[Transanal endoscopic microsurgery (TEM): indications and limitations]

Sessile polyps of the proximal and middle part of the rectum are difficult and sometimes impossible to remove by snaring techniques. The conventional transanal approach to this level results in inappropriate survey and security. Parasacral techniques and low anterior resection require disproportionate measures to treat these adenomas. Transanal endoscopic microsurgery (TEM) is a relatively new operative technique to remove sessile polyps of the entire rectum, developed by Buess et al. [1] in Germany. The system uses a special endorectal scope connected to a stereoscopic angulated optical system for visualization. A continuous pressure-controlled insufflation of carbon dioxide keeps the rectum open for exposure. The excision is done by electrocautery in the submucosal plane or as full thickness excision in the submuscular plane. The defect is closed with an intrarectal running suture. Our report demonstrates the indications and limits of this technique and compares it to conventional techniques mentioned above. 12 patients with different kinds of tumor have been selected and serve as basis for our discussion. TEM offers excellent survey in the entire rectum and permits removal of villous adenomas and incidental low risk and early rectal cancers. High risk patients tolerate this procedure well. Unsuitable are circular and long-distance adenomas and transmural growing benign tumors of the proximal rectum.