Impact of technology on indications and limitations for transanal surgical removal of rectal neoplasms

Figure 1 Conventional transanal excision with the patient in prone-jackknife position. A: Anus at beginning of the surgery; B: Placement of Lone Star retractor; C: Additional hand-held retractor optimizes exposure; D: Direct transanal instrumentation under regular view.

Figure 2 Fixation and orientation of the specimen on a wax board. The tissue is pinned down with needles. L(eft), R(ight), D(istal), and P(roximal) are carved into the wax. The specimen is subsequently placed in formalin for at least 24 h before processing and sectioning it onto slides.

Figure 3 Transanal endoscopic microsurgery-internal view demonstrating an excellent exposure of the lesion. A: Sessile lesion being marked with a dotted line at about 1 cm around the border of the lesion; B: View after full thickness excision with exposed mesorectal fat.

Figure 4 Transanal endoscopic microsurgery-external view. A: Close-up to working anoscope with air insufflation, camera port, and 3 working ports; B: Surgeon and monitor position during procedure with a patient in prone-jackknife position.