Pigot et al. performed this technique in 207 consecutive patients, mean age 68 years, for a villous adenoma of the rectum apparently benign. The mean distance between the lower edge of the lesion from the anal margin is 5.6 cm and 10 cm is less than 82%. Immediate postoperative course was uneventful for 96%. The average size of the resected lesion was 5.4 cm. OR & CIRCUMFERENTIAL villous adenoma tubulovillous exposure RECTUM quality is essential for the removal of a large polyp in the rectum. Lone Star A self-retaining retractor FIGURE 5 and flat villous adenoma of the lower rectum. The dissection of the adenoma in the submucosal plane with a 1 cm margin of normal mucosa. Transverse approximation of the wound with continuous sutures. CHAPTER 19: THE TECHNIQUES 395 FIGURE 6 and transanal & specimen is pinned on cardboard. exposure helps tremendously. If this instrument is not available, two Gelpi retractors placed at right angles to each other at the anal margin can be used as an alternative. A circumferential villous adenoma or tubulovillous with the lower margin in the lower rectum can be removed, even if the margin extends to the proximal midrectum. Although Stuart Parks and removed in three to four longitudinal bands, such lesions can be removed in one piece as a submucosal tube. An incision is made around the dentate line in the plane with a submucosal electrocautery blade. Dilute epinephrine can be injected to raise the submucosal plane. Using an anal speculum Pratt to stretch the anal canal is the dissection in the submucosal plane easier all around to about 7 cm. Submucosal tube is grasped with an Allis clamp, and submucosal dissection is carried proximally to the extent necessary. Circumferential dissection of the submucosa of the rectum can prolapse apparently during traction. It is relatively easy to dissect the submucosa tube the dentate line to the anorectal ring. The anorectal ring to the rectum, the dissection is difficult, and the submucosal plane can be easily lost. Packaging in tube sponges submucosal facilitates traction on the tube during dissection. A speculum Pratt, Sawyer or Hill-Ferguson retractor, and a small Deaver retractor should be used freely, if any. Of the rectum to upper rectum, the dissection is usually easier.