another advantage of the TEO® set is cost, as it eliminates some unnecessary additional acquisitions.

The advantage of endoscopic local excision over traditional procedures lies in the high precision of the resection, which is essential for a good long-term oncologic outcome.

The transanal endoscopic operation (TEO®) is appropriate for rectal tumors that:

are not accessible to endoscopic mucosal resection or submucosal dissection,

have not infiltrated the muscularis propria or metastasized to lymph nodes,

are rectoscopically accessible and are at least 2 cm from the pectinate line,

are not classified as high-risk cancers by biopsy.

Summary:


3.0 InstrumentationOperating rectoscopes are available in lengths of 7.5 cm, 15 cm or 20 cm to provide access for different tumor locations (Fig. 1). They are 40 mm in diameter and can be secured to the operating table with an articulated support arm.

The rectoscope is used with a 5-mm HOPKINS® rod-lens telescope that offers a 30º viewing angle (Figs. 2a, b). The telescope fits into a special guide channel and is connected to a camera system and also to a cold light source by fiberoptic light cable.

TEO® operating rectoscope, available in lengths of 7.5 cm, 15 cm or 20 cm, shown attached to a specially designed support arm.

1

Autoclavable HOPKINS® 5-mm telescope, 30º forward-oblique view, and fiberoptic light connector.

2 a

The 30º viewing angle is like that used in laparoscopic surgery. It provides excellent visibility and easy orientation.

2b


The working attachment is equipped with a Luer lock connector for CO2 insufflation of the surgical site. In addition, there is a separate connector that may be used for cleaning the scope (Fig. 3).

The operating rectoscope has a total of three working channels: two for instruments 5 mm in diameter, and one for instruments up to 12 mm in diameter (Fig. 4a).

Each of the working channels has an inner self-sealing silicone-leaflet valve that reduces intraoperative gas loss (e.g., during instrument changes) to a minimum (Figs. 4a, b).

The ergonomic handle features an integrated connector for smoke evacua tion. Via the KS Lock quick-release coupling, the handle can be easily attached to the KARL STORZ holding system (Fig. 4c).

LUER lock connectors for telescope cleaning and CO2 insufflation.

3

Working attachment with three working channels.

4a

Telescope with integrated cleaning channel located above, and separate insufflation channel in lateral position. Minimal gas loss owing to self-sealing leaflet valves which close while instruments are changed.

4b

More detailed information on the operating instruments can be found at the addendum section of this booklet.

Reinforced mounting element for attachment to a holding system and connector for smoke evacuation.

4c


Working position of the operating rectoscope. The surgical field is located just in front of and below the distal end of the HOPKINS® 30º forward-oblique telescope.

5

Traditional lithotomy position.

6

4.0 Preoperative Preparations

4.1 Patient PositioningPositioning for TEO® requires considerable care and experience to obtain adequate exposure of the operative area and avoid positioning-related complications. Tumor location will determine the optimum patient position (see Local Staging), as the goal is to place the center of the tumor in a deposition position (Fig. 5).

Accordingly, four different positions are available:

Traditional lithotomy position (Fig. 6). This position, used for posterior lesions, is most advantageous from an anesthesiologic standpoint as it allows the patient to remain in the same position after endotracheal intubation and also allows for all other types of anesthetic procedure. The legs should be abducted and flexed past 90º at the hips, if possible, to provide optimum exposure of the perianal region and create sufficient space for instrument manipulations.


Modified prone position.

7

Right or left lateral decubitus position.

8

Modified prone position (Fig. 7) with the legs abducted and flexed at the hips. The anesthesiologist should be consulted to ensure that the thoracic cage and abdominal wall will have sufficient mechanical clearance for ventilation, possibly by positioning the patient on a box frame. The degree of upper-body downward tilt that can be achieved depends on the patient’s individual body habitus and circulatory status.

Right or left lateral decubitus position (Fig. 8), also with the legs abducted and flexed at the hips. The upper leg is secured to a contoured rest on the anterior side of the operating table while the lower leg is placed on the leg rest of the operating table, which is angled forward beneath the hip.

Sufficient padding should always be provided to maintain a stable position during the operation and prevent neurovascular injuries. It is extremely difficult to make position adjustments once the operation has begun.


4.2 Anesthesia In principle, the procedure can be performed under general endotracheal anesthesia or epidural anesthesia. Details should be tailored to the indi vidual patient and discussed with the anesthesiologist, taking into account the expected duration of the operation and the patient position.

4.3 Sphincter DilationThe anal sphincter is carefully dilated to three fingerwidths (Fig. 9) at the start of the procedure. This will help prevent mucosal lesions from movement of the operating rectoscope.

The procedure begins with careful dilation of the anal sphincter to three fingerwidths.

9


5.0 Steps in the Operation

5.1 Insertion of the Operating RectoscopePerianal skin preparation and sterile draping follow the same protocol as in other types of proctologic surgery. The operating rectoscope with obturator in place is inserted into the rectum with copious lubricant and is fastened to the support arm attached to the operating table (Figs. 10a–e). First, the surgeon must choose either the short tube or one of the two longer tubes, depending on the height of the tumor above the anal canal. In general, the shorter tube is used preferably because it provides for a slightly greater freedom of maneuverability for the instruments, but one of the longer tubes is needed to treat findings located more than 7 cm or 15 cm above the anus, respectively.

The support arm is mounted and positioned.

10 a

The rectoscope tube is introduced. The rectoscope tube is fastened to the support arm.

10c

The obturator is removed.

10d

The working attachment is connected.

10e��

10 b


The standard protocols used in laparoscopic surgery are followed in connecting the lines for CO2 gas insufflation, irrigation, illumination, video monitoring, and instrument placement in the working channels of the rectoscope (Fig. 11). The video monitor is placed to the right or left of the patient in a favorable ergonomic position that is within easy view of the surgeon (Fig. 12). As in all endoscopic procedures, the video monitor and operative field should be approximately along the same line of sight from the surgeon’s perspective.

The camera system, cold light cable, and insufflation tubing are connected to the rectoscope.

11

5.2 Visualization of the Operative SiteThe rectoscope should be optimally positioned in relation to the operative site at the start of the procedure. The tube position will have to be intermittently readjusted during the course of the operation to achieve an optimum working position, because mechanical and anatomical constraints will limit instrument maneuvers to a range of action that is smaller than the total field of view. It is essential, however, to make certain at the start of the procedure that the entire tumor is accessible through the operating rectoscope. For lesions that cover an extensive area, the rectoscope may have to be moved frequently to maintain sufficient access.

With the setup completed, the operation is ready to begin.

12


5.3 Introduction of the InstrumentsThe operating rectoscope has multiple ports that will accommodate three instruments in addition to the telescope. It may be most convenient for the right-handed surgeon to use an atraumatic grasping forceps in the left port, and the current working instrument – initially a monopolar needle electrode – in the right port. The lower, central port is occupied by the coagulation- suction tube. As the operation proceeds, additional necessary operating instruments, such as needle holders, clip appliers, and scissors are introduced through the right entry port (Fig. 13).

The coagulation-suction tube has a downward curve at its proximal and distal ends. It should be withdrawn from the operating rectoscope when not in use – not just from the visual field but all the way to its distal curve to avoid interference with the other two instruments.Introduction of the instruments.

13

5.4 Equipment SettingsThe equipment settings necessary for transanal endoscopic operations (TEO®) are basically the same as those used in laparoscopy. The insufflator unit may be set at maximum capacity for CO2 gas flow. The connectors are a limiting factor in this regard, and a setting of 8 L/min should be adequate (Fig. 14).

As far as the gas pressure settings are concerned, we recommend an initial pressure setting of 14 mmHg on the insufflator. This initial setting may be increased to 18 mmHg, if necessary. This should be discussed beforehand with the anesthesiologist. Hyoscine butylbromide (Buscopan®) may be administered as needed to facilitate exposure of the operative site.

The light intensity is adjusted to provide the desired result. While the intensity should initially be set to approximately 50% of maximum to avoid glare, it may be necessary to readjust the intensity during the course of the procedure (Fig. 15).

The settings on the high-frequency generator should be guided according to the manufacturer’s recommendations for monopolar cutting.

Settings are adjusted on the CO2 insufflator.

14

Settings are adjusted on the cold light source.

15


5.5 Marking the Resection PlaneTo satisfy oncologic requirements, the proposed plane of the resection should be marked in a way that encompasses the tumor with at least a 10-mm safety margin. We mark the resection plane by making a series of coagulation points with the monopolar needle electrode, spacing the points at intervals of approximately 8–15 mm around the tumor (Fig. 17). This step also confirms that there will be sufficient access to all portions of the bowel wall.

As is generally the case in transanal endoscopic procedures, it may be helpful at this stage to grasp the rectal wall with the forceps (left hand) and position it so that it can be reached comfortably with the operating instrument in the right hand (in this case the needle electrode), reapplying the forceps as the coagulation proceeds. Of course, the no-touch rule should be rigorously observed with respect to the tumor itself.

Videoendoscopic view of the tumor.

16

The plane of the resection is marked with coagulation points.

17


5.6 Full-Thickness Wall ResectionStarting in the right anterior quadrant (from the surgeon’s perspective), the rectal wall is incised to the perirectal fat with the monopolar needle electrode. An ultrasonic dissector may also be used, especially one with a curved scissor design. A key advantage of the TEO® method is that it provides excellent visibility enabling the surgeon to proceed in layers. After completing the initial cut through the rectal wall, the surgeon can grasp the cut edge of the wall with the forceps and then proceed with accurate, stepwise division of the rectal wall along the preplaced coagulation marks. The plane between the muscularis propria and perirectal fat can also be developed bluntly with an offset suction tip or gauze pledget, for example (Figs. 18, 19).

When resecting an anterior tumor located approximately 9 cm from the anal verge, the surgeon may inadvertently open the peritoneum allowing CO2 to enter the peritoneal cavity (capnoperitoneum). While this is not considered a complication, it does require attention by the anesthesiologist and may require separate suture closure of the peritoneum in addition to the rectal wall.

Start of the resection.

18

Start of the resection.

19

Tumor resection.

20


5.7 HemostasisVarious hemostasis techniques are available in transanal endoscopic operations. When vessels are encountered during the layer-by-layer dissection, they can be grasped with the forceps and prophylactically cauterized by applying a coagulation current through the forceps. For this purpose the high frequency cord is removed from the HF needle electrode and connected to the grasping forceps. Profuse bleeding can be controlled with the forceps or, more easily, with the coagulation-suction tube. This is done by pressing the suction tube gently against the bleeding lesion for some preliminary hemostasis and then delivering current to the insulated metal tip of the suction tube (after moving the high frequency cord to the suction). The current should be applied for an adequate length of time and should be left on until the suction tip has separated from the tissue.

The surgical specimen is pinned to a corkboard.

21

Operative site after tumor resection.

22

5.8 Removing the Surgical SpecimenOnce the specimen has been completely resected from the rectal wall and separated from the underlying tissue, the working attachment of the resectoscope must be withdrawn to allow specimen retrieval. To facilitate histologic assessment, the specimen is spread open and mounted on a cork or plastic board with pins so that it can be photographed, fixed, and sent for histopathologic examination (Fig. 21).


5.9 Suture TechniquesThe surgical defect in the rectal wall is closed with continuous all-layer inverting sutures using a 3-0 absorbable monofilament material. The sutures should encompass a generous amount of tissue. With defects that exceed 40% of the bowel circumference, the closure should be supported with an initial craniocaudal Z-plasty that transforms the typically round defect into a smaller transverse gap. This opening is then closed with a continuous suture line starting on the right side. While knots can be used in principle, the progress of the operation is greatly facilitated by placing clips on the suture ends. The goal is to fully reapproximate the ends of the bowel wall without narrowing the lumen. It is not absolutely necessary to obtain a watertight closure of the defect. Postoperative packing is unnecessary.

Initial suture placement.

23

Suture closure.

24

Suture closure.

25

Suture closure.

26


6.0 Postoperative Care

6.1 Early Postoperative CareAs in classic rectal resections, the resumption of an oral diet is initiated on the third postoperative day. Before the patient is discharged on about the fourth or fifth postoperative day, the wound should be scrutinized with a flexible endoscope, giving particular attention to any impending signs of postoperative bleeding. Suture dehiscence is not uncommon after TEO®, especially in cases where the suture extends close to the pectinate line. Most dehiscences will resolve without significant clinical sequelae.

6.2 Oncologic Follow-UpOncologic follow-up is based on the recommendations of the corresponding professional societies. The standard recommendation for patients with benign lesions and clear margins is endoscopic follow-up at 6 months followed by colonoscopy every 3 years. Patients with low-risk carcinomas initially require endoscopic examinations every 3 months, preferably including endosonography, as part of their standard follow-up protocol. It is also advisable to extend the follow-up period past the usual 5 years.

If postoperative histology indicates a T2 carcinoma, high-risk carcinoma, or R1 margins, the patient should be referred for a conventional reexcision.


References1. VOGELSTEIN B, FEARON ER, HAMILTON SR, KERN SE,

PREISINGER AC, LEPPERT M, NAKAMURA Y, WHITE R, SMITS AM, BOS JL: Genetic alterations during colorectal tumor development. N Engl J Med 1988 Sep 1;319(9):525-32.

2. BRABLETZ T, JUNG A, KIRCHNER T: Beta-catenin and the morpho genesis of colorectal cancer. Virchows Arch 2002 Jul;441(1):1-11.

3. KREBS in Deutschland. Hrsg.: Gesellschaft der epidemiologischen Krebsregister in Deutschland e.V. und Robert-Koch-Institut, 5. Auflage 2006.

4. PTOK H, MARUSCH F, MEYER F, SCHUBERT D, KÖCKERLING F, GASTINGER I, LIPPERT H, COLON/RECTAL CANCER (Primary Tumor) Study Group: Oncological outcome of local vs radical resection of Low-risk pT1 rectal cancer. Arch Surg 2007 Jul;142 (7):649-55.

5. LIPPERT H, GASTINGER I: Versorgung von Patienten mit Rektumkarzinomen in Deutschland. Deutsches Ärzteblatt 2006;103(41):2257-62.

6. BLEDAY R: Local excision of rectal cancer. World J Surg 1997 Sep;21(7):706-14.

7. NIELSEN MB, QVITZAU, PEDERSEN JF, CHRISTIANSEN J: Endosonography for preoperative staging of rectal tumours. Acta Radiol 1996 Sep;37(5):799-803.

8. OBRAND DI, GORDON PH: Results of local excision for rectal carcinoma. Can J Surg 1996 Dec;39(6):463-8.

9. PIDALA MJ, OLIVER GC: Local treatment of rectal cancer. Am Fam Physician 1997 Oct 15;56(6):1622-8.

10. PTOK H, MARUSCH F, MEYER F, WENDLING P, WENISCH HJ, SENDT W, MANGER T, LIPPERT H, GASTINGER I: Feasibility and accuracy of TRUS in the pre-treatment staging for rectal carcinoma in general practice. Eur J Surg Oncol 2006 May;32(4):420-5.

11. MARUSCH F, KOCH A, SCHMIDT U, ZIPPEL R, KUHN R, WOLFF S, PROSS M, WIERTH A, GASTINGER I, LIPPERT H: Routine use of transrectal ultrasound in rectal carcinoma: results of a prospective multicenter study. Endoscopy 2002 May;34(5):385-90.

12. KAUER WK, PRANTL L, DITTLER HJ, SIEWERT JR: The value of endosonographic rectal carcinoma staging in routine diagnostics: a 10-year analysis. Surg Endosc 2004 Jul;18(7):1075-8.

13. MERCURY Study Group: Extramural depth of tumor invasion at thin-section MR in patients with rectal cancer: results of the MERCURY study. Radiology. 2007 Apr;243(1):132-9.

14. LAHAYE MJ, ENGELEN SM, NELEMANS PJ, BEETS GL, van de VELDE CJ, van ENGELSHOVEN JM, BEETS-TAN RG: Imaging for predicting the risk factors – the circumferential resection margin and nodal disease – of local recurrence in rectal cancer: a meta-analysis. Semin Ultrasound CT MR. 2005 Aug;26(4):259-68.

15. BIPAT S, GLAS AS, SLORS FJ, ZWINDERMAN AH, BOSSUYT PM, STOKER J: Rectal cancer: local staging and assessment of lymph node involvement with endoluminal US, CT, and MR imaging – a meta-analysis. Radiology. 2004 Sep;232(3):773-83.

16. CHUN HK, CHOI D, KIM MJ, LEE J, YUN SH, KIM SH, LEE SJ, KIM CK: Preoperative staging of rectal cancer: comparison of 3-T high-field MRI and endorectal sonography. AJR Am J Roentgenol. 2006 Dec;187(6):1557-62.


17. BUESS GF: Local surgical treatment of rectal cancer. Eur J Cancer 1995 Jul-Aug;31A(7-8):1233-7.

18. DREWS M, KOSCINSKI T, MALINGER S, MARCINIAK R, KROKOWICZ P: Local Excision of early rectal cancer. Wiad Lek 1997;50 Su 1 Pt 1:131-4.

19. GALL FP, HERMANEK P: Cancer of the rectum – local excision. Surg Clin Noth Am 1988 Dec;68(6):1353-65.

20. HEINTZ A, MORSCHEL M, JUNGINGER T: Comparison of results after transanal endoscopic microsurgery and radical resection for T1 carcinoma of the rectum. Surg Endosc 1998 Sep;12(9):1145-8.

21. HERMANEK P, GALL FP: Early (microinvasive) colorectal carcinoma. Pathology, diagnosis, surgical treatment. Int J Colorectal Dis 1986 Apr;1(2):79-84.

22. SAID S, MÜLLER JM: TEM – minimal invasive therapy of rectal cancer? Swiss Surg 1997;3(6):248-54.

23. BENOIST S, PANIS Y, MARTELLA L, NEMETH J, HAUTEFEUILLE P, VALLEUR P: Local excision of rectal cancer for cure: should we always regard rigid pathologic criteria? Hepatogastroenterology 1998 Sep-Oct;45(23):1546-51.

24. GRAHAM RA, HACKFORD AW, WAZER DE: Local excision of rectal carcinoma: a safe alternative for more advanced tumors? J Surg Oncol 1999 Apr;70(4):235-8.

25. STIPA F, BURZA A, LUCANDRI G, FERRI M, PIGAZZI A, ZIPARO V, CASULA G, STIPA S: Outcomes for early rectal cancer managed with transanal endoscopic microsurgery: a 5-year follow-up study. Surg Endosc. 2006 Apr;20(4):541-5.

26. AMBACHER T, KASPERK R, SCHUMPELICK V: Einfluss der transanalen Excision auf die Rezidivrate beim Stadium-I-Rectumcarcinom im Vergleich zu radikal resezierenden Verfahren. Chirurg 1999 Dec;70(12):1469-74.

27. STIPA S, LUCANDRI G, STIPA F, CHIAVELLATI L, SAPIENZA P: Local excision of rectal tumours with transanal endoscopic microsurgery. Tumori 1995 May.Jun;81(3 Suppl):50-6.

28. MEYER L, GASTINGER I, KÄHLER G: Lokale Therapieverfahren beim Rektumkarzinom. In: Köckerling F, Lippert H, Gastinger I (Hrsg.): Fortschritte in der kolorektale Chirurgie. Science Med, Hannover 2002, S. 77 – 80.

29. BORSCHITZ T, HEINTZ A, JUNGINGER T: Transanal Endoscopic Microsurgical Excision of pT2 Rectal Cancer: Results and Possible Indications. Dis Colon Rectum. 2007 Mar;50(3):292-301.

30. BORSCHITZ T, HEINTZ A, JUNGINGER T: The influence of histopathologic criteria on the long-term prognosis of locally excised pT1 rectal carcinomas: results of local excision (transanal endoscopic micro surgery) and immediate reoperation. Dis Colon Rectum. 2006 Oct; 49(10):1492-506.

31. CHAKRAVARTI A, COMPTON CC, SHELLITO PC, WOOD WC, LANDRY J, MACHUTA SR, KAUFMAN D, ANCUKIEWICZ M, WILLETT CG: Long-term follow-up of patients with rectal cancer managed by local excision and without adjuvant irradiation. Ann Surg 1999 Jul;230(1):49-54.

32. LE VOYER TE, HOFFMAN JP, COOPER H, ROSS E, SIGURDSON E, EISENBERG B: Local excision and chemoradiation for low rectal T1 and T2 cancers is an effective treatment. Am Surg 1999 Jul;65(7): 625-30.


33. MINSKY BD, ENKER WE, COHEN AM, LAUWERS G: Clincopathologic features in rectal cancer treated by local excision and postoperative radiation therapy. Radiat Med 1995 Sep-Oct;13(5):235-41.

34. NG AK, RECHT A, BUSSE PM: Sphincter preservation therapy for distal rectal carcinoma: a review. Cancer 1997 Feb 15;79(4):671-83.

35. LEZOCHE E, BALDARELLI M, DE SANCTIS A, LEZOCHE G, GUERRIERI M. EARLY RECTAL CANCER: Definition and Management. Dig Dis. 2007;25(1):76-79.

36. LEZOCHE E, GUERRIERI M, PAGANINI AM, BALDARELLI M, De SANCTIS A, LEZOCHE G: Long-term results in patients with T2-3 N0 distal rectal cancer undergoing radiotherapy before transanal endoscopic microsurgery. Br J Surg. 2005 Dec;92(12):1546-52.

37. LEZOCHE E, GUERRIERI M, PAGANINI AM, FELICIOTTI F: Long-term results of patients with pT2 rectal cancer treated with radiotherapy and transanal endoscopic microsurgical excision. World J Surg 2002 Sep;26(9):1170-4.

38. LEZOCHE E, GUERRIERI M, FELICIOTTI F, PAGANINI AM, ZENOBI P, GRILLO RUGGERI FG: Local excision of rectal cancer by transanal endoscopic microsurgery (TEM) combined with radiotherapy: new concept of therapeutic approach. Przegl Lek 2000;57 Suppl 5:72-4.

39. CARICATO M, BORZOMATI D, AUSANIA F, TONINI G, RABITTI C, VALERI S, TRODELLA L, RIPETTI V, COPPOLA R: Complementary use of local excision ans transanal endoscopic microsurgery for rectal cancer after neoadjuvant chemoradiation. Surg Endosc 2006 Aug;20(8):1203-7.

40. BUJKO K, NOWACKI MP, NASIEROWSKA-GUTTMEJER A, KEPCA L, WINKLER-SPYTKOWSKA B, SUWINSKI R, OLEDZKI J, STRYCZYNSKA G, WEICZORAK A, SERKIES K, ROGOWSKA D, TOKAR P: Polish Colorectal Study Group: Prediction of mesorectal nodal metastases after chemoradiation for rectal cancer: results of a randomised trial: implication for subsequent local excision. Radiother Oncol. 2005 Sep;76(3):234-40.

41. TULCHINSKY H, RABAU M, SHACHAM-SHEMUELI E, GOLDMAN G, GEVA R, INBAR M, KLAUSNER JM, FIGER A: Can rectal cancers with pathologic T0 after neoadjuvant chemoradiation (ypT0) be treated by transanal excision alone? Ann Surg Oncol. 2006 Mar;13(3):347-52.

42. HUGHES R, GLYNNE-JONES R, GRAINGER J, RICHMAN P, MAKRIS A, HARRISON M, ASHFORD R, HARRISON RA, LIVINGSTONE JI, MCDONALD PJ, MEYRICK THOMAS J, MITCHELL IC, NORTHOVER JM, PHILLIPS R, WALLACE M, WINDSOR A, NOVELL JR: Can pathological complete response in the primary tumour following pre-operative pelvic chemoradiotherapy for T3-T4 rectal cancer predict for sterilisation of pelvic lymph nodes, a Low-risk of local recurrence and the appropriateness of local excision? Int J Colorectal Dis. 2006 Jan;21(1):11-7.

43. LEZOCHE E, GUERRIERI M, PAGANINI AM, D’AMBROSIO G, BALDARELLI M, LEZOCHE G, FELICIOTTI F, De SANCTIS A: Transanal endoscopic versus total mesorectal laparoscopic resections of T2-N0 low rectal cancers after neoadjuvant treatment: a prospective randomized trial with a 3-years minimum follow-up period. Surg Endosc 2005 Jun;19(6):751-6.

44. BURGHARDT J, BUESS G: Transanal endoscopic microsurgery (TEM): a new technique and development during a time period of 20 years. Surg Technol Int. 2005;14:131-7.


Instrument Set for TEO® Transanal Endoscopic Operations

TEO® – Video Operating Rectoscope Operating Instruments and Rectoscope Holder

IMAGE1 S Camera System and IMAGE1 S Camera Heads, Monitors

KARL STORZ Cold Light Fountains, ENDOFLATOR® 40 SCB, HAMOU® ENDOMAT®

KARL STORZ AIDA® – Digital Archiving of Still Images, Video Sequences and Audio Files


Recommended Configurationfor TEO® – Transanal Endoscopic Operations

Telescope for Operating Rectoscope, working length 7.5 cm and 15 cm24941 BA HOPKINS® Forward-Oblique Telescope 30°, angled eyepiece, diameter 5 mm, length 21 cm, autoclavable,

fiber optic light transmission incorporated, color code: red

Operating Rectoscope, working length 7.5 cm24942 TK TEO® Operating Rectoscope Tube, outer diameter 40 mm, working length 7.5 cm, with handle for holding system,

LUER-Lock connector for vapor evacuation24942 OK TEO® Obturator, for use with Operating Rectoscope Tube 24942 TK24942 AK TEO® Working Attachment, with attachment for Telescope 24941 BA, 2 channels for instrument size 5 mm and

1 channel for instruments up to size 12 mm, automatic sealing with silicone leaflet valve, LUER-Lock connector for insufflation, for use with 24942 TK

Operating Rectoscope, working length 15 cm24942 T TEO® Operating Rectoscope Tube, outer diameter 40 mm, working length 15 cm, with handle for holding system,

LUER-Lock connector for vapor evacuation24942 O TEO® Obturator, for use with Operating Rectoscope Tube 24942 T24942 A TEO® Working Attachment, with attachment for Telescope 24941 BA, 2 channels for instrument size 5 mm and

1 channel for instruments up to size 12 mm, automatic sealing with silicone leaflet valve, LUER-Lock connector for insufflation, for use with 24942 T

Telescope for Operating Rectoscope, working length 20 cm24941 BAL HOPKINS® Forward-Oblique Telescope 30°, angled eyepiece, diameter 5 mm, length 28 cm, autoclavable,

fiber optic light transmission incorporated, color code: red

Operating Rectoscope, working length 20 cm24942 TL TEO® Operating Rectoscope Tube, outer diameter 40 mm, working length 20 cm, with handle for holding system,

LUER-Lock connector for vapor evacuation24942 OL TEO® Obturator, for use with Operating Rectoscope Tube 24942 TL24942 AL TEO® Working Attachment, with attachment for HOPKINS® Telescope 24941 BAL, 2 channels for instrument size 5 mm and

1 channel for instruments up to size 12 mm, automatic sealing with silicone leaflet valve, LUER-Lock adaptor for insufflation, for use with Operating Rectoscope Tube 24942 TL

28272 RLD Holding System, for use with Operating Rectoscope Tubes

Operating Instruments25352 ME CLICKLINE Dissecting and Grasping Forceps, rotating, dismantling, with connector pin for unipolar coagulation,

with LUER-Lock irrigation connector for cleaning, single action jaws, width of jaws 4.8 mm, jaws offset downwards, multiple teeth, atraumatic, size 5 mm, length 36 cm

25352 MG CLICKLINE Dissecting and Grasping Forceps, rotating, dismantling, with connector pin for unipolar coagulation, with LUER-Lock irrigation connector for cleaning, single action jaws, jaws offset downwards, 2 x 4 teeth, size 5 mm, length 36 cm

25351 PMR CLICKLINE Universal Grasping Forceps “PARROT-JAW®”, rotating, dismantling, with connector pin for unipolar coagulation, single action jaws, jaws offset downward, curved to the right, size 5 mm, length 36 cm

25361 ML CLICKLINE KELLY Universal Grasping Forceps, rotating, dismantling, without connector pin for unipolar coagulation, single action jaws, jaws offset downward, long, size 5 mm, length 36 cm

25351 MAR CLICKLINE Scissors, rotating, dismantling, with connector pin for unipolar coagulation, single action jaws, jaws offset down-ward, curved to the right, size 5 mm, length 36 cm

25370 SC Coagulating Suction Tube, insulated sheath, proximally and distally bent downwards, punctual, size 5 mm, length 33 cm25370 DM Coagulating Suction Tube, insulated sheath, proximally and distally bent downwards, needle-shaped, size 5 mm, length 33 cm2x 30804 Handle with Trumpet Valve, for suction or irrigation, autoclavable, for use with 5 mm coagulating suction tubes

and 5 mm suction and irrigation tubes37370 SC Coagulating and Dissecting Electrode, with suction channel, insulated sheath, with connector pin for unipolar coagulation,

size 5 mm, length 36 cm, for use with trocars size 6 mm30805 Handle with Two-Way Stopcock, for suction and irrigation, autoclavable, for use with suction and irrigation tubes size 5 mm


Operating Rectoscopesfor TEO® – Transanal Endoscopic Operations

Special Features:## Available in lengths of 7.5, 15 and 20 cm## Compatible with various working attachments## Integrated telescope irrigation

## Connectors optimized for insufflation and vapor evacuation

## Can be used with instruments 3 – 14 mm

TEO® (Transanal Endoscopic Operations) combines the minimal invasiveness of an intervention via a natural orifice (NOTES) with the precision of resection under visual control. A wide lumen rectoscope enables precise guidance of surgical instruments under visual control.

It is recommended to check the suitability of the product for the intended procedure prior to use.


Operating Rectoscopefor TEO® – Transanal Endoscopic Operations – Working length 7.5 cm

24942 TK 24942 AK

24941 BA

24942 OK

Working length 7.5 cm:

24942 AK TEO® Working Attachment, with attachment for Telescope 24941 BA, 2 channels for instrument size 5 mm and 1 channel for instruments up to size 12 mm, automatic sealing with silicone leaflet valve, LUER-Lock connector for insufflation, for use with 24942 TK

24942 OK TEO® Obturator, for use with Operating Rectoscope Tube 24942 TK

24942 TK TEO® Operating Rectoscope Tube, outer diameter 40 mm, working length 7.5 cm, with handle for holding system, LUER-Lock connector for vapor evacuation

24941 BA HOPKINS® Forward-Oblique Telescope 30°, angled eyepiece, diameter 5 mm, length 21 cm, autoclavable, fiber optic light transmission incorporated, color code: red

TEO® Operating Rectoscope


24942 T

24941 BA

24942 A

24942 O

Working length 15 cm:

24942 A TEO® Working Attachment, with attachment for Telescope 24941 BA, 2 channels for instrument size 5 mm and 1 channel for instruments up to size 12 mm, automatic sealing with silicone leaflet valve, LUER-Lock connector for insufflation, for use with 24942 T

24942 O TEO® Obturator, for use with Operating Rectoscope Tube 24942 T

24942 T TEO® Operating Rectoscope Tube, outer diameter 40 mm, working length 15 cm, with handle for holding system, LUER-Lock connector for vapor evacuation

24941 BA HOPKINS® Forward-Oblique Telescope 30°, angled eyepiece, diameter 5 mm, length 21 cm, autoclavable, fiber optic light transmission incorporated, color code: red


Operating Rectoscopefor TEO® – Transanal Endoscopic Operations – Working length 15 cm


24942 TL

24941 BAL

24942 AL

24942 OL

Working length 20 cm:

24942 AL TEO® Working Attachment, with attachment for HOPKINS® Telescope 24941 BAL, 2 channels for instrument size 5 mm and 1 channel for instruments up to size 12 mm, automatic sealing with silicone leaflet valve, LUER-Lock adaptor for insufflation, for use with Operating Rectoscope Tube 24942 TL

24942 OL TEO® Obturator, for use with Operating Rectoscope Tube 24942 TL

24942 TL TEO® Operating Rectoscope Tube, outer diameter 40 mm, working length 20 cm, with handle for holding system, LUER-Lock connector for vapor evacuation

24941 BAL HOPKINS® Forward-Oblique Telescope 30°, angled eyepiece, diameter 5 mm, length 28 cm, autoclavable, fiber optic light transmission incorporated, color code: red


Operating Rectoscopefor TEO® – Transanal Endoscopic Operations – Working length 20 cm


24941 F

24960 B

24941 I

24941 SP 24941 SPF 24941 AKF

Accessories and Replacement Parts for Operating Rectoscopesfor TEO® – Transanal Endoscopic Operations

24960 B Fiber Optic Light Carrier, with connector pin for fiber optic light cable, with sealing ring

24941 F Sealing Cap, fenestrated, with holder for Fiber Optic Light Carrier 24960 B

Accessories:

24941 SP Sealing Set, for TEO® Working Attachments 24941 A/AK and 24942 A/AK/AL

24941 SPF Sealing Set, for TEO® Working Attachment 24941 AKF

24941 I Insertion Aid, for placement of inner silicone leaflet valves

24941 AKF TEO® Working Attachment, for use with 10 mm HOPKINS® telescopes, 2 channels for instruments up to size 14 mm and 1 channel for instruments up to size 10 mm, automatic sealing with silicone leaflet valve, for use with TEO® Operating Rectoscope Tube 24941 T/TK and 24942 T/TK

Replacement parts:


Operating Instrumentsfor TEO® – Transanal Endoscopic OperationsCLICKLINE Dissecting and Grasping Forceps, rotational, can be dismantled, with and without connector pin for unipolar coagulation

Size 5 mm

Length

36 cm

43 cm

Handle

33162 3316333151 33152 33153 33161

Working Insert

CLICKLINE Dissecting and Grasping Forceps, jaws offset downwards, multiple teeth, atraumatic, width of jaws 4.8 mm

25310 ME 25362 ME 25363 ME25351 ME 25352 ME

25410 ME 25462 ME 25463 ME25451 ME 25452 ME

CLICKLINE Dissecting and Grasping Forceps, jaws offset downwards, 2x 4 teeth

25310 MG 25362 MG 25363 MG25351 MG 25352 MG

25410 MG 25462 MG 25463 MG25451 MG 25452 MG

CLICKLINE Universal Grasping Forceps PARROT JAW®, jaws offset downwards, curved right

25310 PMR 25362 PMR 25363 PMR25351 PMR 25352 PMR

25410 PMR 25462 PMR 25463 PMR25451 PMR 25452 PMR

CLICKLINE Universal Grasping Forceps PARROT JAW®, jaws offset downwards, curved left

25310 PML 25362 PML 25363 PML25351 PML 25352 PML

25410 PML 25462 PML 25463 PML25451 PML 25452 PML

CLICKLINE Universal Grasping Forceps, atraumatic, jaws offset downwards

25310 DF 25362 DF 25363 DF25351 DF 25352 DF

25410 DF 25462 DF 25463 DF25451 DF 25452 DF

CLICKLINE KELLY Universal Grasping Forceps, long, jaws offset downwards

25310 ML 25362 ML 25363 ML25351 ML 25352 ML

25410 ML 25462 ML 25463 ML25451 ML 25452 ML

25353 ME

25453 ME

25353 MG

25453 MG

25353 PMR

25453 PMR

25353 PML

25453 PML

25353 DF

25453 DF

25353 ML

25453 ML

25361 ME

25461 ME

25361 MG

25461 MG

25361 PMR

25461 PMR

25361 PML

25461 PML

25361 DF

25461 DF

25361 ML

25461 ML

Single-action jaws offset downwards

Complete Instrument

|_ _ _ _ 14 _ _ _ _|

|_ _ _ _ 14 _ _ _ _|

|_ _ _ _ 14 _ _ _ _|

|_ _ _ _ 14 _ _ _ _|

|_ _ _ _ 18 _ _ _ _|

|_ _ _ __ 22 __ _ _ _|

n n n n n n


Operating Instrumentsfor TEO® – Transanal Endoscopic OperationsCLICKLINE Scissors, rotational, can be dismantled, with and without connector pin for unipolar coagulation

Working Insert Complete Instrument

CLICKLINE Scissors, jaws offset downwards, serrated

25310 MT 25351 MT 25361 MT

25410 MT 25451 MT 25461 MT

CLICKLINE Scissors, jaws offset downwards, curved right

25310 MAR 25351 MAR 25361 MAR

25410 MAR 25451 MAR 25461 MAR

CLICKLINE Scissors, jaws offset downwards, curved left

25310 MAL 25351 MAL 25361 MAL

25410 MAL 25451 MAL 25461 MAL

Single-action jaws

Size 5 mm

Length

36 cm

43 cm

Handle

33151 33161

offset downwards

|_ _ _ _ 16 _ _ _ _|

|_ _ _ _ 22 _ _ _ _|

|_ _ _ _ 22 _ _ _ _|

n n


Operating Instrumentsfor TEO® – Transanal Endoscopic OperationsCoagulation Suction Tubes, Dissection Hook Electrodes

30805 Handle with Two-Way Stopcock, for suction and irrigation, autoclavable, for use with suction and irrigation tubes size 5 mm

Instrument

Length

33 cm

Instrument

Distal End

Dissection Hook Electrode, proximally and distally bent downwards, needle-shaped

25370 KG

Dissection Hook Electrode, distally bent downward, needle-shaped25370 KGG

Instrument

Length

33 cm

Instrument

Distal End

Coagulation Suction Tube, proximally and distally bent downwards, needle-shaped

25370 DM

Coagulation Suction Tube, proximally and distally bent downwards25370 SC

30804 Handle with Trumpet Valve, for suction or irrigation, autoclavable, for use with 5 mm coagulating suction tubes and 5 mm suction and irrigation tubes


KOH Macro Needle Holder, size 5 mm, dismantling, distally curved, consisting of:## Handle## Outer Sheath

The ergonomic handle and the optimal distal curve of the needle holder ensures easier handling for suturing and grasping the needle, particularly in the narrow space between the tube and the suture line at the rectosigmoid transition to the rectal side walls.

The jaw profile offers a secure hold that makes it easier to grasp the needle.

PD D. SCHUBERT, M.D.

Head of Department, Klinikum Saarbrücken, Germany

## Choice of six different handles## Jaws with tungsten carbide inserts## User-friendly and ergonomic handling

## Can be disassembled into two separate components

## Fully autoclavable## Cleaning connector

The reusable dismantling design offers the user the following benefits:

Operating Instrumentsfor TEO® – Transanal Endoscopic OperationsKOH Macro Needle Holder, dismantling, distally curved

n


Metal Handlesfor KOH Macro Needle Holder, dismantling, distally curved

n

30173 AR Handle, axial, with disengageable ratchet, ratchet position right

30173 AL Handle, axial, with disengageable ratchet, ratchet position left

30173 AO Handle, axial, with disengageable ratchet, ratchet position on top

Handles, axial and pistol, with disengageable ratchet

30173 PR Handle, pistol-shaped, with disengageable ratchet, ratchet position right

30173 PL Handle, pistol-shaped, with disengageable ratchet, ratchet position left

30173 PO Handle, pistol-shaped, with disengageable ratchet, ratchet position on top


Operating Instrumentsfor TEO® – Transanal Endoscopic OperationsKOH Macro Needle Holder, dismantling, distally curved

n

Handle

30173 AR 30173 AL 30173 AO

Complete Instrument

25140 AR 25140 AL 25140 AO

Needle Holder, distally curved, diameter 5 mm

25140

Working Insert

Length

33 cm

Single action jaws

Size 5 mm

Operating Instruments, length 33 cm,with axial handle for use with trocars size 6 mm

Handle

30173 PR 30173 PL 30173 PO

Complete Instrument

25140 PR 25140 PL 25140 PO

Needle Holder, distally curved, diameter 5 mm

25140

Working Insert

Length

Single action jaws

33 cm

Operating Instruments, length 33 cm,with pistol-shaped handle for use with trocars size 6 mm


Special Features:## Simple, fast and accurate positioning## All five joint functions can be fixed by means of a mechanical central clamp

## Variable height adjustment by using the socket## Additional angle adjustment by using socket 28172 HR

## Sockets for use with European and United States standard rails of OR table

## Maintenance-free and autoclavable## With quick release coupling KSLOCK

28272 RLD

Rotation Socket

Socket

28272 KLD Holding System, U-shaped, autoclavable, with quick release coupling KSLOCK

including: Socket, to clamp to the OR table,

for European and US standard rails, also suitable for rails 25 x 10 up to 35 x 8 mm, with lateral clamp for height adjustment of the articulated stand

Articulated Stand, reinforced version, U-shaped, with one mechanical central clamp for all five joint functions, with quick release coupling KSLOCK (female)

28272 RLD Same, including: Rotation Socket, to clamp to the OR table,

for European and US standard rails, with lateral clamp for height and angle adjustment of the articulated stand

Holding Systems, U-shapedfor TEO® – Transanal Endoscopic Operations


Holding Systems, U-shapedfor TEO® – Transanal Endoscopic Operations

28172 HK

28172 HR

28272 UL

optional:

28272 UL Clamping Jaw, universal, clamping range 0 to 18 mm, with quick release coupling KSLOCK (male)

28172 HK Socket, to clamp to the OR table, for European and US standard rails, also suitable for rails 25 x 10 up to 35 x 8 mm, lateral clamp for height adjustment of the articulated stand

28172 HR Rotation Socket, to clamp to the operating table, with one mounted Butterfly Nut 28172 HRS, for European and US standard rails, with lateral clamp for height and angle adjustment of the articulated stand


Mobile Equipment Cart

Monitor:9627 NB 27" FULL HD Monitor

Camera System: TC 200 DE IMAGE1 S CONNECT, connect moduleTC 300 IMAGE1 S H3-LINK, link moduleTH 100 IMAGE1 S H3-Z

Three-Chip FULL HD Camera Head

Light Source:20 1331 01-1 XENON 300 SCB Cold Light Fountain 495 NCSC Fiber Optic Light Cable

HF-Device:20 5352 01-125 AUTOCON® II 40020 0178 30 Two-Pedal Footswitch

Insufflation:UI 400 S1 ENDOFLATOR® 40 UP 501 S3 S-PILOT ™

Pump System:26 3311 01-1 HAMOU® ENDOMAT®

Equipment Cart:UG 120 COR™ Equpiment Cart, narrow, highUG 500 Monitor HolderUG 609 Bottle Holder, for CO2-Bottles29005 DFH Foot-Pedal Holder,

for Two- and Three-Pedal FootswitchesUG 310 Isolation Transformer, 200 V – 240 V UG 410 Earth Leakage Monitor, 200 V – 240 V

Additional for documentation purposes:WD 250 AIDA® with SmartScreen®

TC 009 USB Adaptor, for ACC 1 and ACC 2


Innovative Design## Dashboard: Complete overview with intuitive menu guidance

## Live menu: User-friendly and customizable## Intelligent icons: Graphic representation changes when settings of connected devices or the entire system are adjusted

## Automatic light source control## Side-by-side view: Parallel display of standard image and the Visualization mode

## Multiple source control: IMAGE1 S allows the simultaneous display, processing and documentation of image information from two connected image sources, e.g., for hybrid operations

Dashboard Live menu

Side-by-side view: Parallel display of standard image and Visualization mode

Intelligent icons

Economical and future-proof## Modular concept for flexible, rigid and 3D endoscopy as well as new technologies

## Forward and backward compatibility with video endoscopes and FULL HD camera heads

## Sustainable investment## Compatible with all light sources

IMAGE1 S Camera System n


Brillant Imaging## Clear and razor-sharp endoscopic images in FULL HD

## Natural color rendition

## Reflection is minimized## Multiple IMAGE1 S technologies for homogene-ous illumination, contrast enhancement and color shifting

FULL HD image CHROMA

FULL HD image SPECTRA A *

FULL HD image

FULL HD image CLARA

SPECTRA B **

* SPECTRA A : Not for sale in the U.S.** SPECTRA B : Not for sale in the U.S.



TC 200EN* IMAGE1 S CONNECT, connect module, for use with up to 3 link modules, resolution 1920 x 1080 pixels, with integrated KARL STORZ-SCB and digital Image Processing Module, power supply 100 – 120 VAC/200 – 240 VAC, 50/60 Hz

including: Mains Cord, length 300 cm DVI-D Connecting Cable, length 300 cm SCB Connecting Cable, length 100 cm USB Flash Drive, 32 GB, USB silicone keyboard, with touchpad, US

* Available in the following languages: DE, ES, FR, IT, PT, RU

Specifications:

HD video outputs

Format signal outputs

LINK video inputs

USB interface SCB interface

- 2x DVI-D - 1x 3G-SDI

1920 x 1080p, 50/60 Hz

3x

4x USB, (2x front, 2x rear) 2x 6-pin mini-DIN

100 – 120 VAC/200 – 240 VAC

50/60 Hz

I, CF-Defib

305 x 54 x 320 mm

2.1 kg

Power supply

Power frequency

Protection class

Dimensions w x h x d

Weight

TC 300 IMAGE1 S H3-LINK, link module, for use with IMAGE1 FULL HD three-chip camera heads, power supply 100 – 120 VAC/200 – 240 VAC, 50/60 Hz, for use with IMAGE1 S CONNECT TC 200ENincluding:Mains Cord, length 300 cm

Link Cable, length 20 cm

For use with IMAGE1 S IMAGE1 S CONNECT Module TC 200EN


TC 300 (H3-Link)

TH 100, TH 101, TH 102, TH 103, TH 104, TH 106 (fully compatible with IMAGE1 S) 22 2200 55-3, 22 2200 56-3, 22 2200 53-3, 22 2200 60-3, 22 2200 61-3, 22 2200 54-3, 22 2200 85-3 (compatible without IMAGE1 S technologies CLARA, CHROMA, SPECTRA*)

1x

100 – 120 VAC/200 – 240 VAC

50/60 Hz

I, CF-Defib

305 x 54 x 320 mm

1.86 kg

Camera System

Supported camera heads/video endoscopes

LINK video outputs

Power supply

Power frequency

Protection class


Weight

Specifications:

TC 200EN

TC 300

* SPECTRA A : Not for sale in the U.S.** SPECTRA B : Not for sale in the U.S.


TH 104

TH 104 IMAGE1 S H3-ZA Three-Chip FULL HD Camera Head, 50/60 Hz, IMAGE1 S compatible, autoclavable, progressive scan, soakable, gas- and plasma-sterilizable, with integrated Parfocal Zoom Lens, focal length f = 15 – 31 mm (2x), 2 freely programmable camera head buttons, for use with IMAGE1 S and IMAGE 1 HUB™ HD/HD

IMAGE1 FULL HD Camera Heads

Product no.

Image sensor


Weight

Optical interface

Min. sensitivity

Grip mechanism

Cable

Cable length

IMAGE1 S H3-ZA

TH 104

3x 1/3" CCD chip

39 x 49 x 100 mm

299 g

integrated Parfocal Zoom Lens, f = 15 – 31 mm (2x)

F 1.4/1.17 Lux

standard eyepiece adaptor

non-detachable

300 cm

Specifications:

TH 100 IMAGE1 S H3-Z Three-Chip FULL HD Camera Head, 50/60 Hz, IMAGE1 S compatible, progressive scan, soakable, gas- and plasma-sterilizable, with integrated Parfocal Zoom Lens, focal length f = 15 – 31 mm (2x), 2 freely programmable camera head buttons, for use with IMAGE1 S and IMAGE 1 HUB™ HD/HD

IMAGE1 FULL HD Camera Heads

Product no.

Image sensor


Weight

Optical interface

Min. sensitivity

Grip mechanism

Cable

Cable length

IMAGE1 S H3-Z

TH 100

3x 1/3" CCD chip

39 x 49 x 114 mm

270 g

integrated Parfocal Zoom Lens, f = 15 – 31 mm (2x)

F 1.4/1.17 Lux

standard eyepiece adaptor

non-detachable

300 cm

Specifications:

For use with IMAGE1 S Camera System IMAGE1 S CONNECT Module TC 200EN, IMAGE1 S H3-LINK Module TC 300 and with all IMAGE 1 HUB™ HD Camera Control Units

IMAGE1 S Camera Heads n

TH 100


9826 NB

9826 NB 26" FULL HD Monitor, wall-mounted with VESA 100 adaption, color systems PAL/NTSC, max. screen resolution 1920 x 1080, image fomat 16:9, power supply 100 – 240 VAC, 50/60 Hzincluding:External 24 VDC Power SupplyMains Cord

9619 NB

9619 NB 19" HD Monitor, color systems PAL/NTSC, max. screen resolution 1280 x 1024, image format 4:3, power supply 100 – 240 VAC, 50/60 Hz, wall-mounted with VESA 100 adaption,including:

External 24 VDC Power SupplyMains Cord

Monitors


Monitors

Optional accessories:9826 SF Pedestal, for monitor 9826 NB9626 SF Pedestal, for monitor 9619 NB

26"

9826 NB

l

–

l

l

l

l

l

–

l

–

l

l

l

l

l

l

19"

9619 NB

l

–

–

l

l

l

l

l

l

l

–

l

l

l

l

l

KARL STORZ HD and FULL HD Monitors

Wall-mounted with VESA 100 adaption

Inputs:

DVI-D

Fibre Optic

3G-SDI

RGBS (VGA)

S-Video

Composite/FBAS

Outputs:

DVI-D

S-Video

Composite/FBAS

RGBS (VGA)

3G-SDI

Signal Format Display:

4:3

5:4

16:9

Picture-in-Picture

PAL/NTSC compatible

19"

optional

9619 NB

200 cd/m2 (typ)

178° vertical

0.29 mm

5 ms

700:1

100 mm VESA

7.6 kg

28 W

0 – 40°C

-20 – 60°C

max. 85%

469.5 x 416 x 75.5 mm

100 – 240 VAC

EN 60601-1, protection class IPX0

Specifications:

KARL STORZ HD and FULL HD Monitors

Desktop with pedestal

Product no.

Brightness

Max. viewing angle

Pixel distance

Reaction time

Contrast ratio

Mount

Weight

Rated power

Operating conditions

Storage

Rel. humidity


Power supply

Certified to

26"

optional

9826 NB

500 cd/m2 (typ)

178° vertical

0.3 mm

8 ms

1400:1

100 mm VESA

7.7 kg

72 W

5 – 35°C

-20 – 60°C

max. 85%

643 x 396 x 87 mm

100 – 240 VAC

EN 60601-1, UL 60601-1, MDD93/42/EEC, protection class IPX2


Accessories for Video Documentation

495 NL Fiber Optic Light Cable, with straight connector, diameter 3.5 mm, length 180 cm

495 NA Same, length 230 cm

495 NAC Fiber Optic Light Cable, with straight connector, extremely heat-resistant, with safety lock, increased light transmission, diameter 3.5 mm, length 230 cm, can be used for ICG applications

Cold Light Fountain XENON 300 SCB

20 133101-1 Cold Light Fountain XENON 300 SCB

with built-in antifog air-pump, and integrated KARL STORZ Communication Bus System SCB power supply: 100 –125 VAC/220 –240 VAC, 50/60 Hz

including: Mains Cord SCB Connecting Cord, length 100 cm20133027 Spare Lamp Module XENON

with heat sink, 300 watt, 15 volt20133028 XENON Spare Lamp, only,

300 watt, 15 volt

20 134001 Cold Light Fountain XENON NOVA® 300, power supply: 100–125 VCA/220–240 VAC, 50/60 Hz

including: Mains Cord20 1330 28 XENON Spare Lamp, only,

300 watt, 15 volt

Cold Light Fountain XENON NOVA® 300


Data Management and DocumentationKARL STORZ AIDA® – Exceptional documentation

The name AIDA stands for the comprehensive implementation of all documentation requirements arising in surgical procedures: A tailored solution that flexibly adapts to the needs of every specialty and thereby allows for the greatest degree of customization.

This customization is achieved in accordance with existing clinical standards to guarantee a reliable and safe solution. Proven functionalities merge with the latest trends and developments in medicine to create a fully new documentation experience – AIDA.

AIDA seamlessly integrates into existing infrastructures and exchanges data with other systems using common standard interfaces.

WD 200-XX* AIDA Documentation System, for recording still images and videos, dual channel up to FULL HD, 2D/3D, power supply 100-240 VAC, 50/60 Hz

including: USB Silicone Keyboard, with touchpad ACC Connecting Cable DVI Connecting Cable, length 200 cm HDMI-DVI Cable, length 200 cm Mains Cord, length 300 cm

WD 250-XX* AIDA Documentation System, for recording still images and videos, dual channel up to FULL HD, 2D/3D, including SMARTSCREEN® (touch screen), power supply 100-240 VAC, 50/60 Hz

including: USB Silicone Keyboard, with touchpad ACC Connecting Cable DVI Connecting Cable, length 200 cm HDMI-DVI Cable, length 200 cm Mains Cord, length 300 cm

*XX Please indicate the relevant country code (DE, EN, ES, FR, IT, PT, RU) when placing your order.


Workflow-oriented use

Patient

Entering patient data has never been this easy. AIDA seamlessly integrates into the existing infrastructure such as HIS and PACS. Data can be entered manually or via a DICOM worklist. ll important patient information is just a click away.

Checklist

Central administration and documentation of time-out. The checklist simplifies the documentation of all critical steps in accordance with clinical standards. All checklists can be adapted to individual needs for sustainably increasing patient safety.

Record

High-quality documentation, with still images and videos being recorded in FULL HD and 3D. The Dual Capture function allows for the parallel (synchronous or independent) recording of two sources. All recorded media can be marked for further processing with just one click.

Edit

With the Edit module, simple adjustments to recorded still images and videos can be very rapidly completed. Recordings can be quickly optimized and then directly placed in the report. In addition, freeze frames can be cut out of videos and edited and saved. Existing markings from the Record module can be used for quick selection.

Complete

Completing a procedure has never been easier. AIDA offers a large selection of storage locations. The data exported to each storage location can be defined. The Intelligent Export Manager (IEM) then carries out the export in the background. To prevent data loss, the system keeps the data until they have been successfully exported.

Reference

All important patient information is always available and easy to access. Completed procedures including all information, still images, videos, and the checklist report can be easily retrieved from the Reference module.


HAMOU® ENDOMAT® with KARL STORZ SCBSuction and Irrigation System

* This product is marketed by mtp. For additional information, please apply to:

mtp medical technical promotion gmbh, Take-Off Gewerbepark 46, D-78579 Neuhausen ob Eck, Germany

26 3311 01-1 HAMOU® ENDOMAT® SCB, power supply 100 – 240 VAC, 50/60 Hz

including: Mains Cord 5x HYST Tubing Set*, for single use 5x LAP Tubing Set*, for single use SCB Connecting Cable, length 100 cm VACUsafe Promotion Pack Suction*, 2 l

Subject to the customer’s application-specific requirements additional accessories must be ordered separately.

ENDOFLATOR® 40 with KARL STORZ SCBwith High Flow Insufflation (40 l/min.)

UI400S1 ENDOFLATOR® 40 SCB, Set, with integrated SCB module, power supply 100 - 240 VAC, 50/60 Hz

including: ENDOFLATOR® 40 Mains Cord, length 300 cm SCB Connecting Cable, length 100 cm Universal Wrench Insufflation Tubing Set, with gas filter, sterile,

for single use, package of 5 *

Subject to the customer’s application-specific requirements additional accessories must be ordered separately.* This product is marketed by mtp.

For additional information, please apply to:

mtp medical technical promotion gmbh, Take-Off Gewerbepark 46, D-78579 Neuhausen ob Eck, Germany


Notes:

with the compliments of

KARL STORZ — ENDOSKOPE

teo –– transanal endoscopic operations · 2018-10-30 · teo® – transanal endoscopic...

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