The operative rectoscope is 40 mm in diameter, which compromises the acceptable limit of dilatating the anal sphincter and adequate space inside the tube to perform complex surgery. Two different tubes are available with either a length of 10 or 20 cm. At the distal end, the rectoscope tubes have a 45° angle (Fig. 2). The tubes are introduced into the handpiece. The handpiece allows introduction of the operative recto-scope with the respective obturator for endoscopic examination of the rectum using the glass window. A cold light adapter is integrated into the glass window for optimal illumination during examination. In preparation for the procedure, the handpiece is connected to a holding device, mounted to the rail of the operating table (Fig. 3). A special arm belongs to the operative system. A double-ball joint allows easy adjustment of the rectoscope and optimal handling during the operation. During the actual procedure, the working insert is used. In our recent model, single flexible tubes are adjusted to the working insert to allow sealing during insufflation. The flap seals are integrated as well to prevent gas leakage during instrument removal. This model also allows performance of haemostasis with conventional instrumentation, if needed.
The instruments for TEM are designed specifically because the relatively narrow tube of the rectoscope limits manoeuvrability of instrumentation . Therefore, a bayonet-type angulation has been introduced into the system that allows a wider working area, compared with straight instruments. Figure 4 demonstrates the angular instruments that provide a longer distance between the optic and the working field. Specific technical details have been integrated into the needle holder. A small upper jaw fixes the needle in place, while the broader excavated lower jaw brings the needle into an upright position.
The curves in the suction device allow the assistant to guide the suction tube in case of bleeding without extensive mechanical conflict with the operative instruments of the surgeon. The forceps perform two
different functions. The tip excavations allow safe grasping of the tissue. The jaws are flat so that the needle can be grasped during the suturing process. A silver clip with a central cut is used. Instead of the knotting process a monofilament thread is placed into the central cut, tensed and the clip is fixed to act as a knot substitute.
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