the advent of single incision laparoscopic surgery ( sils ) has made great inroads into various fields of general and gastrointestinal ( gi ) surgery . over the last 20 months , in our unit , we performed several silss cholecystectomy , appendicitis , hernia , fundoplication , and sils sleeve gastrectomy .
we decided to make use of the same technique in trans anal endoscopic microsurgery ( tem ) for 2 patients who had large sessile villous adenomas of the rectum .
the sils port ( covidien ) is a blue pvc port that has an entry port for gas and three other trocars .
we utilized this port and fixed it transanally to the edge of the anus [ figure 1 ] .
the carbon dioxide that used for insufflation in laparoscopic surgery was used through one of the ports and a telescope was inserted to the larger port .
the other two ports were used for right hand and left hand working instrument and we utilized the harmonic shears ( ultrasision , ethicon ) to completely excise the villous adenoma with a 0.5 cm border of the mucosa [ figure 2 ] . during the procedure , we maintained the carbon dioxide insufflation pressure of 80 ml of mercury .
we made sure that the entire polyp was cut out completely until the circular muscle of the internal sphincter was clearly exposed .
next , the cut edges of the rectum were undermined between the mucosa and the circular muscles in order to bring the cut edges closer together . deploying a maryland dissector with the left hand working port and an endo stitch ( covidien ) on the right side
, we were able to close the mucosa by a running suture using 30 polysorb ( polyglactin 910 ) [ figure 3 ] .
the running suture was completed starting from proximal , working down distally , and the procedure was completed .
in both cases , well - differentiated villous adenoma ( colonoscopically , biopsy proven before surgery ) was confirmed after excision . both patients are being followed - up post operation for 1 and 3 months , respectively , and , at this point of time , they are free of recurrence .
the postoperative period was uncomplicated in both the cases with no bleeding , infection , or any other local or systemic complications .
the advent of sils permits the surgeon to pass in two instruments and perform complicated surgery like fundoplication and bariatric surgery . applying the same physics through the rectum
, we felt that continuous insufflation of the rectum with carbon dioxide through a side port would give us an adequate working space for operations , and utilization of higher energy sources like the ultrasation will make surgery swift and bloodless . in order to secure the edges of the mucosa , we initially tried using standard suturing instruments like the regular needle holder and the cambridge endo riveted needle holder .
we found both of them to be associated with much ergonomic difficulties in the performance of suturing .
therefore , we decided to use the endo stitch that we have been using for quite some time in regular laparoscopy and intra abdominal sils surgeries .
we found that utilization of the endostitch was the most important time framing factor in the performance of the sils tem .
we strongly recommend that any group planning to performing a sils tem acquaint themselves with operating with endostitch in order to perform the surgeries completely .
the question that has been raised is whether tem is the new laparoscopy for anorectal surgery .
increasingly , several reports are showing promising results for the treatment of early stage cancers and large rectal adenomas using tem .
, from the netherlands is one of the largest studies because it represents 353 tem procedures .
opening of the peritoneum occurred as a complication in only 9% of cases with the conversion just short of 10% either for this reason or because of the failure of completion of the procedure .
it was stressed in the earlier paper too that , not only is colorectal surgical training important to complete these procedures but also adequate general surgical training is important in order to excise lesions in a piece and to get a proper margin with least recurrence and complications like operation . toward this end , adoption of our technique using
the sils port , which has not been previously described in medical literature , seems to be a promising tool for the future .
 trans anal endoscopic microsurgery ( tem ) first burst upon the scene several decades ago and then underwent a period of immersion . we have herein reported our experience in two cases who underwent tem using laparoscopic techniques . 
 the advent of single incision laparoscopic surgery ( sils ) has made great inroads into various fields of general and gastrointestinal ( gi ) surgery . 
 we decided to make use of the same technique in tem for two patients who had large sessile villous adenomas of the rectum . 
 we used this port and fixed it transanally to the edge of the anus . 
 carbon dioxide used for insufflation in laparoscopic surgery was used through one of the ports , and a telescope was inserted to the larger port . 
 we made sure that the entire polyp was cut out completely until the circular muscle of the internal sphincter was clearly exposed . 
 next , the cut edges of the rectum were undermined between the mucosa and the circular muscles in order to bring the cut edges closer together . 
 we were able to perform this sils tem in two cases . in both the cases , 
 well differentiated villous adenoma ( colonoscopically , biopsy proven before surgery ) was confirmed after excision . 
 the question has been raised whether tem is the new laparoscopy for anorectal surgery . 
 increasingly , several reports are showing promise for treatment for early stage cancers and large rectal adenomas using tem . 
 adoption of our technique using the sils port that has not been previously described in medical literature , seems to be a promising tool for the future.tem first burst upon the scene several decades ago and then under went a period of immersion . 
 in recent years , with the onset of laparoscopic surgery , the thoughts and the ideas of using a laparoscopic surgical technique have invaded the area of colorectal cancer as well . 
 we have herein reported our experience in two cases who underwent tem using laparoscopic techniques . 
INTRODUCTION
TECHNIQUE
HISTOPATHOLOGY
DISCUSSION