Transanal total mesorectal excision (taTME) is a novel approach developed to access malignancies of the distal rectum minimally invasively, with improved oncologic precision and sphincter preservation. Despite early enthusiasm and potentially superior outcomes, introduction of this technique has been met with conflicting opinions about its utility, mainly due to its complication profile, and recent short-term oncologic outcomes. Adoption of any new technique requires a thorough understanding of the intricacies involved in a new anatomic approach. This review article seeks to discuss potential complications and pitfalls of taTME, and tips to avoid them.

BACKGROUND: There are no data comparing the quality of local excision of rectal neoplasms using transanal endoscopic microsurgery and transanal minimally invasive surgery. OBJECTIVE: The purpose of this study was to compare the incidence of tumor fragmentation and positive margins for patients undergoing local excision of benign and malignant rectal neoplasms using transanal endoscopic microsurgery versus transanal minimally invasive surgery. DESIGN: This was a multi-institutional cohort study using coarsened exact matching. SETTINGS: The study was conducted at high-volume tertiary institutions with specialist colorectal surgeons. PATIENTS: Patients undergoing full-thickness local excision for benign and malignant rectal neoplasms were included. INTERVENTIONS: Transanal endoscopic microsurgery and transanal minimally invasive surgery were the included interventions. MAIN OUTCOME MEASURES: The incidence of poor quality excision (composite measure including tumor fragmentation and/or positive resection margin) was measured. RESULTS: The matched cohort consisted of 428 patients (247 with transanal endoscopic microsurgery and 181 with transanal minimally invasive surgery). Transanal minimally invasive surgery was associated with shorter operative time and length of stay. Poor quality excision was similar (8% vs 11%; p = 0.233). There were also no differences in peritoneal violation (3% vs 3%; p = 0.965) and postoperative complications (11% vs 9%; p = 0.477). Cumulative 5-year disease-free survival for patients undergoing transanal endoscopic microsurgery was 80% compared with 78% for patients undergoing transanal minimally invasive surgery (log rank p = 0.824). The incidence of local recurrence for patients with malignancy who did not undergo immediate salvage surgery was 7% (8/117) for transanal endoscopic microsurgery and 7% (7/94) for transanal minimally invasive surgery (p = 0.864). LIMITATIONS: All of the procedures were also performed at high-volume referral centers by specialist colorectal surgeons with slightly differing perioperative practices and different time periods. CONCLUSIONS: High-quality local excision for benign and rectal neoplasms can be equally achieved using transanal endoscopic microsurgery or transanal minimally invasive surgery. The choice of operating platform for local excisions of rectal neoplasms should be based on surgeon preference, availability, and cost. See Video Abstract at http://links.lww.com/DCR/A382.

Purpose Transanal total mesorectal excision (taTME) requires specific technical expertise, as it is often difficult to ascertain the correct dissection plane. Consequently, one can easily enter an incorrect plane, potentially resulting in bleeding (sidewall or presacral vessels), autonomic nerve injury and urethral injury. We aim to demonstrate specific visual features, which may be encountered during surgery and can guide the surgeon to perform the dissection in the correct plane. Method Specific features of dissection in the correct and incorrect planes are demonstrated in the accompanying video. Results The ‘triangles’ created using appropriate traction can aid in performing a precise dissection in the correct plane. Recognition of features described as ‘O’s can alert surgeons that they are entering a new fascial plane and can avoid incursion into an incorrect plane. Conclusion Understanding and recognizing the described features which can be encountered in taTME surgery, a safe and accurate TME dissection can be facilitated.

Over the past 3 years, colorectal surgeons have begun to adapt the technique of transanal total mesorectal excision. As international experience has been quickly forged, an improved recognition of the pitfalls and the practical details of this disruptive technique have been realized. The purpose of this technical note was to express the various nuances of transanal total mesorectal excision as learned during the course of its clinical application and international teaching, so as to rapidly communicate and share important insights with other surgeons who are in the early adoption phase of this approach. The technical points specific to transanal total mesorectal excision are addressed herein. When correctly applied, these will likely improve the quality of surgery and decrease morbidity attributable to inexperience with the transanal approach to total mesorectal excision.

BACKGROUND:Robotic transanal surgery represents a natural evolution of transanal minimally invasive surgery. This new approach to rectal surgery provides the ability to perform local excision of rectal neoplasia with precision. Robotic transanal surgery can also be used to perform more advanced procedures including repair of complex fistulae and transanal total mesorectal excision.METHODS:Data from patients who underwent transanal robotic surgery over a 33-month period were retrospectively reviewed. Patients underwent three types of procedures using this approach: (a) local excision of rectal neoplasia, (b) transanal total mesorectal excision, and (c) closure of complex fistulae, such as rectourethral fistulae.RESULTS:Eighteen patients underwent robotic transanal surgery during the 33-month study period. Of these, nine patients underwent local excision of rectal neoplasia; four patients underwent transanal total mesorectal excision; four patients underwent repair of rectourethral fistulae; and one patient underwent repair of an anastomotic fistula. Of the patients undergoing robotic transanal surgery for local excision, 6/9 were resections of benign neoplasia, while 3/9 were resections for invasive adenocarcinoma. There was no fragmentation (0/9) noted on any of the locally excised specimens, while one patient (1/9) had a positive lateral margin. During the mean follow-up of 11.4 months, no recurrence was detected. Four patients underwent robotic-assisted transanal total mesorectal excision for curative intent resection of rectal cancer confined to the distal rectum. Mesorectal quality was graded as complete or near complete, and an R0 resection was performed in all four cases. Other transanal robotic procedures performed were the repair of rectourethral fistulae (n = 3) and anastomotic fistula (n = 1). This approach was met with limited success, and only half of the rectourethral fistulae were closed.CONCLUSIONS:Robotic transanal surgery for local excision, transanal total mesorectal excision, and repair of fistulae is feasible, although these new approaches represent a work-in-progress. Improvement in platform design will likely facilitate the ability to perform more complex procedures. Further research with robotic transanal approaches is necessary to determine whether or not this approach can provide patients with significant benefit.

The application of transanal minimally invasive surgery (TAMIS) for total mesorectal excision (TME) has undergone rapid adoption by expert colorectal surgeons worldwide [1]. It represents one of the most important new techniques for the management of distal rectal cancer [2]. However, the unique approach from below is unfamiliar to rectal cancer surgeons and mandates appropriate training and education. Even with adequate training, there is a risk of urethral injury with TAMIS-TME [3]. This video demonstrates how the male urethra can be injured during transanal TME and then describes a simple method for identifying the urethra. On a cadaveric model, a clear 24 Fr Foley catheter is introduced into the bladder. Through the Foley, a lighted ureteral stent is placed into the Foley and secured in place. Next, transanal TME trainees are instructed to attempt to injure the urethra with the aim of identifying the urethra prior to transection by identifying the lighted stent. Under normal laparoscopic light, the stent was not visible, but when the light source was toggled to OFF, the lighted stent (within the urethra) was clearly visible. In summary, this video demonstrates that the use of a lighted stent within a clear Foley catheter can help visualize the urethra and may prevent inadvertent injury during transanal TME.

This article documents the consensus of an expert group of surgeons from the Second International Trans-anal Total Mesorectal Excision (TaTME) Conference held in Paris in July 2014. It outlines three facets of the TaTME procedure: (i) the technique and its indications, (ii) training and adoption, and (iii) data collection and the TaTME registry.

Transanal endoscopic surgery (TES) enables the intra-luminal excision of rectal lesions with specialized equipment that maintains a stable pneumorectum and enables magnified visualization of target lesions along with the capacity for using precise instrumentation for tissue resection and re-apposition. The requirement for generalizable, cost-effective access modalities for the local excision of rectal lesions combined with the existing skill set applied to single-incision laparoscopic surgery led to transanal minimally invasive surgery (TAMIS). There currently exists global experience with 5 different TAMIS platforms. TAMIS has a short learning curve, reduced device set up time, flexibility in instrument use, and versatility in application. By comparison, however, its close relation TEM can access more proximal lesions, has specialized insufflators, which permits a more stable pneumorectum, and has a significantly greater duration of patient follow-up in the surgical literature. Overall, TAMIS has enabled the performance of high-quality local excision of rectal lesions by many colorectal surgeons. As TAMIS becomes more broadly utilized, the acquisition of appropriate training must be ensured, and the continued assessment and assurance of oncological outcome must be maintained.