Transanal Excision / TAMIS
Rectal neoplasm / villous adenoma / early rectal cancer (T1)
Same
Transanal minimally invasive surgery (TAMIS), full-thickness transanal excision of rectal lesion
[***, MD/DO]
[Resident/Fellow/PA name]
General or spinal
Patient presents with [benign rectal polyp / T1 rectal adenocarcinoma / rectal neuroendocrine tumor (NET)] at [X] cm from the anal verge on the [anterior / posterior / lateral] wall. Lesion [not amenable to / failed] endoscopic resection. [For invasive lesions: pelvic MRI performed for local staging; endorectal ultrasound obtained for T1 vs. T2 discrimination. No evidence of muscularis propria invasion or lymph node involvement.] Full-thickness local excision planned. Risks including bleeding, infection, fistula, peritoneal entry, and need for radical resection if margins positive discussed.
Under anesthesia, the lesion was identified at [X] cm from the anal verge on the [clock] wall, measuring approximately [X] cm. The lesion appeared [pedunculated / sessile / flat]. No gross evidence of invasion beyond the submucosa. A 1-2 cm margin was marked circumferentially.
The patient was taken to the operating room and positioned in [lithotomy / prone jackknife] position based on lesion location (prone jackknife for anterior lesions; lithotomy for posterior). The perineum was prepped and draped in sterile fashion. The GelPOINT Path transanal access platform was inserted and secured. The working channel was insufflated with CO2 to [12-15] mmHg to maintain pneumorectum. Laparoscopic instruments ([5 or 10]-mm 30-degree scope, graspers, electrosurgical device) were introduced.
The lesion was identified [X] cm from the anal verge at the [clock position]. A circumferential marking was made 1 cm beyond the lesion borders using cautery. Full-thickness excision was performed using [monopolar cautery / ultrasonic shears], starting at the distal margin and proceeding circumferentially. The mesorectal fat was visualized confirming full-thickness excision. [No peritoneal entry occurred / The peritoneum was entered and immediately closed with interrupted 2-0 Vicryl.] The specimen was removed intact through the platform. An orientation suture was placed at the [clock position] for pathologic correlation.
The defect measured approximately [X x Y] cm. The defect was closed transversely with a running 2-0 Vicryl suture. [For upper rectal lesions near the peritoneal reflection: closure is essential.] Hemostasis confirmed. The platform was removed. The patient tolerated the procedure well.
None
Rectal lesion, full-thickness excision, orientation stitch at [position], sent for permanent pathology
Minimal
None
Patient was taken to PACU in stable condition. [Same-day discharge / Overnight observation.]
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: [Rectal villous adenoma / T1 rectal adenocarcinoma / rectal carcinoid] at *** cm from anal verge
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Transanal minimally invasive surgery (TAMIS), full-thickness transanal excision of rectal lesion
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General / spinal
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with a [benign rectal polyp / T1 rectal adenocarcinoma / rectal neuroendocrine tumor (NET)] at *** cm from the anal verge on the *** wall not amenable to endoscopic resection. [Pelvic MRI and endorectal ultrasound performed for invasive lesions; no lymph node involvement identified.] Risks including bleeding, infection, fistula, peritoneal entry, and need for radical resection if margins positive were discussed. Informed consent obtained.
FINDINGS: Under anesthesia, the lesion was identified at *** cm from the anal verge at the *** o'clock position, measuring approximately *** cm, appearing [sessile / flat / pedunculated]. No gross evidence of invasion beyond the submucosa. A 1-cm margin was marked circumferentially.
DESCRIPTION OF PROCEDURE:
The patient was positioned in [lithotomy / prone jackknife] position (chosen based on lesion location) and prepped in sterile fashion. The GelPOINT Path transanal access platform was inserted and secured. The working channel was insufflated with CO2 to *** mmHg maintaining pneumorectum. A [5/10]-mm 30-degree scope and laparoscopic instruments were introduced. Circumferential marking made 1 cm beyond lesion borders using cautery. Full-thickness excision performed using [monopolar cautery / ultrasonic shears] from distal margin circumferentially; mesorectal fat visualized confirming full-thickness excision. No peritoneal entry occurred. Specimen removed intact; orientation stitch placed at *** o'clock position. Defect measured *** × *** cm and was closed transversely with a running 2-0 Vicryl suture. Hemostasis confirmed. Platform removed. Patient tolerated the procedure well.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: Rectal lesion, full-thickness excision, orientation stitch at *** position, sent for permanent pathology
COMPLICATIONS: None
DRAINS: None
DISPOSITION: Patient taken to PACU in stable condition. [Same-day discharge / Overnight observation.]
Signed: .ME, .MYDEGREE
.TODAYVariants
Traditional transanal excision (no platform)
For low-lying lesions generally ≤6-8 cm from anal verge (practical limit for Parks/Hill-Ferguson retractor access). Retractor-assisted approach. Document retractor type and lesion exposure.
TEM (transanal endoscopic microsurgery)
Rigid 40 mm diameter proctoscope. Two standard working lengths available (12 cm and 20 cm) — document which was used.
Charting Tips
- Document distance from anal verge precisely, as this governs staging and adjuvant decisions
- State clock position of lesion; note patient positioning was chosen based on lesion location (prone for anterior, lithotomy for posterior)
- Document full-thickness confirmation (mesorectal fat visualized)
- Document defect closure — current evidence favors closure (significantly lower postoperative bleeding); always close if peritoneal entry occurred
- Document explicitly whether peritoneal entry occurred and how it was managed
- Specimen orientation suture must match pathology request; pin specimen to cork board and photograph
- For T1 lesions, document Kikuchi depth (sm1/sm2/sm3) and lymphovascular invasion status when pathology available — these govern need for salvage proctectomy
- If margins positive on final pathology, document multidisciplinary discussion of radical resection
- "Carcinoid" is obsolete terminology; use rectal neuroendocrine tumor (NET), grade G1/G2/G3
Documentation & Reimbursement Considerations
- Primary service: Report Transanal Excision / TAMIS as the primary service when it is the definitive operation performed.
- Reporting selection: Reporting selection is based solely on depth of excision, not the platform used (rigid proctoscope vs. TAMIS port vs. TEM).
- Use for sessile polyp excision or T1 rectal lesion not involving full thickness of the wall (excision into but not through the muscularis propria).
- Use when excision goes through all layers of the rectal wall with mesorectal fat visible.
Document depth explicitly: partial thickness (into but not through muscularis propria) vs. full thickness (through all layers).
- 90-day global period: postoperative proctoscopy, wound assessment, and pathology review coordination are bundled. Adjuvant radiation or chemoradiation for unexpected T2+ disease is managed by oncology and does not affect surgical billing.
- Postoperative pathology upstaging (T2 or higher on final path) requires multidisciplinary discussion. Document the intraoperative impression vs. final pathology and the subsequent clinical decision-making for medicolegal completeness.