Transanal Endoscopic Microsurgery

Delivery of healthcare in different economic models presents opportunities and challenges for the generations and populations. In the Caribbean nations, there is a wide disparity of level of healthcare provided both between countries and within individual countries. The Cuban medical system is very advanced in comparison to other countries (Caribbean region). In fact in the infant mortality rate or in the survival of the cancer colorectal, it is compared favorably with the western countries. However the introduction of advanced technology in this global environment is hampered by challenges with cost, equipment maintenance and supply chain issues. The benefits of these approaches however are equally advantageous for people of all countries, regardless of the country they were born and live in. A number of surgical techniques have been implemented to remove rectal tumors locally. Transanal endoscopic microsurgery (TEM) is a newly popular, minimally invasive technique for that purpose. In the 1983, Gerhard Buess introduced TEM. He developed the technique according to a fixed action plan, including experiments on animals, after which he progressed to clinical introduction. In addition, he set up training courses for interested surgeons to introduce the new technology safely [1-3]. TEM is ideally performed in patients with benign large adenomas and low-risk superficial carcinomas of the rectum. It is a local excision technique, which enables the surgeon to perform a submucosal or full thickness excision with great precision. By using an operating rectoscope with a diameter of 4 cm and a length of 12 or 20 cm is used the most challenging aspect of transanal surgery, reaching the cephalad margins, is easily achieved. The scope has four work channels, a stereo optic vision channel, a light source, and an insufflations port to obtain a pneumorectum for maximum exposure [4,5]. TEM has been shown to be superior to transanal excision (TAE) for benign and malignant rectal neoplasms. There is a significantly lower risk of fragmented of piecemeal excision, incomplete resection and consequently a lower recurrence rate [4,6-8]. TEM of more advanced rectal cancer remains a controversial issue. However TEM has recently become a more attractive option because of the regular use of neoadjuvant therapy at several centers [4,5,8-13]. Still other indications have also been described: repair of high or supralevator fistulas, rectourethral fistulas and rectal prolapse, drainage of pelvic collections, impacted fecaloma and excision of extra rectal masses [5,14-16]. The aim of this study is a report on the introduction of a national program of advanced surgical technology at the National Center for Minimally Invasive Surgery in Havana, Cuba.