Transanal excision of rectal polyp with gelofusin lift

Transanal minimally invasive surgery (TAMIS) and endoscopic submucosal dissection (ESD) are considered standard of care for benign rectal tumours, and its role for early rectal cancers is being explored. Despite limitations posed by the endoscopic approach, a recent direct comparison of the two techniques suggests non-inferiority of the ESD over TAMIS, with a low recurrence rate in the ESD group as compared to the TAMIS arm, but this was not statistically significant.1 This case report presents an approach to TAMIS that adopts the technique of gelofusin lift used in ESD to facilitate a TAMIS dissection with clear delineation of the dissection plane and margins. A 52-year-old female was found to have a large carpet-like polyp on the posterior wall of the lower rectum extending to the middle rectal fold on colonoscopy for investigation of a positive faecal occult blood test. Biopsies returned as tubulovillous adenoma with low-grade dysplasia. Her past medical history is significant for type 2 diabetes. She subsequently underwent a transanal excision of the rectal polyp via the TAMIS platform (Video S1). Step 1: The patient is positioned in lithotomy, and the transanal access platform is inserted and secured. Insufflation is set at 12 mmHg to maintain pneumorectum. The use of a 5 mm 30° laparoscope or, if available, a flexible laparoscope will reduce instrument clash. Step 2: 500 mL of gelofusin is combined with 4 mL of methylene blue and injected liberally into the submucosal area to lift the polyp off the muscularis propria. Step 3: The extent of the resection is marked with diathermy to allow for a 5 mm margin. Starting at the edges of the lift, the polyp is excised with an angled electrosurgical probe equipped with smoke evacuation and suction capabilities. The lift solution, as it does in the endoscopic approach, highlights the planes of dissection clearly and delineates the margins of dysplastic tissue and normal mucosa, giving a visual aid to dissection. The circular muscle fibres of the rectum can clearly be seen at the base of the TAMIS resection. Additional injections with gelofusin mixture to lift the polyp are administered as required to lift the polyp away from the muscularis propria. Step 4: The specimen is retrieved and marking sutures for orientation are placed, and the haemostasis is achieved. A betadine wash of the rectum is performed. Given this was a mucosal dissection, closure of the defect is not performed. Open access publishing facilitated by Monash University, as part of the Wiley - Monash University agreement via the Council of Australian University Librarians. Video S1. 1. Establishment of pneumorectum (0:00–0:04). 2. Gelofusin/methylene blue injected into submucosal plane (0:05–0:13). 3. Excision margins marked (0:14–0:20). 4. Submucosal dissection performed (0:20–0:43). 5. Circular muscle on view - dissection planes clearly delineated with gelofusin lift (0:44–1:20). 6. Dissection carried out in a caudal-to-cranial fashion (1:21–3:00). 7. Specimen oriented prior to extraction to facilitate marking (3:01–3:09). 8. Circular muscle fibres on view following excision (3:10–3:19). Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.