Tamis 2019
Tamis 2019
Tamis 2019
Sam Atallah
Editor
123
Transanal Minimally Invasive Surgery
(TAMIS) and Transanal Total Mesorectal
Excision (taTME)
Sam Atallah
Editor
Transanal Minimally
Invasive Surgery (TAMIS)
and Transanal Total
Mesorectal Excision
(taTME)
Editor
Sam Atallah
AdventHealth Orlando
Oviedo Medical Center, and University
of Central Florida College of Medicine
Orlando, FL
USA
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
To all the minds filled with youthful curiosity for surgery and
the life sciences, who endeavor to learn and to achieve and
who have witnessed an entire body of knowledge materialize in
the span of a decade – this is for you. It is for those who believe
that the ingenuity of the human mind can capture imagination
itself. It is for those who believe that the future of surgery is
ours to shape.
It is now been over 5 years since Sam Atallah first published on the subject of
TAMIS TME surgery. I was invited to respond by the editor of Techniques in
Coloproctology and wrote at the time: “I believe that 2013 will be the year of
endoscopic transanal approaches to radical low rectal cancer dissection and
anastomosis.” I should have said 5 years, or perhaps 10! I had been following
the NOTES initiatives in Strasbourg by Jacques Marescaux, Joel Leroy, and
their colleagues and so was conscious of the unexploited potentials of the
fundamental orifice!
About the same time, I was invited by Antonio Lacy to share in his endeav-
ors to develop and spread the transanal TME operation in Europe. He used
the medium of a dedicated TV channel, perhaps more effectively than anyone
has done before – “Advances in Surgery” (AIS) – and thus reached surgeons
in far-off places who could never have afforded direct access to the pioneers
and teachers. Regular visits to South America and elsewhere have repeatedly
confirmed the impact of this channel on surgical practice worldwide.
All clinicians involved will find that the documentation and technical
detail in this book provide a valuable practical reference, volumes to digest
all that threatens to change our surgical lives as we work in the depths of the
pelvis.
Twenty years ago, the late Professor Takahashi and I co-convened the
“First International Conference on the Lateral Ligament of the Rectum” in
Tokyo. The very term “lateral ligament” summarizes the widespread igno-
rance of that time about the true anatomy of the lowest one third of the true
pelvis. The ignorance of that century persists as the key surgical challenge of
this one: how best to dissect the mesorectal envelope from the inferior hypo-
gastric plexus and the neurovascular bundles – from above or from below?
Add to that the challenge of the perineal body in abdominoperineal resection
and you have two of the battlegrounds that will decide the defining impor-
tance of TAMIS.
I have followed throughout the intervening years the details of the poste-
rior compartment of deep pelvic surgery both from above and from below:
open, laparoscopically, and with the robots. Starting with the simplest com-
parison between “from above” and “TAMIS” – the stapling is intrinsically
better with the latter – despite all improvements with angled instruments, etc.,
the placement of the transverse staplers from above by any form of minimally
invasive surgery is often less than optimal both in angle and placement and
sometimes removes more rectum than is necessary to clear the cancer.
vii
viii Foreword
Provided enough care is taken to avoid cell implantation, the actual anasto-
mosis can be more precisely placed to optimize the retained anorectal seg-
ment in a TAMIS operation. It is on this segment and its nerve supply, and
incidentally its freedom from radiation damage, that surgeons desperately
seek functional improvement for their patients. This is particularly true for
the lowest possible anastomoses where function may be threatened.
At the time of going to the press, it remains unproven as to which route
best facilitates access to the nerves and muscles of “pelvic happiness” and
how the oncological results from rectal cancer surgery can best be optimized.
The “happiness” aspect is perhaps at the top of the priority list at this time,
comorbidity and metastatic disease fast becoming the final frontiers. Having
performed and then watched many thousands of TME operations by various
approaches, I have become acutely conscious that each important step
requires just the right amount of traction and countertraction, the correct
wattage, and the gentlest of touches with the diathermy, what my friend
Amjad Parvaiz calls “painting.”
Above all, perfect vision from 4 K and more is the greatest single gift of
technology to surgery this century and a key component of the potential of
much in this book. But in order to exploit what she/he can now see, the sur-
geon must acquire a total understanding of the anatomy of the fascial layers
of the human pelvis and retroperitoneum.
When it comes to the visualization and preservation of the autonomic ner-
vous system within the pelvis, a skirmish continues between minimally inva-
sive abdominal surgery, particularly when performed robotically, and
TAMIS. The battle is not as fundamental as it might sound, since the great
majority on the TAMIS side favor laparoscopic support from above. It is
really an argument of whether the key dissection deep in the pelvis is best
done from above or from below, which operating team is dominant, and
whether or not it can all be done perfectly from above. Comparisons between
approaches need to analyze the angles that best facilitate the pursuit of the
correct planes.
Embryologically defined envelopes of tissue, with surgical and MRI defin-
able margins and recognizably shiny surfaces, present the careful surgeon
with particular opportunities for cure – reflecting the fundamental truth that
the primary spread of carcinoma is often contained within these envelopes.
These same margins provide the basis for modern image guidance from MRI
scanning, not only in planning for surgery but in modern radiotherapy (RT) as
well. Furthermore, respect for the surrounding layers and the understanding
of their anatomy, in both surgery and radiotherapy, have a major potential –
not only for more actual “cures” but also for the preservation of the important
autonomic functions of the surrounding nerve plexuses. The areas that
demand the greatest attention are those that we used, in our ignorance, to call
the “lateral ligament” and in the lowest anterior plane in the male.
The importance of understanding those crucial two extra layers between
the mesorectal and parietal fasciae – Denonvilliers’ and Waldeyer’s – is semi-
nal to pelvic anatomy. When the transanal route is chosen, the great dangers
of extending laterally outside Waldeyer’s fascia cannot be overemphasized
Foreword ix
and have indeed threatened the good name of the whole transanal enterprise.
All is revealed herein!
The talent and creative imagination in these pages gathers together the
experience and skill of most of those great pioneers who have established
what is essentially a major new subspecialty – transanal minimally invasive
surgery.
The Pelican Cancer Foundation has been administering and recording an
international database which is carefully monitoring progress. How much of
our work will in 10 years time be performed transanally? What follows will
help you make some current decisions for yourselves. It is certain, however,
that technology, instrumentation, and surgical virtuosity will continue to be
as fascinating in the coming years as this book is right now.
Bill Heald
Pelican Centre, Basingstoke Hospital, UK
Preface
A decade of new knowledge has been neatly compressed into this first of its
kind surgical textbook. Although a decade has eclipsed us seemingly with the
blink of an eye, it is hard to recall a time before TAMIS and before
taTME. Neither of these acronyms, which are this book’s rubric, were spoken
prior to 2009 – and yet today, they are household names to anyone in the field.
It was exactly 2 years to the day, after completing my colorectal fellowship in
Houston, that on June 30, 2009, I performed the first TAMIS in OR Rm. #2 at
a small, unassuming community hospital. As a young impressionable sur-
geon fresh out of training, it left me totally entranced, and I realized at that
very moment that life had been given to an altogether new kind of
operation.
Of course, at that time, the operation lacked a name. I can still recall the
afternoon that Sergio, Matt, and I sat down for Turkish cuisine in Winter Park,
Florida, to establish one. In hand were a few sheets of blank paper and a pen
as we brainstormed what to call this “thing” we had just invented. After
scratching out what seemed like 100 potential names, we rationalized that, at
its core, it was a minimally invasive surgical (MIS) technique, and this had to
be its key identifier. We narrowed our selection down to “minimally invasive
transanal surgery” (MITA) and “transanal minimally invasive surgery”
(TA-MIS). Eventually, we decided on the latter, the hyphen was dropped, and
the term TAMIS was officially coined.
Innovation is often a function of circumstance. The impetus for TAMIS
was borne out of necessity. You see, my local hospital system could not afford
the upfront capital requirement of a TEM platform. This forced consideration
for alternative options and, with a little ingenuity, paved the way for the quite
serendipitous creation of TAMIS. In this context, many commonly referred to
TAMIS as a “poor man’s TEM” during the early days after inception. For the
first time, it allowed advanced transanal surgery to be performed by ordinary
colorectal surgeons like myself, whose only prerequisite was an MIS skillset
and access to an operating theater. With just six TAMIS cases under our belts,
we were certain this was going to be the next big thing.
Sure, there was instant value in the technique for high-quality local exci-
sion of rectal neoplasia. But one could begin to envision TAMIS as a tech-
nique that could be applied more broadly – only to be honest, at the time, I
really didn’t have any clue how. It was not long afterward that the puzzle
pieces would find their fit the day taTME materialized, and these two separate
techniques would soon be melded into a singular one. As though on a
xi
xii Preface
p reordained collision course, the original article describing TAMIS was pub-
lished in the same scientific journal and on the same week as the first human
case of, what would later be termed, taTME – originally performed by Sylla,
Lacy, and colleagues in Barcelona (both articles published online in Surgical
Endoscopy, February, 2010). This would bring together not only two tech-
niques but, far more importantly, a group of pioneers and innovators (the vast
majority of which are authors herein) who would collectively shape TAMIS
and taTME into what they are today. Indeed, the union of TAMIS and taTME
marked the dawn of a new era in advanced transanal surgery and a quantum
leap forward for our field.
The modern taTME is a harmonious amalgam of the most important
developments in rectal cancer surgery to transpire over the past 40 years.
Specifically, taTME is a unification of Heald’s TME, Marks’ TATA, Buess’
1984 TEM invention, and the concept of natural orifice specimen extraction
(NOSE) as developed by Franklin. In addition, it built upon the evolution of
natural orifice transluminal endoscopic surgery (NOTES) to include the cre-
ation of the single-port access channel, keyhole surgery, and, finally, the
advent of TAMIS. As these techniques merged into one, we began to under-
stand the newfound value of the taTME approach. Routed in methods for
improved access to the most difficult portion of the rectum and deep pelvis,
better-quality surgery was possible, not only for invasive rectal neoplasia but
also for benign and premalignant disease spectra.
But, there was something intangible about TAMIS and taTME that
extended beyond technical sophistication. The two approaches, in fact, had
sparked our imagination and interest in exploring what could be accom-
plished through innovation. Rather than merely thinking outside of the box,
we were, instead, kicking the box to the curb, thereby bringing a renaissance
of new ideas and unorthodox surgical strategies for consideration. Hence,
TAMIS and taTME had a truly transforming effect, and these approaches suc-
cessfully granted mainstream appeal to advanced transanal surgery – which
once had been an obscure niche mastered by only a relative handful.
It was this zest for exploring new pathways that had placed these tech-
niques at center stage and had led to adjunctive advancements in rectal cancer
surgery, including robotics for taTME, of which a multitude of next-generation
platforms are actively being tooled for transanal applications. We have also
witnessed the utility of biofluorescence for perfusion analysis and structure
localization, as well as image-guided navigation for taTME, which collec-
tively represents key steps toward the digitization of complex pelvic surgery
and the integration of artificial intelligence into operative algorithms. Indeed,
we now stand on the precipice of exponential growth in technology that will
lead us to realize possibilities never before imagined.
The uptake of TAMIS and taTME has been so rapid that unique academic
models had to be developed to meet the educational demand. It inspired the
development of resource apps, modules, and synchronized deferred live sur-
gery – all recently introduced to aid with the educational process for delegate
trainees. These have been painstakingly designed as adjuncts to de novo
training pedagogies and mentorship programs for taTME worldwide.
Preface xiii
xv
xvi Contents
Index���������������������������������������������������������������������������������������������������������� 509
Contributors
xix
xx Contributors
Transanal Endoscopic
Microsurgery (TEM)
It is often said that necessity is the mother of remains the one most widely used today: Namely,
invention. TAMIS represented an alternate option the GelPOINT path transanal access platform
for advanced transanal access for surgeons and (Applied Medical, Inc., Rancho Santa Margarita,
hospital systems that did not have the highly spe- CA) (Fig. 1.5). The GelPOINT Path, often simply
cialized and costly TEM system. After all, TAMIS referred to as the “TAMIS Port”, is constructed
was simple to set up, relied on conventional lapa- from single-use flexible material composed of
roscopic equipment, and was predicated on lapa- two main parts, an access channel and a remov-
roscopic skills and familiar techniques. able lid. Three 10 mm cannulas are usually used,
Additionally, TAMIS did not appear to have a one for the camera lens and two working ports,
long learning curve and did not require special- through which standard laparoscopic instruments
ized training (as is the case with TEM) [41]. can be introduced. The TAMIS platform is quite
TAMIS provided the surgeon with improved visu- versatile and even allows for robotic access – a
alization and reach. In short, it allowed colorectal technique termed robotic TAMIS or robotic trans-
surgeons to translate their familiar laparoscopic anal surgery (RTS) [43–45].
skill set to transanal surgery, which resulted in TAMIS utilization has rapidly spread world-
rapid dissemination of the TAMIS technique [42]. wide because of its accessibility and the increas-
The first platform placed transanally and the ing number of training courses available for
first series reported on TAMIS utilized the SILS surgeons. Its global adoption has been reflected
Port (Covidien, Mansfield, MA) (Fig. 1.4). While by the increasing number of publications and
suitable for access, this and other single ports citations since 2009 [36, 42, 46–60].
were not designed for transanal access and
required modification. An important limit of the
SILS port was that it did not allow for access into Future of TAMIS
the lumen, without completely removing the
port; there were other limitations as well, includ- TAMIS was created to evolve, and not remain
ing cannula diameter which was restricted to static. The future will likely represent new ave-
5 mm at the time. nues for TAMIS as surgeons explore new applica-
With input from the surgeons who developed tions. To date, many applications beyond local
TAMIS, dedicated platforms were designed spe- excision have been realized. Most notably, TAMIS
cifically for transanal access – the first of which became the standard route of access for the
’s
10
50
83
20
19
19
’s
’s
’s
09
’s
08
15
20
00
80
90
20
19
20
Exenteration
18
20
19
19
Radical Excision
TaTME
Dr. Uematsu
Perineal Abdominoperineal Total Mesorectal Laparoscopic Single Port Surgery RoboticTME Transanal Image guided
colostomy resection Excision(TME) Colorectal surgery Dr. Pelosi, Dr. Pigazzi (53) TME (TaTME) Surgery for
Dr. Lisfranc (1) Dr. Miles (3) Dr. Heald (16) Dr. Jacobs, Dr. Esposito & Dr. Lacy, Dr. Sylla, taTME
Dr. Larach, Dr. Remzi (45–47) Dr. Whiteford Dr. Atallah
Posterior access Dr. Wexner, TAMIS-TME (102)
Dr. Verneuil Dr. Franklin & Dr. Atallah
Dr. Kraske (2) Dr. Nelson (40–44) NOTES (51, 96–98)
Dr. Rattner, Robotic
Dr. Lacy & TaTME
Dr. Zorron Dr. Atallah
(50–52) (103)
transanal excision of T1 rectal cancer: should we be 28. Clancy C, Burke JP, Albert MR, O’Connell PR,
concerned? Dis Colon Rectum. 2005;48(4):711–9. Winter DC. Transanal endoscopic microsurgery ver-
discussion 9-21. sus standard transanal excision for the removal of rec-
13. Garcia-Aguilar J, Mellgren A, Sirivongs P, Buie D, tal neoplasms: a systematic review and meta-analysis.
Madoff RD, Rothenberger DA. Local excision of rec- Dis Colon Rectum. 2015;58(2):254–61.
tal cancer without adjuvant therapy: a word of cau- 29. Suppiah A, Maslekar S, Alabi A, Hartley JE, Monson
tion. Ann Surg. 2000;231(3):345–51. JR. Transanal endoscopic microsurgery in early rectal
14. Greenberg JA, Shibata D, Herndon JE 2nd, Steele GD cancer: time for a trial? Color Dis. 2008;10(4):314–
Jr, Mayer R, Bleday R. Local excision of distal rec- 27. discussion 27-9.
tal cancer: an update of cancer and leukemia group B 30. Jones HJS, Hompes R, Mortensen N, Cunningham
8984. Dis Colon Rectum. 2008;51(8):1185–91. dis- C. Modern management of T1 rectal cancer by
cussion 91-4. TEM:a ten-year single-centre experience. Color Dis.
15. McCall JL, Cox MR, Wattchow DA. Analysis of local 2018;20:586.
recurrence rates after surgery alone for rectal cancer. 31. Heintz A, Morschel M, Junginger T. Comparison of
Int J Color Dis. 1995;10(3):126–32. results after transanal endoscopic microsurgery and
16. Mellgren A, Sirivongs P, Rothenberger DA, Madoff radical resection for T1 carcinoma of the rectum. Surg
RD, Garcia-Aguilar J. Is local excision adequate Endosc. 1998;12(9):1145–8.
therapy for early rectal cancer? Dis Colon Rectum. 32. Kidane B, Chadi SA, Kanters S, Colquhoun PH, Ott
2000;43(8):1064–71. discussion 71-4. MC. Local resection compared with radical resection
17. Gillern SM, Mahmoud NN, Paulson EC. Local
in the treatment of T1N0M0 rectal adenocarcinoma:
excision for early stage rectal cancer in patients a systematic review and meta-analysis. Dis Colon
over age 65 years: 2000-2009. Dis Colon Rectum. Rectum. 2015;58(1):122–40.
2015;58(2):172–8. 33. Maya A, Vorenberg A, Oviedo M, da Silva G, Wexner
18. Lau WY, Leow CK, Li AK. History of endo-
SD, Sands D. Learning curve for transanal endo-
scopic and laparoscopic surgery. World J Surg. scopic microsurgery: a single-center experience. Surg
1997;21(4):444–53. Endosc. 2014;28(5):1407–12.
19. Hatzinger M, Fesenko A, Sohn M. The first human lap- 34. Koebrugge B, Bosscha K, Ernst MF. Transanal
aroscopy and NOTES operation: Dimitrij Oscarovic endoscopic microsurgery for local excision of rec-
Ott (1855-1929). Urol Int. 2014;92(4):387–91. tal lesions: is there a learning curve? Dig Surg.
20. Rock JA, Warshaw JR. The history and future of oper- 2009;26(5):372–7.
ative laparoscopy. Am J Obstet Gynecol. 1994;170(1 35. Atallah S, Keller D. Why the conventional parks trans-
Pt 1):7–11. anal excision for early stage rectal cancer should be
21. Buess G, Theiss R, Gunther M, Hutterer F, Pichlmaier abandoned. Dis Colon Rectum. 2015;58(12):1211–4.
H. Transanal endoscopic microsurgery. Leber Magen 36. Martin-Perez B, Andrade-Ribeiro GD, Hunter L,
Darm. 1985;15(6):271–9. Atallah S. A systematic review of transanal minimally
22. Winde G, Nottberg H, Keller R, Schmid KW, Bunte invasive surgery (TAMIS) from 2010 to 2013. Tech
H. Surgical cure for early rectal carcinomas (T1). Coloproctol. 2014;18(9):775–88.
Transanal endoscopic microsurgery vs. anterior resec- 37. Nieuwenhuis DH, Draaisma WA, Verberne GH, van
tion. Dis Colon Rectum. 1996;39(9):969–76. Overbeeke AJ, Consten EC. Transanal endoscopic
23. de Graaf EJ, Burger JW, van Ijsseldijk AL, Tetteroo operation for rectal lesions using two-dimensional
GW, Dawson I, Hop WC. Transanal endoscopic visualization and standard endoscopic instruments:
microsurgery is superior to transanal excision of rec- a prospective cohort study and comparison with the
tal adenomas. Color Dis. 2011;13(7):762–7. literature. Surg Endosc. 2009;23(1):80–6.
24. Middleton PF, Sutherland LM, Maddern GJ. Transanal 38. Pelosi MA, Pelosi MA 3rd. Laparoscopic appendec-
endoscopic microsurgery: a systematic review. Dis tomy using a single umbilical puncture (minilaparos-
Colon Rectum. 2005;48(2):270–84. copy). J Reprod Med. 1992;37(7):588–94.
25. Buess GF, Misra MC, Bhattacharjee HK, Becerra
39. Patel CB, Ramos-Valadez DI, Ragupathi M, Haas
Garcia FC, Bansal VK, Bermudez JR. Single-port EM. Single incision laparoscopic-assisted right
surgery and NOTES: from transanal endoscopic hemicolectomy: technique and application (with
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cystectomy to transanal rectosigmoid resection. Surg 2010;20(5):e146–9.
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10 S. W. Larach and B. Martín-Pérez
removal of benign, mobile lesions of the rectum ative margin, classically defined as 1 cm, should
that cannot be removed endoscopically and espe- be the objective of local excision of invasive neo-
cially for those lesions that are too proximal to be plasia, and a negative deep margin is mandatory.
approached via Parks transanal excision. Preoperative staging with rectal protocol 3-Tesla-
Traditionally, target lesions for local excision weighted magnetic resonance imaging (3 T MRI)
with TAMIS are relatively small in diameter and or endorectal ultrasound (ERUS) is important to
do not occupy more than 40% of the circumfer- assess depth of invasion and, as best as possible,
ence of the rectal lumen. However, in experi- the presence or absence of lymph node metastases.
enced hands, excision of circumferential lesions The ideal candidate for local excision of rectal
has been reported [7]. Rarely does abdominal cancer has cT1 N0 disease, without high-risk his-
entry necessitate an conversion to a transabdomi- tologic features. Although imaging with ERUS or
nal approach to adequately close the defect and to rectal protocol 3 T MRI may not reveal gross
rule out injury to other viscera. Alternatively, lymphadenopathy, depth of invasion has been
benign polyps of the proximal rectum that do not shown to be a surrogate for predicting the presence
require full-thickness excisions may be of lymph node metastases – one of the most impor-
approached using TAMIS via a submucosal dis- tant reasons that curative intent local excision with
section plane – a quite prudent approach to (espe- TAMIS (or TEM) has never been recommend for
cially anterior) benign neoplasia ≥10 cm from tumors that violate the rectal wall (i.e., cT3, T4
the anal verge. lesions). Tumors with the least likelihoods for
Other tumors of the rectum such as neuroen- lymph node metastases and local recurrence are
docrine and gastrointestinal stromal tumor may T1 cancers. These are further stratified using the
also be excised using TAMIS. Local excision is Kikuchi classification system [10]. This subdi-
especially suited for these tumor types as they do vides T1 tumors into three categories: slight sub-
not spread via lymphatic channels. Thus, the con- mucosal invasion from the muscularis mucosa to
cern about leaving behind disease in lymph the depth of 200–300 μm (sm1), intermediate sub-
nodes is irrelevant. The traditional parameters mucosal invasion (sm2), and submucosal adeno-
for excision of such pathology include mobile carcinoma invading near the inner border of the
tumors that are <2 cm in diameter and that do muscularis propria (sm3). Tumors that are T1 sm3
not demonstrate evidence of distal disease. With have been shown to behave more like T2 tumors in
greater experience and expertise, larger lesions that they have similar risk of lymph node metasta-
can be approached via TAMIS approach; how- ses – 12% to 25% vs 23.1%, respectively [11, 12].
ever, for neuroendocrine lesions that measure For this reason, both T2 cancers and those which
>2 cm in diameter, a radical resection is recom- are histologically staged pT1sm3 are not consid-
mended [4, 8, 9]. ered to be adequately treated by local excision
While TAMIS is well suited for local excision alone. Another predictor of lymph node metasta-
(full or partial thickness) of benign neoplasia ses is tumor histology. Tumors that are well dif-
throughout all three segments of the rectum, it can ferentiated without lymphovascular invasion,
be very carefully applied as a method of local exci- mucinous features, tumor budding, or perineural
sion for select, early-stage rectal cancer, in the invasion are less likely to have tumor deposits in
proper setting, with curative intent. Deciding lymph nodes and are more suitable candidates for
which patients with rectal cancer are good candi- local excision [11, 13, 14].
dates for local excision is multifactorial and should Perhaps one of the most important factors in
require a thorough workup and multispecialty determining a patient’s candidacy for local exci-
tumor board evaluation. Central to the discussion sion is deciding the probability and risk of local
is assessing the risk of nodal disease. Focusing on recurrence. In addition to depth of invasion, lym-
the technical ability of the TAMIS approach, one phovascular invasion, and poor differentiation,
of the key factors to consider is the ability to another predictor of local recurrence is tumor
achieve negative margins. For rectal cancer, a neg- size. Tumors less than 3 cm in maximum d iameter
2 TAMIS: Indications and Contraindications 13
without lymphovascular invasion are associated except in rare cases, for palliation. Patients with
with <5% risk of local recurrence at 3 years [14]. any node-positive cancers should not undergo
Another surrogate for potential lymph node transanal excision as this will rarely provide
tumor deposits is anatomic location of the tumor definitive therapy. The inability to define and
within the rectum. Of tumors that are located in obtain a clear margin would risk leaving behind
the distal third of the rectum, 34% have lymph diseased tissue and would be considered futile,
node metastases compared to 8% found in the although salvage re-excision after positive mar-
upper rectum [15]. gin resection has been described. As referenced
Certain patients may choose transanal exci- above, T1 tumors with a depth of invasion of sm3
sion as a strategy to avoid a permanent stoma and should be treated like T2 tumors, and transanal
also to avoid the morbidity associated with pelvic excision alone as definitive treatment should
surgery when reconstruction is possible. In this not be offered. Instead, salvage radical resec-
setting, patients with histologically unfavorable tion is recommended for good-risk operative
cT1 cancers or T2 lesions may undergo local candidates.
excision against the preferred recommendation Technical aspects of the procedure relate to
of radical surgery and en bloc resection. On pro- the available access platforms and procedure
tocol, this may be an option for local excision in conduct. Lesions that are low in the rectum or
combination with external beam radiotherapy. border the anal canal can be obscured by the cur-
Additionally, more advanced malignant lesions rently available disposable TAMIS access plat-
can be excised via the TAMIS approach when form; although there are techniques available
patients are not considered fit for a major surgery which allow for access to the distal most one-
or for palliation of symptoms such as bleeding. third of the rectum. One such technique is to sus-
This may be performed in conjunction with che- pend the access channel to a LoneStar retractor
motherapy and radiation as well. so that only part of the channel is introduced into
Beyond the excision of rectal neoplasia, the the anal canal. Alternatively, the distal most dis-
TAMIS technique can be used to treat and surgi- section (inferior to the lesion’s caudal extent) can
cally manage other conditions affecting the rec- be addressed by direct visualization. Once this is
tum. There are case reports of the TAMIS completed, conversion to a TAMIS approach can
platform being used to repair rectourethral fistula be performed to achieve more precise visualiza-
after cryoablative treatment of prostate cancer, tion and dissection of the proximal aspect of the
ligation of a rectal Dieulafoy’s lesion, extraction lesion.
of a sigmoid foreign body [16], and repair of a Inability to adequately insufflate the rectal
vesicorectal fistula after prostatectomy [17]. lumen in patients with massive obesity or non-
TAMIS has also been described for the treatment compliant tissues may prevent adequate visual-
of rectovaginal fistula, repair of anastomotic leak, ization of the lesion and maintenance of exposure.
and control of rectal bleeding and to address Finally, transanal access and placement of the
benign stenosis [18, 19]. Complex fistulae platform, both flexible and rigid, may be impos-
(fistula-in-ano, rectovaginal, rectourethral) are sible due to the presence of an anorectal stricture
approached via this innovative technique as a tool or loss of rectal compliance.
to create a rectal advancement flap with or with-
out biologic or native tissue interposition.
Controversial Areas
excision of proximal T1 N0 rectal adenocarcino- ypT1, and ypT2 diseases were 0%, 0%, and 8%,
mas risks violation of the peritoneum and entry respectively. The ACOSOG Z6041 non-
into the abdomen. However, there are multiple randomized trial included patients with cT2 N0
case series that document safe transanal excision rectal cancer less than 40% of the bowel wall cir-
of tumors greater than 8 cm from the anal verge cumference and less than 4 cm in greatest dimen-
[7, 20]. Thus, proximal rectal tumors may be con- sion. Patients were assigned to receive
sidered a relative contraindication to local exci- preoperative chemoradiation followed by local
sion depending upon surgeon experience and excision. After a median follow-up of 56 months
ability to securely close the rectal wall following (IQR 46–63), using intention to treat analysis, the
resection. 3-year disease-free survival was 88.2% (95% CI
Another area under investigation is local exci- 81.3–95.8). By the end of the follow-up period,
sion after chemoradiation for T1 N0 rectal can- 10% developed recurrences (all received local
cers with adverse features and T2 N0 rectal excision as their initial treatment) – 6% distant
cancers. A retrospective study from Japan evalu- and 4% local – and 91% of the cohort had rectal
ated 53 patients with T1 N0 lesions with adverse organ preservation. This study revealed that neo-
features and 4 patients with T2 N0 lesions [21]. adjuvant chemoradiation followed by local exci-
For those with T1 N0 disease, the 5-year disease- sion may be an organ-preserving option for those
free survival rate was 94%, and the overall sur- with cT2 N0 rectal cancer who cannot or will not
vival rate was 98%. There was one patient who undergo transabdominal resection [25].
developed local recurrence in the T1 group and Aside from disease characteristics, patient
one in the T2 group. This disease-free survival characteristics also play a large role in determin-
rate compares to the rate for patients with T1 N0 ing suitability for local excision. The patient’s
disease with adverse features who underwent ability to tolerate an abdominal operation or to
total mesorectal excision (TME) [22]. However, live with a permanent stoma is considered. Local
the local recurrence rate is higher in the local excision is associated with lower perioperative
excision group. A study of the National Cancer mortality (RR 0.31, 95% CI 0.14–0.71), lower
Database evaluated outcomes in patients with post-op complications (RR 0.16, 95% CI 0.08–
T2 N0 who underwent transabdominal resection, 0.30), and decreased need for permanent ostomy
chemoradiation followed by local excision, and (RR 0.17, 95% CI 0.09–0.30) [26]. Thus, for
local excision followed by chemoradiation [23]. patients with more advanced stage rectal cancer
The results of the study suggest that the differ- who are poor operative candidates for LAR or
ences in 5-year overall survival rates are not sta- APR, local excision may be discussed in spite of
tistically significant. The GRECCAR 2 trial increased risk of local and distant failure. For
evaluated outcomes in patients with T2 or T3 rec- good operative candidates, patients should be
tal cancer ≤8 cm from the anal verge and tumors counseled that subsequent radical resection may
<4 cm who underwent preoperative chemoradia- be necessary depending upon final pathology and
tion followed by either local excision or TME that the TAMIS procedure for local excision ulti-
[24]. Patients were only randomized if they had mately should be considered an “excisional
good response to therapy defined as residual biopsy” in this instance.
lesion/scar less than or equal to 2 cm. After local Another subset of patients who may be con-
excision, patients with ypT2 or ypT3 disease or sidered for local resection are those with good
those who have a margin-positive excision under- response to preoperative chemoradiation. The
went salvage radical surgery. Results showed that rate of lymph node metastasis in those found to
3-year local and distant recurrence rates were not have ypT0–1 rectal cancer after transabdominal
statistically different. resection was 3–8% [27–30]. Thus a good
Disease-free survival and overall survival response to preoperative therapy may be used as
were also not statistically different. In the TME an indicator of low risk of spread to lymph nodes.
group the rates of node-positive disease for ypT0, Though the risk of nodal metastases is low, it is
2 TAMIS: Indications and Contraindications 15
not zero, so a thorough discussion with the patient surgery (TAMIS) approach for large juxta-anal gas-
trointestinal stromal tumour. J Minimal Access Surg.
is warranted. Caution should be noted as wound 2016;12:289–91.
dehiscence, and delayed excision site healing can 9. Hussein Q, Artinyan A. Pushing the limits of local
have a major impact on postoperative rectal pain, excision for rectal cancer: transanal minimally inva-
hospital readmission, and quality of life [31]. sive surgery for an upper rectal/rectosigmoid lesion.
Ann Surg Oncol. 2014;21:1631.
10. Kikuchi R, Takano M, Takagi K, Fujimoto N, Nozaki
R, Fujiyoshi T, Uchida Y. Management of early inva-
Conclusion sive colorectal cancer. Risk of recurrence and clinical
guidelines. Dis Colon Rectum. 1995;38:1286–95.
11. Chang H-C, Huang S-C, Chen J-S, et al. Risk factors
In conclusion, TAMIS is ideal for benign lesions of for lymph node metastasis in pT1 and pT2 rectal can-
the rectum, small carcinoid, and GIST tumors and cer: a single-institute experience in 943 patients and
is also an option for select, early-stage rectal ade- literature review. Ann Surg Oncol. 2012;19:2477–84.
nocarcinomas. Compared to traditional transanal 12. Maeda K, Koide Y, Katsuno H. When is local excision
appropriate for “early” rectal cancer? Surg Today.
excision, TAMIS provides better exposure and 2014;44:2000–14.
results in more complete excision of the specimen. 13. Kobayashi H, Mochizuki H, Kato T, et al. Is total
Compared to TEM, TAMIS is less costly, more mesorectal excision always necessary for T1–T2 lower
widely available, and accordingly has led to broader rectal cancer? Ann Surg Oncol. 2010;17:973–80.
14. Bach SP, Hill J, Monson JRT, Simson JNL, Lane L,
access and surgeon adoption. Proper patient selec- Merrie A, Warren B, Mortensen NJM, Association of
tion remains paramount. In addition, TAMIS can Coloproctology of Great Britain and Ireland Transanal
be used as a palliative option for patients whose Endoscopic Microsurgery (TEM) Collaboration. A
comorbidities prohibit transabdominal resection. predictive model for local recurrence after transanal
endoscopic microsurgery for rectal cancer. Br J Surg.
2009;96:280–90.
15. Nascimbeni R, Burgart LJ, Nivatvongs S, Larson
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8. Wachter N, Wörns M-A, Dos Santos DP, Lang H, chemoradiotherapy after local resection for high-risk
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An Algorithm for Local Excision
for Early-Stage Rectal Cancer 3
George J. Chang and T. Paul Nickerson
improved quality of life. To overcome these chal- nary results demonstrating feasibility [18].
lenges of TAE, in the early 1980s, Gerald Buess Recently, Lee et al. published their 3-year follow-
developed transanal endoscopic microsurgery up results of 200 consecutive TAMIS operations,
(TEM), the first of a series of platforms to accom- with 11% rate of postoperative complications,
plish transanal endoscopic surgery (TES). The 93% of specimens with negative margins, and
TEM system consists of a rigid proctoscope 95% of specimens submitted without fragmenta-
anchored to the operating room table to provide a tion. Fifteen of these procedures were performed
stable platform to accommodate pneumorectum, with the da Vinci robotic platform [19]. These
specialized dissecting instruments, and a magni- results compare favorably to the results of a
fying stereoscope (Richard Wolf Company, recent meta-analysis of over 1400 TEM proce-
Tubingen, Germany). In a recent meta-analysis dures, reporting 82% of specimens with negative
by Clancy et al. comparing outcomes from TAE margins and 95% submitted without fragmenta-
and TEM, there were no differences in complica- tion [20]. Although no long-term oncologic
tion rates between approaches (OR, 1.018; 95% results of TAMIS procedures have been described,
CI, 0.658–1.575; p = 0.937). There was a signifi- it is the authors’ opinion that the TEM data can
cantly higher rate of negative resection margins be safely extrapolated to all TES procedures,
(OR, 5.281; 95% CI, 3.201–8.712; p < 0.001), including laparoscopic and robotic TAMIS, as
decreased specimen fragmentation (OR, 0.096; long as the operating surgeon has sufficient profi-
95% CI, 0.044–0.209; p < 0.001), and reduced ciency in the platform of choice and quality
incidence of lesion recurrence (OR, 0.248; 95% improvement measures are in place to continu-
CI, 0.154–0.401; p < 0.001) with TEM in com- ously evaluate surgical outcomes.
parison to standard TAE [12]. Despite the
improvement in exposure of mid- to proximal
rectal lesions, wider adoption of TEM has been Traditional Indications
limited to select high-volume centers due to the for Local Excision
expense of the system, prolonged learning curve,
and relative scarcity of training programs. Traditional indications for the local excision of
Transanal minimally invasive surgery rectal tumors include excision of benign rectal
(TAMIS) has improved the popularity of TES by pathologies and early-stage neoplasia, such as
providing a more affordable and accessible large rectal adenomas, incompletely excised rec-
option. Atallah first described the transanal place- tal adenomas, adenomas with dysplasia, and
ment of a commercially available single port intramucosal adenocarcinoma with or without
platform to perform transanal surgery with stan- foci of submucosal invasion [21]. The strategy of
dard laparoscopic instruments and insufflators in local excision of these pathologies has demon-
2010 [13]. The TAMIS platform is disposable, strated safety, efficacy, and local recurrence rates
more readily available, and compatible with of less than 10%, and progression to malignancy
existing laparoscopic equipment (SILS Port, is rare [22]. Often a rectal polyp is biopsied or
Covidien, Mansfield, MA; GelPOINT Path, resected in a piecemeal fashion during colonos-
Applied Medical, Rancho Santa Margarita, CA). copy, and additional en bloc tissue is necessary to
The familiar instruments and lack of a rigid proc- ensure complete resection or assess depth of
toscope appear to translate into a shorter learning invasion. In such cases, full-thickness resection
curve for TAMIS procedures [14–16]. In 2010, of the polypectomy scar can be both diagnostic
the da Vinci Robotic Surgical System (Intuitive and therapeutic. This approach should be used
Surgical, Inc., Sunnyvale, CA) was used to per- with caution in cases where more advanced neo-
form TAMIS surgery in cadavers [17]. This off- plasia or invasion is suspected. Especially in low-
label use of the robotic system, in combination lying rectal lesions where the perirectal fat is
with the FDA-approved GelPOINT Path TAMIS thinnest, full-thickness excisions can result in
port, has subsequently expanded with prelimi- violation of the mesorectal fascial plane impairing
3 An Algorithm for Local Excision for Early-Stage Rectal Cancer 19
subsequent radical resection or even sphincter rectal cancers treated with neoadjuvant multi-
preservation if deemed necessary based on patho- modal therapy. Of these tumors, only two speci-
logical review of the surgical specimen. mens demonstrated intramural extension beyond
Furthermore, it is important to note that if local the mucosal edge of the tumor, and both were
excision is possible, then radical resection with less than 0.95 cm [25]. Shimada et al. retrospec-
anastomosis, including intersphincteric resection tively reviewed 381 consecutive rectal cancer
and coloanal anastomosis, will also be possible specimens to evaluate distal spread, both intra-
but will be associated with a much greater impact mural and mesorectal, in patients without neoad-
on bowel function. In cases where malignancy is juvant therapy. They found intramural spread was
not suspected, often submucosal excision alone is rare in early-stage rectal cancers (T1 = 3%) and
sufficient and avoids full-thickness rectal defects. did not exceed 4 mm. By comparison, T2 tumors
demonstrated intramural spread up to 19 mm,
beyond the standard accepted margin for trans-
isk Factors for Failure of Local
R anal excision [26]. Thus, it would appear that a
Excision of Early Rectal Cancer 1 cm resection margin in T1 tumors should be
sufficient, even in the absence of neoadjuvant
Complete surgical management of rectal cancer therapy, and a more generous margin should be
consists of obtaining tumor-free margins of the considered in more advanced tumors.
resected specimen and treating the lymph node Besides tumor size, depth of invasion, positive
basin that drains the tumor site. Local excision resection margins (R1 resection), and degree of
techniques, by necessity, are only able to accom- differentiation, additional risk factors for local
plish the first goal [23]. Local excision of inva- recurrence and distant metastases that have been
sive rectal cancer has largely been reserved for born out in the literature include lymphovascular
patients with severe comorbidities such that radi- invasion and tumor budding.
cal resection poses undue risk, or for patients In a retrospective study of 125 patients who
refusing radical surgery due to concerns for underwent either local excision (n = 56) or radi-
potential complications, side effects, and stoma cal resection (APR, n = 69) of T1–T2 rectal ade-
formation. Performing local excision as a cura- nocarcinomas, the authors found that for tumors
tive procedure for early-stage rectal cancer has removed via local excision with favorable histo-
long been a controversial topic due to early pathology (G1, G2, and no lymphovascular inva-
reports of unacceptably high rates of local recur- sion), the 5-year local recurrence rate was 4%.
rence. In 1992, Nivatvongs and Wolff outlined Conversely, when the histopathology was unfa-
acceptable indications for local excision of rectal vorable (poorly differentiated or with lympho-
cancer via the transanal approach. The authors vascular invasion), the 5-year local recurrence
reported that tumors located within 7 cm of the rate was 32%. Similarly, in the favorable pathol-
anal verge, less than 3 cm in diameter, confined to ogy cohort, the disease-free survival (DFS) was
the submucosa or superficial muscularis and with 87% compared to 57% in those tumors with unfa-
a favorable pathologic grade, either well differen- vorable pathology [27]. This difference in DFS
tiated (G1) or moderately differentiated (G2), could likely be attributed to inadequately treated
were acceptable candidates for local excision – lymphatic metastases.
provided adequate resection margins of at least Depth of invasion appears to be a primary risk
15 mm could be obtained [24]. The authors also factor for lymph node metastasis and subsequent
note that less than 5% of patients presenting with failure of local excisional techniques. The gen-
rectal cancer would meet these criteria. Indeed, eral incidence of nodal metastases in T1 tumors
many studies have evaluated the intramural is about 10%, whereas nodal metastases can be
spread of rectal cancer. In 2007, Guillem et al. present in as many as 22% of T2 tumors. Work by
published their comprehensive whole mount Kikuchi et al. has further subdivided T1 tumors
pathological analysis of 109 locally advanced arising in the setting of adenomatous polyps
20 G. J. Chang and T. P. Nickerson
based on the depth of submucosal invasion into overall rate of local recurrence of 31%. When the
sm1, those that invade only the upper third of the extent of submucosal spread was confined to the
submucosa; sm2, those that invade the middle superficial 2/3 (Sm1/Sm2) in tumors smaller than
third; and sm3, those that invade the deepest third 3 cm, the local failure rate was 7% at 3 years
of the submucosa [28]. T1 tumors confined to the [34]. Based on the available literature, it seems
most superficial third of the submucosa (sm1) that tumor size larger than 3 cm, depth of inva-
have been associated with as low as 6% rates of sion beyond the superficial submucosa, poorly
lymph node positivity, whereas T1 tumors invad- differentiated histopathology, lymphovascular
ing into the deepest third of the submucosa (sm3) invasion, and tumor budding are all primary
have approached the same rates of occult lymph tumor features associated with high rates of
node metastases as T2 tumors (23%) [29]. As occult lymph node metastases. As local excision
local excision techniques cannot address the is unable to manage these lymph node basins,
draining lymph node basin, the long-term onco- only tumors without these factors should be con-
logic success of local excision is closely tied to sidered for local excision, provided complete R0
the risk of occult lymph node metastases. resection can be achieved.
Tumor budding is defined as small (less than
five cells) clusters of tumor cells at the invasive
edge of the tumor [30]. In a case-control study esults of Local Excision of T1
R
comparing 48 rectal cancer patients with local Rectal Cancer
recurrence to 82 rectal cancer patients without
local recurrence, tumor budding was an indepen- The earliest reports of long-term follow-up in the
dent prognostic factor for local recurrence, irre- local excision of rectal cancer were published in
spective of TNM staging [31]. A 2013 the 1980s and 1990s. In 1990, a review of 16
meta-analysis by Beaton et al. reviewed 23 cohort series (n = 404) with mid- to long-term follow-up
studies to analyze 4510 early-stage colon and data of rectal cancers managed with local exci-
rectal tumors managed with RR, either as the pri- sion demonstrated that the risk of local recur-
mary procedure or salvage of malignancy follow- rence was increased with poorly differentiated
ing endoscopic resection. The authors identified histologic grade (relative risk =6) or positive
four factors associated with significantly resection margins increased risk of local recur-
increased risks of lymph node metastases: depth rence (relative risk =27). The overall rate of local
of submucosal penetration >1 mm [OR 3.87, recurrence for the series was 19% (range 0–27%):
95% CI 1.5–10.0, p = 0.005], lymphovascular 5% in T1 rectal cancers and 18% in T2 cancers
invasion [OR 4.81, 95% CI 3.14–7.37, [35]. These studies were retrospective case series
p < 0.0001], poorly differentiated histopathology and therefore subject to selection biases, heterog-
[OR 5.60, 95% CI 2.90–10.82, p < 0.0001], and enous cohorts of tumor stage, and lack of modern
tumor budding [OR 7.74, 95% CI 4.47–13.39, staging techniques including pelvic MRI and
p < 0.001] [32]. were often not analyzed according to known
Additionally, the classical indications may be pathologic risk features. Over the subsequent two
inadequate predictors of lymphatic involvement. decades, multiple single-institution retrospective
In a retrospective review of 76 early-stage rectal series were published to further evaluate the
cancers managed by RR, 29% of lesions smaller oncologic feasibility of local excision of T1 rec-
than 2 cm (n = 7) had evidence of lymph node tal cancers. Table 3.1 summarizes the results of
metastases at time of radical resection [33]. A retrospective single institution studies comparing
more recent report of 62 patients with T1 tumors local excision alone (either TAE or TEM) to radi-
excised via TEM described a significantly higher cal resection of T1 rectal tumors (Table 3.1) [36–
local recurrence rate for tumors greater than 3 cm 42]. Note the rate of local recurrence following
in diameter when compared to tumors less than local excision alone varies from 4% to 24%.
3 cm in diameter (39% vs 11%, p = 0.03), with an Possibly the largest series of prospectively
3 An Algorithm for Local Excision for Early-Stage Rectal Cancer 21
Table 3.1 Oncologic outcomes comparing local excision (LE) and radical resection (RR) of early-stage rectal cancer
Local Radical Follow-up
Author, year excision resection (y)
N 5-year 5-year local N 5-year 5-year local
OS (%) recurrence OS (%) recurrence
(%) (%)
Single institutional cohort studies
Winde, 1996 [36] 24 96 4.1 26 96 0 3.8
(TEMS)
Mellgren, 2000 [37] 69 72 18 30 80a 0a 4.8
Lee, 2003 [38] 52 96b 4.1 100 94b 0 2.6
(TEMS)
Nascimbeni, 2004 [39] 70 72 6.6 74 90a 2.8a 8.1
Bentrem, 2005 [40] 152 89 15 168 93 3a 4.3
de Graaf, 2009 [41] 80 75 24 75 77 0a 3.5
(TEMS)
Nash, 2009 [42] 137 87b 13.2 145 96a 2.7a 5.6
Multi-institutional cancer registries
Endsreth, Norwegian 35 70 12 256 80a 6a Not
Rectal Cancer Group, reported
2005 [43]
You, National Cancer 601 77 12.5 493 82 6.9a 6.3
Database, 2007 [44]
Ptok, German Colon/ 85 84 5.1 359 92 1.4a 3.5
Rectal Cancer study
group, 2007 [45]
Folkesson, 2007 [46] 256 87 7 1141 93 2a Not
reported
Denotes statistically significant difference
a
collected data includes 282 T1 rectal cancer [TAE 87% vs RR 96%, p = 0.03, HR 2.8 (range,
patients undergoing either local excision via the 1.04–7.3)] for tumors removed via local excision.
standard transanal approach (TAE) or radical Interestingly, of the 145 patients whose tumors
resection (RR) from 1985 to 2004 at Memorial were removed via RR, 20% of resected speci-
Sloan Kettering Cancer Center. Tumors were mens harbored lymph node metastases [42].
located within 12 cm of the anal verge and Many of these patients were staged with CT scan
patients who underwent adjuvant therapies were and endorectal ultrasound, and none of the
excluded from analysis. The mean distance from patients underwent high-resolution MRI imag-
the anal verge was shorter [TAE 5.9 cm (SD 1.9) ing. In recent years, several national cancer regis-
vs RR 7.8 cm (SD 2.6), p < 0.001] and the mean tries have reported oncologic outcomes of
tumor diameter was smaller [TAE 2.3 cm (SD early-stage rectal cancers managed with either
1.4) vs RR 3.1 cm (SD 2.2), p, 0.001] in those local excision or RR (Table 3.1) [43–46].
tumors removed via TAE. The rates of lympho- Although these registries report substantially
vascular invasion [TAE 12% vs RR 17%, larger sample sizes than the previously men-
p = 0.18], perineural invasion [TAE 4% vs RR tioned single institution series, they are limited in
2%, p = 0.50], and poorly differentiated histopa- lack of the pathological details, inherent selection
thology [TAE 4% vs RR 6%, p = 0.46] were com- biases, and represent outcomes of a wide range of
parable between groups. Local recurrence was preoperative assessment and surgical techniques.
higher [TAE 13.2% vs RR 2.7%, p = 0.001], and Notwithstanding, these studies confirm the higher
5-year disease-specific survival was inferior rates of local recurrence after local excision
22 G. J. Chang and T. P. Nickerson
(5–13%) when compared to RR (1.4–7%). It is failure rates of limited resection across tumor
worth mentioning that again the overall survival stage, and (3) evaluate the possibility of manag-
at 5 years is comparable between groups and not ing low-lying T2 rectal adenocarcinomas with
statistically different in many studies. In the 2007 local excision and adjuvant combined modality
study of the US National Cancer Database therapy. Of the 59 patients with T1 adenocarci-
(NCDB), You et al. report that after excluding noma managed with local excision alone, the 6-
patients with a positive resection margin, local and 10-year local failure rates were 6.8% and
excision remained an independent predictor of 8%, the 10-year disease-free survival was 75%,
local failure. Yet the overall survival was not sig- and the overall survival at 5 and 10 years was
nificantly different even after 8 years of surveil- 91% and 84% [48]. The authors report that results
lance. Instead, patient-related factors, including compare favorably to historical data queried from
age and number of comorbidities, were more the NCDB, whose 5-year overall survival for T1
influential on overall survival than type of proce- patients managed with APR was 94%.
dure (LE vs RR) [44]. From these studies, it Interestingly, recurrences after local excision of
seems clear that the main oncologic risk of local T1 adenocarcinoma occurred as late as 8 years
excision is local recurrence, and patient-related after local excision, corroborating findings by
factors must be taken into consideration when other authors [49] that local and distant recur-
planning either approach. rences can occur at long intervals and that pro-
Perhaps the most meaningful information on longed surveillance is advisable.
local recurrence following local excision of
early-stage rectal cancer come from two prospec-
tive multi-institutional trials: the Radiation Local Excision of T2 Rectal Cancer
Oncology Therapy Group (RTOG) 89-02 and the
Cancer and Leukemia Group B (CALGB) 8984. With rates of lymphatic spread in tumors invading
Long-term results from the RTOG 89-02 study beyond the submucosa as high as 30%, local exci-
were published in 2000. Of 27 patients with T1 sion has traditionally been reserved for patients
disease who were followed, only 1 patient (4%) either unfit or unwilling to undergo radical resec-
suffered from local failure after a mean follow-up tion. Five-year rates of local failure as high as
of 6.1 years. Although the details of this particu- 47% after local excision of T2 tumors, compared
lar case were not specifically reported by the to only 6% after radical resection of staged
authors, only 40% of all patients enrolled were matched cancer, have been demonstrated in prior
found to be in complete compliance with the sur- studies [50]. Additionally, a comparison of local
gical protocol [47]. Long-term results of the excision versus radical resection of T2 tumors has
CALGB study were published in 2008. This been performed by NCDB studies, confirming the
study had clear inclusion criteria: T1 or T2 alarmingly high rate of local recurrence (LE 22%
tumors; mobile tumors within 10 cm of the anal vs RR 14%, p = 0.01) and associated reduction in
verge, <4 cm in size, and 40% of the circumfer- 5-year overall survival (LE 68% vs RR 77%,
ence of the rectum; and full-thickness resection p = 0.02) [44]. These results suggest that local
with negative margins. Of the initial 180 patients excision should not be considered adequate onco-
accrued to the study, 51 were deemed ineligible logic management as the primary treatment
due to failure to meet these criteria and excluded modality of rectal tumors that extend beyond the
from subsequent analysis. Instead of attempting submucosa. As the use of multimodality adjunc-
to randomize patients to local excision versus tive therapy has been shown to improve oncologi-
radical resection, the authors sought to (1) com- cal outcomes in locally advanced rectal cancer,
pare the survival of patients with early rectal this approach has been considered to enable local
adenocarcinoma (T1/T2) undergoing local exci- excision of T2 rectal tumors. Several single insti-
sion to historical controls treated with abdomino- tution studies with relatively small patient num-
perineal resection (APR), (2) assess the local bers have been reported (Table 3.2) [51–54].
3 An Algorithm for Local Excision for Early-Stage Rectal Cancer 23
Table 3.2 Local excision followed by adjuvant therapy tumors or positive margins after excision under-
for T2 rectal tumors
went salvage total mesorectal excision. All
Local patients were followed for a median of 56 months
Number recurrence, Overall
Author, year of patients n (%) survival
(IQR 46–63), with local recurrence rates reported
Minsky et al., 7 1 (14%) 88% at as 4%, distant metastases developed in 6%, the
1991 [51] 3 years disease-free survival was 88% (95% CI 81.3–
Benson et al., 36 5 (15%) 58% at 95.8), and the overall survival was 95% (95% CI
2001 [52] 5 years 91.1–100). At the end of the study, 91% of patients
Wagman et al. 25 6 (24%) 70% at who received neoadjuvant chemoradiotherapy
1999 [53] 5 years
had rectal preservation, with no substantial dete-
Bouvet et al., 27 5 (20%) 89% at
1999 [54] 4 years rioration in rectal function as measured by the
Fecal Incontinence Severity Index (FISI) [55, 56].
The main problem with this approach lies in the
These studies report a local failure rate of 14–24% treatment toxicity; after 53 patients were recruited,
for T2 rectal tumors treated by local excision fol- the regimen was altered to 50.4 Gy radiation by
lowed by adjuvant multimodal therapy with che- reducing the 9 Gy boost to 5.4 Gy, and capecitabine
motherapy and radiation. While potentially was reduced to 725 mg/m2, twice daily, 5 days a
improved compared to surgery alone, the rate of week for 5 weeks. Of the 79 patients who com-
failure was still much higher than rates that have pleted protocol, 29% had severe gastrointestinal
been reported following TME. The earliest pro- adverse events, 15% had severe pain, and 15%
spective data on this topic comes from the had severe adverse hematological adverse events
CALGB 8984 study, wherein 51 patients with [55]. It seems that appropriately selected, highly
low-lying rectal tumors were treated with local motivated T2 N0 patients with excellent response
excision followed by postoperative adjuvant to neoadjuvant therapy managed by local excision
radiotherapy (5400 cGy in 30 fractions) with con- approach the oncologic outcomes of T1 N0
current 5-fluorouracil (5-FU). Long-term out- patients managed by local excision alone.
comes of this study demonstrate a 10-year local However, these patients could also be managed
recurrence rate of 18% and overall survival 66% with radical surgical extirpation of their rectal
[48]. However, improved outcomes may be tumor and avoid the toxicity of radiation therapy
achieved by moving the multimodality therapy to [57]. More recently the results of the GRECCAR
the neoadjuvant setting. This strategy was 2 study have been published [58]. This was a pro-
explored in the ACOSOG z6041 trial. Strict entry spective, randomized, multi-institutional phase III
criteria were observed; patients were staged by study performed in France and enrolled patients
endorectal ultrasound or endorectal coil MRI and from March 2007 through September 2012 with
had tumors less than 4 cm in diameter and involv- clinically staged T2–3 N0–1 that demonstrated a
ing less than 40% of the rectal circumference good clinical response (residual tumor ≤2 cm) to
located within 8 cm of the anal verge. In this neoadjuvant chemoradiotherapy [capecitabine
multi-institutional, non- randomized, phase II (1600 mg/m2 per day, 5 days per week), oxalipla-
trial, 79 patients with clinically staged T2 N0 dis- tin (50 mg/m2 per week), and concurrent radiation
tal rectal cancer completed the protocol between therapy (2Gy per day, 5 days per week for
May 2006 and October 2009. These patients 5 weeks, total 50Gy)]. Tumors were less than
underwent neoadjuvant chemoradiotherapy 4 cm in maximum diameter and less than 8 cm
[capecitabine (825 mg/m2 twice daily on days from the anal verge. Patients were randomly
1–14 and 22–35), oxaliplatin (50 mg/m2 on weeks assigned to either local excision or radical resec-
1, 2, 4, and 5), and radiation (1.8 Gy per day, tion prior to surgery, and those randomized to
5 days a week for 5 weeks totaling 45 Gy, fol- local excision that were found to have a poor path-
lowed by a boost of 9 Gy for a total dose of 54Gy)] ological response (ypT2–3) or incomplete resec-
followed by local excision. Patients with ypT3 tion (R1) underwent completion total mesenteric
24 G. J. Chang and T. P. Nickerson
excision. A total of 145 patients met criteria for of the rectal circumference, and without evidence
randomization, and of the 71 patients randomized of nodal metastasis. Transanal endoscopic sur-
to local excision, 26 underwent subsequent TME gery (TEM, TAMIS) may facilitate local excision
due to findings at interpretation of pathology. of more proximal tumors. Tumors should be
Median follow-up was 36 months (IQR 36–36). carefully resected en bloc and without fragmen-
Primary endpoint was a composite outcome of tation, and the specimens should be oriented with
death, recurrence, morbidity, and treatment side the surgical pathologist. Pathologic evidence of
effects. Between study groups there were no dif- positive margins, lymphovascular invasion, poor
ferences in local recurrence (LE 3% vs RR 3%, differentiation, or invasion into the deeper layers
p = 0.63), metastatic recurrence (LE 15% vs RR of the submucosa (Sm3) or muscularis propria
13%, p = 0.47), 3-year DFS (LE 75% vs RR 82%, (T2) should prompt consideration of radical
p = 0.84), and 3-year OS (LE 89% vs RR 95%, resection [57]. These recommendations are mir-
p = 0.40). No patients who were randomized to rored by the European Association of Endoscopic
local excision and converted to radical resection Surgery (EAES), the European Society of
based on pathologic criteria developed local Coloproctology (ESCP) [60], the practice param-
recurrence. Although there were no differences in eters of the American College of Colon and
oncologic outcomes, the authors failed to demon- Rectal Surgeons (ASCRS) [61], and the Japanese
strate superiority of local excision over radical Society for Cancer of the Colon and Rectum
resection, which they attributed to the high rates (JSCCR) [62]. It should be noted that the JSCCR
of conversion to TME [58]. Interestingly, the only recommends local excision for rectal can-
combination of local excision and adjunctive ther- cers with limited submucosal invasion (malig-
apies seems to prolong the time interval to local nant polyp, Sm1), as the national cancer registry
recurrence when compared to local excision alone in Japan reports approximately 10% incidence of
[49, 59]. In the long-term results of the aforemen- nodal metastases in T1 rectal cancer. Thus,
tioned Memorial Sloan Kettering series, patients Japanese surgeons routinely perform a minimum
undergoing adjunctive therapies had a median D2 lymphadenectomy in the setting of cT1 dis-
time to recurrence of 2.1 years compared to ease. Finally, adherence to the NCCN guidelines
1.1 years for those undergoing local excision has been previously demonstrated to impart a
alone [59]. Chakravarti et al. report local failures survival benefit in locally advanced colon cancer
beyond 5 years in patients managed by adjuvant patients [63]. One could extrapolate this finding
chemoradiotherapy, again supporting the need for to rectal cancer, and the authors prefer to err on
long-term follow-up in these patients [49]. The the side of caution when managing these patients.
long-term results of the GRECCAR 2 trial may
provide additional insights into rates of late recur-
rences and are eagerly anticipated. Patient-Related Factors
considering local excision for an early-appearing radical resection appears to offer a survival bene-
rectal cancer, the patient’s willingness to undergo fit over salvage surgery at the time of recurrence
subsequent salvage resection or adjunctive thera- [5-year DFS 94.1% for immediate radical resec-
pies, as well as to be compliant with surveillance tion vs 55.5% for salvage at time of recurrence,
strategies, should also be considered. p < 0.05] [64]. Salvage surgery at the time of
recurrence often involves multivisceral resection
and is associated with high rates of perioperative
Technical and Surgeon-Related complications, and a significant portion of patients
Factors will present with unsalvageable recurrence. At the
University of Texas MD Anderson Cancer Center,
The feasibility of performing local excision or among 46 patients with recurrence after initial
radical resection should take into consideration treatment with TAE, 91% were candidates for sur-
the local expertise of the surgeon and available gical salvage and 87% elected to proceed. The R0
technologies. Radical resection of rectal cancer resection rate was 80%, and the required resec-
has increasingly been performed with sphincter tions were complex, requiring multivisceral resec-
preservation. Despite relatively high rates of low- tion (33%), total pelvic exenteration (5%), or
grade (Clavien-Dindo I and II) complications, metasectomy (25%). The rate of sphincter preser-
major morbidity and mortality (Clavien-Dindo vation was 33%, perioperative morbidity was
III–V) after radical resection remain relatively 50%, and 5-year OS was 63% [65]. In a similar
low in high-volume centers of expertise. fashion, Doornebosch et al. reviewed 18 patients
Sphincter-preserving radical resection of mid to who developed local recurrence after TEM exci-
distal rectal cancers has been described with sion of pT1 rectal cancer. Two of these recur-
good oncologic outcomes in the setting of adjunc- rences were unsalvageable, and the remainder
tive multimodality therapy [5]. Additionally, underwent TME without multivisceral resection
local recurrence of 5% or less should be consid- for salvage. The 3-year OS reported in this series
ered the standard for well-selected early-stage was 31% [66]. Current NCCN guidelines recom-
rectal cancer patients undergoing local excision mend immediate salvage surgery if high-risk his-
alone. If these nationally accepted standards can- topathological features are noted after local
not be met, then consideration for referral to a excision [57]. Clearly, waiting until the patient
high-volume center should be considered. develops a recurrence is associated with a poorer
prognosis. Newer data considering adjunctive
chemoradiotherapy as salvage after local excision
Salvage of Recurrence After Local of high-risk pT1 tumors has some promise, with
Excision some studies reporting 5-year OS and DFS as
94% and 89%, respectively; however these
Given the wide spectrum of local failure rates, patients still require very close follow-up and may
prior to embarking on local excision as definitive remain at increased risk for disease recurrence.
treatment, with or without adjuvant therapies, the Locoregional recurrence at 5 years remains as
surgeon must consider the feasibility of salvage high as 9% [67]. More studies are needed to deter-
after local recurrence occurs. In a review of 8 mine if this is an acceptable approach in LE with
studies with a total of 493 patients undergoing high-risk features.
local excision, 73 patients experienced locore-
gional recurrence with or without distant disease.
Sixty percent were successfully treated with a An Algorithm
curative radical resection, but approximately 50%
eventually died from disease [23]. In those The authors’ algorithm for consideration of local
instances where high-risk features were found on excision of rectal neoplasia is shown in Fig. 3.1.
pathologic review after local excision, immediate All patients presenting with rectal tumors
26 G. J. Chang and T. P. Nickerson
pT1N0; No high
Surveillance
risk features
No high risk Immediate
Local Excision*
features No comorbidity Salvage Radical
cT1N0 >pT1N0 or high Resection
High risk risk features
Radical
features present Comorbidity Consider
Resection
present present adjuvant CRT
Early Rectal
Cancer Radical
No comorbidity
Resection**
pT1N0; No high
cT2N0 Surveillance
risk features
Local Excision
>pT1N0 or high Consider
Comorbidity
risk features adjuvant CRT
present
CRT and present
observation
Fig. 3.1 An algorithm for management of early-stage vant CRT with intersphincteric resection for low rectal
rectal cancer. *Radical resection may be considered based cancer desiring sphincter preservation
on surgeon/patient discussion. **May consider neoadju-
undergo a full history and physical examination, rectal cancer exhibiting nodal metastasis are not
including digital rectal exam and either rigid considered for local excision; instead these
proctoscopy or flexible sigmoidoscopy to con- patients proceed to neoadjuvant therapy as indi-
firm the anatomical position of the tumor within cated and followed by TME except in rare cases
the rectum and obtain additional tissue via of patients unwilling to undergo a radical
biopsy if clinically indicated. If diminished surgery.
sphincter function is detected, we proceed with After nearly 30 years of ongoing investigation,
FISI questionnaire [68] and anorectal manome- the previously established initial recommenda-
try to further evaluate. When considering local tions of Wolff and Nivatvongs have changed little
excision and organ preservation, understanding [24]. Based on the aforementioned studies, it fol-
and documenting the baseline sphincter function lows that T1 N0 tumors 3–4 cm or less in maximal
is crucial. For patients with poor sphincter func- diameter, within reach of modern transanal instru-
tion, often appropriate counselling is more use- mentation, and involving less than 30–40% of the
ful than organ preservation, as these patients can rectal circumference, would be candidates for
demonstrate improved quality of life with a local excision – provided the tumor can be com-
colostomy. pletely excised and specimen fragmentation can
Staging images are obtained with high-qual- be avoided. Sometimes this is performed as a
ity computed tomography (CT) of the chest, radical biopsy, to evaluate for the presence of the
abdomen, and pelvis, to rule out metastatic dis- previously mentioned high-risk features on histo-
ease, and pelvic magnetic resonance imaging pathology: (1) depth of invasion beyond 1 mm
(MRI) with rectal cancer protocol for further into the submucosa or into the deepest one-third
characterization of the tumor and locoregional of the submucosa (Sm3); (2) poorly differentiated
disease including risk for lymph node metasta- features on histopathology; (3) presence of lym-
sis. Patients with early T category tumors may phovascular invasion; and (4) tumor budding. If
require evaluation by endorectal ultrasound, to these features are found on final analysis by an
improve the accuracy of determination of T1 vs experienced pathologist, the patient should
T2 tumors. All pertinent information is reviewed undergo immediate salvage resection, as delaying
by a multidisciplinary treatment team prior to salvage until the recurrence occurs is associated
recommendation for local excision. Patients with with unfavorable outcomes. Patients who lack
3 An Algorithm for Local Excision for Early-Stage Rectal Cancer 27
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2016;11(1):114.
Complete Clinical Response
in Rectal Cancer After 4
Neoadjuvant Therapy: Organ
Preservation Strategies
and the Role of Surgery
Laura Melina Fernandez,
Guilherme Pagin São Julião, Bruna Borba Vailati,
Angelita Habr-Gama, and Rodrigo O. Perez
nCRT would also constitute the ideal candidates expected anorectal function). Patients with
to consider organ preservation strategies such as cT2 N0 or early cT3N0 are potentially more
no immediate surgery and strict surveillance likely to develop a complete clinical response
(also known as the “watch and wait” strategy following nCRT and could benefit the most from
(WW)) [8]. In order to even consider these nCRT if organ preservation is considered
approaches, colorectal surgeons have to address [14–16].
several aspects of the assessment of the disease, Therefore, nCRT should be considered for
patients, and treatment modalities that may be local disease control purposes in patients with
quite relevant during their clinical decision- high-risk features (threatened cCRM, cN2, or
making process. cEMVI+) if total mesorectal excision (TME) is to
be performed regardless of response. However, it
could be offered to most rectal cancer patients if
Neoadjuvant Chemoradiation organ preservation is an option (including stage I
(nCRT): Indications and Options disease—mrT2N0M0) [17].
Different regimens of neoadjuvant chemora-
Following the results of the German trial, nCRT diation may influence response rates and should
was considered the preferred initial strategy for be considered if an organ preservation approach
most cT3–4 or cN+ rectal cancer patients due to is an option. Long-course CRT was the first reg-
the potential benefits in terms of local disease imen associated with significant rates of com-
control after radical surgery [9, 10]. However, the plete response. However, with the idea of
MERCURY study suggested that nCRT could prolonged interval period for the assessment of
preferably be restricted only to patients at highest response, short-course RT may result in similar
risk for local recurrence after TME. This would rates of response to long-course regimens [18].
include patients with radiological evidence of a In addition to the effect of time interval, the
threatened or positive circumferential margin final dose of radiation therapy and the method of
(cCRM+), presence of extramural venous inva- delivered may also influence the odds of devel-
sion (cEMVI+), and ≥3 positive lymph nodes oping a cCR. Dose escalation studies have dem-
(cN2) [11]. In addition, preoperative radiation onstrated a direct relationship between CR rates
following radical surgery was shown to result in with doses of RT delivered to the primary tumor
inferior functional outcomes and higher surgical [19]. In this mathematical model, depending on
morbidity when compared to surgery alone [12, tumor size (as an estimate of tumor volume),
13]. Altogether, these findings suggested that the progressive increases in RT dose (dose escala-
sole benefit of nCRT would be to improve local tion) would lead to predictive rates of major and
disease control only in high-risk rectal cancer complete response [19]. Dose escalation may be
patients (defined by high-resolution MR). facilitated with the combination of external
Considering that baseline staging may affect beam or intensity- modulated RT (EBRT or
rates of response to nCRT, one could expect that IMRT) with endorectal brachytherapy (HBRT)
very few patients with considerably advanced or even with contact RT. The idea of adding sig-
disease would ever develop a complete clinical nificant doses of RT with these approaches may
response and benefit from avoiding radical surgi- ultimately maximize the chances of developing
cal resection. complete clinical response and still avoid major
Instead, the idea of offering nCRT to inten- treatment-related toxicity [20–22]. Recently,
tionally achieve a cCR and avoid radical surgery one study has investigated the role of CXB in
with its related comorbidities led colorectal sur- patients with an initial incomplete clinical
geons to consider nCRT to more early-stage dis- response (residual tumor ≤3 cm) in successfully
ease, particularly in most distal tumors otherwise achieving a complete clinical response and
candidates for abdominal perineal resections or improving the chances of organ preservation
ultralow intersphincteric anastomosis (and worse [23].
4 Complete Clinical Response in Rectal Cancer After Neoadjuvant Therapy: Organ Preservation… 33
Finally, another way of increasing the rates of consisted of systemic chemotherapy first
cCR and organ preservation is optimization of (FOLFOX) followed by nCRT and finally radical
concomitant or even exclusive chemotherapy surgery. The comparison of TNT to standard
regimens. nCRT-surgery-adjuvant suggested higher rates of
The incorporation of additional chemotherapy complete planned treatment among patients with
cycles in standard nCRT has been suggested. The TNT regimen. Although very promising and
incorporation of additional chemotherapy during attractive, the implementation of TNT in clinical
the interval between RT completion and assess- practice should be done with caution. The inclu-
ment of response using 5FU-based chemotherapy sion of systemic chemotherapy, including oxali-
(consolidation CRT regimens) demonstrated an platin in this regimen, may lead to overtreatment
increase of CR rates to more than half of con- of a significant proportion of patients that may
secutive patients with T2/T3 rectal cancer [24, have ultimately never have required oxaliplatin in
25]. Although the observation that chemotherapy the adjuvant setting. Also, TNT will need to be
may have an important role in tumor regression, compared to standard nCRT with consolidation
the incorporation of additional drugs to 5FU has chemotherapy (without oxaliplatin) already with
been disappointing. The addition of oxaliplatin considerably high cCR and organ preservation
did not improve pCR rates in most studies. rates.
Instead, it resulted in significantly higher toxicity
rates [26].
Alternative neoadjuvant strategies that could Assessing Tumor Response to nCRT
spare patients from the potential detrimental
effects of radiation (with the same benefits) are Assessment of tumor response to nCRT becomes
an attractive alternative. Patients may develop crucial when considering patients for organ pres-
worse functional outcomes after TME in the set- ervation management. During this process two
ting of previous exposure to RT [13]. Even important issues remain as challenges: the opti-
patients that develop a cCR and avoid radical sur- mal timing for assessment and clinical/radiologi-
gery may not have perfect function [27, 28]. In cal tools for this purpose.
this setting, the use of chemotherapy alone is an Assessment of tumor response should be rou-
attractive option and has been used to restrict tinely performed independently of the decision
standard CRT to patients showing poor response for an organ-preserving strategy. Even if the plan
to chemotherapy alone and therefore decreasing is radical surgery, it is important to consider that
the number of patients receiving RT [29]. Also, CRT may lead to significant modifications in the
the incorporation of biological agents including primary tumor dimension and architecture and its
anti-EGFR or anti-VEGF has been tested in the relationship with surrounding tissues. Knowing
neoadjuvant setting of patients with rectal cancer. these potential anatomical changes between pre-
Even though these agents have demonstrated and posttreatment status ahead of time may help
good safety profiles, their real benefits in terms of in optimization of intraoperative surgical strate-
tumor regression have been even more disap- gies and anticipate surgical challenges during the
pointing with pCR rates even lower than usually procedure [33].
observed with standard CRT regimens [30–32].
A recent study reported the results with the
use of total neoadjuvant treatment (TNT, induc- Intervals After nCRT
tion of fluorouracil- and oxaliplatin-based che-
motherapy followed by CRT) for patients with Tumor regression after nCRT appears to be time-
rectal cancer. The authors compared patients dependent. The first association between differ-
treated with standard long-course neoadjuvant ent time intervals (from CRT completion and
regimen followed by postoperative adjuvant che- surgery) and tumor response was reported by the
motherapy with patients receiving TNT. TNT French randomized trial comparing 2 versus
34 L. M. Fernandez et al.
6 weeks from nCRT. The study showed that those period. In this study, patients with a “near” clini-
patients with longer interval to surgery (6 weeks) cal complete response and mrTRG1 or 2 were
were more likely to present tumor regression deferred from immediate radical surgery and
after nCRT [34]. Six-week intervals from nCRT underwent further reassessment in a 6–8-week
completion to assessment of tumor response interval. Outcomes revealed that 90% of these
shortly became the standard of care for many patients went on to achieve a cCR and were suc-
years. However, retrospective data suggested that cessfully managed by organ preservation [39].
patients operated on after longer intervals from Altogether, it is possible that individual tumors
CRT completion, as long as 12 weeks, were more respond differently to nCRT as a function of
likely to develop pCR [35]. After the observation time. In this setting, responsive tumors may
that these considerably longer intervals could require and benefit from extended intervals,
increase response to CRT, a hypothesis was made whereas unresponsive tumors may not [40].
suggesting that waiting more time to surgery
could lead to tissue fibrosis and increased techni-
cal difficulties and postoperative morbidity after Studies for the Assessment
radical surgery. In order to address this concern, of Response
a prospective, non-randomized study evaluated
patients in nCRT regimens with progressively Clinical and Endoscopic Findings
longer interval periods prior to surgical resection
[36]. Patients after a 6-week interval showed sim- Clinical assessment remains as one of the most
ilar postoperative complications than patients important tools in the evaluation of tumor
after a 12-week interval. In addition, after pro- response to treatment. Digital rectal examination
gressively longer intervals (6, 12, 18, and (DRE) may be able to detect subtle residual irreg-
24 weeks), the study showed that longer intervals ularities within the rectal wall, residual masses,
were associated with significantly higher rates of ulceration, or stenosis, even in the absence of
pCR with no negative impact on postoperative clinical symptoms after nCRT. During DRE, the
morbidity, even with additional chemotherapy surgeon has to be able to feel a regular and
cycles during the longer intervals (consolidation smooth surface with only mild induration and
mFOLFOX) [37]. However, another recently subtle loss in the pliability of the rectal wall.
published prospective randomized study failed to These are acceptable findings consistent with a
demonstrate increased rates of pCR when com- cCR [7].
paring 7- and 11-week intervals from standard Suspicious findings of incomplete clinical
nCRT. Moreover, the trial observed that more response (irregularity or superficial ulcer missed
postoperative complications and worse quality of during DRE) are easily detected during endo-
the mesorectum were associated with the scopic evaluation. Instead, a flat white scar and
11-week interval group, suggesting the poten- telangiectasia are normal findings encountered
tially negative effects of prolonged time intervals during endoscopic assessment of patients with a
after nCRT associated with fibrotic changes in cCR (Fig. 4.1).
the surgical and previously irradiated fields [38]. In the context of a cCR (during clinical and
The optimal interval after nCRT remains endoscopic assessment), routine endoscopic
undetermined, and additional ongoing trials will biopsies are not recommended. In other words, in
provide more data to allow us to understand the the presence of a regular and smooth mucosa,
benefits and risks of waiting extended intervals there is no need for a negative biopsy to confirm
after treatment. One recently published study a complete clinical response. Even in the pres-
suggested that patients with an excellent radio- ence of an incomplete clinical response, endo-
logical response and minor irregularities during scopic biopsies should be interpreted with
the clinical exam, referred as “near”-complete caution. A negative biopsy in the context of resid-
responses, may benefit from additional waiting ual ulcers, mass, or stenosis (incomplete clinical
4 Complete Clinical Response in Rectal Cancer After Neoadjuvant Therapy: Organ Preservation… 35
Radiological Assessment
In addition, completion of TME in this setting has even pT4 disease [57]. Also, the risk of a pCRM+
been associated with a risk factor for poor quality specimen may be quite significant here [58].
of the mesorectal specimen. A recent review of Second, after undergoing previous transanal
patients undergoing completion TME indicated endoscopic microsurgery, patients requiring sal-
that previous TEM was a risk factor for poor qual- vage resection often require abdominal perineal
ity of the TME specimen [56]. Finally, in the pro- resections (APRs) [55]. Finally, these patients
spective GRECCAR 2 study, patients with baseline requiring salvage or completion total mesorectal
small cT2/T3 tumors (≤4 cm) underwent excision frequently present suboptimal TME
nCRT. Those with “good” clinical response specimens at the time of resection [56]. In this
(≤2 cm) were randomized to TME or local exci- setting, salvage resection after a local recurrence
sion (LE). In an “intention to treat” analysis (using following transanal local excision should be con-
a composite primary endpoint including mortality, sidered at high risk for unfavorable outcomes,
morbidity, function, and recurrence), patients who and surgical management should be optimized to
underwent LE had similar oncological and func- provide a R0 resection. One recent case-matched
tional outcomes to those after TME. On a first study has compared the short-term outcomes of
glance, this could suggest that local excision after patients undergoing completion TME after previ-
nCRT is a valid alternative in this highly selected ous local excision with transanal TME or stan-
patient population (small baseline tumors and dard TME. The study suggests superior quality of
excellent clinical response). However, in a sub- the specimen and decreased risk of rectal perfora-
group analysis of patients that needed completion tion with the transanal approach [59]. Still, fur-
TME due to the presence of high-risk/unfavorable ther studies comparing taTME to standard TME
pathological features in the LE specimen, out- in the setting of local recurrences after previous
comes were not as good. These patients had signifi- local excision are warranted. The reason is that
cantly more postoperative complications, need for completion TME and salvage TME may have
APR, and worse functional outcomes. In conclu- distinct surgical outcomes. Still, transanal TME
sion, patients that underwent LE alone (with favor- seems to be an attractive approach for the man-
able pathological features) did the best when agement of these patients requiring salvage TME
compared to TME or LE + TME. Patients who in an attempt to provide optimal oncological and
underwent LE and required TME (unfavorable functional outcomes.
pathological features) did the worse when com-
pared to LE alone or TME alone [38].
omplete Clinical Response: Watch
C
and Wait Strategy
pecial Situation: Salvage
S
for Local Recurrence After a Transanal Non-operative management of patients with a
Local Excision complete clinical response has to be coupled to a
relative intensive follow-up strategy. The impor-
Several series reported on the outcomes of local tance to adhere to this strict follow-up program is
excision with or without the use of preoperative to allow early recognition of any local or sys-
CRT. A few significant issues may represent temic recurrence and, therefore, increase the
challenges in the setting of a local recurrence fol- chances of successful salvage. Visits have been
lowing local excision with significant conse- recommended with 1–2-month intervals in the
quences in terms of optimal salvage. First, local first year, 3-month intervals for the second year,
recurrences after a previous local excision usu- and 6-month for the remaining years of follow-
ally present as more advanced disease when com- up. Complete clinical and endoscopic assess-
pared to initially resected. One interesting series ments are recommended in all visits. Even though
looking at pT1 managed by transanal endoscopic not yet standardized, radiological assessment of
microsurgery revealed that local recurrences response has been performed at least every
were frequently salvaged in the setting of pT3 or 6 months for the first 2 years and yearly thereafter
38 L. M. Fernandez et al.
in our practice [60]. PET/CT imaging has been recurrence and excellent survival long-term results
reserved for equivocal cases. further support this organ preservation strategy as
an attractive alternative for the management of
selected patients with rectal cancer and complete
Outcomes clinical response to nCRT [67].
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4 Complete Clinical Response in Rectal Cancer After Neoadjuvant Therapy: Organ Preservation… 41
Sook C. Hoang and Charles M. Friel
I mmediate Salvage Surgery mary upfront radical surgery [5, 6]. For example,
for Disease Upstage Baron et al. noted no difference in long-term
oncologic outcomes in patients that had immedi-
Patients with T1 rectal cancers who are candi- ate salvage surgery following a failed local exci-
dates for local excision must be thoroughly sion [6]. They compared patients who underwent
assessed prior to surgery. This includes imaging immediate resection for adverse features encoun-
studies to accurately determine the depth of inva- tered in the local excision specimen with patients
sion. Prior studies have shown that T1 rectal can- who underwent delayed resection only after the
cers can have lymph node metastases in emergence of local recurrence. The disease-free
approximately 10% of patients, while those with survival in the immediate resection group was
T2 cancer, the rate of lymph node metastases 94.1% compared to 55.5% in the delayed resec-
approaches 20% [1, 2]. Both endorectal ultra- tion group. Similarly, a study performed by Levic
sound (ERUS) and high-definition MRI have et al. found that the recurrence rates for radical
been used to determine the depth of invasion and surgery after TEM for rectal cancer were similar
to detect pathological lymph nodes in the meso- to historical controls [7]. They identified 25
rectum. Unfortunately, neither is 100% reliable patients within their institution who underwent
resulting in rectal lesions that can be either under- TME after local excision with TEM. Outcomes
staged or overstaged. One study found 44.3% of were matched with historical controls who had
pT1 and 31.2% of pT2 tumors were thought to be primary upfront radical excision with TME. There
benign lesions prior to surgery [3], highlighting were no significant differences between the two
the imperfections of current selection processes. groups in the number of harvested lymph nodes,
Underestimation of T category preoperatively median circumferential resection margin, and
can lead to partial-thickness rectal wall excision completeness of mesorectal fascial plane.
and a subsequent sixfold increase in odds of an Additionally, there were no recurrences in the
R1 margin [3]. Furthermore, tumors may have salvage TME group within 25 months. Despite
aggressive pathological features (poor differenti- these promising oncologic results, this study
ation, lymphovascular invasion, tumor budding) reports a compromise in oncologic principles
that increase the chances of having lymph node during definitive resection including:
metastases substantially but are only fully identi-
fied once a complete excision is performed. 1. Intraoperative perforation was reported at
While surgeons strive for perfect patient selec- 20%, likely secondary to weakening of the
tion, the reality is that a local excision serves as specimen from the previous TEM.
an excisional biopsy of the lesion. Most of the 2. Thirty-seven percent of patients had an incom-
time, the final pathology is consistent with preop- plete mesorectal excision.
erative evaluation, and compulsive surveillance is
all that is necessary. However, in approximately The significance of these findings remains
4–23% of patients, the final tumor will either unclear but does suggest there may be some
have unrecognized aggressive features, be deeper oncologic compromise as a result of the previous
than expected, or have a close surgical margin [3, attempt at local therapy.
4]. Because of a high rate of local failure under While at first glance there seems to be no sig-
any of these circumstances immediate salvage nificant compromise to first attempting a local
surgery, with TME, is indicated. excision, this algorithm certainly raises some
It is currently unclear if the outcomes of concern. Patients are subjected to two surgical
immediate salvage TME for disease upstaging procedures often within a short period of time.
vary from upfront radical surgery with Additionally, there is currently no consensus in
TME. Some studies suggest immediate salvage the timing of salvage surgery following TEM for
TME after a failed local excision does not com- lesions that are upstaged on pathology. Some
promise oncologic outcomes compared to pri- centers report salvage surgery as early as 4 weeks
5 Salvage Surgery After TAMIS Excision of Early-Stage Rectal Cancer 45
from the initial TEM, and some centers report has important repercussions which highlight the
delay of up to 3 months [5]. What is clear is that importance of proper preoperative selection.
surgical morbidity after salvage TME is reported
to be as high as 56% [7]. More importantly, in the
same study from Levic et al., 40% of the patients elayed Salvage Surgery
D
having a salvage procedure required an APR and for Recurrent Disease
permanent colostomy which raises the possibility
that these patients could have had a LAR if While local excision for an early rectal cancer
upfront radical surgery was performed and the may be an excellent option for carefully selected
surgical planes not disrupted by the previous full- patients, there is little doubt it is an oncologically
thickness excision. These findings suggest that inferior option when compared to a radical resec-
salvage TME after local excision may be more tion. Local excision removes the tumor with a
technically challenging. The local excision scar limited mucosal margin and spares the mesorec-
has to be completely excised, resulting in a more tal lymph nodes. Unresected disease in regional
distal resection margin, which could increase the lymphatics has been identified as a cause of fail-
rate of a permanent colostomy. Van Gijn et al. ure after local excision [9]. As a result, there is an
evaluated the risk of local recurrence, effects on increased risk for recurrence after local excision
survival, and rate of ostomy after immediate sal- compared to proctectomy with a TME [3]. Local
vage TME [8]. Patients who had a local excision recurrence rates after local excision can range
for presumed benign or superficial malignant rec- from 0 to 33% compared to local recurrence rates
tal lesions and had subsequent pathologic upstag- after upfront proctectomy with total mesorectal
ing underwent salvage TME within 15 weeks. excision at 0–2.4% [10].
They found a greater risk for colostomy (OR Surveillance and follow-up of patients who
2.51, p < 0.0006) and a greater local recurrence have undergone local excision for T1 rectal can-
rate (HR 6.8, p < 0.0001) in patients who had sal- cer are therefore critical for detection of local
vage surgery. There was no difference in develop- recurrence. Since local recurrence may present as
ment of distant metastasis at 2.5 years. These an intraluminal or extraluminal mass, a multi-
data suggest that salvage TME is technically modal surveillance scheme should be followed.
more challenging in a re-operative field. Because Current guidelines recommend proctoscopy
of these challenges, both rates of local recurrence every 3 months for the first 2 years and then every
and colostomy creation are likely increased. 6 months for a total of 5 years [11]. However,
In summary, following a local excision, some surveillance with proctoscopy alone may still
patients will have unfavorable pathological fea- lead to missed recurrences. Additionally, despite
tures that mandate a radical resection. Under imaging modalities such as MRI or endorectal
these circumstances immediate (within 3 months) ultrasound (ERUS), lymph node metastasis may
salvage surgery is recommended since waiting also be missed [12]. For these reasons, some cen-
for a local recurrence tends to have worse onco- ters argue for aggressive surveillance with sur-
logical outcomes. When performed early survival veillance proctoscopy and ERUS in addition to
may be equivalent to upfront radical resection. yearly pelvic MRI for patients who have had
However, radical surgery may be more techni- local excision for early rectal cancer [12, 13].
cally challenging as a result of scarring and fibro- Close surveillance may lead to an earlier detec-
sis from a previous local excision. Unfortunately, tion of recurrence and subsequent need for a less
this may increase the likelihood of requiring a involved salvage surgery. However, even with
permanent colostomy. Furthermore, the impact active surveillance, outcomes following salvage
on local recurrence remains ill-defined with some surgery is poor with 3-year overall survival at
studies suggesting similar outcomes and others 31% and disease-free survival of 58% [12].
hinting at a higher rate of local failure. What does Bach et al. sought to identify predictors to
seem clear, however, is that a failed local excision recurrence after local excision for rectal cancer.
46 S. C. Hoang and C. M. Friel
Recurrence after local excision occurs at a vival rates of 92–97% after upfront proctectomy
median of 13 months (range of 3–55 months) for a T1 lesion, they found a 5-year overall sur-
[3]. They found that recurrence is independently vival rate of 50% (95% CI, 30–74%) and a 5-year
predicted by depth of tumor invasion, maximum recurrence-free survival rate of 47% (95% CI,
tumor diameter, and presence of intramural lym- 25–68%) after salvage surgery for recurrence.
phovascular invasion. Additionally, as the maxi- There are now several studies (Table 5.1) showing
mum tumor diameter increased by 1 cm, the risk similar disappointing outcomes with overall sur-
of recurrence also increased by 18% (95% CI, vival hovering around 50%. Recalling that upfront
3–35%). Lymphovascular invasion was noted to TME for a T1 rectal cancer has nearly a 100%
increase the risk of recurrence by a factor of overall survival, these data remind us that salvage
1.86. This is consistent with previous studies that surgery for a local recurrence does not achieve
have found lymphovascular invasion to be an similar oncologic success and therefore cannot be
independent predictor of local recurrence [9]. relied upon for patients that have a recurrence fol-
In general, local recurrence portends a poor lowing a local excision.
prognosis. In most patients, when recurrence Additionally, salvage TME for recurrence after
occurs after local excision, the stage of the recur- local excision for early-stage rectal cancer often
rent tumor is more advanced than the initial pri- involves an extensive operation with increased
mary tumor [14]. Another study noted 41% finding morbidity. Pelvic recurrence is often advanced
of positive node involvement in the surgical speci- requiring an extended pelvic resection of adjacent
men, despite the use of preoperative radiation ther- pelvic organs to achieve salvage [16]. For exam-
apy in patients with recurrence [14]. Bikhchandani ple, in the study from Weiser et al., 50 patients
et al. identified 27 patients who underwent multi- underwent attempted surgical salvage for local
modal salvage therapy for locally recurrent rectal recurrence following initial transanal excision
cancer after previous local excision for early rectal [16]. Thirty-one of the 50 patients underwent an
cancer [15]. Compared to 5-year disease-free sur- APR and only 11 patients had an
Table 5.1 Summary of studies regarding salvage surgery after local excision for rectal cancer
N (study Initial Median time Sphincter
Author, year years) tumor stage to recurrence Location of recurrence preservation OS, DFS
Friel et al., 1988– T1, T2 – – 34% DFS 55%
2002 [14] 1999
Weiser et al., 50 T1, T2 20 months 17 patients within – 5-year OS 53%
2005 [16] (1970– rectal mucosa,
2003) metastatic disease
8 patients
Doornebosch 88 pT1 10 months Intraluminal 10 56% 3-year OS 31%,
et al., 2010 [12] (1996– (11%), cancer-related
2010) Extraluminal 6 survival 58%
(6.8%),
Distant mets 39%
You et al., 2012 43 cT1 43% 1.9 years Local/regional 67%, 33% 5-year OS 63%,
[17] (1993– cT2 7% Distant 18%, 3-year
2011) cT3 22% Both 15% recurrence-free
unknown survival 43%
28%
Bikhchandani 27 T1, T2 52 weeks Luminal 23 patients, 33% 5-year OS 50%,
et al., 2015 [15] (1997– Locoregional recurrence-free
2013) 3 patients, survival 47%
Locally advanced
disease(T3/T4) 73%
OS overall survival, DFS disease-free survival, − not reported
5 Salvage Surgery After TAMIS Excision of Early-Stage Rectal Cancer 47
LAR. Additionally, 55% of patients required an more technically possible with the introduction
extended resection involving the pelvic sidewall, of TEM and TAMIS, with lower associated mor-
prostate, seminal vesicle, bladder, vagina, ureter, bidity compared to radical surgery. For many rea-
and ovary, with a resulting 5-year disease-free sons, local excision for properly selected patients
survival rate of 53%. Similarly, in a series by You with a T1 rectal cancer remains an appealing
et al., 33% of patients with recurrence after local option. Since T1 rectal cancers have up to a 10%
excision required a multivisceral resection and risk for lymph node metastasis, preoperative
5% required a pelvic exenteration to achieve R0 staging is extremely important. Unfortunately,
disease [17]. Additionally, they noted that only available modalities such as MRI and endorectal
33% of patients who underwent salvage surgery ultrasound are not able to detect micrometastases
achieved sphincter preservation which was con- that may be associated with T1 lesions [18].
sistent with sphincter preservation rates of Therefore, despite careful patient selection, some
30–50% across studies [12, 15, 17]. The goal of patients will require a salvage TME for either
salvage surgery is to achieve R0 resection which poor pathological features or a local recurrence.
often requires extensive resection and sphincter Initially surgeons believed that outcomes of these
compromise. When R0 resection is achieved, salvage procedures would likely be similar to pri-
survival rates of up to 59% can be achieved. mary surgery for these early rectal cancers. When
However, in situations where an R1 or R2 resec- performed in a timely fashion, salvage surgery
tion is achieved, survival rates drop to 0% [16]. for pathologic upstaging results in acceptable
In efforts to improve outcomes and survival survivability. However, salvage surgery can be
after salvage surgery, multimodality therapy is technically more challenging compared to
frequently adopted. This includes the use of both upfront radical surgery which increases the likeli-
neoadjuvant and adjuvant chemotherapy and hood of a permanent colostomy. Furthermore,
radiation, in addition to intraoperative radiother- local recurrence rates for a salvage TME is likely
apy in some centers [15]. However, morbidity higher. For patients that recur following a local
rates after salvage surgery is consistently reported excision, the recurrence is often at a higher stage
at 40–50%. Bikhchandani et al. were able to compared to the initial stage of presentation. As a
achieve R0 resection in 93% of patients with the result, more extensive surgical resection is needed
use of multimodality therapy and salvage surgery to achieve tumor-free resection, resulting in
[15]. Despite this, they reported 5-year greater morbidity and compromised functional
recurrence-free survival rate and 5-year overall outcomes. This includes diminished sphincter
survival rate of <50%. Similarly, despite aggres- preservation rates of only 30–50% across studies
sive multimodal therapy including neoadjuvant and often requires an extended resection to
chemoradiation and intraoperative radiation to achieve an R0 resection. Survival outcomes fol-
achieve R0 resection in 80% of patients, You lowing salvage surgery, even with multimodality
et al. also reported modest outcomes (5-year OS therapy, are also disappointing and hover at about
63%, 3-year re-recurrence-free survival 43%) 50%. These data suggest that salvage surgery is
[17]. Therefore, even with the use of multimodal- not a panacea for the patients who develop a local
ity therapy, recurrences after a failed local exci- recurrence. What it does suggest is that compul-
sion are significant challenges with overall sive and aggressive surveillance is critical in the
outcomes which remain disappointing given the management of these patients. Presumably if
initial stage of these tumors. local recurrences are found early, then salvage
surgery may have better overall outcomes. It is
our recommendation that all patients be followed
Summary by endoscopic evaluation and careful exam every
3 months for 2 years and biannually until 5 years.
There have been significant advances in the treat- Since there are examples of late recurrence, an
ment of rectal cancer. Local excision for benign annual exam after 5 years may be reasonable.
rectal lesions and T1 rectal cancers has become Ideally this is done by the operating surgeon who
48 S. C. Hoang and C. M. Friel
is more attuned to subtle recurrence patterns. excision of rectal cancer: an oncologic compromise?
Dis Colon Rectum. 2005;48(3):429–37.
While most recurrences are intraluminal, there 6. Baron PL, Enker WE, Zakowski MF, Urmacher
will be some local recurrence outside of the C. Immediate vs. salvage resection after local treat-
lumen. Therefore, a pelvic MRI should be done ment for early rectal cancer. Dis Colon Rectum.
at least once per year. Similarly, some patients 1995;38(2):177–81.
7. Levic K, Bulut O, Hesselfeldt P, Bulow S. The out-
will develop distant metastases so a CT scan of come of rectal cancer after early salvage surgery
the chest, abdomen, and pelvis annually is also following transanal endoscopic microsurgery seems
reasonable. By staggering the CT scans and the promising. Dan Med J. 2012;59(9):A4507.
pelvic MRI every 6 months, the patient can get 8. van Gijn W, Brehm V, de Graaf E, Neijenhuis PA,
Stassen LP, Leijtens JW, et al. Unexpected rectal
pelvic imaging every 6 months with this approach. cancer after TEM: outcome of completion surgery
compared with primary TME. Eur J Surg Oncol.
2013;39(11):1225–9.
Conclusion 9. Paty PB, Nash GM, Baron P, Zakowski M, Minsky
BD, Blumberg D, et al. Long-term results of local exci-
sion for rectal cancer. Ann Surg. 2002;236(4):522–9.
Since salvage surgery cannot be relied upon for a discussion 9-30
failed local excision, the best opportunity to 10. Garcia-Aguilar J, Mellgren A, Sirivongs P, Buie D,
improve outcomes for local excision is by Madoff RD, Rothenberger DA. Local excision of rec-
tal cancer without adjuvant therapy: a word of cau-
improving the patient selection process. Until we tion. Ann Surg. 2000;231(3):345–51.
can reliably rule out disease within the mesorec- 11. National Comprehensive Cancer Network. NCCN
tum, there will be patients that will recur. We now clinical practice guidelines in oncology (NCCN
know that salvage surgery clearly results in infe- guidelines): Rectal Cancer. Version 1.2018 2018.
Available from: https://www.nccn.org/professionals/
rior outcomes. Therefore, since our “first shot is physician_gls/pdf/rectal.pdf.
our best shot,” when considering local excision 12. Doornebosch PG, Ferenschild FT, de Wilt JH, Dawson
as a treatment option, we must choose and inform I, Tetteroo GW, de Graaf EJ. Treatment of recurrence
our patients carefully. after transanal endoscopic microsurgery (TEM) for T1
rectal cancer. Dis Colon Rectum. 2010;53(9):1234–9.
13. de Anda EH, Lee SH, Finne CO, Rothenberger DA,
Madoff RD, Garcia-Aguilar J. Endorectal ultrasound
References in the follow-up of rectal cancer patients treated by
local excision or radical surgery. Dis Colon Rectum.
1. Chang HC, Huang SC, Chen JS, Tang R, Changchien 2004;47(6):818–24.
CR, Chiang JM, et al. Risk factors for lymph node 14. Friel CM, Cromwell JW, Marra C, Madoff RD,
metastasis in pT1 and pT2 rectal cancer: a single- Rothenberger DA, Garcia-Aguilar J. Salvage radical
institute experience in 943 patients and literature surgery after failed local excision for early rectal can-
review. Ann Surg Oncol. 2012;19(8):2477–84. cer. Dis Colon Rectum. 2002;45(7):875–9.
2. Rasheed S, Bowley DM, Aziz O, Tekkis PP, Sadat AE, 15. Bikhchandani J, Ong GK, Dozois EJ, Mathis
Guenther T, et al. Can depth of tumour invasion predict KL. Outcomes of salvage surgery for cure in
lymph node positivity in patients undergoing resection patients with locally recurrent disease after local
for early rectal cancer? A comparative study between excision of rectal cancer. Dis Colon Rectum.
T1 and T2 cancers. Color Dis. 2008;10(3):231–8. 2015;58(3):283–7.
3. Bach SP, Hill J, Monson JR, Simson JN, Lane L, 16. Weiser MR, Landmann RG, Wong WD, Shia J,
Merrie A, et al. A predictive model for local recur- Guillem JG, Temple LK, et al. Surgical salvage of
rence after transanal endoscopic microsurgery for rec- recurrent rectal cancer after transanal excision. Dis
tal cancer. Br J Surg. 2009;96(3):280–90. Colon Rectum. 2005;48(6):1169–75.
4. Borschitz T, Heintz A, Junginger T. The influence of 17. You YN, Roses RE, Chang GJ, Rodriguez-Bigas MA,
histopathologic criteria on the long-term prognosis Feig BW, Slack R, et al. Multimodality salvage of
of locally excised pT1 rectal carcinomas: results of recurrent disease after local excision for rectal cancer.
local excision (transanal endoscopic microsurgery) Dis Colon Rectum. 2012;55(12):1213–9.
and immediate reoperation. Dis Colon Rectum. 18. Landmann RG, Wong WD, Hoepfl J, Shia J, Guillem
2006;49(10):1492–506. discussion 500-5 JG, Temple LK, et al. Limitations of early rectal
5. Hahnloser D, Wolff BG, Larson DW, Ping J, cancer nodal staging may explain failure after local
Nivatvongs S. Immediate radical resection after local excision. Dis Colon Rectum. 2007;50(10):1520–5.
Organ Preservation and Palliative
Options for Rectal Cancer 6
Nienke den Dekker, Stefan Erik Van Oostendorp,
and Jurriaan Benjamin Tuynman
Local Excision
N. den Dekker · S. E. Van Oostendorp (*)
J. B. Tuynman
Department of Surgery, Amsterdam University Treatment with solely local excision offers the
Medical Center, location VUmc, Cancer Center lowest burden for patients, since it is a minimally
Amsterdam, Amsterdam, The Netherlands invasive technique and results in low morbidity
e-mail: [email protected]
and colostomy rates. You et al. reported an over- The recurrence rates after local excision of T3
all 30-day morbidity rate of 5.6% compared to cancer are expected to be even higher and are the
14.6% for radical resections, because of less gas- reason that local excision for T3 is not supported
trointestinal and infectious complications, with a by clinical guidelines as treatment strategy with
consequent shorter hospital stay after local exci- curative intent. As expected, data is scarce con-
sion [6]. However, the question remains whether cerning this group of advanced disease. Some
it is a sufficient treatment since local excision publications report a few cases of patients who
only treats the primary tumor and not the poten- refused radical surgery or were deemed unfit for
tial remaining tumor cells in the mesorectum. major surgery. In seven publications which
The clinically pathological features such as depth address this subject, an overall recurrence rate of
of submucosal invasion, differentiation, lympho- 68% (15 of 22 patients) was reported [8–14].
vascular invasion, budding, and clustering are This increase in recurrences might be an
related to recurrence, whether endoluminal or acceptable clinical outcome if a radical resection
within the mesorectum. When local excision is is not desirable nor possible in frail patients who
carried out, the surrounding muscular wall and present unacceptably high risk of perioperative
mesorectum are left untreated. Therefore, tumor morbidity and mortality. Therefore, expected
cells are potentially left behind where they may longevity and predicted survival rates are impor-
propagate and eventually develop into a clinically tant factors when a deliberate choice for a sub-
detectable local recurrence. standard operation is carried out by performing
Many cohorts and population-based studies local excision. Allaix et al. [15] reported 5-year
have provided data concerning oncological out- survival rates of 76% in 32 patients after TEM
come after local excisions for T1 and T2 tumors. and 96% of 33 patients after anterior resection or
A meta-analysis of local excision as sole treat- APR. However, radical resection was indicated in
ment, covering all published data from 1990 to all patients. Those who underwent a TEM proce-
2018, revealed local recurrence rates of 10% in dure were either not fit for surgery or refused
2120 patients with a T1 tumor and 32% in 357 radical surgery. A meta-analysis showed overall
patients with a T2 tumor as shown in Table 6.1 5-year survival rates of 65–100% for T1 tumors
(Tuynman et al. in preparation [7]). Distant fail- and 30–95% for T2 tumors [7]. The majority of
ures occurred in 6% of 1805 patients and 12% of all recurrences appears within 3 years after initial
230 patients with, respectively, T1 and T2 tumors. treatment. Salvage treatment usually consists of
The substantial increase in recurrences of T2 major surgery or less effective radiotherapy, and
tumors indicates the reduced effectiveness of it is often associated with complications.
local excision for more advanced early rectal In conclusion, local excision for rectal cancer
cancer. is accompanied by low morbidity rates and good
functional outcome. However, it is also associ-
Table 6.1 Recurrence rates ated with poor oncological outcome in high-risk
tumors which increases with tumor (T) stage. In
T1 T2 T3
Local recurrence
case of low-risk T1 tumors, local excision alone
LE 10% 32% 58% is a viable and accepted treatment strategy.
(n = 2120) (n = 357) (n = 19)
LE + adjuvant 7% 16% 33%
(n = 278) (n = 382) (n = 27) Local Excision with Adjuvant Therapy
Distant recurrence
LE 6% 12% 31%
Especially for infirm patients, local excision is an
(n = 1805) (n = 230) (n = 13)
LE + adjuvant 5% 7% 4% attractive strategy compared to radical surgery
(n = 214) (n = 254) (n = 23) concerning morbidity. Therefore, other additional
n number of patients included in this analysis, LE local options to improve the associated oncological
excision, adjuvant (chemo)radiation compromise have been studied. One of these
6 Organ Preservation and Palliative Options for Rectal Cancer 51
explored options is addition of adjuvant (chemo) tumors seem to benefit from adjuvant therapy as
radiation following local excision. This might well, but oncological outcome remains poor with
increase oncological outcomes including sur- high recurrence rates.
vival, while still offering organ preservation.
A meta-analysis reported average local recur-
rence rates of 7% in 278 patients with T1 and 16% eoadjuvant Therapy Followed by
N
in 382 patients with T2 tumors (Table 6.1). Distant Local Excision
recurrence rates were 5% in 214 patients and 7% in
254 patients with, respectively, T1 and T2 tumors The incorporation of neoadjuvant chemoradio-
[7]. In particular, it was noted that recurrence rates therapy and subsequent local excision is a possible
of T2 tumors decreased remarkably with the addi- treatment strategy. Neoadjuvant therapy might
tion of adjuvant therapy compared to local excision lead to downstaging and shrinkage of the primary
alone. Overall recurrence rate of local excision lesion, which could enable local excision of what
with adjuvant (chemo)radiation of T3 tumors was were initially larger tumors. More importantly,
38% (12 of 32 patients) [8, 9, 12, 14, 16–19]. such a protocol targets the mesorectum via irradia-
A US National Cancer Database analysis tion, which could sterilize occult nodal disease.
showed a 5-year survival rate of 79.7% for Local recurrence rates of 7–17% have been
T2N0M0 tumors, similar to radical surgery [20]. reported for T2 and T3 tumors treated with neo-
After exclusion of 90-day mortality, survival was adjuvant chemotherapy prior to local excision
significantly worse than after radical surgery. [22–24]. This is substantially lower than the pre-
Others report 5-year overall survival rates are viously mentioned rates of local excision alone
63–98% for T1 tumors and with 61–93% slightly and slightly better than adjuvant therapy.
lower for T2 tumors [7]. Compared to local exci- Focusing on survival, an American National
sion alone, the survival benefit of adjuvant therapy Cancer Database analysis revealed 5-year overall
seems to be substantial for T2 tumors. However, survival of 76.1% for T2N0M0 tumors [20]. This
due to serious heterogeneity of the studies, direct was similar to radical surgery and local excision
conclusions cannot be established. Nevertheless, with adjuvant chemoradiation. Allaix et al.
the addition of adjuvant CRT after local excision reported a comparable 5-year survival rate of
seems to be a promising strategy as tailored 77.8% in 11 patients, which was equal to local
approach for tumors at high risk of recurrence, excision alone [15]. Based on these numbers,
such as T1 tumors with risk features or T2 tumors. neoadjuvant and adjuvant therapy seem to be
The TESAR trial was initiated in 2015 to gain equally effective strategies.
insight into the oncological and functional out- However, morbidity of neoadjuvant treatment
come of local excision with adjuvant chemora- is highly underestimated. Local excision after neo-
diotherapy [21]. In this study, local excision of adjuvant chemoradiation is associated with higher
intermediate and high-risk T1 tumors and T2 risk of wound dehiscence (61% vs. 23%), post-
tumors without adverse features is followed by procedural pain (52% vs. 15%), and an increase of
randomization of patients between either adju- hospital readmissions (44% vs. 7%) compared to
vant chemoradiotherapy or completion TME. The local excision alone [25]. Another series reported
hypothesis is that both treatments offer similar the increase in wound-related morbidity following
recurrence and survival rates, while adjuvant TEM [26]. This series by Marks et al. included 43
chemoradiation offers better quality of life and patients with neoadjuvant therapy, of whom 36
functional outcome. The trial remains ongoing at received chemoradiation. The remaining seven
the time of this writing. patients were deemed not fit for chemotherapy and
Summarized, addition of adjuvant therapy to therefore underwent radiotherapy only. In total, 11
local excision potentially improves recurrence (25.6%) patients suffered wound complications.
rates and survival in locally excised rectal cancer None of the 19 patients treated with TEM alone
staged as T1 with risk features or T2 tumors. T3 had wound complications.
52 N. den Dekker et al.
Despite the increased short-term morbidity growth, such as pain, obstruction, bleeding, or
associated with neoadjuvant therapy, the promising tenesmus. A systematic review was performed in
oncological outcomes account for ongoing studies 2014 to assess the efficacy of radiotherapy on
on this subject. An example is the multicenter inter- palliation [31]. Improvement of symptoms
national randomized STAR-TREC trial [27]. In occurred in 75% of patients. However, all
this study, small cT1–3 N0 lesions are randomized included studies used different dosages.
between primary TME and rectal preserving ther- More recently, a study was published adminis-
apy. In the rectal preservation arm, neoadjuvant tering 5 fractions of 5 Gy in 5 days for palliation
chemoradiotherapy is followed by local excision in of locally advanced rectal cancer [32]. They
case of good clinical response. In case of complete reported reduction or resolution of pain in 87.5%
clinical response, crossover to a watch and wait and of bleeding in 100% of cases. Colostomy-
regime is offered. The hypothesis behind this pro- free rates were 100% after 1 year, 71.4% after
tocol is that chemoradiation could be sufficient as 2 years, and 47.6% after 3 years. Toxicity of this
sole treatment for early stage rectal cancer. dose was low.
This hypothesis is supported by the group of Endorectal brachytherapy has been shown to
Professor Angelita Habr-Gama (São Paulo, be effective in patients with inoperable tumors
Brazil) among others. They described complete and in the palliative setting. When used as a
responses up to 22.4% of the irradiated tumors, boost, it seems to improve the pCR (complete
omitting the need for surgery and enabling a response) but does not impact recurrence rates or
watch and wait follow-up regimen [28, 29]. In overall survival. Local administration of radio-
another publication, they reported improvement therapy by brachytherapy for palliation is an
of absolute survival after chemoradiotherapy option whose use is derived from experience with
alone in the setting of complete clinical response, prostate and cervical cancer. Brachytherapy as
compared to incomplete responses to neoadju- local treatment of rectal cancer has been reviewed,
vant therapy followed by radical surgery in octo- but data are sparse.
genarians (age 80), regardless of whether they In a study by Hoskin et al., 50 patients with
were fit or if they had significant comorbid condi- either inoperable or incurable tumors were
tions [30]. Absolute survival advantage, after treated with brachytherapy as sole treatment or
chemoradiotherapy without versus with radical as a boost to external beam radiotherapy
surgery, was 10.1% for fit octogenarians and (EBRT) [33]. A clinical response was achieved
13.5% for comorbid octogenarians after 1 year. in 75% of all patients, including 14 complete
In summary, the addition of neoadjuvant responses. Median survival for patients treated
chemoradiation appears to improve oncological with definitive EBRT and brachytherapy boost
outcome of local excisions. However, the was 25 months and 7 months for patients
increased morbidity after neoadjuvant radiother- treated with a palliative intent. Of the 28
apy requires caution. Complete responses after patients with rectal bleeding at presentation,
chemoradiation are found in less than one of four 57% achieved a complete clinical resolution
patients. Nevertheless, this might offer opportu- with a median response duration of 10 months.
nities to improve survival and organ preservation, The HERBERT trial also examines the efficacy
if the good responders can be identified. of the combination of EBRT followed by high-
dose-rate endorectal brachytherapy boost in
elderly and medically inoperable patients with
Palliative Radiotherapy rectal cancer. The first results have shown that
response occurred in 29 of 33 patients (87.9%),
The administration of short course radiotherapy with 60.6% complete response (CR). The local
can be regarded in an attempt to avoid surgical progression-free survival and overall survival
intervention. Radiotherapy is often used for pal- rates were 42% and 63%, respectively, at
liative relief of symptoms associated with tumor 2 years [34].
6 Organ Preservation and Palliative Options for Rectal Cancer 53
In conclusion, radiotherapy as sole treatment In conclusion, radical surgery offers the best
for infirm and otherwise inoperable patients oncological outcome. By opting for a Hartmann
seems to be a valid option as palliative treatment procedure, anastomosis-related morbidity and
with significant improvement of tumor related mortality could be avoided in high-risk patients,
symptomology. The combination of external while still maintaining superior oncological
beam radiotherapy with endoluminal brachyther- outcomes.
apy shows especially high response rates. More
data on long-term outcome after radiotherapy is
needed to evaluate toxicity. Conclusion: Tailoring
Palliative Treatment
26. Marks JH, Valsdottir EB, DeNittis A, Yarandi SS, 32. Picardi V, Deodato F, Guido A, Giaccherini L,
Newman DA, Nweze I, et al. Transanal endoscopic Macchia G, Frazzoni L, et al. Palliative short-course
microsurgery for the treatment of rectal cancer: radiation therapy in rectal Cancer: a phase 2 study. Int
comparison of wound complication rates with and J Radiat Oncol Biol Phys. 2016;95(4):1184–90.
without neoadjuvant radiation therapy. Surg Endosc. 33. Hoskin PJ, de Canha SM, Bownes P, Bryant L,
2009;23(5):1081–7. Glynne Jones R. High dose rate afterloading intralu-
27. Rombouts AJM, Al-Najami I, Abbott NL, Appelt A, minal brachytherapy for advanced inoperable rectal
Baatrup G, Bach S, et al. Can we save the rectum carcinoma. Radiother Oncol. 2004;73(2):195–8.
by watchful waiting or TransAnal microsurgery fol- 34. Rijkmans EC, Cats A, Nout RA, van den Bongard D,
lowing (chemo) radiotherapy versus Total mesorec- Ketelaars M, Buijsen J, et al. Endorectal brachytherapy
tal excision for early REctal Cancer (STAR-TREC boost after external beam radiation therapy in elderly
study)?: protocol for a multicentre, randomised feasi- or medically inoperable patients with rectal Cancer:
bility study. BMJ Open. 2017;7(12):e019474. primary outcomes of the phase 1 HERBERT study. Int
28. Glynne-Jones R, Hughes R. Critical appraisal of the J Radiat Oncol Biol Phys. 2017;98(4):908–17.
‘wait and see’ approach in rectal cancer for clinical 35. Manceau G, Karoui M, Werner A, Mortensen
complete responders after chemoradiation. Br J Surg. NJ, Hannoun L. Comparative outcomes of rectal
2012;99(7):897–909. cancer surgery between elderly and non-elderly
29. Dattani M, Heald RJ, Goussous G, Broadhurst J, patients: a systematic review. Lancet Oncol.
Sao Juliao GP, Habr-Gama A, et al. Oncological 2012;13(12):e525–36.
and survival outcomes in watch and wait patients 36. Surgery for colorectal cancer in elderly patients: a
with a clinical complete response after neoadju- systematic review. Colorectal Cancer Collaborative
vant Chemoradiotherapy for rectal Cancer: a sys- Group. Lancet. 2000;356(9234):968–74.
tematic review and pooled analysis. Ann Surg. 37. Damhuis RA, Meurs CJ, Meijer WS. Postoperative
2018;268:955. mortality after cancer surgery in octogenarians and
30. Smith FM, Rao C, Oliva Perez R, Bujko K, Athanasiou nonagenarians: results from a series of 5390 patients.
T, Habr-Gama A, et al. Avoiding radical surgery World J Surg Oncol. 2005;3:71.
improves early survival in elderly patients with rectal 38. Mamidanna R, Eid-Arimoku L, Almoudaris AM,
cancer, demonstrating complete clinical response after Burns EM, Bottle A, Aylin P, et al. Poor 1-year survival
neoadjuvant therapy: results of a decision- analytic in elderly patients undergoing nonelective colorectal
model. Dis Colon Rectum. 2015;58(2):159–71. resection. Dis Colon Rectum. 2012;55(7):788–96.
31. Cameron MG, Kersten C, Vistad I, Fossa S, Guren 39. Mellgren A, Sirivongs P, Rothenberger DA, Madoff
MG. Palliative pelvic radiotherapy of symptomatic RD, Garcia-Aguilar J. Is local excision adequate
incurable rectal cancer – a systematic review. Acta therapy for early rectal cancer? Dis Colon Rectum.
Oncol. 2014;53(2):164–73. 2000;43(8):1064–71; discussion 71–4.
Operative Equipment
and Insufflator Options 7
William Frederick Anthony Miles,
Muhammad Shafique Sajid,
and Eleni Andriopoulou
Introduction History
Access to the proximal rectum via the anus has Transanal intraluminal and extra-luminal rectal
been the limiting factor for transanal surgery since surgery has four limiting factors, which are as
the earliest records of colorectal surgery [1, 2]. follows: (1) the maximum dilation of the anus
Access has always been dependent on instrumen- that can be achieved without damage to the anal
tation. Transanal surgery is limited by these four sphincter muscle, (2) illumination and visualiza-
factors: tion of the rectal lumen, (3) distension of the rec-
tal lumen or pelvic space by insufflation, and (4)
(a) Access the operative instruments which can function
(b) Illumination within the restriction of the rectum or pelvis.
(c) Insufflation Historically rectal access has been achieved by
(d) Instruments dilating the anus with a retractor such as a Parks
retractor or dilating the anus and inserting some
The earliest proctoscopes and sigmoidoscopes form of tube described by Phillip Bozzini in
were limited in all of these areas [3]; however, it 1804 [5]. Alternatively, access can be obtained
is the development of these simple devices into by the buttock or anus [6] or by dividing the
the currently available rectal devices [4] that has sphincter complex and entering the rectum
led to the very significant change in the scope of directly [7]. Access by dividing the anus or an
transanal surgery. In this chapter, we will explore incision through the buttock while allowing
how the development of the anal and rectal access good access to some portions of the rectum has
devices and the associated equipment has led to proved to have the insurmountable problem of
the current revolution in transanal surgery. reconstruction of the rectum and anus. Historic
and more recent series have unacceptable rates
of severe infection and incontinence which ren-
der this approach unacceptable in current medi-
W. F. A. Miles (*) · M. S. Sajid · E. Andriopoulou cal practice [8].
Department of Digestive Disease, The Royal Sussex
County Hospital, Brighton and Sussex University
Hospitals NHS Trust, Brighton, UK
Flexible Sigmoidoscopy
Southend-on-Sea. Further development of the not been refined in more than 20 years of further
flexible sigmoidoscope and colonoscope is development.
beyond the scope of this chapter – however it is Early TEM series have confirmed that it is
possible and even likely the currently divergent possible not only to resect luminal lesions in the
technologies will converge in the arena of trans- upper rectum but also to perform full-thickness
anal robotic surgery [16]. resection of the rectal wall and then close the
defect by suturing [11, 18, 19]. Outcomes in
terms of morbidity, mortality, completeness of
Transanal Endoscopic Microsurgery resection, and completeness of specimens are
improved compared to conventional transanal
The introduction of the transanal endoscopic excision [11].
microsurgery (TEM) device by Wolf, designed The contribution of Karl Storz GmbH and the
by Professor G. Buess [17] (Fig. 7.2), represented development of the Hopkins rod lens system
a step change in transanal surgery. The device must be recognized and their development of a
allowed microscopic, stereoscopic, illuminated similar device, the transanal operating endoscope
vision within the lumen of a stable insufflated (TEO). This provided similar access but without
rectum with the ability to extract both smoke and stereoscopic vision, stable insufflation, or smoke
fluid. With this equipment it was possible to per- extraction. Comparative series have, however,
form operative surgery using specialized instru- shown no difference in the outcome between
ments with excellent vision. The inflation of the TEM and the TEO system when using a high-
rectum was maintained by the special TEM definition 2D camera [20].
insufflator and by the presence of seals on all of These so-called rigid platforms (TEM/TEO)
the instrument and optical channels. While the have enjoyed more than 20 years of predomi-
entire TEM setup represents an unprecedented nance as the equipment of choice for advanced
development in the instrumentation of transanal transanal surgery. There have been a number of
surgery, the TEM insufflator, in particular, has series published which have confirmed that such
systems can be used to achieve complete excision
of both benign polyps and early rectal cancer and
achieve very low local recurrence with minimal
mortality and morbidity [21–26]. Furthermore,
there is evidence that the quality of specimen
achieved is independent of the platform used
with Lee et al. demonstrating equivalence
between all advanced transanal platforms for
transanal local excision of rectal neoplasia [27].
While the majority of transanal surgery using
TEM/TEO devices has been limited to the exci-
sion of benign tumors and early rectal cancer
leaving the rectum and mesorectum intact, there
have been a number of small series whereby
these systems have been used to remove the
entire rectum and in some cases the sigmoid
colon. Using a TEM scope for access,
M. Whiteford et al. described the first transanal
proctectomy without abdominal access and with
anastomotic reconstruction in a cadaveric model
Fig. 7.2 The TEM telescope introduced in 1983 by
Richard Wolf. https://www.richard-wolf.com/company/ in 2007 [28], which would ultimately serve as the
history.html prequel to the modern taTME operation.
60 W. F. A. Miles et al.
This extended use of TEM-type equipment to transanal minimally invasive surgery (TAMIS).
remove the rectum has not entered into main- Subsequently, Hompes et al. similarly showed
stream practice but, as a point of distinction, the that by using a combination of an CAD (circular
first cadaveric series [28] and the first report of anal dilator) and a GelPOINT mini access sheath,
taTME in a human was reported in May 2010 it was possible to preform intraluminal surgery
using the TEM system [29]. As will be discussed using standard laparoscopic equipment including
in the following section, the parallel development the ports, laparoscope, and instruments [33]. The
of single-incision laparoscopic surgery (SILS) same group also described the use of the glove
and the subsequent use of such ports for rectal port for transanal access [34]. The further devel-
access represented a paradigm shift and was an opment of TAMIS to taTME is discussed below.
important step forward in the evolution of
advanced transanal surgery [30].
TEM and TEO platforms continue to be used Transanal Access Platforms
and may have some advantage in the resection of
intraluminal lesions in the upper rectum and are Transanal Retractors
still preferred by some surgeons as a platform for
taTME. Small comparative trials have shown no Open access to the low rectum and anus can be
difference in specimens retrieved with either the achieved by metal retractors which typically have
rigid or flexible platforms when used for taTME two or three opposing metal blades. Once inserted
in cadavers [31]. into the anus, these blades are separated provid-
ing access. This is the simplest form of low rectal
access device and includes the Parks anal retrac-
SILS, TAMIS, and the Glove Port tor and the Pratt or Eisenhammer type of
instrument.
SILS ports have been developed to meet the
demand to improve the cosmetic outcome of lap-
aroscopic surgery by performing operations Operating Sigmoidoscopes
through a single abdominal incision, particularly,
via the embryonic natural orifice, the umbilicus. The use of rigid sigmoidoscopies is now predom-
Whereas previously a laparoscopic cholecystec- inately limited to diagnosis and biopsy [35, 36].
tomy might have required the insertion of three However the operating sigmoidoscope may con-
or typically four ports, the SILS technique tinue to be used for the removal of foreign bodies
required a single point of access [32]. A number from the rectum [37].
of multichannel laparoscopic ports have been
developed for abdominal access and some spe-
cifically designed for transanal access. The Lone Star Retractor
GelPOINT path transanal access platform
(Applied Medical, Rancho Santa Margarita, The Lone Star retractor is a patient-mounted
California, USA) was developed specifically for retractor employing multiple hooks on elastic
transanal access, and the SILS port (Covidien, mounts. This can be used to evert the anus and to
Norwalk, Connecticut, USA) was the first port to stabilize the pelvic floor. It is particularly useful
be used for transanal access. Atallah et al. in a when placing the flexible access channel in the
series of 6 patients [30] showed that the SILS anus to ensure that the top edge of the channel
port could be used to provide rectal access to engages above the levator plate.
operate within the rectum with the minimum of The Lone Star retractor can also be used to
additional equipment over and above that which operate at the in the inter-sphincteric space and is
would normally be found on a laparoscopic very useful in the initial phase of surgery of the
colorectal tray. The authors termed this technique anorectal junction [38, 39].
7 Operative Equipment and Insufflator Options 61
TAMIS SILS
There are a number of flexible ports that utilize The Covidien (Medtronic, 710 Medtronic
the TAMIS technique currently available. They Parkway, Minneapolis, Minnesota, USA) SILS
are discussed below. port (Fig. 7.4) is a foam port which is seated in
the anal canal and is sutured in place. This has
three preformed holes which allow the insertion
elPOINT Path Transanal Access
G of three ports (usually one 10 mm and two 5 mm
Platform ports) to allow rectal access and insufflation. The
SILS port was the platform used to perform the
The GelPOINT path transanal access platform initial report of TAMIS surgery as reported in the
(Fig. 7.3) (Applied Medical, Rancho Santa literature [30].
Margarita, California) is perhaps the most com-
monly used access channel for transanal surgery
and, with the aid of the surgeons who developed OCTO Port
TAMIS, was designed specifically for this pur-
pose. The single-use, disposable device comprises The OCTO port (DalimSurgNET, B1401Woolin
of a deformable semirigid access channel with a Blue Nine, 583, Yangcheon-ro, Gangseo-gu,
proximal flange and a distal flange supported by a Seoul, Korea) is a flanged sleeve which can be
metal ring. The access channel can be introduced inserted into the anal canal and a plate carrying
into the anus with gentle pressure. The second multiple access ports attached. In Europe and
part of the device, a gel cap, is attached to the dis- North America, it is not commonly used, and its
tal end of the channel. Three, or if required four, use was supported by only 21.6% of the St.
ports are inserted through the gel. This provides a Gallen expert group – although availability of
semirigid gastight support for the camera and this platform may limit its use by this group and
instruments. The gel cap has two luer lock con- the port itself has not been compared to other
nections for insufflation and evacuation of gas. A TAMIS ports in a meaningful way. There are a
recent development of the GelPOINT path system number of other ports suitable for TAMIS includ-
has been the incorporation of a special high flow ing the Dapri-Port (manufactured by Karl Stortz)
port to be used with the insufflation stabilization (Fig. 7.5) and the KeyPort flex (Richard Wolf)
bag (ISB; see below). The access channel is avail- (Fig. 7.6).
able in three lengths and with or without the prox-
imal flange. Of the experts performing taTME,
91% utilize the GelPOINT path as the access
channel of choice [43].
Transanal Instrumentation
after local excision. While preferred by some in general dissection. The St. Gallen consensus
TAMIS experts, automated suturing devices are meeting reached 94.6% consensus on the state-
generally not in widespread use due to cost limi- ment that monopolar and bipolar diathermy were
tations. Furthermore, for most closures of rectal the energy source of choice [43] and vessel-
wall defects after full-thickness excision of rectal sealing devices for transanal access, although
neoplasia, a laparoscopic needle holder and used, are less preferred for both local excision
absorbable suture are sufficient to reapproximate and more advanced procedures.
most defects in the rectal wall. Endoluminal
suturing is however made more straightforward
by the use of a self-locking, barbed suture such as Energy Devices
the V-Loc suture (Medtronic, 710 Medtronic
Parkway, Minneapolis, Minnesota, USA,) or the Ultrasonic dissection is most suited for full-
STRATAFIX suture (Ethicon, Bridgewater, New thickness dissection of the rectal wall and close
Jersey). dissection of the rectal wall from the mesorec-
tum when performing proctectomy for inflam-
matory bowel disease. The ultrasonic dissector
Diathermy has the advantage of providing division of tis-
sue with simultaneous hemostasis. This is an
Monopolar diathermy is the most commonly advantage when dividing the full thickness of
used option for transanal surgery. The choice of the rectal wall including the rectal mucosa.
instrument tip, hook, spatula, or needle knife is These layers of tissue have a robust blood sup-
very much dependent on the operator. The ply and may bleed especially during full-thick-
advantage of monopolar diathermy, as a method ness excision of a large polyp or an early rectal
of tissue division, is that the energy released cancer.
leads to tissue vaporization with separation of In some circumstances however, the sealing
the tissue [52]. This causes a release of the ana- process can also seal the tissue planes together
tomical planes allowing them to separate. In causing the dissection to pass unnoticed by the
comparison, energy devices such as ultrasonic surgeon from one tissue plane to another. This is
shears or other tissue-sealing devices tend to particularly so during taTME. This sealing effect
seal the anatomical planes together. The dia- can impede the surgeon’s attempts to stay within
thermy effect may be adjusted to provide more the correct anatomical planes.
or less hemostasis by blending the “pure cut” Advanced energy devices use a low voltage
current with the “coagulation” current. As the and a high electrical current between bipolar
dissection is predominantly in an avascular electrodes along with pressure to plasticize and
plane, there is usually no need for advanced fuse tissue. The overall effect is similar to the
energy devices. Most experts prefer low-energy effect created by an ultrasonic dissector.
settings for electrosurgery to minimize the accu- Advanced energy devices can be used in a similar
mulation of smoke and to lessen the effect of way to ultrasonic dissectors to complete dissec-
tissue charring. The use of foot switch or finger tion. There are no published data to suggest
switch to operate the diathermy machine based which may be more effective. As mentioned
upon surgeon’s preference although foot switch- above, the close dissection of the rectum during
ing may allow more accurate dissection with proctectomy for inflammatory bowel disease is
less fatigue [53] . facilitated by using either an ultrasonic dissec-
Bipolar energy is not generally used for trans- tor or any commercially available advanced
anal surgery although it may be used to control energy device. Advanced energy devices are not
troublesome bleeding from venous channels on commonly used for local excision or rectal neo-
the pelvic side wall, presacral veins, or the pros- plasia or advanced procedures such as taTME
tate gland’s neurovascular bundles. It is not used dissection [54].
7 Operative Equipment and Insufflator Options 65
Volume pressure curve none compliant [58]. Almost all insufflators in current use are
pressure and flow rate controlled [59, 60]. The
30
insufflator is set to a pressure which creates suf-
Pressure in cm water
Volume pressure curve normal laparoscopy Volume pressure curve for the rectum
30
Inflation
Volume of isufflated gas within the rectum
Volume of isufflated gas within the abdomen Fig. 7.13 Volume of insufflated gas against the volume
of the insufflated rectum
Fig. 7.11 Volume of gas insufflated and the change in the
measured volume of the abdomen
of gas added increases. This is the situation at the
Volume pressure curve small volume non-compliant beginning of a TAMIS for local excision or
TAMIS for taTME immediately following place-
Intraluminal pressure in cm water
atmospheric pressure is added, then P = 200/100 uted to the work of Dr. Kurt Semm (1927–2003).
P = 2. That is, the pressure in the rectum would Semm, an experienced toolmaker and gynecolo-
rise to 2x atmospheric pressure or 1020 cm of gist, had developed a device for controlled CO2
water above atmospheric pressure. insufflation of the fallopian tubes. This was the
Clearly, this does not happen in vivo, and, in basis of his electronically controlled CO2 insuf-
fact, two things do happen. First, in the example flation device for laparoscopy produced by the
using the GelPOINT path TAMIS port, the volume Wisap Company in the 1960s (Wisap® Medical
of the system is not fixed, and so the gel cap and Technology GmbH, Fichtenstrasse 27, 85,649
the rectum both stretch. Second, only a small Brunnthal/Hofolding, Germany).
amount of gas is added before the insufflator The most simple insufflation control circuit
senses an increase in pressure and stops delivering allows insufflation and pressure sensing to occur
additional gas. It can be seen that in these circum- through a single tube connected to the laparo-
stances the pressure in the rectum increases almost scopic port which has been inserted into the
in direct relation to the amount of gas added. The abdomen. This is the delivery and sensing cycle
smaller and less compliant the insufflated volume, (Fig. 7.14) [65]. The controls of the insufflator
the larger the pressure rise for a given amount of allow the rate of insufflation (as measured in
gas insufflated. With very small non-compliant liters per minute) and maximum pressure (as
volumes such as a rectal access device in a closed measured by cm of water) to be set before insuf-
rectum, there can be very rapid and large change in flation begins. Typically, the insufflator will dis-
pressure for only a small amount of gas added. The play the preset pressure and the actual
rate of change of pressure is directly related to the intra-abdominal pressure measured by the insuf-
rate of insufflation of the gas. It is this relationship flator, the preset flow rate and the actual flow rate,
between pressure, volume, insufflation rate, and and the volume of gas which has been delivered.
the method of control of the insufflator that leads The sensing and insufflation cycle is governed by
to billowing and overpressure in the rectum [64]. a control algorithm within the device (Fig. 7.15).
In order to achieve insufflation in a reasonable
time and with the restriction imposed by insuffla-
Insufflators and Insufflation Control tion being achieved via a standard luer lock con-
nections to the insufflation tube and laparoscopic
The earliest versions of what we would now rec- port, during insufflation, the pressure in the deliv-
ognize as a laparoscopic insufflator began to ery tubing will be much higher than the set pres-
appear in the 1960s and have largely been attrib- sure of the insufflator. With a single tube
insufflation system, it is not possible to measure pressure. In these circumstances, very high pres-
the pressure in the abdomen during insufflation, sures compared to the set pressure can be
and so insufflation is briefly suspended and the achieved (Fig. 7.16).
pressure in the delivery tube allowed to equili- As discussed previously, the commonly used
brate with the abdominal pressure. Then the true insufflation devices have a single channel to both
abdominal pressure can be measured. The insuf- insufflate the abdomen and measure the pressure
flator employs a control algorithm to allow it to in the abdomen. There is a brief pause in insuffla-
reach the preset intra-abdominal pressure by tion during the sensing phase, and then insuffla-
cycling between gas delivery and pressure sens- tion is resumed. This continues until the set
ing until the required set pressure is reached. pressure is reached. The intermittent nature of the
Once this has occurred, sensing continues and insufflation is not generally noticeable during
insufflation is suspended when the set pressure is abdominal laparoscopy because the volume of
reached. Should the abdominal pressure fall for the abdomen is high and the changes in the vol-
any reason, then the insufflation process will ume of gas are small as a percentage of the total
resume. Should the abdominal pressure increase volume. The insufflator is working in the compli-
above the preset value, the insufflator will auto- ant phase of the pressure-volume curve of the
matically vent gas from the system, retrograde abdomen (see above). The damping effect caused
via the insufflation tube, until the pressure again by the compliance of the abdomen creates the
reaches the preset value [66]. impression that the insufflation pressure is stable.
In this system, it is not possible to simultane- This compliance also moderates any changes in
ously deliver gas and sense the pressure in the volume related to a small change in pressure.
abdomen. This is the basis of the control circuit This is not the case when the insufflated volume
employed by the majority of simple insufflators is small, such as in the closed rectum, and when
used for laparoscopy. While the simple insuffla- the compliance is low, with a rigid or flexible
tion control circuit is suitable for basic laparos- access channel. When this is the case, insufflation
copy, by the nature of its design, it is not possible of a small volume of gas can lead to very large
to maintain the abdominal pressure at exactly the changes in the pressure and almost no change in
set pressure all of the time. It is always an approx- volume of the rectum.
imation. Furthermore, as the flow rate increases In the majority of current systems, insuffla-
and the volume and compliance of the space tion is achieved via a standard luer lock connec-
decrease, there is a greater deviation from the set tor and small bore tubing. The dimension of the
Outflow to
patient
Luminal pressure
luer lock connector is governed by an interna- may be as small as 62 ml as discussed previ-
tional standard (ISO 80369) which requires that ously. During insufflation especially at high flow
the internal diameter of the male connector be rates, the pressure in the delivery tubing is much
2.7 mm in diameter. This is generally the small- higher than the pressure in the rectum. As the
est diameter pipe in the system although the rectum begins to fill, the pressure in the rectum
valves have a similar internal diameter. This nar- rises. During the sensing phase of the insuffla-
row point in the gas pathway provides a signifi- tion sensing cycle, the rectal pressure equili-
cant restriction to flow. To overcome this and to brates to the pressure in the delivery tubing. As
deliver a sufficient volume of gas in a short time, the pressure in the rectum nears the set pressure
the pressure difference across these restrictions on the insufflator, one of three things can
must be high. To produce a flow rate of 20 L/pm happen:
would require a pressure difference across the
connector of 60 mmHg. This, in turn, can lead to 1. The insufflator senses that the rectal pressure
high pressures within the inflated volume once it is lower than the set pressure and resumes
has reached its maximum capacity. In the abdo- insufflation.
men, the maximum volume is governed by the 2. The insufflator senses the rectal pressure has
compliance of the abdominal wall and dia- reached the set pressure and pauses
phragm and the compressibility of any intra- insufflation.
abdominal organs. As discussed above, this 3. As the pressure in the insufflation tubing
creates a compliant system, and so there may be equilibrates with the rectum, the pressure is
a relatively small change in pressure with quite higher than the set pressure and the system
large changes in the volume of gas within the vents.
abdomen. This is not however the situation when
inflating the rectum within the confines of the In the third scenario, as the system vents CO2, the
bony pelvis where the volume is constrained pressure in the rectum can fall below the set pressure,
[67]. The rectal volume within the pelvis is rela- and so the sensing insufflation cycle resumes.
tively small and the compliance is low. Persistent overshooting of the set pressure and subse-
Insufflating a small volume of gas can lead to quent venting is observed as billowing. The overshoot
very large changes in pressure. This is most of the set pressure can be substantial [68] and may be
apparent with a standard insufflator during the exaggerated if there is a constant loss from the system
initial step of taTME. In this situation, after due to smoke extraction or suction. Billowing may
placement of the purse string suture, the insuf- also occur without overshooting of the set pressure if
flated volume of the access channel and rectum losses from the system are high (Fig. 7.17).
7 Operative Equipment and Insufflator Options 71
Luminal pressure
Billowing
During billowing, rectal pressure falls below of its pressure control systems, these periods of
the collapsing pressure of the rectum (the pres- overpressure can be small and short-lived or
sure at which the rectal distension is no longer more prolonged and more severe. It is possible
maintained). It is at this point that movement of that overpressure in the rectum could drive CO2
the rectum is observed. It is also possible that into the blood stream and thus a potential cause a
unintentionally high pressures may occur, depen- CO2 embolus, a rare but serious complication of
dent on the insufflator settings and design, as the taTME surgery [64, 69].
insufflator attempts to achieve the set pressure.
The resultant movement can be a very significant
impediment to safely continuing the operation. The TEM Insufflator
Billowing is most prominent when the inflated
volume is very small. Billowing can occur with It was the problems with the simple insufflation
any of the currently available TAMIS ports when system that spurred Professor Buess to pursue the
used with a standard insufflator. Billowing occurs development of the TEM insufflator (Wolf
infrequently with the TEM-specific insufflator GmbH). In this system there are four separate
and rarely when the AirSeal® insufflator connections to the TEM apparatus. They are as
(ConMed, Inc. Utica, New York) is employed follows:
together with a TAMIS port, as discussed in the
following sections. 1. Gas delivery
Smoke extraction can require rapid exchange 2. Pressure sensing
of the gas in the rectum. These high flow rates 3. Smoke evacuation
demand high pressures to overcome the resis- 4. Camera washing
tance of small bore insufflation tubing but more
so the luer lock connections which are found uni- In this system, gas delivery is continuous apart
versally on both ports and anal access channels. from very brief periodic interruptions when the
The need for high pressure to create enough flow machine has to recalibrate. Pressure sensing is
to overcome leakage and the suction used to also continuous as is smoke evacuation. Camera
evacuate smoke can lead to overpressure of the washing is via a separate channel and is con-
system. Overpressure occurs when the insufflator trolled by the operator and does not take part in
continues to insufflate despite the luminal pres- the insufflation circuit. The rate of smoke evacu-
sure reaching the set pressure on the insufflator. ation never exceeds the rate of gas delivery, and
Depending on the type of device being used, the the evacuated smoke is lost from the system
set pressure, its flow settings, and the sensitivity (Fig. 7.18). Because both the delivery and loss of
72 W. F. A. Miles et al.
Outflow to
patient
Insufflation control
Pressure sensor
from patient
The AirSeal® system (ConMed, 525 French Fig. 7.19 The AirSeal insufflator (ConMed, 525 French
road, Utica, New York, USA) was not developed road, Utica, New York, USA)
specifically for TAMIS or taTME, but because of
its design and the way in which it controls and
maintains the pressure within the system, it has replaced into the circulating volume by the
been found to have significant advantages. In insufflator without pausing circulation of the
“AirSeal® mode” the AirSeal® insufflator gas. The gas flow created at the tip of the AirSeal®
(Fig. 7.19) uses a pump to circulate CO2 through trocar is turbulent, and so the smoke is mixed
the AirSeal® trocar – commonly placed through with the inflow gas and is removed as the gas is
the gel cap of the GelPIONT Path TAMIS Port. recirculated. As it is a constantly sensing system,
The design of the hub of the trocar creates a vor- the AirSeal® insufflator is able to create a very
tex which effectively creates a local high- stable operating environment with reduced lev-
pressure barrier which prevents CO2 from els of smoke in the operating field (Fig. 7.20). It
escaping the abdomen (i.e., there is no trapdoor is not, however, possible to remove fluid via the
barrier, only an invisible pressure barrier). A AirSeal® insufflation system, and if fluid or
separate channel continuously measures the blood enters either the recovery side of the circu-
pressure of the tip of the AirSeal® trocar. CO2 is lating loop or the pressure sensing channel, the
circulated through a high-capacity filter which system may shut down. Furthermore, if fluid
removes the smoke and the gas and then recircu- passes through the filter in the system, the insuf-
lates the gas. If gas is lost from the system, it is flator may be damaged (Fig. 7.21).
7 Operative Equipment and Insufflator Options 73
Outflow to
Filter patient
Insufflation control
Return from
patient
Emergency over pressure vent
Pressure sensor
from patient
High pressure CO2
Off Delivery and sensing Delivery and sensing Delivery and sensing
The published data for the AirSeal® insuffla- California) system is a novel approach to the
tion system show that it provides a significantly problem of billowing [64]. The ISB creates a
more stable luminal pressure than a standard large, compliant dead space between the insuffla-
insufflator. Bucur et al. showed in a randomized tor and the GelPOINT path (Fig. 7.22). This
trial of patients undergoing renal surgery with an increases the insufflated volume and also the
insufflation pressure of 12 mm hg that the actual compliance of the system. The effect of this is to
pressure was between 12 and 18 mm for 79% of simulate insufflation of a much larger, abdominal
the time with a standard insufflator, while the volume where billowing is not observed
AirSeal® device maintained the actual pressure (Fig. 7.23). In this circumstance, the control sys-
within this range for 87.4% of the time. tems of the insufflator work in a predictable man-
ner, and fluctuations in pressure are minimized.
The compliant nature of the ISB ensures that
ISB and EPIX insufflation occurs in the compliant phase of dis-
tension of the ISB. The device is connected to the
The insufflation stabilization bag (ISB) and EPIX rectum via a custom port placed through the
(Applied Medical, Rancho Santa Margarita, GelPOINT path (Fig. 7.24). This large diameter
74 W. F. A. Miles et al.
ISB device
Outflow to
Emergency over pressure patient
vent
Hazards of Insufflation
The risk of CO2 embolus may be reduced by will allow improved maneuverability within the
maintaining as low an insufflation pressure [69, confines of the pelvis [51]. The field of advanced
71] as will allow the operation to proceed, employ- transanal surgery is expanding exponentially.
ing steep Trendelenberg position to allow lower This expansion is dependent on surgeons con-
working pressure in the rectum and employing a tinuing to explore novel ways of using the equip-
stabilized insufflation device which reduces peak ment that is available to them and assisting the
pressures during insufflation. It is likely that, as in equipment manufactures to develop new and
other laparoscopic surgery, CO2 embolus occurs more useful devices.
when the insufflation pressure is high enough to
allow CO2 to enter an open venous channel. The
open channel may not bleed, while the insufflation References
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Operating Theater Setup
and Perioperative Considerations 8
Teresa H. deBeche-Adams, Raymond Yap,
and George Nassif
on the length of the patient’s anal canal, the correct section difficult. One solution is the use of an
access channel should be selected to ensure that advanced insufflator such as the AirSeal
the proximal end of the port is seated above the (ConMed, NY, USA, see below) [6]; however,
anorectal ring when inserted. In the United States, there is a considerable upfront capital cost.
this port is an FDA-approved device for TAMIS Another solution, which now is included in the
and has been specifically designed for transanal GelPOINT path kit, is an insufflation stabiliza-
access. Alternatively, the SILS™ port (Medtronic, tion bag (ISB) (Applied Medical, CA, USA,
MN, USA), although not designed for TAMIS, has Fig. 8.2) [7]. This device, placed between the
been used for this procedure and is quite suitable insufflator and access valve, helps stabilize the
as well; it is also FDA approved [2]. Other com- rate of insufflation and reduces the amount of
mercially available ports designed for single inci- billowing in the rectum (Fig. 8.3).
sion laparoscopy have been described [4]. For taTME cases, a Lone Star retractor
Standard laparoscopic equipment is essential. (CooperSurgical, CT, USA) is preferred
This includes a camera and light system, a (Fig. 8.4). By retracting the anal skin in this area,
30-degree 5 mm or 10 mm rigid laparoscope, the dentate line is everted and exposed in a more
laparoscopic graspers such as a Maryland grasper,
laparoscopic needle holders, monopolar cautery,
a laparoscopic suction/irrigation set, and laparo-
scopic insufflator. Other required equipment
includes betadine to irrigate the surgical field, a
0-silk suture to secure the port in place from
rotating during surgery, and open suction tubing.
One of the challenges with using standard
laparoscopic insufflation is the “billowing” due
to gas continuously escaping through the proxi-
mal colon at an uneven rate. This, combined
with the fact that CO2 insufflation disrupts the
pressure sensing unit, results in uneven CO2
cycling within the rectum [5]. The consequence
of this is that the rectum can move in a cyclic Fig. 8.2 Insufflation stabilization bag (ISB), used during
fashion during the operation making precise dis- a TAMIS case
Fig. 8.3 Demonstration Gas Flow Into ISB Gas Flow Out of ISB
of the ISB setup. It is
usually placed between
the insufflator and
Flow
Flow
Insufflator
Insufflation tubing
8 Operating Theater Setup and Perioperative Considerations 83
a b
Fig. 8.4 Insertion of GelPOINT into anus. Note the placement of the Lone Star retractor: (a) without cap, (b) with cap
and ports in place
A flexible-tip laparoscope can also be employed fresh specimens to minimize shrinkage and for a
for use at the surgeon’s preference. Although the more accurate interpretation of margins.
authors have found this cumbersome to use within
the strict confines of the rectum, some experts have
found this option beneficial. Proponents would Operating Theater Setup
argue that the flexible-tip scope would be useful to
reduce instrument clashing and to allow for greater The setup for TAMIS is similar to the setup for
visualization of the operative field. However, the TAMIS-based taTME. Figure 8.7 is a diagram-
small operating space actually causes the instru- matic representation of the typical theater setup
ments to collide with the tip of the camera, causing during a taTME procedure. For the purposes of
it to deflect away from the field of view. TAMIS setup, only the bottom-labeled elements
Finally, anti-stick solutions such as Electro in the picture and Boom 2 are required. In addi-
Lube® (Eagle Surgical Products, TX, USA) tion, due to the absence of an abdominal compo-
placed onto the hook diathermy tip can reduce the nent, Boom 2 is often placed on the right side of
char deposited on the instrument, reducing the the patient where the top team would be standing
need to clean the tip. In addition, a needle board is so that laparoscopic cables are all running cepha-
also recommended to pin the specimen immedi- lad over the patient’s leg. The surgeon and assis-
ately after extraction to facilitate pathological tant are positioned as for any perineal case, and
examination. Local excision specimens should be the scrub nurse usually stands to the right of
appropriately oriented and sent to pathology as them.
Fig. 8.7 Diagrammatic
representation of TAMIS/ Boom 1
taTME setup. Please note Bovie
that only the elements Bipolar Air Seal Air Seal
marked with “bottom” are Suction 1 2
required for a TAMIS Camera (Bottom) (Top)
Patient Table
setup
T
O Top
P Monitor
T
E
A
M
Bottom Team
Bottom Scrub
Boom 2
Bovie
Bipolar
Camera
86 T. H. deBeche-Adams et al.
recommended equipment is not essential, it is 5. Burke JP, Albert M. Transanal minimally invasive sur-
gery (TAMIS): pros and cons of this evolving proce-
highly recommended to have this available as it dure. In: Seminars in colon and rectal surgery, vol. 26,
will provide important adjuncts to the safe and no. 1. WB Saunders; 2015. p. 36–40.
expeditious completion of TAMIS. Most patients 6. Bislenghi G, Wolthuis A, van Overstraeten ADB,
who undergo TAMIS for local excision can be et al. AirSeal system insufflator to maintain a stable
pneumorectum during TAMIS. Tech Coloproctol.
managed in an ambulatory fashion. 2015;19(1):43–5.
7. Waheed A, Miles A, Kelly J, et al. Insufflation stabili-
zation bag (ISB): a cost-effective approach for stable
References pneumorectum using a modified CO2 insufflation
reservoir for TAMIS and taTME. Tech Coloproctol.
2017;21(11):897–900.
1. Maslekar S, Pillinger S, Sharma A, et al. Cost analy-
8. Maykel JA. Laparoscopic transanal total mesorectal
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tumours. Color Dis. 2007;9(3):229–34.
Surg. 2015;19(10):1880–8.
2. Rimonda R, Arezzo A, Arolfo S, et al. TransAnal min-
9. Artinyan A. Transanal minimally invasive sur-
imally invasive surgery (TAMIS) with SILS™ port
gery for rectal cancer. In: Kim J, Garcia-Aguilar
versus transanal endoscopic microsurgery (TEM):
J, editors. Surgery for cancers of the gastrointes-
a comparative experimental study. Surg Endosc.
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2013;27(10):3762–8.
org/10.1007/978-1-4939-1893-5_27.
3. Albert MR, Atallah SB, Izfar S, et al. Transanal mini-
10. Debeche-Adams T, Hassan I, Haggerty S, et al.
mally invasive surgery (TAMIS) for local excision of
Transanal minimally invasive surgery (TAMIS): a
benign neoplasms and early-stage rectal cancer: effi-
clinical spotlight review. Surg Endosc. 2017;31(10):
cacy and outcomes in the first 50 patients. Dis Colon
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11. Sumrien H, Dadnam C, Hewitt J, et al. Feasibility
4. Barendse RM, Verlaan T, Bemelman WA, et al.
of transanal minimally invasive surgery (TAMIS)
Transanal single port surgery: selecting a suitable access
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port in a porcine model. Surg Innov. 2012;19(3):323–
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Surgical Technique for Local
Excision of Rectal Neoplasia 9
Matthew R. Albert and Paul Kaminsky
within the mesorectum, and every effort must be ticularly regarding any benefit to adjuvant
made to select patients with minimal risk of nodal chemoradiation therapy.
metastasis for curative-intent local excision [4]. Patients with T3 tumors with a response to
Published rates of lymph node metastasis (LNM) neoadjuvant therapy can, in select instances, be
for all T1 and T2 rectal tumors range from 10% considered for local excision – however, the
to 14% for T1 and ~20% to 25% for T2 cancers authors caution that complete pathologic response
[5–9]. However, when lesions with unfavorable in the primary tumor does not imply complete
histology are excluded (poor differentiation, lym- nodal response. T3 tumors frequently have nodal
phovascular, and perineural invasion), these rates metastasis (40–50%) and may have positive nodes
drop significantly (T1, 2.2–6%; T2, 11%) [5, 7]. despite a complete pathologic response in the pri-
The National Comprehensive Cancer Network mary tumor [5, 12]. Therefore, we do not recom-
rectal cancer guidelines state that patients with mend local excision in these cases unless the
mobile, well to moderately differentiated, cT1N0 patient cannot tolerate radical surgery. There are
lesions that are less than 3 cm in diameter with no no specific contraindications for TAMIS local
lymphovascular or perineural invasion are appro- excision other than those outlined above.
priate candidates for local excision. Lesions
larger than 3 cm may also be eligible for local
excision depending on risk of postoperative rec- Operative Technique
tal lumen stenosis. Although current recommen-
dations suggest that lesions that demonstrate Preparation and Positioning
invasion deeper than the first third of the submu-
cosa (i.e., sm2/3) are at higher risk of lymph node Mechanical bowel preparation is essential in
metastases, recent literature suggests that sm2 TAMIS as a clear field of view is required to
tumors with favorable histology have rates of operate endoluminally. A simple enema prepa-
lymph node metastasis similar to sm1 [5–7, 9]. ration is often sufficient. In the setting of a
Strict adherence to these criteria may result in poor preparation, high-volume irrigation uti-
equivalent oncologic outcomes for local excision lizing a rigid proctoscope can easily be per-
of malignant neoplasia, when compared to radi- formed. Patients with mid-rectal or higher,
cal surgery. An analysis of the Surveillance, especially anterior lesions, should undergo
Epidemiology, and End Results database reported complete mechanical bowel preparation to
that comparable cancer-specific survival between minimize contamination in case of peritoneal
local excision and transabdominal resection [10] entry. Current evidence supports the use of oral
and a meta-analysis comparing TEM local exci- antibiotics in addition to a mechanical bowel
sion and radical surgery for T1 rectal cancer also preparation in patients undergoing a large
demonstrated equivalent 5-year overall survival bowel anastomosis for reduction in wound-
[2, 11]. Additionally, patients must be informed related complications; however its effect in
that a final pathological analysis may yield high- transanal surgery is unclear.
risk factors and warrant additional radical Surgical site infection and thromboprophy-
surgery. laxis are given within 30 minutes of surgery in
Patients with T1 sm3 or T2 tumors who are accordance with guidelines for colonic surgery.
considered high risk for radical surgery or Foley catheterization is optional as urinary reten-
patients with tumors that would result in a perma- tion is rare.
nent stoma may consider local excision, albeit Patients can be placed in lithotomy position
with informed discussion over the increased risk regardless of lesion position within the rectal
of local and mesorectal recurrence, in the context lumen. The main operative monitor is placed at
of current guidelines and patient desired out- the head of the operative bed, and both surgeon
comes [5, 6]. Treatment of these tumors should and assistant are seated between the legs of the
be discussed in a multidisciplinary setting, par- patient (Fig. 9.1).
9 Surgical Technique for Local Excision of Rectal Neoplasia 91
sal (partial-thickness) excision is an alternative as exhibit tumor shedding with even minor instru-
full-thickness excision is not necessary in this ment manipulation; this can theoretically result
setting. This is particularly important for proxi- in the implantation of live tumor cells within
mal, proven benign anterior lesions, as the risk of resection bed. Although controversial, some sur-
peritoneal entry is minimized by this approach. geons advocate en bloc removal of mesorectal
Furthermore, for large, flat carpeted benign fat beneath the lesion to retrieve lymph nodes,
lesions (classically, tubulovillous adenomas) especially when the lesion is located posteriorly
whereby the defect after excision is too large to in the rectum. No literature supporting the supe-
reapproximate, a planned partial-thickness exci- riority of this technique exists, although theoreti-
sion is a good option. It should be stressed that cally the sampling of positive or negative
partial-thickness excision is never considered an juxtaposed mesorectal lymph nodes potentially
option for polyps suspected to harbor a cancer may significantly alter treatment recommenda-
based on staging or endoscopic assessment and tions when the node is found to be positive. This
lesion morphology. notion is supported by several small studies of
sentinel lymph node biopsy in rectal cancer. The
echnique for Local Excision
T dye-containing nodes are typically near the pri-
The procedure begins by defining the excision mary tumor. Care must be taken to avoid breach-
perimeter of the lesion with at least a 1 cm mar- ing the mesorectal fascial envelope to minimize
gin circumferentially using electrocautery disruption of the anatomic planes should proc-
(Fig. 9.3). For malignant lesions, a full-thickness tectomy become necessary [14].
division of the rectal wall distal to the lesion is
then performed, which allows manipulation of nterior Lesions and Peritoneal Entry
A
the specimen without directly contacting the Anterior lesions are still best accessed in the
tumor. Perpendicular division through the entire lithotomy position, in contrast to conventional
rectal wall until the mesorectal fat is encoun- transanal excision or TEM where the prone jack-
tered is critical to achieving a complete speci- knife position is necessary. Careful attention
men when the lesion is known or suspected to be must be given for anterior lesions, as there is a
invasive (Fig. 9.4). During excision and manipu- risk of prostate or vagina injury, and this dissec-
lation, the specimen must be grasped on the edge tion can be quite challenging since the anterior
of normal mucosa or underneath the lesion on mesorectum is much thinner than it is posteriorly.
the mesorectal fat to minimize fragmentation of Anterior organ injury was described in the early
the tissue and tumor. It should be noted that literature of TEM in the 1980s; however, it has
many rectal lesions are extremely friable and not been reported in any series on
TAMIS. Familiarity with the anatomical planes
and surrounding critical structures is important.
Peritoneal entry is an uncommon event, occur-
ring in up to 4% of patients with anterior tumors
located in the mid- and upper rectum. If this
occurs, mandatory closure of the rectal wall is
performed by first closing the peritoneum and
then the rectal wall. Transient loss of pneumorec-
tum may occur but is re-established following
peritoneal closure. Rarely, laparoscopic access is
required to cleanse the pelvis, facilitate wall clo-
sure, or perform a leak test. Informed consent in
Fig. 9.3 Lesion excision margin being delineated during
TAMIS local excision Monopolar cautery device is used
patients at risk of peritoneal entry should be
to score the rectal mucosa with a 1 cm circumferential obtained prior to surgery and the operating room
margin prepared accordingly.
9 Surgical Technique for Local Excision of Rectal Neoplasia 93
Fig. 9.4 Full-thickness excision. Note the mesorectal fat underneath the lesion, signifying that the entire rectal wall has
been transected
noma of the colon and rectum. Dis Colon Rectum. treatment for locally advanced rectal cancer? Ann
2002;45(2):200–6. Surg Oncol. 2013;20(5):1551–9.
10. Bhangu A, Brown G, Nicholls RJ, Wong J, Darzi 13. Waheed A, Miles A, Kelly J, JRT M, Motl JS, Albert
A, Tekkis P. Survival outcome of local excision ver- M. Insufflation stabilization bag (ISB): a cost-
sus radical resection of colon or rectal carcinoma: a effective approach for stable pneumorectum using a
Surveillance, Epidemiology, and End Results (SEER) modified CO2 insufflation reservoir for TAMIS and
population-based study. Ann Surg. 2013;258(4):563– taTME. Tech Coloproctol. 2017;21(11):897–900.
9; discussion 9–71 https://doi.org/10.1007/s10151-017-1716-7. Epub
11. Lu JY, Lin GL, Qiu HZ, Xiao Y, Wu B, Zhou
2017 Nov 14
JL. Comparison of transanal endoscopic microsur- 14.
deBeche-Adams T, Nassif G. Transanal mini-
gery and total mesorectal excision in the treatment mally invasive surgery. Clin Colon Rectal Surg.
of T1 rectal cancer: a meta-analysis. PLoS One. 2015;28(3):176–80.
2015;10(10):e0141427. 15. Hahnloser D, Cantero R, Salgado G, Dindo D, Rega
12. Tranchart H, Lefevre JH, Svrcek M, Flejou JF,
D, Delrio P. Transanal minimal invasive surgery for
Tiret E, Parc Y. What is the incidence of metastatic rectal lesions: should the defect be closed? Color Dis.
lymph node involvement after significant pathologic 2015;17(5):397–402.
response of primary tumor following neoadjuvant
Pyramidal Excision for Early Rectal
Cancer and Special Closure 10
Techniques
Giovanni Lezoche, Mario Guerrieri,
and Emanuele Lezoche
No other topic in general and colorectal surgery case of histologically high-risk tumors, which are
has had similar dramatic changes such as the not eligible for PE or other local procedures.
therapy of low rectal cancer in the last two Furthermore, the full-thickness LE, which is
decades. The changes are not only related to the the most frequent operation reported in TEM &
new minimally invasive technologies but also to TAMIS literature, does not permit examination
the doctrinal acceptance that more aggressive of the locoregional lymphatic stations. On the
surgery does not necessarily translate into contrary, PE performed by TEM/TAMIS allows
improved oncologic results applicable to all one to remove the locoregional nodes, and for
stages rectal cancer. In other words, the same these reasons we have termed this endoluminal
revolution that occurred in the 1980s for breast locoregional resection (ELRR). In fact, the ratio-
cancer is now in progress within the community nale of this operation is to remove (en bloc) the
of colorectal surgeons. pyramidal excision (PE) lesion and all the surrounding tissue, performing
of rectal tumors is the counterpart of the a wide round incision including a minimum of
“lumpectomy” for breast cancer. The partial 1 cm of normal mucosa. Radially, the rectal wall
removal of the rectum obtained by PE has rele- and the mesorectum are excised to the level of the
vant advantages when compared to TME in “holy plane,” in order to obtain a surgical speci-
terms of postoperative morbidity, mortality, and men in the shape of a pyramid, whose base is
functional sequelae. very large and composed by the mesorectal fascia
Comparing PE with conventional local exci- (i.e., the circumferential deep diameter is greater
sion (LE), the main benefit is represented by the than the mucosal resection diameter).
possibility of examining the locoregional nodes Analyzing the papers that report the clinical
in order to arrive at a more accurate tumor stage. results of LE, it has been observed that in absence
In this regard, it is useful to emphasize that for of an internationally accepted definition, in the
rectal cancer (in the literature), there is no evi- majority of cases, the employed surgical tech-
dence of metastatic skip lesions in lymphatic nique is not sufficiently described. Therefore, the
nodes. This observation has been noted in the different results reported in terms of local recur-
rences can also be related to the different tech-
niques applied towards LE. It is hoped that
Scientific Societies organize a Consensus
G. Lezoche · M. Guerrieri
Università Politecnica delle Marche, Ancona, Italy Conference to define the terminology of the dif-
ferent local operations that can be performed to
E. Lezoche (*) treat rectal lesions through traditional surgery
Università di Roma “SAPIENZA”, Rome, Italy
and TEM/TAMIS. Proper nomenclature is often out the whole. Consequently the term “total
not properly used, and this is clarified in the fol- mesorectal resection” (and its acronym “TMR”)
lowing section. seems to be more appropriate instead of “total
mesorectal excision” or TME.
Another matter of lexical confusion is the
omenclature: Excision versus
N term “local excision,” as in the majority of pub-
Resection lished research does not specify which extension
(depth) of tissue has been removed. To define the
The majority of medical terminology origi- spatial model of the “LE” dissection, several
nates from ancient Greek and Latin. A paradig- items should be characterized, as follows: (a) the
matic example of misunderstanding semantics modality to assess tumor-free margins, (b) width
is the operation described by Prof. RJ “Bill” of free mucosa included in the circumferential
Heald in 1982, termed total mesorectal ‘exci- excisional margin, (c) depth of incision, (d) angle
sion’ (TME). Nowadays, the term TME is uni- (or degree) of the lateral margin with respect to
versally accepted despite the fact that it is a the mucosal surface, (e) depth of basal dissection,
contradiction in terms: in fact “excidere” as well as other factors. These data are important
comes from the Latin language and is the union elements to evaluate the amplitude and quality of
of two terms “ex” and “cidere.” The term “ex” dissection.
has implicit the concept of a part of the whole Utilizing either TEM or TAMIS, it is possible
and “cidere” to cut. Consequently, the correct to follow five different levels of dissection as
meaning of “excidere” is to remove a part of shown in Fig. 10.1 and as delineated below:
the whole. Therefore, in coining the name
“total mesorectal excision,” Bill Heald utilized A. Submucosal dissection. This has the advan-
conflicting terms that conveyed a meaning that tage of removing “en bloc” the specimen
is quite opposite to the message intended. without violating the entire bowel wall and
On the other hand, the term “resection” is considered acceptable for benign neopla-
draws its origin from another Latin word that sia, especially large sessile polyps which are
likewise represents the synthesis of two differ- more difficult to excise endoscopically.
ent words: “re” and “secare.” “Re” plays the B. Infra-muscle layer dissection. This proce-
role of strengthening the term “secare,” which dure requires high surgeon dexterity. Usually
means to cut, with the final meaning of to take it is performed only to remove large benign
5 –ELRR: Endolumen
Loco-Regional Resection
polyps of the upper part of the rectum to (ELRR). With this approach, the excised speci-
avoid intraperitoneal entry. Furthermore, in men resembles the shape of a pyramid. When
case of flat degenerative polyps, it allows the Gerard Buess, in the 1980s, introduced TEM into
morphologist to analyze cancer cell penetra- clinical practice, the operation that he proposed
tion into the submucosa space without ther- was a mucosectomy, or a partial-thickness exci-
mal artefacts. sion of a portion of the rectal wall. During the
C. Full-thickness rectal wall excision. In this early 1990s, Buess subsequently adopted the
technique, generally employed from the technique of ELRR.
majority of the authors and too often is It is intuitive that by removing a larger amount
defined erroneously as a TEM procedure, the of lymphatic tissue juxtaposed to the tumor, the
entire rectal wall is excised circumferentially risk of local recurrence could be is reduced.
including the neoplasm, with a typically rec- While this is fundamental to the principles of en
ommended 1 cm minimal radial margin bloc radical resection, whereby tumor resection
(mucosal margin). is predicated upon the vascular supply and drain-
. Full-thickness rectal wall removal combined
D ing lymph node basin. The same concept of
with the resection of the upper part of the “removing more” is probably also applicable for
mesorectum. This follows the principles of early-stage (T1) rectal cancers.
full-thickness local excision but also includes The assessment of tumor diffusion depth into
a small portion of mesorectum underlying the submucosa (Kikuchi Classification, sm1–sm3)
rectal wall. on the biopsies performed with flexible endos-
E. Full-thickness rectal wall resection com- copy is not usually reliable. At the same time,
bined with resection of all the mesorectum literature clearly demonstrated that sm1 lesions
adjacent to the tumor. In this case the resec- have a risk of nodal metastasis up to 3%; sm2
tion reaches the lower level of the mesorec- have a risk of 5–8%; and sm3 have a risk of
tum, and the base dissection is performed ≥25%. Thus T1sm3 nodal metastatic risk is simi-
following the so-called holy plane, that is, lar to that of T2 tumors [2]. Interestingly, T1sm3
a pyramidal local excision. tumors represent more than 40% of all cases [3].
The data and concepts presented thus far can
The possibility for the surgeon to choose so be surmised in the following key points:
many different levels of deep dissection during
the TEM (or TAMIS) procedure makes clear that • Full-thickness excision alone (without pyra-
expressions, such as “the patient underwent midal excision) is likely an inadequate ther-
TEM,” are simply an insufficient descriptor. apy in the majority of T1 rectal cancer, except
Depth of excision, as well as the status of the for very well-selected, histologically favor-
radial margins (including minimum distance of able lesions.
normal mucosa to involved edge of tumor), • It is very important to perform multiple macro-
should be, but is not always, routinely described. biopsies to assess preoperatively tumor depth
This is a likely factor contributing to the wide particularly to characterize T1 submucosal
variability among series when describing local penetration.
recurrence rates [1]. • As a significant fraction of T1 rectal cancers
have a similar risk of lymphatic involvement
as T2 cancers, it is a not appropriate to treat T1
Rationale of Pyramidal Excision lesions (e.g., T1sm3) differently than T2
staged cancers. For these lesions, stan-
Pyramidal excision (PE) is a full-thickness rectal dard full-thickness local excision alone, in the
wall resection combined with resection of all the authors’ opinion, is insufficient and is more
mesorectum adjacent to the tumor and is synony- likely to result in treatment failure than pyra-
mous with endoluminal locoregional resection midal excision.
100 G. Lezoche et al.
20.5
11.6
2.96
10 Pyramidal Excision for Early Rectal Cancer and Special Closure Techniques 101
remain the preferred method to evaluate submu- by utilizing a local procedure (namely PE)
cosal infiltration. Furthermore, surgeons who rather than radical resection for several rea-
perform EUS have the advantage of acquiring in sons. First, TME, even with the advent of less
their mind the virtual spatial reconstruction of the invasive (laparoscopic/robotic) techniques,
lesion with its anatomic location, extension, and maintains the same risk of morbidity and mor-
limits. All this allows one to perform a surgical tality unmodified from open techniques.
dissection following optimal plans to obtain a Second, postoperative urinary, sexual, and
pyramidal shaped specimen containing the tumor, bowel dysfunctions are very high (Fig. 10.4).
with equidistant free margins. Last but not least, quality of life is strongly
PET-CT. This imaging modality has no proven compromised by stoma creation (even when
diagnostic value for the staging of rectal cancer. constructed for temporary fecal stream diver-
When performed after ELRR, it may result in sion). In Mediterranean countries, patients
false positive results, which can be caused by the (and their treating surgeons) generally try to
long process of healing required for some large avoid stomas, even if it is temporary. This is
defects created during the process of pyramidal particularly important for specific cultures and
excision. Therefore, when PET-CT is used, it is locales [6] Fig. 10.5.
recommended to not be performed prior to For these reasons, in the past decades, many
9 months post-ELRR. surgeons, to avoid the postoperative risk of
TME, have preferred to perform unstandard-
• Anal Sphincter Manometry. Preoperative ized local excision despite the disappointing
assessment of sphincter function is advisable high percentage of local recurrence. According
in patients with low-lying rectal cancer, in all to the data from the US National Cancer
elderly subjects, and/or in patients with Database (NCDB), the local excision rate from
reduced sphincter tone. the 1990s to the beginning of this century dou-
• Quality of Life Forms. All patients should bled for T1 and tripled for T2, as shown in
complete a specific quality of life (QoF) Fig. 10.6.
forms (C39 and C38): upon diagnosis and Combining conventional LE with NT does
prior to surgical intervention; the assessment not significantly increase the clinical results in
is ideally completed at 6, 12, and 24 months terms of local recurrences (Fig. 10.7) and prob-
after ELRR.
the draining lymph node basins. Coupled with • Sexual dysfuntions 13–70%
the favorable clinical results observed with ELRR • Anastomotic leaks 5–17%
for such lesions, the addition of fdNT for non- • Definitive colostomy 10–15%
advanced, select rectal cancer has provided • Temporary oostomy 20–100%
(Data from litterature)
improved cure rates.
At our center, the preferential surgical Fig. 10.4 Morbidity, mortality, and functional sequelae
option for treating early-stage rectal cancer is of TME according to the data from literature
10 Pyramidal Excision for Early Rectal Cancer and Special Closure Techniques 103
30
20
10
0
Praying in mosque Praying alone Fast in ramadan
USA NATIONAL CANCER DATA BASE Local recurrence rate after transanal excision
1989-2003 Local Excision rate for Rectal Cancer (Surgery + Pre/PostOp. Adjuvant Therapy)
(sample 2124 pts: L.E. 765)
N. Loc. Rec.
45
T1 Benoist et al. 1998 30 13
40 Baron et al. 1995 91 21
Read et al.1995 22 9.1
35 Willet et al. 1994 46 18
Rounet et al. 1993 18 11
30
Bailey et al. 1992 53 8
25 DeCosse et al. 1989 57 NS
CC
L/C angle L
B L
C
L
120° B “holy plane”
it is mandatory to enlarge laterally the mar- • Next, the circular incision of mucosa and mus-
gin of the resection following an obtuse cles around the tumor is completed at 360°,
angle of at least 135°. We call this angle including 1 cm of free margin.
L/C – where C is the plane of the mucosal • At this point the mesorectum is widely mobi-
circular free margin and L is the lateral mar- lized and pulled caudally; the division of the
gin of the dissection (see Fig. 10.9). mesorectum is performed following an obtuse
5. It is very important to remove as much meso- angle (Fig. 10.8), circumferentially.
rectal tissue as possible to include a high num- • Upon completion, the specimen takes on the
ber of excised/sampled lymph nodes. characteristic shape of a pyramid.
6. We register the volume of the removed speci- • The specimen volume is estimated by placing
men in cubic centimeters (cc). it into a graduated cylinder.
7. To prove that all the nodal tributaries of the • Then, the specimen is fixed onto a cork pad
tumor have been removed, we have developed with pins – taking care to orient the lesion.
a modified sentinel node technique that is rou- • The surgeon should then wash carefully the
tinely used for assessment, which is termed operative field and the defect with a continu-
“nucleotide-guided mesorectal excision” ous lavage of saline containing diluted
(which will be discussed in a later section). Betadine for 5 minutes before starting the
suture closure of the defect. This step is impor-
Note: The description of the following steps tant to remove any exfoliated tumor cells.
are indicated for a right-handed surgeon. • The distal rim of the defect should be assessed
to assure it is well mobilized; if not, the sur-
geon should extend cranially and laterally the
Posterior Lesions (Patient Supine) dissection.
• The proximal and distal aspects of the defect
• In case of posterior lesions, if the tumor is should be reapproximated without tension.
very close to the anal ring, it is preferable to • At this point it is possible to start the suture
start the full-thickness dissection of the rectal closure.
wall from the 6–7 o’clock to 3 o’clock posi-
tion, making a transverse circular incision Lateral Lesions (Patient Positioned Lateral,
1 cm from the margin of the neoplasia. The Lying Ipsilateral to the Lesion in Jackknife
mucosa and the muscle layer are cut with the Position)
TEM Wolf scalpel.
• Once the mucosal and muscular layers have • In case of lateral lesions, the rectoscope degree
been transected, the avascular plane between of freedom can be limited by obesity and
the mesorectal fascia and the endopelvic fas- impaired mobility of hip articulations.
cia can quite easily be established. • For lesions of the left side, it is advisable to
• If the neoplasia is very close to the sphincter, start the full-thickness dissection of the rec-
a limited resection of the internal sphincter tal wall from the 8 o’clock position to the 4
muscle can also be done, leaving those fibers o’clock position (with an anticlockwise
attached to the specimen that will be removed progression); in case of right-side lesions, it
en bloc. is advisable to start from the 4 o’clock to 8
• The further preparation of the mesorectal fas- o’clock position. The rationale is to start the
cia is performed by smooth dissection follow- dissection from where the mesorectum has
ing the avascular holy plane. more thickness, which facilitates the identi-
• A large dissection of the holy plane is per- fication of the “holy plane.”
formed widely exceeding the limit of the • The following surgical steps are similar to
neoplasia. those reported for posterior lesions.
10 Pyramidal Excision for Early Rectal Cancer and Special Closure Techniques 107
Anteriol Lesions (Patient Prone) and hemorrhage control can require argon
beam laser coagulation.
Female • As for females, it is mandatory to remove a
• It is advisable to start the full-thickness dis- high volume of mesorectum juxtaposed to the
section of the rectal wall as laterally as possi- tumor. If the tumor is localized in a position
ble, starting the incision from the 3 to the 5 corresponding exactly to the midline of the
o’clock position. prostate gland, both the mesorectum structures
• At this level, as soon as the rectal wall has located in the left and right sides of the gland
been transected, it is easier to find adipose must be removed en bloc with the specimen.
tissue; this facilitates the smooth dissection • The remaining procedures are similar to those
of the rectal wall along the rectovaginal reported for posterior lesions.
septum.
• With a delicate grasper, the rectum wall can be
pulled and the dissection continued with a Peritoneal Entry
clockwise progression utilizing a cautery with
low wattage settings. During the dissection of large proximal speci-
• Once the correct plane has been identified, it is mens during ELRR, peritoneal entry can occur in
easy to perform a smooth dissection of all the around 6–7% of cases.
rectovaginal septum. Management Recommendations:
• During this maneuver, it is recommendable
that the surgeon introduces one finger of the • The first sign is generally a reduction of rec-
left hand in the vagina to better control the tum distention; in other cases it is possible to
pressure applied during dissection. note a bubbling at level of the opening.
• In relationship to the tumor position, it is • As a first maneuver, it is advisable to immedi-
mandatory to remove as much as possible ately close the opening in order to avoid the
the mesorectum adjacent to the tumor. If the CO2 from distending the abdominal cavity
tumor is localized in a position correspond- which can reduce the working space within
ing exactly to the midline of the vagina, the rectal lumen.
both the hemispheres of the mesorectum • If the gas leakage into the peritoneal cavity is
must be completely removed en bloc with problematic, a Veress needle should be placed
the specimen. to desufflate the abdominal cavity.
• The remaining procedures are similar to those • In order to avoid peritoneal contamination, a
reported for posterior lesions. suction tube is used to aspirate all the fecal
contaminants present in the operative field and
Male in the rectal lumen.
• It is advisable to start the full-thickness dis- • Irrigate the operative field and the opening
section of the rectal wall as lateral as possible area with saline containing diluted Betadine
starting the incision from the 3 o’clock and solution.
extending it to the 6 ‘clock position. • While suturing the peritoneum, the transanal
• At this level, the prostatic capsule is usually surgeon must be certain that stitches do not
recognizable, as a smooth, pale-colored inadvertently incorporate loops of small bowel
organ. that easily herniate into the opening, due to the
• Once the right plane is identified, a smooth increased pressure within the abdominal
dissection is recommended to avoid signifi- cavity.
cant bleeding from the prostate gland. Severe • Generally, a double-layered suture repair is
bleeding can occur if the capsule is damaged, recommended.
108 G. Lezoche et al.
Oral rim
Caudal rim
makes it difficult to tie the suture line. To obviate Fig. 10.11 When the defect is very wide and with a dis-
the need for suture knot tying, a silver clip is crepancy in length between the two rims, it is advisable to
placed at both ends of the suture. Previously, sil- place a first stitch in the middle
ver clips were utilized, but this metal creates
interference with MR, making subsequent images
interpretation difficult. This problem has been
solved by the introduction in the clinical use of
titanium clips, which are nonferrous and do not
interfere with the magnet.
Due to the narrow space, it is advisable that
the length of each suture does not exceed 6–7 cm;
a suture longer than this makes suturing motion
more difficult inside the narrow operative field.
of a dead space induces the formation of fluid nique is closure of the surgical wound after PE
collection that, with microbial seeding, must be maticulous.
evolves into a pelvic abscess that initially can
be asymptomatic. The abscess naturally and
spontaneously drains through the path of least References
resistance, as at the level of the suture line. To
avoid fluid accumulation, before placing the 1. Bach SP, Hill J, Monson JR, Simson JN, Lane L,
Merrie A, Warren B, Mortensen NJ. A predictive
last stitch, it is recommended that the model for local recurrence after transanal endo-
defect be filled with 10 ml of FloSeal® scopic microsurgery for rectal cancer. Br J Surg.
(Ethicon, Inc.). 2009;96:280–90. https://doi.org/10.1002/bjs.6456.
• Filling the rectal ampulla with iodine- 2. Kikuchi R, Takano M, Takagi K, Fujimoto N, Nozaki
R, Fujiyoshi T, Uchida Y. Management of early inva-
impregnated sponges. With the same purpose sive colorectal cancer. Risk of recurrence and clinical
(to avoid the fluid collection behind the suture guidelines. Dis Colon Rectum. 1995;38(12):1286–95.
line), at the end of the operation, once the 3. Riccardo N, Burgart LJ, Nivatvongs S, Larson
TEM (or TAMIS) apparatus has been removed, DR. Risk of lymph node metastasis in T1 carci-
noma of the colon and rectum. Dis Colon Rectum.
the rectal ampulla is filled with three iodine 2002;45(2):200–6.
sponges that reduce the presence of bacteria 4. Doornebosch PG, Ferenschild FT, de Wilt JH, Dawson
and dead space in the residual cavity, by I, Tetteroo GW, de Graaf EJ. Treatment of recurrence
serving as a wick. The sponges are removed after transanal endoscopic microsurgery (TEM) for T1
rectal cancer. Dis Colon Rectum. 2010;53(9):1234–9.
48 hours postoperatively. 5. Stipa F, Giaccaglia V, Burza A. Management and
outcome of local recurrence following transanal
endoscopic microsurgery for rectal cancer. Dis Colon
Conclusions Rectum. 2012;55(3):262–9.
6. Ayhan KM, Topçu Ö, Uçar K, Ulukent S, Ünal E,
Erverdi N, Elhan A, Demirci S. Effect of sphincter-
The quest to preserve function for stage I rectal sacrificing surgery for rectal carcinoma on qual-
cancer has encouraged colorectal surgeons to ity of life in muslim patients. Dis Colon Rectum.
explore alternatives other than radical resection 2002;45:1359–66.
7. Lezoche E, Guerrieri M, Paganini AM, Baldarelli
for curative intent. The crux of controversy M, De Sanctis A, Lezoche G. Long-term results in
remains in the inability to accurately stage rectal patients with T2–3 N0 distal rectal cancer undergoing
cancer in terms of nodal positivity. Even with NT, radiotherapy before transanal endoscopic microsur-
there remains uncertainty about nodal treatment. gery. Br J Surg. 2005;92(12):1546–52.
8. Quaresima S, Paganini AM, D’Ambrosio G, Ursi P,
Such limitations have led to the development of Balla A, Lezoche E. A modified sentinel lymph node
pyramidal excision (ELRR after NT), combined technique combined with endoluminal loco-regional
with NGME as the best approach to treat highly resection for the treatment of rectal tumours: a 14-year
selected non-advanced rectal cancers. The tech- experience. Color Dis. 2017;19(12):1100–7.
Closure Versus Non-closure
After Local Excision 11
Dieter Hahnloser
Review of the Literature
losure Is Mandatory if
C
the Abdominal Cavity Is Entered Table 11.1 lists studies comparing patients whose
defects were either closed or left open [1, 11–14].
Peritoneal entry occurs in up to 28% and man- A recent meta-analysis including 4 of these trials
dates defect closure after full-thickness defect with 489 patients (317 in the closed and 182 in
excision of proximal rectal neoplasia [2]. the open group) did not find a significant differ-
Suturing these defects can be very difficult, as the ence in overall morbidity (OR 1.26) [15].
pneumorectum is often lost once the abdominal Postoperative bleeding (5.6% vs. 7.7%), local
cavity is entered. When the rectal wall collapses, infection (3.1% vs. 4.9%), as well as the need for
the operative view is diminished. Insertion of a reintervention (1.9% vs. 1.1%) were comparable
rigid TEM (or TEO) proctoscope may help stabi- between the left open and the closed group. A
lizing the defect and may allow endoluminal recently published three-institution study using
suturing. However, 30% of defects are deemed propensity score matching compared open and
not amenable to endoluminal closure [3], and closed defects each after full-thickness (n = 220)
laparoscopic or even open suturing might become and partial-thickness (n = 210) excisions [12].
necessary which increases morbidity modestly. The incidence of 30-day complications was simi-
The technical ability to close the peritoneal defect lar for open and closed defects after full- (15%
endoluminally has therefore definitive advan- vs. 12%, p = 0.43) and partial-thickness excision
tages. Care must be taken as closure of large (7% vs. 5%, p = 0.55). However, there were more
defects may result in subsequent stricture forma- bleeding complications in open defects after full-
tion or stenosis, although the incidence of steno- thickness excision. For these reasons, it is recom-
sis in the literature in large series is low [4, 5]. mended to carefully check the mucosal resection
margins and the mesorectal defect for bleeding
before concluding the operation and removing
Technical Issues of Closure the TAMIS platform. We recommend a stepwise
reduction in the insufflation pressure keeping the
Suturing remains very challenging as instruments defect under direct vision. Even minor bleeding
clash, adequate tension is difficult, and, hence, should be treated by cauterization. Another pos-
the procedure is time-consuming. Studies have sibility is to leave a swap in the defect for a cou-
reported that defect closure using the TAMIS ple of minutes to check for venous bleeding once
platform increased operative time by 30 minutes the pneumorectum has been discontinued, since
[1]. In the literature different methods of suturing the pneumatic pressure may lessen the effect of
have been described using Endo-GIA staplers venous bleeding, giving a false reassurance that
[6], intracorporeal running sutures [7, 8], or the operative site is hemostatic.
extracorporeal single suturing with a knot pusher The use of TEM versus TAMIS did not affect
[9]. In addition, the use of self-locking barbed the decision to close the defect in the
11 Closure Versus Non-closure After Local Excision 115
Table 11.1 Literature comparing closure versus non-closure of the rectal wall defect
Surgical % left
N= Study type technique open Closure technique Results open vs. closed
Ramirez et al. 40 RCT LE, TEM 50% Running suture, Overall complication NS
(2002) [11] 3–0 absorbable
microfilament
Hahnloser et al. [1] 75 Prospective TEM, 47% Single stitches Bleeding (11% vs. 3%,
TAMIS (75%) or running p = 0.2)
suture (25%) of Infection (6% vs. 10%,
Vicryl 3–0 or p = 0.3)
V-Loc 3–0
Brown et al. [14] 341 Prospective TEM 30% Running suture Overall complication (19%
PDS 2–0 and vs. 8.4%, p = 0.03)
secured with clip Bleeding (7.6% vs. 4.7%,
p = 0.27)
Infection (6.7% vs. 2.1%,
P = 0.06)
Noura et al. [13] 43 Retrospective LE, 51% – Bleeding (0% vs. 24%,
TAMIS p = 0.02)
Fever (0% vs. 5%,
p = 0.49)
> = Clavien grade IIIa (0%
vs. 19.0%, p = 0.04)
Lee et al. [12] 220 Retrospective, TEM, 50% 3–0 absorbable Overall complications
FT paired TAMIS 50% suture, endostitch (15% vs. 12%, p = 0.43)
210 matched Overall complications (7%
PT vs. 5%, p = 0.55)
LE local excision, TEM transanal endoscopic microsurgery, NS not significant, FT full thickness, PT partial thickness
a bovementioned studies. Surgeons seem to more caution must be exercised in the interpretation of
often close smaller defects and leave large this finding.
defects open. Also, partial-thickness excisions Functional impairments do not seem to be
seem to be more frequently closed than full- affected by defect closure. There was no differ-
thickness defects. In a small prospective ran- ence in Vaizey incontinence scores at 12 months
domized study of 44 TEM operations for local with regard to defect closure in two studies [1,
excision, no difference in outcome was noted if 13]. Disturbances in anal manometry and fecal
the defect was sutured closed or left open [11]. incontinence after TAMIS appear to be related to
At 4 weeks, the rectal wound had completely the depth of excision [16, 17]. Moreover, conti-
healed in 85% in the non-closure group and in nence and outlet function tend to improve after
95% in the closure group. At follow-up endos- local excision due to the otherwise obstructive
copy at 3 months, all defects in the “left open” effect that (especially bulky) neoplasms tend to
group healed. In another study 47% of rectal create and which resolves upon successful
defects were not sutured closed and rather left TAMIS excision.
open. Although this was mainly depending on There are several limitations in each of these
the participating centers, there was no difference studies with differences in perioperative manage-
in size and location of the defect, and, most ment, surgeons’ experience, and operative tech-
interestingly, there was no increased complica- nique used (for instance, energy source used).
tion rate in the group of patients whose excision Also, the location (anterior-posterior) and the
defect was left open [1]. This suggests that distance from the anal verge and therefore the
defects can be left open without increased mor- risk of peritoneal entry varied among these stud-
bidity. However, all studies were not designed to ies. This could have affected the decision to close
answer this particular question, and therefore or not to close the defect.
116 D. Hahnloser
Fig. 12.2 End result of the closure of the rectal defect with a laparoscopic stapler
Intraoperative Hemorrhage
Fig. 12.3 Flexible sigmoidoscopy 3 months after a sta-
pled TAMIS
Intraoperative bleeding is rare, as electrocautery
is usually sufficient for hemostasis. However, a
Inadvertent Closure of Rectal Lumen laparoscopic tissue sealer device or laparoscopic
clip applier via the TAMIS platform can always
Closure of the rectal lumen is a potential risk in any be used, if necessary.
anorectal procedure, and, therefore, extreme vigi-
lance is required when doing any significant inter-
vention after removal of the specimen in TAMIS, Short-Term Complications
particularly after removal of large or circumferen-
tial lesions. This has been described in stapled Postoperative Hemorrhage
hemorrhoidopexy [11] and could potentially be an
issue in TAMIS as well. A simple approach to iden- Generally, postoperative bleeding is uncommon
tify the rectal lumen and keep it patent throughout if hemostasis has been maintained throughout the
the procedure is to insert a small sponge into the procedure. Nevertheless, it has been described in
rectal lumen proximal to the lesion at the start of up to 10% of patients, occasionally even requiring
120 E. A. T. Vikis et al.
blood transfusion [5, 7, 12]. As our most com- lesions, and 13 had not been taking prophylactic
mon short-term complication, postoperative rec- perioperative tamsulosin, which has now been
tal bleeding occurred in 25 of 230 cases, with introduced at our center as part of a routine pro-
only 5 requiring intervention (2.2%). Of the five tocol. A clinical trial in progress TEMPOUR [19]
patients who required blood transfusion, one was addresses the use of perioperative tamsulosin in
taken back to the operating room the same opera- TEM, which is hypothesized to decrease the inci-
tive day, while two others were treated endoscop- dence of urinary retention, and this data may be
ically on postoperative days 16 and 17, translatable to TAMIS practices for local exci-
respectively. Successful cessation of bleeding sion of rectal neoplasia. This could be a simple
was achieved by hemostatic agent placement or and cost-effective approach to minimizing this
endoscopic clipping [5]. complication.
Closure of the defect has been thought to
influence hemostasis. While numerous studies
demonstrate a trend toward a higher bleeding Subcutaneous Emphysema
incidence [12–16] leaving the defect open, none
show statistical significance. Regardless, an Subcutaneous emphysema has been described
attempt to close all defects could potentially previously in TAMIS [4] and is generally an
influence clinically significant bleeding and is a uneventful complication in similar transanal pro-
mandatory technique to master in cases of poten- cedures [20]. However, it can lead to intraopera-
tial peritoneal breach. Since TAMIS is a novel tive hypercapnia [21] and is occasionally an
procedure, utilizing existing techniques for indication of peritoneal breach. If ventilatory dif-
hemostasis postoperatively in other anorectal ficulty is encountered secondary to hypercarbia,
procedures, such as hemorrhoidectomy, can be decreasing the rectal insufflation pressure, com-
useful. Rosen et al. [17] treated post- pleting the procedure quickly, and potentially
hemorrhoidectomy bleeding using hemostatic delaying extubation can all be utilized [22]. At
agent (Gelfoam) packing at the site of the defect. our center, the overall rate of subcutaneous
In TAMIS, in addition to suturing, placement of a emphysema for n = 230 was 0.4%. Generally, this
hemostatic agent, such as Surgicel or Gelfoam, is a self-limited complication and is managed
can be considered. conservatively. Rarely, patients can become
symptomatic and may even develop free air on
plain radiographs [5].
Urinary Retention and Infection
Rectal Stricture
References
Rectal strictures have been described in 1–3% of
patients after TAMIS [5, 7, 10, 18]. Generally 1. Atallah S, Albert M, Larach S. Transanal minimally
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indications and early anorectal cancers: short-term . Identifier NCT03314025, Prophylactic tamsulosin
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6. Molina G, Bordeianou L, Shellito P, Sylla P. Transanal in men after transanal endoscopic microsurgery
endoscopic resection with peritoneal entry: a word of (TEMPOUR); 2017 Oct 6 [cited 2018 Jun 29];
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8. Mege D, Petrucciani N, Maggiori L, Panis 21. Kerr K, Mills GH. Intra-operative and post-operative
Y. Peritoneal perforation is less a complication than hypercapnia leading to delayed respiratory fail-
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Functional Outcomes After Local
Excision for Rectal Neoplasia 13
Elizabeth R. Raskin
and perineum, although it is unclear in the exact The rectoanal excitatory reflex (RAER)
manner they behave. Unquestionably, excitatory denotes the contraction of the EAS upon rectal
activity is elicited from sympathetic innervation distention, which manifests as an anorectal
from the hypogastric and pelvic plexus. squeeze. Unlike the RAIR, this reflex is deter-
Anal canal sensation originates from the mined by S2–S4 innervation and can be dis-
inferior rectal branch of the pudendal nerve, rupted by injury to the pudendal nerve endings.
which arises from S2 to S4, and helps to dis- Continence can be disrupted if the RAER is
criminate between gas and liquid/solid stool. In either blunted or abolished secondary to
contrast, the rectum senses only distention; it pudendal nerve block or surgical trauma.
also receives innervation from S2 to S4. The Specifically, the external anal sphincter is
perception of flatus is attributed to receptors in largely responsible for maintaining continence
the walls of the rectum and the fascia of the pel- with increases in intraabdominal pressure,
vis. Surgical trauma to either the mucosa of such as during coughing, sneezing, or heavy
the anal canal or the wall of the rectum can lifting [3].
distort the ability to differentiate stool consis-
tency and lead to incontinence and/or urgency.
In addition, postoperative inflammation can Measuring Anorectal Function
lead to hyper-acute sensation, precipitating
poor accommodation and subsequent fecal Functional assessment tools such as the Fecal
frequency. Incontinence Severity Index (FISI) and the Fecal
Incontinence Quality of Life (FIQL) scale have
been utilized to quantify the magnitude of incon-
Compliance and Capacity tinence and the impact it has on patients’ lives
[4, 5].
Rectal compliance and capacity refer to the dis- The FISI, a severity rating score for fecal
tensibility of the walls and the volume of the rec- incontinence (FI), assesses the types of leakage
tal reservoir, which directly impact continence. experienced by those with FI (gas, mucus, liquid,
Compliance can be altered in the early postopera- or solid) and the frequency of the occurrences of
tive period by inflammation and edema and, in incontinence [4]. This validated score has been
the later postoperative phase, by fibrosis. shown to be a useful measure of anorectal func-
Similarly, prior radiotherapy can negatively tion, with good concordance between patient and
impact the reservoir function, resulting in fecal surgeon assessment of the condition.
urgency, frequency, and stool fragmentation. On the other hand, the FIQL scale is a tool for
specifically measuring the impact of FI on the
quality of life (QOL) [5]. There are 29 items
Anorectal Reflexes addressed in 4 general categories: (1) life-
style, (2) coping/behavior, (3) depression/self-
The rectoanal inhibitory reflex (RAIR) describes perception, and (4) embarrassment. Given the
the relaxation of the IAS upon distention of the reliability of this score, it has become a standard
rectum, and it allows for the sampling process instrument in subsequent studies for qualifying
within the anal canal. This enables stool and/or gas QOL after interventions [6, 7].
to make contact with receptors within the walls of Multiple other incontinence scores exist, such
the anal canal to signal the nature of the substance as the Pescatori score, the Wexner Continence
above in the rectal vault. While this reflex can be Scale, and the American Medical Systems score.
lost following low anterior resection, it typically These grading systems evaluate the type of incon-
remains intact following transanal surgery, as it is tinence experienced, the frequency, severity, and
contingent upon intrinsic innervation. impact of incontinence on lifestyle [8].
13 Functional Outcomes After Local Excision for Rectal Neoplasia 125
Preoperative Evaluation of the perianal skin and anus can be tested with a
cotton swab or electrical stimulation.
A thorough preoperative evaluation should be
performed to understand a patient’s baseline
function and to anticipate the potential risks for I maging and Functional Assessment
postoperative anorectal disturbance. Direct ques- Technology
tions regarding continence are warranted to
understand preoperative status. If FI is described, Endoanal ultrasonography and magnetic reso-
validated questionnaires, as described above, can nance imaging (MRI) can provide anatomic
be helpful for accurate assessment and documen- detail such as sphincter width and integrity. These
tation. In addition to prior anorectal and/or pelvic modalities are useful for classification of sphinc-
surgery, a history of pelvic malignancy, obstetri- ter defects, noting level, depth, and size within
cal injury, or pelvic radiation therapy should be the anal canal [9]. Interestingly, there is no direct
elicited. correlation between the presence of a sphincter
injury and incontinence. In a study of 1495
women with prior third- or fourth-degree obstet-
Physical Exam rical tears who underwent endoanal ultrasonogra-
phy, no significant difference was noted in
Visual inspection of the anal and perineal areas can continence scores between those with residual
reveal scarring from prior treatment, trauma, or sur- sphincter defects and those with normal sphinc-
gery. In women, the width of the perineum should ters [10] (Fig. 13.1).
be noted, as a thin perineal body may be associated Anorectal manometry and rectal barostat mea-
with prior injury and a weakened sphincter mecha- surements can give more objective functional
nism. Anal canal resting tone and squeeze, as well data in the form of anal resting pressure, anal
as moderate to large sphincter defects, can be sub- squeeze pressure, rectal wall compliance, and
jectively assessed on digital exam. Intact sensation rectal perception [11] (Figs. 13.2 and 13.3).
Fig. 13.1 Endoanal
ultrasound
demonstrating anterior
internal and external
sphincter injury. (Photo
credit: Dr. Yan Zhao)
126 E. R. Raskin
Fig. 13.2 Anorectal manometry resting pressure. (Photo credit: Dr. Yan Zhao)
Fig. 13.3 Anorectal manometry squeeze pressure. (Photo credit: Dr. Yan Zhao)
13 Functional Outcomes After Local Excision for Rectal Neoplasia 127
have resolved at the 4-month postoperative mark FIQL questionnaires revealed no significant
(p = 0.05). In fact, only 6.6% of patients were changes in continence and little impact on
noted to have EUS abnormalities at the later eval- QOL. Similar to previously mentioned studies,
uation. Interestingly, no reports of incontinence continence changes did not correlate with length
occurred, despite the noted disruptions in the of surgery, location within the rectum, nor the
sphincter muscle. size of the rectal lesion.
These findings were corroborated by a study
from Allaix et al. in which 100 patients were fol-
lowed after TEM, utilizing manometry, inconti- Effects of Chemoradiation
nence scores, and quality of life scores [17]. Thirty on TEM Outcomes
percent of patients had decreased postoperative
anorectal resting pressures at 3 months following An increase in FI has been observed following
surgery, but all had completely returned to preop- TEM after preoperative radiation therapy [20,
erative baseline pressures by 12 months. Initial 23]. Poor wound healing, suture dehiscence, and
decreases in manometric measurements were not older age have been suggested as contributors to
correlated to the length of the operation or the dis- poor anorectal function following excision in this
tance of the tumor from the anal verge. No signifi- setting. A study by Habr-Gama et al. evaluated
cant decline in QOL was found at 12 and 60 months, patients who were enrolled in a “watch and wait”
despite transient reports of fecal urgency that grad- protocol following neoadjuvant chemoradiation
ually improved by the 60-month mark. for rectal cancer. The patients that underwent
These findings suggest that the TEM proce- subsequent TEM for local excision experienced
dure likely stretches or fractures the sphincter significantly lower resting pressures (p < 0.001),
complex, but that continence is contingent upon squeeze pressures (p = 0.004), and rectal capacity
other factors besides IAS integrity [3, 7, 11, 18]. (p = 0.002). This particular cohort of patients also
Other studies have suggested that female sex, reported significantly worse incontinence and
age, length of surgery, location of rectal tumor, quality of life as measured by questionnaires.
low preoperative anal resting pressure, and A corroborating study by Gornicki et al. dem-
extended full-thickness excisions are associated onstrated worse functional outcomes after chemo-
with postoperative incontinence [6, 19, 20]. radiation therapy followed by full-thickness local
However, the majority of these studies demon- excision compared to those who underwent
strate a resolution of symptoms over a discrete chemoradiation alone [24]. These findings were
amount of time. Fairly consistently, these univar- comparable to the functional outcomes following
iate and multivariate analyses have not indicated radical resection via proctectomy. The majority of
patient or operative factors that directly lead to the manometric measurements, incontinence
loss of anorectal function following TEM. scores, and QOL scores were within normal
ranges when chemoradiation therapy alone was
given, suggesting that there is probably a com-
Fecal Incontinence Scores pounding effect of neoadjuvant treatment when
combined with TEM/full-thickness local excision
Incontinence scores and quality of life following resulting in poorer anorectal function.
TEM have been investigated in multiple studies
[6, 7, 17, 19, 21, 22]. Cataldo and colleagues per-
formed one of the first studies evaluating conti- ransanal Minimally Invasive
T
nence and QOL after TEM [21]). In their Surgery (TAMIS)
prospective study involving 41 patients, no sig-
nificant increase in number of daily bowel move- First described in 2009, transanal minimally
ments and no loss of ability to defer defecation invasive surgery (TAMIS) emerged as a more
were noted after surgery. In addition, FISI and accessible and affordable option to supplant TEM
13 Functional Outcomes After Local Excision for Rectal Neoplasia 129
[25]. Given the well-demonstrated advantages of and the size of tumor. Better general quality of
TEM over traditional transanal excision, life scores were also noted and proposed to be
proponents of TAMIS have quickly gained a sub- associated with an alleviation of tumor symp-
stantial experience with the technology and have toms, although this was not demonstrated specifi-
shown comparable results to TEM [26, 27]. cally on the questionnaires.
Functional outcomes and quality of life data fol- Longer-term functional results were evaluated
lowing TAMIS have not been well-studied given by Clermonts and colleagues, assessing FISI
the relatively short amount of time the technol- scores at 1-year and 3-year post-TAMIS [29].
ogy has been utilized, but several small studies Forty-two patients were followed after TAMIS
exist which address these topics. local excision of benign and early-stage malig-
Reporting on their initial experience in 37 nant rectal neoplasms. FISI scores were noted to
patients with benign and early malignant rectal diminish at 1-year post-TAMIS (8.3 pre-TAMIS
lesions, Schiphorst and colleagues were the first vs. 5.4 post-TAMIS) but rebound significantly
to investigate short-term functional results fol- higher at 3 years following surgery (5.4 pre-
lowing TAMIS [28]. Fecal Incontinence Severity TAMIS vs. 10.1 post-TAMIS; p = 0.01). Of those
Index (FISI) scores were obtained preoperatively with normal continence prior to TAMIS, 63%
and postoperatively at 3, 6, 9, and 12 months. A experienced a decline in anorectal function at
significant decline in mean FISI scores was 3 years. Univariate and multivariate analyses did
observed (10 pre-TAMIS vs. 5 post-TAMIS; not reveal any significant variables that resulted
p = 0.02), suggesting an improvement in conti- in either an improvement or decline of FISI
nence following surgery. Specifically in patients scores at these follow-up intervals. The authors
with decreased preoperative continence, postop- emphasize that short-term results of both their
erative FISI scores were significantly lower (21 study and the prior studies suggest that TAMIS
pre-TAMIS vs. 9 post-TAMIS; p = 0.001). has no detrimental effect on continence; however,
Although postulated that FISI scores improved in longer-term results indicate poorer outcomes.
those with low-lying rectal lesions that produced Multiple hypotheses exist regarding the etiology
excessive mucus, univariate analysis revealed no of the deterioration of function – i.e., tumor size,
independent factors associated with change in location, extent of resection, age of patient,
FISI score. stretch of sphincters with platform placement,
A study by Verseveld et al. investigated simi- and total amount of operating time (>2 hours) –
lar parameters in a prospective study involving but no statistically significant contributors to
24 patients but also included quality of life mea- functional decline have been identified [7, 17,
surements [22]. Mean FISI scores decreased 20].
overall, although a number of patients (21%) Although a small study of ten patients,
experienced a minor deterioration in FISI score. Karakayali and colleagues used preoperative and
Contrary to the findings of Schiphorst, patients postoperative anal manometry and Cleveland
who had an increased FISI score post-TAMIS Clinic Incontinence Score (CCIS) to evaluate
local excision had a significantly shorter distance anorectal function after TAMIS [30]. Resting
of the tumor to the dentate line (4.4 vs. 7.4 cm; pressure, maximum squeeze pressure, squeeze
p = 0.04) and had larger tumors (21 vs. 9cm2; endurance, minimum rectal sensory volume, and
p = 0.05). rectoanal inhibitory reflex during cough were
Improvements in quality of life were seen recorded. Manometry readings and CCIS were
after TAMIS excision in this study. Utilizing normal preoperatively for all patients. At the
FIQL scores to assess change following surgery, 3-week follow-up, CCIS declined in one patient
the authors found an improvement in the subscale (0 pre-TAMIS vs. 3 post-TAMIS), although it
“coping behavior.” Similar to the previously was resolved by 6 weeks following surgery.
mentioned study, no correlation could be made Despite maintaining continence, mean minimum
between distance of the tumor to the dentate line rectal sensory volume was significantly decreased
130 E. R. Raskin
outcomes for local excision using the TAMIS Table 14.2 Indications for curative-intent local excision
platform for benign rectal adenomas [12]. for early rectal cancer [14, 15]
However, Lee et al. demonstrated that resection Less than 30% of the bowel
quality is similar between TAMIS and TEM, as Less than 3 cm in size
there was no difference in the incidence of speci- Mobile
men fragmentation and margin involvement T1 only (without high-risk features)
between these two platforms as long as a full- Absence of lymphovascular (LVI) and perineural
(PNI) invasion
thickness excision is performed [13].
Well or moderately differentiated
No evidence of lymphadenopathy on preoperative
staging investigations
ocal Excision for Malignant
L
Pathology
morbidity and mortality, as well as the improved
Early rectal cancer can be managed by local exci- functional outcomes associated with local exci-
sion instead of TME surgery in carefully selected sion, should be balanced against the potentially
patients (Table 14.2). These patients, who have higher risk of recurrence. Several studies have
well-to-moderately differentiated clinical T1 reported lower postoperative morbidity and simi-
tumors with the absence of lymphovascular and lar long-term outcomes between local excision
perineural invasion, are at the lowest risk of and radical resection for T1 rectal adenocarci-
lymph node metastasis and local recurrence and noma. In the only published randomized clinical
therefore are amenable for local excision with trial, Winde et al. randomly assigned 52 patients
curative intent. While oncologic outcomes after with well-to-moderately differentiated T1 tumors
radical surgery (i.e., TME) for T1 tumors are excel- to TEM versus anterior resection [21]. The TEM
lent, with 5-year survival approaching 90% [16–18], group had fewer complications and equal sur-
TME is also associated with significant periopera- vival outcomes, but this study was limited by the
tive complications and long-term functional small sample size and was underpowered to
impairments [19, 20]. The lower perioperative detect any real differences in these outcomes.
14 Oncologic Outcomes for Local Excision of Rectal Neoplasia 135
Other published meta-analyses have reported sig- invasion (OR 4.81, 95% CI 3.14–7.37), and poor
nificantly lower postoperative morbidity (8.2% differentiation (OR 5.60, 95% CI 2.90–10.82)
vs. 47.2%, p = 0.01) and mortality (0% vs. 3.7%, were independent risk factors for lymph node
p = 0.01) for local excision by TEM compared to metastasis [30]. Finally, Bach et al. reviewed pro-
TME [22]. These pooled analyses also demon- spectively collected data from 21 regional centers
strated higher risk of local recurrence for TEM in Great Britain and Ireland and found that larger
compared to radical resection, but without any tumors, depth of invasion beyond sm1, and lym-
differences in disease-free or overall survival phovascular invasion were independent predic-
[22–24]. In the subgroup of “low-risk” T1 can- tors of local recurrence after local excision of
cers (well-to-moderate differentiation, absence rectal cancer [11]. Patients with any of these risk
of lymphovascular invasion), the incidence of factors should not undergo curative local exci-
recurrence was similar between TEM and radical sion, or if these features are found on final pathol-
surgery (4% vs. 3%), but for “high- risk” T1 ogy after local excision, radical surgery should be
tumors (poor differentiation or presence of lym- recommended. The risk of nodal metastases pro-
phovascular invasion), TEM had significantly gressively increases with T stage [31]. T2 lesions
higher rates of local recurrence (33% vs. 18%) have a 25% risk of lymph node involvement [31].
[24]. Quality of life is also superior in patients Current society guidelines also deem local exci-
undergoing TEM compared to radical surgery for sion an acceptable definitive treatment option for
early rectal cancer. In a study by Lezoche et al., patients with more advanced disease who are
the quality of life impairments (using the EORTC medically unfit for radical surgery [14].
QLQ–C30 and –CR38) after TEM local excision
persisted only for 1 month postoperatively,
whereas these impairments remained up to Quality of Local Excision
6 months after laparoscopic TME [25]. However,
quality of life measures returned to baseline at Local excision can be performed using several
1 year in both groups. Other studies have demon- different methods. Upon introduction, local exci-
strated similar results, but with a higher incidence sion was performed using Parks transanal exci-
of defecation problems in patients undergoing sion (TAE) technique, which utilized traditional
radical surgery [26]. surgical retractors and instruments to expose and
The main limitation of local excision is the resect tumors in the distal rectum. TAE can be
inability to pathologically assess the draining technically challenging and lacks precision due
nodal basins; therefore careful selection of to poor visualization and exposure of more proxi-
patients is necessary. T1 lesions have a 5–10% mal rectal lesions or larger tumors but remains a
risk of harboring nodal metastases depending on commonly performed procedure. Moreover,
other histological features [27]. Kikuchi et al. specimen fragmentation occurs in up to 24–35%
showed that further division of T1 cancers into of cases, and negative margins can be a challenge
three levels of submucosal invasion also corre- [32–34]. Clear margins have been reported to be
lates with the risk of nodal involvement (Sm1 as low as 50–70% with TAE [32–34]. Multiple
0–3%, Sm2 8–11%, Sm3 11–25%) [28]. An anal- case series demonstrated local recurrence rates of
ysis of T1 tumors undergoing radical excision 8–26% for T1 lesions, 18–47% for T2 lesions
from the Surveillance, Epidemiology, and End with 5-year disease-free survival (DFS) ranging
Results database reported that tumors over 1.5 cm from 72% to 87% for T1 lesions, and 54–65% for
in size which exhibited poorly differentiated his- T2 lesions [35–39]. In the context of these data, it
tology were at significantly higher risk of nodal is not surprising that local excision was initially
involvement [29]. Moreover, a meta-analysis of reserved for palliation or patients who were med-
23 studies including 4510 patients found that T1 ically unfit to undergo radical surgery.
tumors with >1 mm invasion into the submucosa The advent of transanal endoscopic surgery
(OR 3.87, 95% CI 1.50–10.00), lymphovascular with transanal endoscopic microsurgery (TEM)
136 L. Lee et al.
and transanal minimally invasive surgery that local excision using TAE should be largely
(TAMIS) platforms has greatly improved the abandoned [47]. However, local recurrence
quality of local excision. Buess et al. published remained higher after local excision compared to
their single-center data reporting improved local radical surgery for both TAE and TEM, thus
recurrence rates of 4–10% and 5-year DFS of stressing the importance of careful patient selec-
96–100% for T1 lesions [40]. The improvement tion. Data from the multi-institutional Association
in oncologic outcomes was credited to better of Coloproctology of Great Britain and Ireland
visualization due to the magnified view provided TEM Collaboration identified submucosal depth
by the laparoscopic camera and a more precise of invasion, T-stage size, lymphovascular inva-
technique established with pneumorectum and sion, poorly differentiated histology, and elderly
laparoscopic instruments [21, 41–45]. patients (>80 years) to be predictive of local
A recent systematic review and meta-analysis, recurrence following TEM [11]. Advanced T
which included 6 studies and 927 local excisions, stage was also associated with increased local
found no difference in the rate of postoperative recurrence and worse disease-free survival
complications but reported a higher rate of nega- (Table 14.3 and Fig. 14.2).
tive margins (OR 5.28, 95% CI 3.20–8.71), lower TAMIS is similar to TEM but uses a soft oper-
rate of specimen fragmentation (OR 0.10, 95% ating platform and standard laparoscopic instru-
CI 0.04–0.21), and fewer local recurrences (OR mentation. First described in 2010, large series
0.25, 95% CI, 0.15–0.40) following TEM com- with long-term follow-up are lacking. Lee et al.
pared with TAE (Fig. 14.1) [46]. As a result of reported outcomes after the first 200 cases with a
improvements in the quality of local excision, mean follow-up of 14.4 months [48]. The quality
excellent oncologic outcomes can be obtained of excision was similar to large TEM series,
with TEM in carefully selected patients and including 7% margin positivity and 5% specimen
meticulous surgical technique. In a meta-analysis fragmentation rate. In patients with rectal adeno-
comparing local excision (subgrouped by TAE carcinoma, the incidence of local recurrence was
and TEM) and radical resection for early rectal 6% with a mean time to recurrence of 16.9 months.
cancer, disease-free and overall survival was Cumulative 1-, 2- and 3-year disease-free surviv-
worse for local excision in the TAE vs. radical als were 96%, 93%, and 86%, respectively. There
surgery comparison, but no differences were have been few direct comparisons between the
found between local excision and radical surgery different transanal endoscopic surgery platforms.
in the TEM subgroup [24]. These data suggest A multi-institutional matched cohort study
Fig. 14.1 Meta-analysis of TEM vs. TAE for lesion recurrence. N = 918, p < 0.001. TAE traditional transanal excision,
TEM transanal endoscopic microsurgery. (Adapted from Clancy et al. 2015 [46])
14 Oncologic Outcomes for Local Excision of Rectal Neoplasia 137
Table 14.3 Local recurrence and disease-free survival after local excision by T stage
Year N Local recurrence (%) 5-year disease-free survival (%)
Multicenter T1 T2 T3 T1 T2 T3
Bach [11] 2009 424 18 29 >50 ~85 ~70 ~50
UK
Baatrup [71] 2009 143 13 26 100 94 v 84 70
Denmark
Single center
Zacharakis [72] 2007 28 7 43 67
UK
Bretagnol [73] 2007 52 9 11 75 81 79
UK
Maslekar [74] 2007 52 0 14
UK
Stipa [75] 2006 44 8 9 100 70
Rome
Lee [43] 2003 52 4 19 96 80
Korea
pT2
0.9 pT3 Advanced Tumors
this management strategy. Adjuvant radiotherapy 12% vs. surgery 10%, p = 0.686), as was cancer-
with or without chemotherapy may result in ade- related (89% vs. 94%, p = 0.687) and overall
quate local control [54, 55], but oncologic out- (72% and 80%, p = 0.609) survival. The ACOSOG
comes are still inferior to radical resection. Z6041 phase II trial also investigated preopera-
Long-term follow-up of the Cancer and Leukemia tive chemoradiation followed by local excision
Group B (CALGB) 8984 trial reported 10-year for patients with clinical T2 N0 tumors [60]. Of
local recurrence rates for T2 lesions treated with the 77 patients that completed the preoperative
local excision and postoperative chemoradiation regimen and underwent local excision, 64%
were high at 18% compared to 8% for T1 lesions experienced tumor downstaging with 44% over-
treated with curative intent local excision [38]. all achieving a pathologic complete response
Disease-free and overall survival was also lower [61]. At 3-year follow-up, only 4% of patients
for the T2 lesions despite chemoradiotherapy. A experienced local recurrence, and 6% experi-
pooled analysis of 14 studies including 405 enced distant metastasis, resulting in a cumula-
patients treated by local excision with salvage tive 3-year disease-free and overall survival of
adjuvant chemoradiotherapy and 7 studies with 88.2% and 94.8%, respectively. The GRECCAR
130 patients treated with local excision followed 2 trial also demonstrated similar oncologic out-
by radical surgery reported that the weighted comes between 148 patients with pretreatment
local recurrence rate for local excision with adju- cT2/3 tumors and good response to neoadjuvant
vant chemoradiation was 10% (95% CI 4–21) for chemoradiotherapy that were randomly assigned
high-risk T1 compared to 6% (95% CI 3–15) for to local excision or TME surgery [62]. The trial
local excision with radical surgery [56]. In protocol required patients in the local excision
patients with T2 lesions, the weighted local group to subsequently undergo TME surgery if
recurrence was 15% (95% CI 11–21) for adju- final pathology demonstrated ypT2-3 or R1 dis-
vant chemoradiation compared to 10% (95% CI ease. Three-year local recurrence (5% vs. 6%,
4–22) for radical surgery. p = 0.68), disease-free (78% vs. 76%, p = 0.45),
With the increasing awareness of the func- and overall survival (92% vs. 92%, p = 0.92)
tional impairments and high morbidity after TME were similar between the local excision and TME
surgery, there is significant interest for organ surgery arms, but 36% of patients in the local
preservation for patients with cT2 lesions. excision arm underwent subsequent TME sur-
However, locoregional recurrence for T2 tumors gery for adverse pathology.
is high, ranging from 13% to 30% [36, 57, 58] While these data appear promising, the suc-
which is likely secondary to the 30–40% inci- cess of this neoadjuvant chemoradiation followed
dence of occult nodal involvement [59]. by local excision for more advanced tumors is
Therefore, local excision alone for T2 lesions is dependent on the tumor response. Local recur-
insufficient. Administration of neoadjuvant rence is high in these patients if a pathologic
chemoradiation prior to local excision may be a complete response is not obtained after preopera-
potentially viable management strategy for tive chemoradiotherapy [63]. Although local
patients with T2 lesions who wish to avoid radi- recurrence is 4.0% (95% CI 1.9–6.9) in patients
cal TME surgery. with ypT0, the incidence of local recurrence
Lezoche et al. randomly assigned 100 patients increases with more advanced T stages. In
with T2N0M0 tumors less than 3 cm within 6 cm patients with ypT1, local recurrence is 12.1%
of the anal verge that underwent neoadjuvant (95% CI 6.3–19.4), but in tumors ≥ ypT1, the
long-course chemoradiation to local excision by incidence was 21.9% (95% CI 15.9–28.5).
TEM versus laparoscopic TME. There was favor- Similarly, distant metastasis occurred in 2.8%
able tumor downstaging in both groups, with (95% CI 0.8–6.1) for ypT0 and 20.9% (95% CI
28% in the TEM and 26% in the surgery arm 14.7–27.9) for ≥ ypT1 tumors. These findings are
achieving ypT0. After a long-term follow-up, likely explained by the high incidence of residual
local recurrence was similar for both arms (TEM nodal involvement (>20% of ypT1/2 tumors)
14 Oncologic Outcomes for Local Excision of Rectal Neoplasia 139
[64]. Furthermore, Perez et al. demonstrated that T1sm1N0 tumors without lymphovascular inva-
patients with cT2-4N0M0 that do not result in sion or perineural invasion, have the best results
complete clinical response after chemoradiation with curative-intent local excision. The quality
are likely to exhibit unfavorable histology (ypT2 of local excision will also translate to superior
or 3 in at least 66%) [65]. These data suggest that oncologic outcomes. Transanal endoscopic sur-
local excision alone after neoadjuvant chemo- gery platforms, including TEM and TAMIS,
therapy in patients without complete clinical or likely result in better resection quality compared
pathologic response would result in understaging to traditional transanal excision. Organ preserva-
and undertreatment in a significant proportion of tion techniques involve perioperative chemora-
patients, thus tempering enthusiasm for this diation, and local excision may be a viable
approach. treatment strategy for patients with more
advanced tumors that refuse or are medically
unfit to undergo TME surgery. Careful patient
Recurrence After Local Excision selection and high resection quality are essential
to optimize the outcomes of local excision for
Local recurrence after local excision usually rectal neoplasia.
occurs within the first 1–2 years after resection
[49]. Initial data has suggested that local recur-
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142 L. Lee et al.
excisions, and the feasibility and outcomes have with the shaft of the stapler, and a single-stapled
been described [9, 10]. The specific benefits for a anastomosis is performed. Studies have shown
TaIPAA include avoiding the most difficult part outcomes of a transanal ileal pouch-anal anasto-
of the operation—the difficult dissection of the mosis (ta-IPAA) with TAMIS have lower odds
distal rectum by approaching the pathology from for postoperative morbidity than laparoscopic
below and potentially reducing the risk of anasto- IPAA [11].
motic leakage with the precise, hand-sewn anas-
tomosis instead of multiple firings of the stapler
[10]. For the procedure, a total abdominal colec- Pelvic Exenteration
tomy with an end ileostomy is performed using a
single-incision or multiport laparoscopic tech- Total pelvic exenteration utilizing TAMIS-based
nique. The ileostomy site is used as the extraction taTME techniques was introduced by Uematsu
site for the specimen. The patient is positioned in et al. as a potentially curative strategy in T4
modified lithotomy for the transanal completion locally advanced primary rectal cancer [12].
proctectomy and restorative stage. The ileostomy Transanal total pelvic exenteration involves en
is detached through a circumstomal incision, and bloc resection of multivisceral pelvic organs
a stapled pouch is created through the ileostomy enveloped within the visceral pelvic fascia with
site after full mobilization of the small bowel and the objective of completing this radical resection
mesenteric root using a single port with three with tumor-free distal and circumferential mar-
cannulas and returned to the abdominal cavity gins. The authors of this study advocated that the
after the anvil is inserted and secured. An transanal approach had significant advantages
18-French catheter is secured on the tip of the including improved visibility, a broader working
anvil to facilitate positioning from the transanal field than the conventional transabdominal
side. The focus is then shifted to the transanal approach, reduced blood loss, and ease in the pel-
portion. The anus is everted with a LoneStar vic dissection to prevent injury of the visceral
retractor for greater exposure (CooperSurgical, pelvic fascia [13]. With the success of the trans-
Trumbull, CT, USA), and a purse string is placed anal total pelvic exenteration, the same authors
and tied at ~3 cm above the dentate line, cautery then performed a sphincter-preserving transperi-
is used to circumferentially mark 2 cm distal to neal total pelvic exenteration, avoiding the dou-
the purse string, and a transmural, circumferen- ble stoma. The procedure was successful, and
tial incision is then made just distal to the purse they noted it suitable for large rectal cancers with
string. After the initial distal rectal wall is incised, widespread invasion to the adjacent organs within
the TAMIS port—GelPOINTPath transanal plat- the visceral pelvic fascia and vascular ligation
form (Applied Medical, Santa Margarita, CA, that would be otherwise difficult to mobilize lap-
USA)—is placed in the anus, and stable insuffla- aroscopically [14].
tion is obtained with the AirSEAL® System
(Conmed, Inc., Utica, NY, USA). A circumferen-
tial rectal dissection is performed with a vessel ysterectomy with Vaginal Access
H
sealer, and the rectum is extracted through the Minimally Invasive Surgery (VAMIS)
stoma site. The 18-French catheter on the pouch
anvil is grasped and retracted through the anus. A Vaginal hysterectomy is among the most com-
purse string is placed at the free edge of the distal mon gynecologic operations performed, and an
rectal cuff, the pouch is then pulled into the rectal incisionless procedure, making it ideal to advance
cuff, and the purse string is secured. The orienta- the concept of natural orifice surgery. The TAMIS
tion is reconfirmed to assure the mesentery is access channel can also be applied vaginally,
properly oriented and that the pouch is not extending the incisionless, minimally invasive
twisted, and the posterior vaginal wall is free approach into vaginal access minimally invasive
anteriorly in females. Then the anvil is mated surgery (VAMIS) for a hysterectomy. Atallah
15 Applications Beyond Local Excision 145
et al. showed the feasibility and standardized the to allow access. A circumferential purse-string
steps for the procedure in a cadaveric model [15]. suture was placed around the rectum under direct
The authors used both laparoscopic access for vision, and an extrarectal dissection was per-
monitoring and transvaginal access to perform formed until the rectal stump was circumferen-
the operation. The patient was positioned in tially mobilized, and then the specimen was then
Trendelenburg, and small bowel loops were removed transanally.
removed from the pelvis through the laparoscopic A TAMIS proctectomy can also be performed
port to prevent iatrogenic injury bowel during in reoperative cases. Reoperative pelvic surgery
VAMIS). Otherwise, there was no laparoscopic is inherently complex and fraught with complica-
assistance during VAMIS hysterectomy. Next, tions. Using TAMIS provides great benefit to
the GelPOINT Path platform (Applied Medical, enter a hostile pelvis from “bottom-up,” thereby
Santa Margarita, CA, USA) was inserted trans- approaching the pathology from a clean plane.
vaginally, and pneumatic inflow was attained. Borstlap et al. demonstrated the feasibility of
Three 5 mm trocars were used for the proce- TAMIS for redo pelvic surgery with a low colonic
dure—an atraumatic grasper was used to provide anastomosis or an ileoanal pouch in a series—14
counter tension and a hook electrocautery was anastomotic reconstruction and 3 completion
used or the dissection. The authors (1) circum- proctectomy. The authors were able to success-
scribed the cervix with electrocautery, (2) entered fully perform these complex cases with simulta-
the peritoneal cavity at the pouch of Douglas, (3) neous transabdominal access in 15 patients and
entered the vesicouterine pouch, (4) divided the TAMIS alone in 2 cases. There were five patients
cardinal ligaments with the uterine vessels, (5) who were readmitted, two developed an anasto-
divided the fallopian tube and ovarian ligaments, motic leakage, and four developed a pelvic
(6) extracted the specimen vaginally, and (7) pri- abscess requiring reintervention within 30 days.
marily closed the vaginal cuff under direct vision After a median follow-up of 9 months, intestinal
[15]. The intra-abdominal monitoring showed no continuity was restored in 71% of the patients.
inadvertent injury. With the feasibility demon- The authors found TAMIS was a valuable
strated and improvements in the ability to approach in redo pelvic surgery. While there was
securely close the vaginotomy, VAMIS) for hys- a high complication rate, this is related to the
terectomy and movement toward complete natu- complexity of the underlying pathology and not
ral orifice surgery without abdominal access has the platform [19].
great potential and has since been utilized clini-
cally by gynecologists [16, 17].
Rectal Prolapse
Retrorectal Masses
TAMIS provides an alternative option for such as with a continuous V-Loc suture, or left
transanal resection of clinically benign retrorec- open, depending on the location of the lesion and
tal cysts with excellent exposure and visualiza- the surgeon’s preference. To date, the safety and
tion of the cephalad extent of the cyst, decreased feasibility have been described for excising a
risk for sacral neurologic injury, and decreased variety of rectal lesions and neoplasia over a wide
overall morbidity [25]. McCarroll et al. described range of anatomical levels [26–28]. The Xi plat-
the steps for TAMIS resection of a retrorectal form may allow greater intraluminal excision and
cyst with the patient in the lithotomy position, suturing following excision [28]; however, the Si
where the contour of the lesion could be seen dis- platform permits 5 mm instruments, which could
torting the posterior wall of the rectum after permit more room to “move” intraluminally.
establishing pneumorectum. The authors used a Expanded options with new platforms, such as
vessel-sealing device to incise through the rectal the da Vinci single-port system robotic platform
wall overlying the cyst, expose the surrounding (SPS) [29] and flexible robotic platforms, have
avascular plane, and dissect the cyst free from all the potential to access anatomy along circuitous
attachments using a hybrid TAMIS and transanal paths [30].
approach for the most caudal aspect. As no rectal
wall was excised, the proctectomy was easily
closed in one layer without tension or ischemia. Managing Complications
While not a common procedure, TAMIS can, in
select cases, provide a minimally invasive option In addition to performing stand-alone proce-
for complete excision with rapid recovery in dures, TAMIS has great utility in managing com-
those patients requiring surgery. plications. The TAMIS approach allows the
surgeon to perform both diagnostic and therapeu-
tic maneuvers, with the enhanced visualization
Robotic TAMIS and working ports on the transanal platform.
TAMIS also offers benefits, such as improved
Robotic TAMIS was introduced as an alternative visibility and a minimally invasive, incisionless
to help overcome the limitations of conventional tool to approach the complication without added
TAMIS for the local excision of rectal lesions morbidity.
[26], but the application can be applied broadly
beyond rectal lesions. Robotic TAMIS allows for
greater versatility in motion while operating in nastomotic Bleeding After
A
the limited space of the rectum. Procedures gen- a Colorectal Anastomosis
erally use the GelPOINT Path (Applied Medical,
Rancho Santa Margarita, CA, USA) TAMIS port In reality, all stapled anastomoses bleed. Luckily,
with the patient positioned either dorsal lithot- few are clinically significant enough to require
omy or in the prone jack-knife position, with intervention. In these cases, TAMIS is a valuable
three robotic arms docked from the patient’s left tool as it enables the precise localization of the
or right side (da Vinci Xi System, Intuitive bleeding site and intervention under direct visu-
Surgical Inc., Sunnyvale, California, USA). The alization. Evaluating the staple line endoscopi-
margins of the lesions can be marked with the cally is safe and feasible and routinely done with
robotic spatula tip cautery, and then the mucosa a colonoscope after creation to assess the integ-
over the lesion is held with forceps in one hand, rity of the anastomosis. In our practice, we have
while the lesion is dissected and excised in the found that addressing a bleeding staple line with
other hand. Depending on the pathology and sur- the TAMIS platform is safe and feasible. With the
geon preference, either the cautery or a vessel- endoscopic assessment, if there is significant
sealing device can be used for the dissection. The bleeding, a TAMIS platform can be placed trans-
subsequent defect can be easily sutured closed, anally and pneumorectum established to
148 D. S. Keller
a b
Fig. 15.2 TAMIS repair of staple line bleeding. (a) Visualization of the bleeding area. (b) Direct suture repair
12 mmHg. The insufflation adds benefit, as it TAMIS port transanally and established pneu-
helps reduce intraluminal venous bleeding. A 30° morectum and then punctured the blind stricture
laparoscopic camera is then used to identify the with a 21 gauge needle and injected contrast
exact location of the bleed. The 360° magnified medium through the needle to fluoroscopically
endoscopic view can aid in visualization for the confirm the position of the proximal lumen. The
ideal repair. If needed to control the bleeding, the lumen was incised by electrocautery, and fibrotic
gal cap can be removed, and a Raytec sponge is tissue was removed around the stenosis to main-
introduced and held in place over the area of the tain the bowel continuity. The authors reassessed
bleeding, applying direct pressure. Using regular the area weeks after the procedure, both digitally
laparoscopic instruments, the staple line can be and using a contrast enema, confirming the
directly repaired, such as with a V-Loc stitch for patency. While unconventional, the TAMIS port
a continuous running repair. After the repair, a allowed a minimally invasive solution to a com-
suction irrigator can be used to clear any clots plex problem that could otherwise have required
and assure hemostasis (Fig. 15.2). major revisionary surgery which could have
resulted in a permanent stoma.
infected presacral cavity can form along with between the sinus and the bowel lumen can be
fibrosis which negatively impact defecatory func- divided under direct vision with a laparoscopic
tion and stoma closure rates. vessel-sealing device, and the sinus cavity can be
A TAMIS approach can be used for low anas- debrided with the suction cautery wand.
tomotic sinuses, with excellent short-term out- Depending on the quality of the tissue, it can be
comes. We advocate that the pouch-anal or primarily repaired or left open (Fig. 15.3). In
colorectal anastomoses should be protected with clinical practice, we wait 4–6 weeks after the pro-
a diverting loop ileostomy and treated if it fails to cedure to perform a contrast enema to identify
resolve with observation before intestinal conti- any residual anastomotic problems before ileos-
nuity is restored. For the procedure, the patient is tomy closure. In our experience, when used in
placed in lithotomy position in moderate conjunction with fecal diversion, TAMIS divi-
Trendelenburg, the transanal access platform is sion of the common wall between the sinus and
inserted and secured, insufflation pressure is set bowel lumen can effectively treat low pelvic
to 12 mmHg, and pneumorectum is established. sinuses, improving patient outcomes and func-
A 30° 5 mm laparoscopic camera lens is used to tion and allowing closure of the diverting
identify the sinus opening. The common wall ileostomy.
a b
Fig. 15.3 TAMIS management of an anastomotic sinus. (a) The sinus is localized. (b) The common channel is opened
to the rectal lumen. (c) The defect is closed
150 D. S. Keller
Urethral, Vaginal, and Bladder body become entrapped and patients present for
Fistula Repairs management, the surgeon must be cognizant that
extended time may have passed before the patient
Rectourethral, rectovaginal, and rectovesical fis- reported for medical aid due to embarrassment.
tulae represent significant postoperative or postra- Attempts at extraction may have already occurred
diation complications that are difficult to by the patient, causing spasm and possibly further
definitively treat, due to the poor quality of the trauma as sharp or breakable objects may have
tissue attempting to be repaired as well as the ana- been used, which can be hard to retrieve and which
tomic locale. Multiple approaches have been risk perforation. In such a setting, an abdominal
applied for repair, but none are considered the operation for foreign body retrieval may be
gold standard due to morbidity and high failure required. In cases where there is no peritonitis or
rates. A TAMIS approach allows for an incision- free air on imaging, and the foreign body is below
less, minimally invasive repair with excellent the rectosigmoid junction, but cannot be removed
visualization in these conditions. Atallah et al. with forceps, TAMIS can be considered an option
described the use of TAMIS for repair of a recto- for extraction before resorting to an abdominal
urethral fistula in patient after cryoablative treat- operation [35]. With TAMIS, after the transanal
ment for prostate cancer [18, 33]. Gastrografin platform is inserted and insufflation is achieved,
enema and colonoscopy were used to confirm the laparoscopic instruments can be used to grasp and
communication between the rectum and the uri- remove the foreign body. After removal, the cap
nary system. In this case, the TAMIS platform can be replaced and pneumorectum reestablished
was used to repair the fistula in two layers, with to allow a high-definition magnified view of the
separate closure of the urethral defect using an mucosa for inspection and identification of any
automated suturing device (Endo Stitch™, defects or perforations [36]; if identified, any inju-
Covidien, Mansfield, MA, USA) in combination ries could also be directly repaired with suturing or
with LAPRA-TY® (Ethicon, Inc., Summerville, clips through the TAMIS platform.
NJ, USA). A full-thickness rectal wall flap was
then created as a second layer and primarily
closed [33]. In their experience, the authors advo- AMIS as a Bridge to taTME
T
cate considering TAMIS as modality of repair for with Image-Guided Surgery
rectourethral fistulae that are not radiation induced
[33]. Tobias-Machado et al. used TAMIS for suc- Stereotactic navigation allows for real-time,
cessful management of a rectovesical fistula after image-guided surgery, thus providing an aug-
radical prostatectomy, performing cystoscopy mented and potentially safer intraoperative work-
with implant of guidewire through fistula, then ing space [37]. With TAMIS, the technique can be
positioning the patient in prone jack-knife posi- applied to fixed anatomic targets. TAMIS with
tion and inserting the transanal access device to stereotactic navigation can be used to facilitate
identify the fistula. The authors dissected the tis- bringing new procedures safely into practice,
sue around the bladder side, closed the bladder such as the transanal total mesorectal excision
wall and injected fibrin glue in defect, and then (taTME), by helping operators map the anatomy
closed the rectal wall. They reported challenged as they ascend the learning curve. The taTME was
in instrumentation and suturing, but showed the born from the need for a technique that combined
procedure was feasible with no recurrence [34]. the benefits of minimally invasive abdominal sur-
gery with the visualization and functional benefits
of TAMIS and the precise distal dissection of the
Foreign Body Retrieval transanal transabdominal (TATA) bottom- up
approach to the total mesorectal excision. This
Rectal foreign bodies may be inserted transanally “reverse” proctectomy is particularly helpful in
in association with sexual acts, assault, or self- the obese male patient with a narrow pelvis, pro-
treatment of constipation. When rectal foreign viding excellent exposure, despite the difficulty
15 Applications Beyond Local Excision 151
imposed by body habitus [18]. In the learning 2. Atallah S, Albert M, Larach S. Transanal minimally
invasive surgery: a giant leap forward. Surg Endosc.
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navigation can serve as a gateway for safer sur- 3. Albert MR, Atallah SB, deBeche-Adams TC, Izfar
gery, although this remains highly experimental S, Larach SW. Transanal minimally invasive surgery
and is reserved to few centers that have the exper- (TAMIS) for local excision of benign neoplasms and
early-stage rectal cancer: efficacy and outcomes in the
tise to perform such operations [38]. A tool such first 50 patients. Dis Colon Rectum. 2013;56:301–7.
as stereotactic navigation could help surgeons 4. Clancy C, Burke JP, Albert MR, O’Connell PR,
implement the taTME safety into practice and Winter DC. Transanal endoscopic microsurgery ver-
potentially improve the resection quality by sus standard transanal excision for the removal of rec-
tal neoplasms: a systematic review and meta-analysis.
improving the surgeon’s spatial awareness [37]. Dis Colon Rectum. 2015;58:254–61.
5. Moore JS, Cataldo PA, Osler T, Hyman NH. Transanal
endoscopic microsurgery is more effective than tra-
Neuromapping with TAMIS for taTME ditional transanal excision for resection of rectal
masses. Dis Colon Rectum. 2008;51:1026–30; dis-
cussion 1030.
Sparing the extrinsic autonomic innervation of the 6. McLemore EC, Weston LA, Coker AM, et al. Transanal
internal anal sphincter during total mesorectal minimally invasive surgery for benign and malignant
excision is important for maintaining anal sphinc- rectal neoplasia. Am J Surg. 2014;208:372–81.
7. Maglio R, Muzi GM, Massimo MM, Masoni
ter function postoperatively. Kniest et al. described L. Transanal minimally invasive surgery (TAMIS):
electrophysiologically confirming the topography new treatment for early rectal Cancer and large rec-
of the internal anal sphincter nerve supply with tal polyps-experience of an Italian center. Am Surg.
TAMIS prior to a transanal total mesorectal exci- 2015;81:273–7.
8. Verseveld M, Barendse RM, Gosselink MP, Verhoef
sion in six patients with low rectal cancers. The C, de Graaf EJ, Doornebosch PG. Transanal mini-
authors described key zones of risk for pelvic mally invasive surgery: impact on quality of life and
autonomic nerve damage with the advantageous functional outcome. Surg Endosc. 2016;30:1184–7.
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A. Transanal completion proctectomy after total col-
innervation to the internal anal sphincter near the ectomy and ileal pouch-anal anastomosis for ulcer-
levator ani muscle with this tool [38]. ative colitis: a modified single stapled technique.
Colorectal Dis. 2016;18:O141–4.
10. Leo CA, Samaranayake S, Perry-Woodford ZL, et al.
Initial experience of restorative proctocolectomy for
Conclusions ulcerative colitis by transanal total mesorectal rectal
excision and single-incision abdominal laparoscopic
TAMIS is a versatile platform with proven pur- surgery. Colorectal Dis. 2016;18:1162–6.
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Wasmann KA, et al. Transanal versus transabdominal
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ized minimally invasive surgery, and the success ileal pouch-anal anastomosis in ulcerative colitis: a
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Yamaguchi T, Sano T. Transanal total pelvic exentera-
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functional benefits of the TAMIS approach, the excision with transanal pelvic exenteration. Dis Colon
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J Gynecol Surg. 2016;32(5):257–62. port system: a cadaveric feasibility study. Tech
18. Atallah S, Albert M, Debeche-Adams T, Larach
Coloproctol. 2017;21:541–5.
S. Transanal minimally invasive surgery (TAMIS): 30. Atallah S, Hodges A, Larach SW. Direct target
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2013;17:239–43. eration robotic platforms. Tech Coloproctol.
19. Borstlap WA, Harran N, Tanis PJ, Bemelman
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WA. Feasibility of the TAMIS technique for redo pel- 31. Bong JW, Lim SB. Transanal minimally inva-
vic surgery. Surg Endosc. 2016;30:5364–71. sive surgery as a treatment option for a completely
20. Senapati A, Gray RG, Middleton LJ, et al. PROSPER: occluded anastomosis after low anterior resection:
a randomised comparison of surgical treatments for a new approach to severe anastomotic stenosis.
rectal prolapse. Colorectal Dis. 2013;15:858–68. Asian J Endosc Surg. 2018; https://doi.org/10.1111/
21. Cirocco WC. The Altemeier procedure for rectal pro- ases.12599.
lapse: an operation for all ages. Dis Colon Rectum. 32. van Koperen PJ, van Berge Henegouwen MI, Rosman
2010;53:1618–23. C, et al. The Dutch multicenter experience of the
22. Althoff A, Rowen R, Dakermandji M, Kelly J, Atallah endo-sponge treatment for anastomotic leakage after
S. Perineal rectosigmoidectomy combined with colorectal surgery. Surg Endosc. 2009;23:1379–83.
TAMIS rectopexy: a NOTES operation for rectal 33. Atallah SB, deBeche-Adams TC, Larach S. Transanal
procidentia. Tech Coloproctol. 2017;21:815–6. minimally invasive surgery for repair of rectourethral
23. Al Furajii H, Cahill RA. TAMIS completion proc- fistula. Dis Colon Rectum. 2014;57:899.
tectomy and concomitant parastomal hernia repair 34. Tobias-Machado M, Mattos PA, Reis LO, Juliano CA,
with transperineal mesh fixation – a video vignette. Pompeo AC. Transanal minimally invasive surgery
Colorectal Dis. 2016;18:726. (TAMIS) to treat vesicorectal fistula: a new approach.
24. Al Furajii H, Cahill RA. Dual endolaparoscopic
Int Braz J Urol. 2015;41:1020–6.
technique (DUET) for TAMIS proctectomy and con- 35. Cawich SO, Thomas DA, Mohammed F, Bobb NJ,
comitant parastomal hernia repair. Tech Coloproctol. Williams D, Naraynsingh V. A management algo-
2016;20:67–9. rithm for retained rectal foreign bodies. Am J Mens
25. McCarroll RH, Moore LJ. Transanal minimally inva- Health. 2017;11:684–92.
sive surgery for resection of retrorectal cyst. J Surg 36. Cawich SO, Mohammed F, Spence R, Albert M,
Case Rep. 2018;2018:rjy021. Naraynsingh V. Colonic foreign body retrieval
26. Warren CD, Hamilton AER, Stevenson ARL. Robotic using a modified TAMIS technique with standard
transanal minimally invasive surgery (TAMIS) for instruments and trocars. Case Rep Emerg Med.
local excision of rectal lesions with the da Vinci Xi 2015;2015:815616.
(dVXi): technical considerations and video vignette. 37. Atallah S, Larach SW, Monson JR. Stereotactic navi-
Tech Coloproctol. 2018; https://doi.org/10.1007/ gation for TAMIS-TME. Minim Invasive Ther Allied
s10151-018-1816-z. Technol. 2016;25:271–7.
27. Atallah S. Assessment of a flexible robotic system 38. Kneist W, Rink AD, Kauff DW, Konerding MA, Lang
for endoluminal applications and transanal total H. Topography of the extrinsic internal anal sphinc-
mesorectal excision (taTME): could this be the solu- ter nerve supply during laparoscopic-assisted TAMIS
tion we have been searching for. Tech Coloproctol. TME: five key zones of risk from the surgeons’ view.
2017;21:809–14. Int J Colorectal Dis. 2015;30:71–8.
The Evolution of Robotic TAMIS
16
Sam Atallah, Nicolas C. Buchs,
and Seon-Hahn Kim
precision and therefore quality, attempted to required careful dry laboratory testing to determine
demonstrate an advantage of robotic surgery over how to dock a robotic cart through a single-port
laparoscopic surgery [16–18]. The two minimally apparatus (aka, TAMIS port) so that it could be
invasive techniques share much in common, and used for transanal surgery. This testing took place
a definite advantage has not been demonstrated in 2010 and predated the era of transanal-specific
for robotics over laparoscopy for colon and rectal platforms, when most TAMIS – including the orig-
surgery [19–22]. inal description of the technique [23] – utilized the
At first, it seemed as though the objective in SILS™ Port (Covidien-Medtronic) and other such
surgery was to somehow prove that the existing “single ports” designed for transabdominal access.
robotic, multi-arm systems were somehow supe- However, the SILS™ Port was not able to admit
rior to laparoscopy, thereby justifying the known robotic 8 mm effectors, and the port radius was too
cost differential. However, with the advent of small to allow multi-arm robotic access. In 2010, a
transanal minimally invasive surgery (TAMIS) new kind of single port had emerged, which had a
[23], a new quest to access anatomic targets and faceplate that would accommodate robotic 8 mm
apply robotics to (specifically) endoluminal sur- instruments. This first-generation QuadPort+
gery has refocused current interest in developing (Olympus, Shinjuku, Tokyo, Japan) was FDA
systems that do not mimic laparoscopy but approved for abdominal single-port access, and the
instead are completely different systems that fuse initial robotic transanal experiments were per-
next-generation computer processors with plat- formed utilizing this port (Fig. 16.1). Initially, the
forms configured in such a way as to address objective was to simply answer this question: could
problems and challenges in surgery whose solu- a da Vinci robotic cart be docked through this nar-
tions had heretofore been unattainable. Thus, the row channel while preserving the robot’s
general impetus and drive behind robotics in sur- functionality?
gery has completely shifted over time. The origi- Initial experiments were conducted in a dry
nal objective of telesurgery replaced be a quest laboratory setting to determine the feasibility
for precision; the rivalry between laparoscopy and ergonomics of robotic cart docking through
and robotics placed on pause as the potential for a single port. This was performed in September,
robotics to access anatomic targets in ways not 2010 (S. Atallah et al. in Orlando, FL, USA), uti-
otherwise possible is currently being explored. It lizing the da Vinci Si platform with 8 mm effec-
is with this pretext that the evolution of robotic
TAMIS can be best understood.
Docking and Configuration
Fig. 16.6 Docking and patient configuration is often Notwithstanding, one of the most common configurations
dependent on the specific robotic platform, the type of of the da Vinci Si systems with GelPOINT Path Transanal
TAMIS port or glove port, and sometimes the position of Access Platform is shown. Note that the robotic cart is
the lesion. Surgeons who perform robotic TAMIS may docked flush with the operating table and working arms
also have a specific preference; although for robotic one and two are delivered over the thigh to prevent
TAMIS (as compared to conventional TAMIS), there is encroachment and collision during robotic TAMIS. The
more likely to be position and docking variability. patient is typically positioned in steep Trendelenburg
16 The Evolution of Robotic TAMIS 159
Fig. 16.9 July 28, 2015: The first robotic TAMIS using Fig. 16.10 A custom-made port, developed by Marcos
the Xi® system was performed by S. Atallah in Orlando, Gómez-Ruiz, MD, is a hybrid cross between a TEM scope
FL, USA. The lesion was a 2.8 cm adenoma and was and a TAMIS port. The rigid reusable portion of the device
excised with negative margins. Note the configuration of is secured to the bedrail with a mount to hold it in posi-
the working arms with a 30° downward lens placed superi- tion. The faceplate (disposable) is an 80 mm GelPOINT
orly and equidistant to two 8 mm working arms. An addi- (Applied Medical, Inc.). The configuration improves
tional 5 mm AirSeal port (ConMed, Inc., Utica, NY, USA) ergonomics and decreases collisions between working
was used to provide stable pneumorectum. This fourth port arms
allows for access of 5 mm instruments (such as a suction
irrigator) which can be operated by a bedside assistant
defect measuring 1.5 cm and therefore was surgery is toward the development of taTME,
graded as a Quirke II (near complete); all mar- with the objective of improving the operative
gins were negative [54]. approach and reducing the challenges of conven-
While limited to expert centers, small series tional instrumentation [58–60]. Image-guided
and pilot studies on robotic taTME have been pub- surgery in conjunction with robotics for complex
lished in both the preclinical and clinical settings surgical procedures, such as taTME, is also an
[47–49, 51, 55, 56], each series concluding that area actively being investigated. Robotic taTME
high-quality excision is feasible with the robotic is discussed further in Chap. 44.
platform (Fig. 16.11). Although most robotic
approaches to taTME have applied the platform
transanally in conjunction with laparoscopy for
the abdominal portion of the operation, Marcos
Gómez-Ruiz has used a totally robotic approach
by double docking abdominally and then subse-
quently transanally [49]. This technique utilizes a
specialized platform that is a hybrid between TEM
and TAMIS with some components reusable and
others disposable, as described previously.
There has been an accelerated advancement in
minimally invasive approaches to transanal sur-
gery over recent years (Fig. 16.12). Robotic
approaches are continuing to evolve with several
new venders rapidly filling the space with cre-
Fig. 16.11 Robotic taTME represents the next step in the
ative systems that, instead of mimicking laparos- evolution of advanced, robotic transanal access. Here the
copy, are being designed with computerized, da Vinci Si platform with a 5 mm hook monopolar cautery
remodeled mechanics that provide improved and 5 mm grasper is used to initiate the posterior TME
flexibility and thus an ability to access anatomic dissection. The theoretical advantage of the robotics in a
confined space is the potential to improve resection qual-
targets not previously believed possible [50, 57]. ity by providing a platform with superior optics, magnifi-
Today, much of the focus on robotic transanal cation, and surgeon control
Fig. 16.12 Timeline delineating the milestones in robotics in colorectal surgery including transanal approaches
162 S. Atallah et al.
and single-site plus one-port (R-SSPO) technique for 56. Atallah S, Drake J, Martin-Perez B, Kang C, Larach
ultra-low rectal surgery-initial experience with a new S. Robotic transanal total mesorectal excision with
operation approach. Int J Color Dis. 2017;32(2):249– intersphincteric dissection for extreme distal rectal
54. https://doi.org/10.1007/s00384-016-2686-3. Epub cancer: a video demonstration. Tech Coloproctol.
2016 Oct 15. 2015;19(7):435. https://doi.org/10.1007/s10151-015-
52. Laird R, Obias VJ. Robotic transanal fistula repair – a 1304-7. Epub 2015 May 12.
video vignette. Color Dis. 2015;17(1):90. https://doi. 57. Son J, Cho CN, Kim KG, Chang TY, Jung H, Kim SC,
org/10.1111/codi.12799. Kim MT, Yang N, Kim TY, Sohn DK. A novel semi-
53. Stack ME, Umanskiy K. Robotic-assisted transanal automatic snake robot for natural orifice transluminal
repair of a rectovaginal fistula. J Gastrointest Surg. endoscopic surgery: preclinical tests in animal and
2016;20(12):2106. Epub 2016 May 24. human cadaver models (with video). Surg Endosc.
54. Atallah S, Nassif G, Polavarapu H, deBeche-Adams 2015;29(6):1643–7. https://doi.org/10.1007/s00464-
T, Ouyang J, Albert M, Larach S. Robotic-assisted 014-3854-6. Epub 2014 Oct 8.
transanal surgery for total mesorectal excision (RATS- 58. Melani AF, Diana M, Marescaux J. The quest for
TME): a description of a novel surgical approach precision in transanal total mesorectal excision. Tech
with video demonstration. Tech Coloproctol. Coloproctol. 2016;20(1):11–8.
2013;17(4):441–7. https://doi.org/10.1007/s10151- 59. Hompes R. Robotics and transanal minimal inva-
013-1039-2. Epub 2013 Jun 26. sive surgery (TAMIS): the “sweet spot” for robot-
55. Gomez Ruiz M, Martin Parra I, Calleja Iglesias A, ics in colorectal surgery? Tech Coloproctol.
Stein H, Sprinkle S, Manuel Palazuelos C, Alonso 2015;19(7):377–8. https://doi.org/10.1007/s10151-
Martin J, Cagigas Fernandez C, Castillo Diego J, 015-1326-1. Epub 2015 Jun 25.
Gomez Fleitas M. Preclinical cadaveric study of 60. Mohd Azman ZA, Kim SH. A review on robotic sur-
transanal robotic proctectomy with total mesorec- gery in rectal cancer. Transl Gastroenterol Hepatol.
tal excision combined with laparoscopic assistance. 2016;1:5. https://doi.org/10.21037/tgh.2016.03.16.
Int J Med Robot. 2015;11(2):188–93. https://doi. eCollection 2016.
org/10.1002/rcs.1581. Epub 2014 Feb 27.
Transanal Robotic Surgery
and Future Directions 17
Kevin M. Izquierdo, Thushy Siva, Jean Salem,
Brigitte Anderson, and John Marks
Abbreviations
Introduction
MIS Minimally invasive surgery
NOTES Natural orifice transluminal The challenges inherent to rectal cancer surgery
endoscopic surgery have inspired ideological innovations in the field.
RATS-TME Robotic transanal total mesorec- Driven by high recurrence rates and high morbid-
tal excision; robotic taTME ity seen with the earliest rectal cancer operations,
RTAS Robotic transanal surgery and by the technical difficulty of operating in the
SILS Single incision laparoscopic surgery deep and narrow confines of the pelvis, the surgi-
TAMIS Transanal minimally invasive cal treatment of rectal cancer has continued to
surgery evolve. The total mesorectal excision (TME) as
TATA Transanal transabdominal described by Dr. Bill Heald [1] and the transanal
proctosigmoidectomy transabdominal proctosigmoidectomy (TATA) as
taTME Transanal total mesorectal excision described by Dr. Gerald Marks [2], which ensures
TEM Transanal endoscopic a clear distal margin in the rectum pre-treated
microsurgery with radiation, have both become core oncologic
tenets of rectal cancer surgery. Furthermore, the
TATA allows sphincter preservation, even for
patients with low rectal cancers, without sacrific-
ing the quality of oncologic outcomes [3].
Combined with TEM, these concepts have given
rise to the transanal total mesorectal excision
K. M. Izquierdo (*) · J. Salem (taTME).
Lankenau Medical Center, Division of Colorectal Benefits and advances in minimally invasive
Surgery, Wynnewood, PA, USA
e-mail: [email protected] surgery (MIS) have been applied successfully to
rectal cancer surgery. Prior to the 1980s, trans-
T. Siva
Easton Hospital, Department of Surgery, anal excision of rectal neoplasms was restricted
Easton, PA, USA by limited reach and exposure. In 1983, Dr.
B. Anderson · J. Marks Gerhard Buess invented transanal endoscopic
Colon and Rectal Surgery, Lankenau Medical Center, microsurgery (TEM) [4], setting the stage for a
Marks Colorectal Surgical Associates, Wynnewood, long technological evolution in rectal surgery.
PA, USA Building off of Dr. Buess’ TEM technique, the
e-mail: [email protected]; [email protected]
applications of transanal surgery have been the stage for the rapid evolution of technology in
extended by Atallah, Albert, and Larach using colorectal surgery over the next three decades.
single-port transanal laparoscopy, today known However, the steep learning curve and significant
as transanal minimally invasive surgery (TAMIS); cost were major barriers to its universal
and most recently, robotic surgical technology is adoption.
applied transanally (Robotic TAMIS). By Transanal minimally invasive surgery
addressing many of the technical challenges that (TAMIS), first described in 2009 by Drs. Atallah,
have hindered wider adoption of TEM, TAMIS, Albert, and Larach, is a cost-effective alternative
and taTME, robotic transanal surgery promises to to TEM [9]. Building upon TEM concepts,
increase surgeon access to these techniques so TAMIS uses a flexible single incision laparo-
that more patients can benefit. Future directions scopic surgery (SILS) port transanally rather than
of transanal robotic surgery will undoubtedly the rigid proctoscope used in TEM. Cost is
lead to a new era of pure natural orifice translu- decreased by avoiding the large start-up cost of
minal endoscopic surgery (NOTES), the ultimate TEM equipment and through the use of laparo-
in minimally invasive surgery. scopic instrumentation readily available in
modern-day operating rooms. Atallah et al. pub-
lished their experience with TAMIS in the exci-
Evolution of Transanal Surgery sion of both malignant and benign lesions of the
rectum, and early data suggests that oncologic
Dr. Gerhard Buess’ transanal endoscopic micro- outcomes are comparable to TEM [10].
surgery (TEM) platform in 1983 represented a From a technical standpoint, TAMIS, allows
disruptive change in surgical approach and tech- access to the full 360 degrees of the lumen,
nology. TEM predates laparoscopy – the first whereas with TEM, the workspace is limited to
demonstration of the laparoscopic cholecystec- the lower 180 degrees of the visualized operative
tomy was presented in 1989 at the Surgical field. Furthermore, the flexible platform allows
Association of Gastrointestinal and Endoscopic better access to more proximal structures, allow-
Surgeons (SAGES) conference by Drs. Perissat ing its application to expand to complete trans-
and Mouiel [5, 6]. In 1983, open surgery was the anal total mesorectal excision. However, TAMIS
only approach in the surgical treatment of rectal initially suffered from the lack of a stable pneu-
cancer. The original application of TEM was in matic platform that TEM provides. Drs. Lacy,
the removal of rectal polyps and was later Rattner, and Sylla published a systematic study
expanded to treating malignant lesions with local of the transanal total mesorectal excision using
excision. Although unpublished, it is believed the TAMIS platform [11]. In doing so, they suc-
that in 2008 Dr. John Marks performed the first cessfully melded the core principles of TATA,
transanal total mesorectal excision (taTME) hybrid NOTES, and TAMIS.
using the TEM platform. Pushing the limits of transanal surgery using
Key technological features of TEM are bin- the TAMIS technique, Dr. Leroy pioneered
ocular stereotactic optics, improved access to “pure” NOTES proctosigmoidectomy with trans-
more proximal lesions, and incisionless natural anal completion of the TME dissection, release
orifice surgery via the anus. As applications of of the splenic flexure, transection of the inferior
TEM expanded to T1 cancers, the technical mesenteric vessels, and coloanal anastomosis. He
advantages became evident with significantly coined the procedure perirectal oncologic gate-
lower recurrence rates as compared to open trans- way for retroperitoneal endoscopic single site
anal approaches. Experiences at the University of surgery (PROGRESSS) [12]. Select centers have
Minnesota and the Cleveland Clinic reported further pioneered pure NOTES taTME [13, 14].
local recurrence rates of 4.2–9% with TEM com- As it was with TEM for local excision of rec-
pared to 25–33% with conventional transanal tal lesions, a steep learning curve is the primary
excision for T1 rectal cancers [7, 8]. This disrup- obstacle to wider adoption of pure NOTES for
tive transanal minimally invasive approach set rectal cancer as it requires the highest level of
17 Transanal Robotic Surgery and Future Directions 167
technical difficulty of TEM and TAMIS is the manipulated to control the Flex® scope
primary barrier to wide adoption. The effective- (Fig. 17.1b). The Flex® Base accommodates a
ness of an operative technique is determined by disposable Flex® Scope CR drive, which is then
the level of difficulty relative to other docked transanally (Fig. 17.1c). The two main
approaches. Thus, broadly speaking, a specific units of this system are operated by a single sur-
operative approach is highly effective if the geon, eliminating the need for a bedside assis-
majority of surgeons can perform the operation tant. Flexible, pistol-grip instruments are used to
with high completion rates and good/excellent perform the surgery, through a bedrail-mounted
clinical outcome. If an operation is so difficult apparatus, permitting triangulation (Fig. 17.1d).
that few surgeons can perform it with good out- This flexible robotic system allows access to
come, it is effective in the hands of a select few remote anatomic fields with an operative reach
but has limited effectiveness in the wide world of 17 cm. In addition, smaller 3.5 mm instru-
of surgical practice. Thus any technology which ments allow for minimal restriction of the field
reduces the technical difficulty in the execution of view [24].
of an operation will automatically increase its Obias, Sylla, and Pigazzi presented their ini-
effectiveness and ultimately benefit patient care. tial experience of this system for transanal access
This aim motivates ongoing innovation in in a preclinical setting during the proceedings of
robotic transanal surgery. the American Society of Colon and Rectal
An ideal platform for robotic TAMIS Surgeons and Tripartite Meeting in Seattle,
addresses four challenges of robotic TAMIS: (1) Washington, in 2017 [25]. Feasibility of this plat-
optimal visualization, (2) ergonomic instrument form in performing targeted NOTES operations
control, (3) improved proximal access, and (4) in a cadaveric model was reported by Atallah in
ease of tissue extraction and manipulation. To 2018 [22].
address these goals, a multitude of systems have Visualization with the Flex® Robotic System
been and are under development. The Flex® is improved compared to laparoscopic TAMIS
Robotic System, STRAS (Single-Access in that it does not require an assistant and the
Transluminal Robotic Assistant for Surgeons) operative field of view can be set by the operat-
robot, and the da Vinci Single-Port (SP) Surgical ing surgeon. The primary advantage of the
System are all emerging robotic platforms Flex® Robotic platform is that it allows trans-
designed to meet the challenges of transanal mission of the platform along circuitous path-
surgery. ways for better access to more proximal lesions
than would otherwise not be possible by con-
ventional methods. Drawbacks of this platform
Flex® Robotic System are that the robotic camera and platform move-
ments use separate modules and redefining the
The Flex® Robotic System together with the operative field of view is time consuming [22].
Flex® Colorectal (CR) Drive (MedRobotics, In addition, the flexible arms are not robotically
Corp. Raynham, MA, USA) is a semi-robotic assisted, and thus this system is considered
apparatus specifically indicated for transanal semi-robotic. This introduces the problem of
surgery. This single-port access platform with tremor, and this can detract from the precision
flexible effector arms allows for instrument tri- of an operation. The flexible pistol-grip instru-
angulation and purposeful steering of the instru- ments also require a high level of laparoscopic
ment head along nonlinear circuitous pathways technical skill, even more so than the straight
making it more suitable for NOTES, even for instruments used in l aparoscopic TAMIS. While
transluminal lesions proximal to the rectosig- this platform addresses some of the fundamental
moid junction (Fig. 17.1a). The robotic console challenges of transanal surgery, it has signifi-
or Flex® cart, driven by the operating surgeon at cant ergonomic shortcomings that are likely to
the bedside, has a control knob that can be limit its adoption.
17 Transanal Robotic Surgery and Future Directions 169
a b
c d
Fig. 17.1 Flex® Robotic System. (a) Two 3.5-mm diam- the Flex® Robotic Colorectal Drive. (d). Simulation of a
eter flexible effector arm interface. (b) Round control transanally docked Flex® Robot System with Colorectal
knob that serves as the master control for the Flex® Drive. (From Atallah [24])
Robotic Scope. (c). Flex® Robotic base accommodates
a b
c d
Fig. 17.5 da Vinci SP Surgical System. (a) Three-arm control shown working in the rectum. (b) Local excision using
three-dimensional retraction. (c) Transanal knot tying. (d) Full thickness transanal rectal closure
s ystem has been studied in the preclinical setting suture c losure of the defect and endoluminal knot
by Marks et al. [23] The da Vinci SP Surgical tying were carried out with relative ease [23].
System with Applied GelPOINT Path Transanal To date, the feasibility and safety of this flex-
Access Platform (Fig. 17.6) was used to perform ible single-arm robot has been studied primarily
transanal local excision in cadavers. Twelve sim- for transoral applications. This system is yet to be
ulated lesions were excised with negative mar- validated in a clinical setting for transanal sur-
gins and without fragmentation. In addition, gery in the United States; in Hong Kong, it is
172 K. M. Izquierdo et al.
being used in early clinical trials for colorectal With the existing robotic platforms, which
applications, including taTME. This exciting were originally designed for transabdominal sur-
new technology in endoluminal access will likely geries, proper working angles (and the inability
expand its applications, stepping into the current to obtain them) represent an important limitation.
era of NOTES. Interesting developments in robotic surgery, as
described above, promise to increase the ability
to perform larger portions or even entire colorec-
uture Directions: Pure NOTES
F tal operations transanally. This has been demon-
Colorectal Surgery strated in cadavers by Marks, Ng, and Mak with
transanal dissection and transection of the infe-
The concept of NOTES has gained popularity rior mesenteric artery using the da Vinci SP
since the first transgastric appendectomy per- Surgical System (Fig. 17.7).
formed by Rao and Reddy in 2004. In con- However, taTME in its current form using the
cept, however, Dr. Buess’ TEM in 1983 was available transanal platforms has several limita-
the first NOTES procedure. Now, nearly tions. Lesions located in the upper rectum are
40 years later, technology has advanced to a more difficult to reach. The anastomosis in
point where this concept can be revisited by taTME for lesions at this level is more difficult
surgeons. due to inadequate visual exposure and requires
Avoiding altogether an abdominal incision endoscopic placement of the purse-string suture
and its associated risks, such as surgical site rather than by hand. Another major limiting fac-
infections and incisional hernias, as well as pro- tor of pure NOTES is its extreme technical
viding perfect cosmesis, RTAS represents a para- demand, including the preference for having two
digm shift in MIS. The final step on the path of complete surgical teams to perform the operation
transanal NOTES colorectal surgery would be to (at most centers).
perform a rectal resection via a transanal endo- With the newly FDA-approved Single-Port da
scopic approach without requiring access through Vinci robot, the performance of transanal NOTES
the abdominal wall. and its democratization in the surgical commu-
Cumulatively, the published data from case nity will undoubtedly be facilitated.
series on taTME demonstrate technical feasibility
and preliminary oncologic safety in carefully
selected patients. The quoted benefits of a transanal Conclusions
endoscopic approach for very low rectal cancers in
particular include the ability to expand the upper An ideal platform for robotic TAMIS would
limit of intersphincteric resection under much have single-port access and flexible camera
improved visualization and exposure and the facili- and effector arms capable of triangulation for
tation of a complete rectal and mesorectal dissec- optimal visualization and ergonomics.
tion. This is especially helpful in male patients with Additionally, the system would be able to adapt
narrow pelvises in whom a laparoscopic approach and navigate itself along the circuitous path-
poses substantial technical difficulty, with a high ways of the distal gastrointestinal tract, reach-
risk of conversion, as well as a high rate of poor ing beyond the anal verge with the curve of the
quality, incomplete mesorectal excision. sacrum. The da Vinci SP, Flex® Robotic
The natural extension of the taTME movement System, and STRAS robot realize some of
has been to perform the entirety of the operation these specifications and will serve as high-util-
transanally; however, the general applicability ity platforms in the continued evolution of
outside of a few centers remains limited. robotic TAMIS.
17 Transanal Robotic Surgery and Future Directions 173
a b
c d
Fig. 17.7 RTAS Transection of IMA. (a) After entry into Transanal inferior mesenteric artery dissection.(c)
the peritoneum, the arms of the da Vinci SP Surgical Transanal inferior mesenteric artery is clipped. (d)
System retract the small bowel out of the pelvis. (b) Transanal inferior mesenteric artery is transected
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TAMIS: Current Controversies
and Challenges 18
Heather Carmichael and Patricia Sylla
In terms of local recurrence, in a retrospective constraints, TEM and TEO generally allow the
series of 50 patients undergoing TAMIS excision surgeon to stent past the rectal valves to access
for rectal cancer, Albert et al. reported one case of high rectal tumors [18]. This underscores a fun-
local recurrence in a patient with a pT1 tumor damental difference between the two platforms;
(6.3% of all pT1 lesions reported) with a mean as with TEM and TEO, the access channel (shaft)
follow-up of 20 months [8]. Lee et al. and itself is advanced to the target lesion, whereas,
McLemore et al. reported a series of 25 and 34 with the TAMIS technique, the access channel
patients undergoing TAMIS with no cases of remains in the same position, and, instead, only
local recurrence but with only short-term follow- the laparoscopic instruments are navigated to the
up (9.8 months or 3–23 weeks, respectively) [3, target lesion.
11]. Schiphorst et al. in a series of 37 patients TAMIS, on the other hand, is limited in access
found one case of local recurrence for a pT1 to very low rectal tumors because the TAMIS
lesion (25% of pT1 lesions) with 11 months mean transanal port occupies the first several centime-
follow-up [12]. In a recent series of 50 patients ters of the anal canal [19]. The TEM platform, by
by Caycedo-Marulanda et al., there were two virtue of being secured to the operative room
cases of local recurrence (6%) after TAMIS for table, can be withdrawn to the level of the anal
early rectal cancer, with a median follow-up of verge itself, allowing access to very low rectal
21 months [13]. More recently, Lee et al. reported tumors [18]. A hybrid approach can be used with
outcomes of 200 TAMIS cases for local excision TAMIS for these low lesions, dissecting the distal
of rectal neoplasia from the center that estab- margin using a conventional transanal approach
lished TAMIS as a technique (Orlando, FL, with retractors, followed by insertion of the
USA). The authors reported a 7% overall margin TAMIS port for the proximal dissection [20].
positivity and 5% rate of specimen fragmenta-
tion. Of 110 malignant lesions excised using the
TAMIS technique, 6% recurred locally, and 2% eritoneal Entry in TAMIS
P
presented with distant organ failure (follow-up Versus TEM
was 14.4 months) [14]. Overall, these results sug-
gest that local recurrence after TAMIS for early Peritoneal entry during transanal endoscopic sur-
rectal cancer is similar to TEM; however, large gery is not uncommon and is not usually consid-
series with long-term oncologic outcomes are ered a complication, so long as the surgeon can
lacking. adequately repair the defect without conversion
to a transabdominal procedure. For TEM, the rate
of peritoneal entry in the reported literature var-
Technical Limitations ies widely from 0% to 32.3% [21–23]. More
with the TAMIS Platform: Low recent series with over 300 patients have demon-
and High Rectal Lesions strated lower rates of 5–10.7% [24, 25]. However,
expanding indications for TEM and TAMIS
TAMIS, given the shorter length of the dispos- including the increasing use for resection of more
able platform, is generally limited to the first proximal, anterior, and circumferential tumors
8–10 cm from the anal verge. Beyond this point have the potential to make peritoneal perforation
it becomes difficult to provide adequate retrac- a more common occurrence over time [23, 26].
tion to visualize upper rectal lesions, particularly The loss of pneumorectum that occurs follow-
those located behind and beyond the rectal ing peritoneal entry can impede visualization and
valves [15]. retraction, presenting a significant technical chal-
TEM and TEO, on the other hand, have rigid lenge for the surgeon. Prone positioning of the
rectoscopes as long as 15–20 cm in length [16, patient with a high anterior lesion can help to min-
17]. While these platforms may be limited by a imize the impact of CO2 leakage into the abdomi-
narrow rectosigmoid junction or other anatomical nal cavity should peritoneal entry occur [26].
18 TAMIS: Current Controversies and Challenges 177
Complete muscle paralysis, decompression of tions using both TEO/TEM and TAMIS plat-
the pneumoperitoneum with a Veress needle, and forms [29]. They found that peritoneal entry
higher insufflation pressures can also help main- occurred in 22 cases (28%) and the use of a
tain a stable pneumorectum in the face of perito- TAMIS platform was associated with a higher
neal entry [8]. With increasing experience, the risk of peritoneal entry. Furthermore, of four
rate of conversion following peritoneal entry dur- cases where peritoneal entry occurred during
ing TEM has steadily decreased to below 10% TAMIS, all four required conversion to a rigid
[16, 26, 27]. platform to adequately expose and suture the
It is unclear whether TAMIS has an increased defect. Overall, the risk of peritoneal entry during
risk of peritoneal entry as compared to TEM. Two TAMIS appears to increase with distance from
recent case-matched studies comparing TEM/ the anal verge, as does the risk of conversion to
TEO and TAMIS did not find any difference in an alternative transanal or transabdominal
the rate of peritoneal entry between the two approach (Table 18.1).
methods [10, 28]. The larger of these studies When it does occur, peritoneal entry during
compared 181 TAMIS resections to 247 matched TAMIS has been identified as a particular chal-
TEM resections and found similar rates of perito- lenge [29]. In a training model comparing TEM
neal entry (3% versus 3%, p = 0.97) for lesions and TAMIS, surgeons consistently found TEM to
with a median tumor distance of 7.0 cm from the be superior for dissection, quality of vision, and
anal verge in both groups [10]. However, other suturing difficulty and found that TAMIS was not
studies have indicated that TAMIS is associated effective for suture of the simulated rectal lesion
with a higher risk of peritoneal entry. Molina [30]. However, others have argued that this
et al. examined this issue in 78 transanal resec- ex vivo study did not account for either the variety
Table 18.1 Summarization of recent, larger TAMIS series and rates of peritoneal entry, as well as the need for conver-
sion to an alternative surgical approach
Median distance
from anal verge Rate of Rate of conversion
Series N Platform (cm) peritoneal entry following peritoneal entry
Albert et al. [8] 50 Gelpoint path 8.1 1 (2%) Not converted
Lee et al. [3] 25 SILS 9 0 N/A
McLemore et al. 34 Gelpoint path 4 3 (9%) 3/3 (100%) converted to
[11] laparoscopic
Hahnloser et al. [2] 75 SILS 6.4 3 (4%) 3/3 (100%) converted to
laparoscopic or open
Schiphorst et al. 37 SILS, SSL 7a 1 (3%) 1/1 (100%) converted to
[12] laparoscopic
Gill et al. [59] 65 Gelpoint path 7.5 0 N/A
Sumrien et al. [60] 28 Gelpoint path, NR 1 (4%) Not converted
SILS
Haugvik et al. [61] 51 Gelpoint path, 8 0 N/A
SILS
Verseveld et al. [35] 24 SSL 8a 0 N/A
Quaresima et al. 31 Gelpoint path, 9.5 5 (16%) 1/5 (20%) converted to
[62] SILS transanal excision (TAE)
Keller et al. [32] 75 Gelpoint path, 10 3 (4%) 3/3 (100%) converted to
SILS laparoscopy
Caycedo- 50 Gelpoint path 7 5 (10%) No conversions
Marulanda et al.
[13]
Total 545 22 (4%) 11/22 (50%)
Distance from the dentate line
a
178 H. Carmichael and P. Sylla
of TAMIS platforms available or the use of auto- there were cases of local recurrence and lung
mated suturing and knot-forming devices [31]. metastases, no cases of liver or peritoneal metas-
Worryingly, multiple TAMIS series have reported tases occurred with a median follow-up of
conversion to laparoscopy or laparotomy for an 48 months. Similarly, Mege et al. followed 13
inability to close a rectal defect, detailed in patients where peritoneal perforation occurred
Table 18.1 [2, 11, 12, 32]. In contrast to TEM, the after TEM for adenocarcinoma, with no cases of
overall rate of conversion following peritoneal local recurrence or distant metastasis after a
entry in TAMIS appears to be as high as 50% median follow-up of 11.5 months [23]. Again,
across larger series. It is unclear if this difficulty even with regard to TEM, long-term oncologic
is primarily reflective of the long learning curve outcomes after peritoneal perforation are sparse.
required for managing complex rectal lesions via
TAMIS. In a large series of 50 TAMIS cases by
Caycedo-Marundo et al., there were five cases of Fecal Incontinence
peritoneal entry, and all defects were closed
transanally via TAMIS [13]. The authors noted There is an ongoing debate with regard to whether
that for this to be feasible, the surgeon must have functional outcomes differ between TAMIS and
considerable experience suturing using TAMIS. TEM, particularly with regard to fecal inconti-
Thus, a reasonable approach may be to recog- nence. TAMIS has been hypothesized to be less
nize that there may be increased risk of peritoneal likely to result in damage to the anal sphincter
entry with TAMIS as compared to TEO and TEM given the relative flexibility of the disposable
and that when TAMIS is used for lesions in the transanal ports as compared to the rigid TEM
upper rectum, particularly larger and more ante- design [34]. Alternatively, outcomes could theo-
rior lesions, the surgeon should have experience retically be worse given the more extreme move-
and comfort with closing the defect using the ments and stretch exerted on the sphincter in
TAMIS platform [23, 26]. If the surgeon does not TAMIS. Although the literature on functional
have extensive experience with TAMIS, it may be outcomes after TEM, both short and long term, is
worthwhile to consider prone positioning, avail- robust, there are few studies that have explored
ability and experience with TEM equipment if functional outcomes after TAMIS.
difficulty is encountered in closing via TAMIS, Short-term functional outcomes after TAMIS
or discussing the risk of conversion to an abdomi- have been explored in two small prospective
nal approach with the patient prior to surgery. studies [12, 35]. Schiphorst et al. examined out-
comes in 37 patients using the fecal incontinence
severity index (FISI) and found that 88% of
ncologic Outcomes After
O patients with abnormal baseline function experi-
Peritoneal Entry During TAMIS enced improvement in FISI scores, while 5% of
patients overall experienced postoperative
Risk of peritoneal entry is similar or even impaired continence [12]. Similarly, Verseveld
increased with TAMIS as compared to TEM, as et al. examined functional outcomes in 24 patients
previously mentioned [28, 33]. Thus, peritoneal after TAMIS and found that 79% of patients with
seeding is also a concern in TAMIS. However, abnormal baseline FISI experienced improve-
the literature on long-term oncologic impacts of ment in continence after TAMIS, while 21% of
peritoneal entry during TEM for rectal cancer is patients overall experienced postoperative
sparse, and there is no published literature related impaired continence [35]. These studies had a
specifically to the concern of tumor seeding in median follow-up of 11 and 6 months, respec-
the abdominal cavity with TAMIS. With regard tively. These short-term results appear to be
to TEM, Morino et al. followed 13 patients where comparable to TEM, which has been shown to
peritoneal perforation occurred during TEM per- have rates of postoperative impaired continence
formed for rectal adenocarcinoma [26]. Although ranging from 0% to 21% [36–39].
18 TAMIS: Current Controversies and Challenges 179
However, a recent study by Clermonts et al. and underwent radical resection, with no recur-
was the first to examine long-term functional rence at 42 and 24 months follow-up, respec-
outcomes of TAMIS, with 42 patients and tively. One patient who was upstaged to a T3
median follow-up of 36 months [40]. The authors lesion and did not undergo resection due to
found that FISI score 1 year after TAMIS was comorbidities developed a local recurrence at
similar to preoperative FISI (5.4 vs. 8.3, 18 months. One patient with high-grade dyspla-
p = 0.501), although worse at 3 years (10.1, sia on final pathology had a local recurrence that
p = 0.01). In this study, 80% of patients with an was salvaged with transanal excision, with no
abnormal FISI prior to TAMIS exhibited recurrence at 30 months. No other patients had
improved FISI at 3 years; however, 63% of local recurrence on follow-up.
patients with normal continence at baseline The authors reported no incidence of fecal
experienced worsened incontinence at 3 years. incontinence or sexual dysfunction. However,
This far exceeds the number of patients found to stenosis at the level of the anastomosis occurred
have impaired continence in studies with long- in four patients. These patients were all treated
term follow-up after TEM [41–43]. However, the with endoscopic balloon dilation. One patient
authors noted that most of the functional impair- developed a urinary fistula after dilation that was
ment that developed after TAMIS was minor and managed conservatively. Similarly, Mege et al.
perhaps with minimal impact on quality-of-life documented 6 cases of rectal stenosis managed
(QOL) measures. Indeed, a recent follow-up with endoscopic or surgical dilatation in a series
demonstrated that the worsened FISI scores did of 194 patients undergoing resection with TEM,
not affect broader QOL measures for these all of which occurred in large, circumferential
patients [44]. Given the current lack of head-to- adenomas (>50% of the rectal lumen) [23].
head comparisons of TEM and TAMIS, it is Although there are no published reports of
unclear if one approach is superior in regard to the use of TAMIS for resection of circumferen-
functional outcomes. tial adenomas, it is reasonable to believe that
this could be a feasible and effective option
given the prior experience with the use of TEM
Sleeve Resections for this purpose, provided the surgeon has expe-
for Circumferential Lesions rience with suturing via a TAMIS platform.
Furthermore, TAMIS platforms have been used
There are currently no published reports of the for transanal total mesorectal excision (taTME),
use of TAMIS for circumferential or “sleeve” which required full-thickness and circumferen-
resections. Arezzo et al. reported the use of TEO tial rectal dissection, indicating the technical
for resection of 17 circumferential rectal adeno- feasibility of performing the anastomosis trans-
mas encompassing greater than three-quarters of anally [46, 47]. The concerns about the high rate
the rectal wall circumference [45]. Lesions were of stenosis observed in the previously described
at a median of 4 cm from the anal verge, with study of TEM for circumferential adenomas,
lesions’ longitudinal extent of 7 cm. Sleeve resec- however, would also be germane to the applica-
tion was performed, with circumferential full- tion of TAMIS for these lesions. The use of
thickness dissection of the distal margin, followed TEM or TAMIS to accomplish full-thickness
by tunneling through perirectal fat to the proxi- excision of these lesions, as compared to par-
mal margin, and then circumferential incision of tial-thickness excisions using endoscopic sub-
the rectal wall at the proximal margin. The anas- mucosal dissection (ESD) or endoscopic
tomosis was performed transanally using a full- mucosal resection (EMR), has the advantage of
thickness running suture with 3–0 Maxon secured avoiding the need for further surgery if lesions
with silver clips (Richard Wolf, Knittlingen, are upstaged to early and low-risk rectal cancer,
Germany). All patients had negative margins. as is frequently the case for these bulkier lesions
Two patients were upstaged to T2 rectal cancer [48, 49].
180 H. Carmichael and P. Sylla
GIST excision and pelvic abscess drainage [57]. invasive surgery for benign and malignant rectal neo-
plasia. Am J Surg. 2014;208:372–81.
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18 TAMIS: Current Controversies and Challenges 183
The surgical management of rectal cancer contin- lenges of abdominal TME. The novel transanal
ues to present surgeons with many challenges. vantage point, in theory, could facilitate better
Total mesorectal excision (TME) is the standard margins and higher rates of success with mini-
of care in rectal cancer surgery, with the goal of mally invasive procedures in patients with rec-
negative circumferential and distal resection mar- tal cancer. Currently, long-term outcomes of the
gins (CRM and DRM) and clearance of the asso- procedure are not known, and there are no stan-
ciated lymph nodes. High-quality TME is dardized methods for patient selection. The
associated with lower locoregional recurrence procedure should not be applied to all patients,
rates and improved patient outcomes [1]. and careful consideration of the potential risks
Innovations in rectal cancer surgery have led to and benefits to the individual patient is required.
the introduction of laparoscopic and robotic tech- This chapter reviews the various indications for
niques of TME dissection. Regardless of opera- taTME in malignant disease of the rectum and
tive approach, the traditional “top-down” TME its proposed advantages for certain patient
retains several significant challenges. Operating populations.
in the confined space of the pelvis is technically
challenging due to several tumor- and patient-
related factors, particularly for low lesions. High Operative Approach for TME
rates of conversion, positive margins, and subop-
timal TME quality remain ongoing issues. Abdominal TME
Additionally, as transanal minimally invasive
approaches to rectal neoplasms are increasingly The gold standard for rectal cancer resection is
used, radical resection following local excision is high-quality TME, as described by Heald [1].
more common, which poses new technical chal- Conventionally, TME has been performed via an
lenges related to perirectal inflammation and open abdominal approach in the “top-down” fash-
fibrosis. ion. Laparoscopic and robotic TME have recently
The “bottom-up” approach of taTME has become more widely adopted in recent years.
several advantages in overcoming the chal- Whatever the approach, low pelvic dissection
presents many well-described technical chal-
lenges. The bony pelvis creates a rigid and narrow
R. L. Robertson · C. J. Brown(*) operative field, and visualization is often subopti-
St. Paul’s Hospital, Department of Colorectal mal. The use of long instruments leads to p roblems
Surgery, Vancouver, BC, Canada with conflict and angulation. Delineation of the
distal margin and rectal transection with stapling patient populations. In addition, two recent stud-
devices can be difficult and imprecise. These dif- ies, the ALaCaRT and ACOSOG Z6051, failed to
ficulties become further exaggerated in the nar- show non-inferiority of lapTME over open TME
row male pelvis or in obese patients with a bulky for rectal cancer when assessing margin status
mesorectum [2, 3]. In laparoscopic surgery, the and TME quality [14, 15]. Traction injuries to the
traction required to obtain adequate visualization mesorectum sustained while attempting to gain
may lead to mesorectal tearing and defects. exposure in the deep pelvis and difficulty with
Multiple laparoscopic stapler firings may also be accurate definition of the distal resection margin
required for distal transection, which may lead to from above are thought to have contributed to the
more anastomotic complications [3–6]. These results. Abdominal TME has reported rates of
challenges may have negative effects on patients’ positive CRM of 1.2–18.1% and incomplete or
pathologic and oncologic outcomes. Correct near-complete TME in 11–13% and 25–28% of
plane of dissection is critical when performing patients, respectively [16]. These findings high-
TME. Wrong plane dissection can lead to poor light the ongoing challenges with performing
quality TME (incomplete mesorectal envelope), TME dissection and the need for alternate opera-
which is associated with worse long-term onco- tive strategies that may improve outcomes.
logic outcomes [1, 7]. Alternatively, dissecting
outside the mesorectal plane can lead to injury to
other critical structures such as the pelvic nerves, Transanal TME
presacral and side-wall vasculature, or urogyne-
cologic structures. Such injuries can have impor- taTME combines a variety of surgical approaches,
tant deleterious effects on patient function and including lapTME, open and endoscopic trans-
quality of life. anal dissection, and natural orifice surgery. It has
Laparoscopic TME (lapTME) has some short- become apparent that the “bottom-up” dissection
term advantages over open TME, including addresses some of the problems inherent to
shorter length of stay and return of bowel func- abdominal TME. Precise delineation of the distal
tion, less postoperative pain, and lower rates of margin is easily accomplished with the transanal
wound infection [8]. Multiple studies have also operating scope and placement of a distal purse
shown that lapTME appears to be a safe alterna- string (Fig. 19.1). Accurate definition of a clear
tive to open TME for rectal cancer in terms of
morbidity and oncologic outcomes [9, 10].
Regardless, lapTME continues to pose some sig-
nificant challenges. A need for conversion to an
open procedure has been reported in 10–34% of
patients, particularly for males, the morbidly
obese, and those with a narrow pelvis [9, 11, 12].
In the COLOR II trial, 16% of patients were con-
verted to open; a narrow pelvis (22%), obesity
(10%), and issues with visualization and tumor
bulk were also cited as common reasons [9].
Robotic TME hoped to address some of the issues
seen with lapTME, but conversion rates remain
high in certain patients with predictors of diffi-
cult TME, such as obesity [13]. Converted proce-
dures are known to have worse oncologic Fig. 19.1 Demonstration of delineation of the distal mar-
outcomes than both their open and laparoscopic gin with the purse-string suture during taTME. The rectal
tumor is visible in the proximal rectal lumen with a clear
counterparts [2]. These results raise concern distal margin between the lesion and the proximal purse-
regarding the use of lapTME, especially in these string suture
19 Indications for Malignant Neoplasia of the Rectum 189
distal margin may allow reanastomosis for some Table 19.1 Quirke grading system for completeness of
low tumors that would have otherwise required total mesorectal excision (TME) [44]
APR. Purse-string closure of the distal rectal TME
stump obviates the need for surgical staplers and grade Definition Description
Grade 1 Incomplete Poor, incomplete excision of
their associated problems. Enhanced visualiza-
mesorectum with defects
tion of the tissue planes also allows for more down to rectal muscularis
accurate circumferential TME dissection, with- propria
out the need for traction on the rectum from Grade 2 Nearly Fair, superficial defects in
above [2, 4, 16, 17]. Unobstructed views of the complete mesorectum that do not
expose muscularis propria
circumferential plane may improve preservation
Grade 3 Complete Good, intact mesorectum
of surrounding critical structures such as the pel- with only minor irregularities
vic nerves [2]. Lower rates of pelvic and urinary and no defects >5 mm
dysfunction have been reported for taTME [16].
Finally, the effect of pneumodissection from p < 0.01), and fewer positive CRMs (OR 0.39,
below is not entirely clear, but may help better 0.17–0.86, p = 0.02) [20].
delineate planes for the abdominal portion of the Despite these encouraging results, other small
procedure [16, 18]. series have failed to show any advantage of
Initial results suggest the transanal approach taTME, possibly in the setting of increased com-
improves the ability to perform minimally inva- plication rates with taTME [22, 23]. However, it
sive TME dissection. Low rates of conversion to is likely that learning curve-related factors can
open have been reported in most series [16, 19, mask technical advantages in early reports. It is
20]. The first 720 patients collected in the interna- not known if improved histopathologic and short-
tional taTME database had a conversion rate of term outcomes will translate into better long-
6.4%, as reported by Penna et al. [19]. taTME also term outcomes. Until long-term data are known,
had a significantly lower rate of conversion to a cautious approach to the adoption of taTME
open when compared to lapTME on meta-analysis with careful patient selection remains critical.
of 573 patients (OR 0.29, 0.11–0.81, p 0.02) [20].
Histopathologic results have also been promising.
taTME has been associated with fewer involved Patient Selection
circumferential and distal resection margins, and
more compete TME than lapTME on several No standard criteria exist for selecting taTME for
comparative studies [12, 21]. Of the 634 patients patients with malignant disease. There is hetero-
with pathology data in the series reported by geneity in the literature for most patient- and
Penna, 97.3% had negative margins, and only tumor-related factors considered when choosing
4.1% had an incomplete TME. Ninety-two per- the technique. Many studies exclude T4 and high
cent of patients had “good-quality” surgery, com- (>10 cm) rectal tumors, yet others do not. The
prised of a composite measure of negative distal first taTME consensus statement including indi-
and circumferential margins with complete or cations for patient selection was published in
near-complete TME (Table 19.1). None of the 2014, following the second international taTME
patient factors that have previously been shown to consensus conference (Table 19.2). The group
be high risk for incomplete TME were signifi- concluded that taTME can be used for any malig-
cantly related to poor TME on meta-analysis, pos- nant condition where accurate dissection of the
sibly suggesting the taTME approach may distal to mid-rectum is required [4]. Due to the
mitigate the influence of these factors [19]. In a technical challenges of lapTME, the group stated
meta-analysis by Ma et al., compared to lapTME, that taTME may be the preferred approach for
taTME was associated with significantly better cancer in the following patients: males, patients
rates of complete TME (OR 1.75, CI 1.02–3.01), with narrow and/or deep pelvis, obese patients
greater distance to CRM (WMD 0.96, 0.6–1.31, (visceral obesity or BMI > 30), low to mid-rectal
190 R. L. Robertson and C. J. Brown
cancers (<12 cm from anal verge), tumor diame- consensus group included T4 tumors, obstructing
ter >4 cm, prostatic hypertrophy, distortion of tis- tumors, and emergency resections.
sue planes from neoadjuvant therapy, and The recently published protocol for an upcom-
impalpable low tumors. Additionally, taTME is ing randomized control trial assessing oncologic
indicated in any case where failure to progress outcomes of taTME compared to lapTME
during a transabdominal approach would neces- (COLOR III) has set out clear guideline for
sitate conversion to an abdominoperineal resec- patient selection [24]. Patients with biopsy-
tion (APR). Contraindications listed by the proven stage I–III rectal cancer with tumors of
the low (0–5 cm) and mid (5–10 cm) rectum will
Table 19.2 Consensus statement indications and contra- be eligible for inclusion. Tumors must be within
indications for taTME [4]
10 cm of the anal verge on staging MRI. Patients
Relative will not be excluded on the basis of BMI, previ-
Preferred indications contraindications
ous abdominal or pelvic surgery, or receipt of
Failure to progress from the Obstructing tumor
abdominal approach where APR neoadjuvant therapy. Locally advanced tumors
would be required will be eligible for inclusion, so long as signifi-
Obesity (visceral or BMI > 30) T4 tumor cant downstaging occurs with neoadjuvant ther-
Male Emergency apy. A downstaged tumor may be included
surgery provided after treatment there is no evidence of
Narrow or deep pelvis
residual T4 disease, no anal sphincter or levator
Low tumor (<12 cm)
Tumor diameter >4 cm
ani involvment, and evidence of a CRM >2 mm.
Distortion or scarring of tissue Using the published literature as a guide, fac-
planes tors that may influence selection of patients for
Prostatic hypertrophy taTME technique can be divided into patient-,
Low, impalpable primary tumor tumor-, and procedure-related factors (Fig. 19.2).
Male
Obesity
• Visceral
• BMI > 30 Narrow pelvis
Fig. 19.3 The angle between the superior and inferior pubic symphysis and the sacral promontory was shown to be
significantly associated with quality of TME. A smaller angle was associated with poorer-quality TME [28]
19 Indications for Malignant Neoplasia of the Rectum 193
fewer rectal perforations [36]. Letarte et al. dem- patients with low tumors who desire sphincter
onstrated fewer conversions to open surgery and preservation [37].
a lower APR rate in these patients. While more With the use of high-definition cameras and
investigation is necessary, this is an important magnification with the minimally invasive “bot-
indication where patients may benefit from the tom-up” approach, taTME provides often supe-
taTME approach [35]. rior visualization of intersphincteric tissue
planes, which is another unique situation where
ow/Ultra-Low Anterior Resection
L taTME may be advantageous to patients. Further
By and large, taTME is performed for rectal study is needed to ascertain the impact of taTME
malignancies requiring a low pelvic dissection on the quality of intersphincteric dissection and
with planned restoration of intestinal continuity. the number of patients who are selected for the
The technique has a theoretical benefit in these intersphincteric approach. The application of
situations, where accurate definition of the distal taTME for intersphincteric resection is addressed
margin for transection and anastomosis may not more completely in a dedicated chapter on this
be possible from the abdominal approach. topic.
Table 19.3 Classification of low rectal tumors with stan- Patient Counselling
dardization of surgical approach [37]
Classification Definition Surgical procedure Although several potential benefits of taTME
Type I Supra-anal Conventional coloanal exist, long-term outcomes have not been estab-
tumor anastomosis lished. Early recurrence data have been encour-
>1 cm from
the anal ring
aging, with similar local and distant recurrence
Type II Juxta-anal Partial intersphincteric rates compared to lapTME [3, 19]. Lacy et al.
tumor resection reported an overall recurrence of 8.4% in their
<1 cm from group’s first 140 patients undergoing taTME at
the anal ring median follow-up of 15 months (6.1% distant,
Type III Intra-anal Total intersphincteric
tumor resection
0.8% local, and 1.5% both local and distant) [3].
Internal Well-designed randomized control trials are in
sphincter development, and long-term survival results are
invasion pending. As such, taTME has not been shown to
Type IV Transanal Abdominoperineal be equivalent to more conventional approaches at
tumor resection
External this time.
sphincter taTME is an innovative surgical procedure,
invasion and patients undergoing innovative procedures
194 R. L. Robertson and C. J. Brown
are not subject to the same ethical scrutiny as when feasible, participation in clinical registries,
patients receiving experimental treatment [38]. and reporting and publication of outcomes. The
The IDEAL framework has been developed as a first 720 cases reported from the taTME registry
method to standardize the adoption of innovative had 50% of patients provided by institutions that
techniques and treatments [39–41]. Checkpoints had only performed 1–5 cases [19]. The total
for the research and evaluation of a novel treat- cohort had acceptable clinical outcomes, so it
ment are integrated along the natural innovation appears good outcomes are possible even early in
adoption curve. These measures aim to ensure the learning curve, especially when methods to
acceptable patient safety and outcomes. With this ensure safe adoption are considered. Therefore,
in mind, in-depth counselling regarding the risks surgeons must consider their own expertise and
and benefits of an innovative technique by the experience and how to sensibly integrate taTME
surgeon is a critical aspect of patient selection into their practice prior to offering the technique
and consent. The authors also encourage discus- to patients with malignant disease.
sion of patient selection at multidisciplinary
rounds or patient case conferences when possi-
ble. Surgeons must be transparent about unknown Summary
long-term cancer-specific survival and functional
results during the informed consent process. In High-quality TME remains the gold standard for
this regard, selection of patients who have a clear rectal cancer resection, regardless of the
understanding of the innovative nature of taTME, approach. Complete TME is essential to ensure
and who are keen to accept currently unknown optimal oncologic outcomes. There are currently
risks for the possibility of better short-term out- no long-term outcomes available to support the
comes, is critical. Ideally, these patients would be use of taTME over conventional laparoscopic or
agreeable to anonymized sharing of their data open TME approaches. Regardless, short-term
with one of the taTME registries (such as the histopathologic and survival outcomes for taTME
OSTRiCh registry), or participation in a random- are acceptable and comparable to standard
ized control trial where available, to expedite the approaches. taTME may provide some benefit in
global acquisition of this important information challenging patients at high risk for incomplete
[24, 42]. TME, such as the narrow male pelvis, obesity,
and low tumors. Additional high-quality, ran-
domized studies are needed to further support
Surgeon Training and Experience these findings and provide clear evidence for the
preferential use of taTME over other approaches.
taTME remains a novel surgical approach with Careful patient selection and counselling are crit-
multiple technical challenges. Much has been ical when choosing taTME for the management
published on the specialized nature of the proce- of malignant disease. Discussion of patient selec-
dure and the need for adequate training and case tion at multidisciplinary rounds or case confer-
volumes. At present, taTME cannot be recom- ence should be strongly considered. Finally,
mended for all patients from all surgeons. As adequate training and case volumes of surgeons
such, appropriate surgeon selection is as impor- and institutions offering taTME for rectal cancer
tant as patient selection. are essential to ensure safe practices and good
Those wishing to perform the procedure patient outcomes.
should have adequate case volume in laparo-
scopic pelvic dissection and minimally invasive
transanal techniques. Participation in proctored References
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44. West NP, Morris EJ, Rotimi O, Carins A, Finan PJ,
Brown CJ. Salvage TME following TEM: a possible Quirke P. Pathology grading of colon cancer sur-
indication for TaTME. Tech Coloproctol [Internet]. gical resection and its association with survival: a
2018;22(5):355–61. https://doi.org/10.1007/ retrospective observational study. Lancet Oncol.
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Indications for Benign Disease
of the Rectum 20
Willem A. Bemelman
approached transanally. Typically, the transanal in patients with ulcerative colitis and polyposis
dissection is completed to the level of the perito- syndromes. Reconstructive surgery creating an
neal reflection anteriorly. The transanal approach ileal pouch started in the late 1970s. Several surgi-
is particularly well-suited for the horizontal ante- cal groups experimented with different types of
rior plane along the rectovaginal septum or, in reservoirs. This resulted in a variety of small bowel
males, along the rectoprostatic (Denonvilliers’) reservoirs. The three most well-known today are
fascia to the level of the seminal vesicles. This the J-, the S-, and the W-pouch. Over time, accu-
access is quite difficult to achieve in a top-down mulative evidence demonstrated that the J-pouch
manner. When this point is reached in the bottom- is the superior pouch, because of its relatively ease
up dissection, the rendezvous can be made with of construction and its superiority in emptying
the top-down dissection, which can be accessed compared to the S- and W-pouches [3, 4].
either via lower midline laparotomy incision, The reservoirs can be stapled to the anus using
optional Pfannenstiel incision, or, laparoscopi- the double-stapling technique leaving a small rim
cally depending on patient characteristics, the of rectal mucosa, or “cuff.” When applying a
indication for surgery and the presence of intra- hand-sewn technique, this is done mostly in com-
abdominal adhesions and other factors which bination with a mucosectomy. The current stan-
define case complexity. Ultimately, surgery is not dard for most surgeons is to perform a stapled
about one technique per se, but rather about com- ileoanal J-pouch reservoir with a remaining rec-
bining the best of all approaches tailored to the tal cuff of less than 2 cm. If the cuff is longer than
characteristics of the patient, to their condition, 2 cm, the remaining rectum is called a “retained
and to the characteristics of the pathology to cre- rectum,” which should be considered a technical
ate a safe and effective operation. error and which may ultimately lead to revision-
ary pouch surgery.
Most patients require proctocolectomy because
Inflammatory Bowel Disease the disease process is, or has become, refractory
to medical therapy. A minority of patients require
Inflammatory bowel disease basically consists of proctocolectomy because of dysplasia or cancer
two major types – ulcerative colitis and Crohn’s that has developed, likely in the background of
disease. In ulcerative colitis, the disease is chronic proctocolitis. Proctocolectomy done for
restricted to the rectum and colon. If the disease refractory inflammation is mostly done as a three-
is refractory to medical therapy, proctocolectomy or modified two-stage procedure [5]. As a first
is indicated. In Crohn’s disease both small as step, a colectomy is performed, followed by com-
well as large bowel can be affected. Mostly, pletion proctectomy and pouch creation with
Crohn’s disease is located in the terminal ileum. defunctioning ileostomy (three-stage) or with-
Up to 25% of the patients develop perianal fistu- out it (modified two-stage). When it comes to
las sometimes in combination with proctitis or colectomy, patients are generally immunocom-
proctocolitis. Most surgeons would defunction promised due to therapy with biologics (e.g.,
the rectum as a first step if proctitis with or with- immunomodulatory agents, TNF-alpha antago-
out complex perianal fistula has caused such a nists), chronic malnutrition, a persistent nega-
disability that creation of an ostomy restores tive nitrogen balance, and anemia of chronic
quality of life. If defunctioning does not relieve disease. Combined data of three referral insti-
the symptoms adequately or there is a risk of can- tutes demonstrated that defunctioning the pouch
cer, surgical resection is indicated. in these deconditioned patients – in the setting
of a two-stage procedure – is ineffective in pre-
venting anastomotic leakage and is associated
a Proctectomy and Ileoanal
T with long-term complications. In contrast, the
Pouch Surgery three-staged procedures enable such patients to
be wean from the immunomodulators and often
Restorative proctocolectomy and reconstruction corticosteroids and recover physiologically
with an ileoanal pouch is the procedure of choice before embarking on pouch constructing.
20 Indications for Benign Disease of the Rectum 199
Ultimately, this resulted in lower leak rates and tery” in situ, avoids a wide pelvic cavitation
thus improved clinical outcomes [6]. For this and limits extra-pelvic space that can be prob-
reason, a modified two-stage or three-stage pro- lematic. Furthermore, it is suggested that by
cedure is preferred for UC. Nowadays, the col- preserving the mesorectum and its nerves, a
ectomy is often completed laparoscopically greater awareness of pouch filling is achieved
with reduced postoperative complications, compared to removing the mesorectum, prob-
reduced incidence of clinically significant adhe- ably due to different proprioception provided
sions, and preserved fecundity [7]. Due to the by proprioceptors that are intrinsic to the
relative absence of adhesions with this approach, mesorectum itself [10]. It should be noted that
the completion proctectomy can be done via the top-down dissection close to the rectal muscle
Pfannenstiel incision or, alternatively, with a tube and especially deep within the pelvis is
combination of a single-port introduced via the difficult because of lack of exposure due to the
ileostomy site and a TAMIS platform, which mesorectal fat. In contrast, bottom-up dissec-
provides a minimally invasive option. There are tion along the muscle tube of the rectum using
a number of reasons why the transanal approach either the electric hook or vessel sealing
for completions proctectomy for UC might be devices is relatively easy.
advised: 5. The Ta approach allows the pouch anastomo-
sis to be completed with a single-stapled con-
1. The Ta platform enables a tailored transection struction, and this obviates the need for a
of the distal rectum, thus assuring a precise double-stapled technique, which is associated
length of the rectal cuff and thus avoiding the with problematic intersecting staple lines and
risk of a retained rectum. the “dog ears” on both sites of the circular
2. Laparoscopic cross-stapling of the distal rec- anastomosis [8, 9].
tum has been shown difficult resulting in too 6. Combining the Ta bottom-up approach with
long cuffs and the necessity to use multiple single-port top-down proctectomy via the
staple cartridges, thereby increasing the risk stoma site, abdominal access trauma is mini-
for anastomotic leakage [8]. mized, and the requirement for an incision for
3. Using the TAMIS technique, the difficulty of the purpose of extraction or pouch creation is
the double stapling is obviated and is replaced avoided (Fig. 20.1).
by a single-stapled (double purse-string) anas-
tomosis [9].
4. The best plane of dissection is still being
Technique
debated. The TME plane is an avascular plane
and surgeons are used to do this for rectal can- Preparation: Patients are managed periopera-
cer. In order to avoid nerve injuries, most IBD tively in an enhanced recovery program. Patients
surgeons would do a “bad” TME anteriorly are positioned in the Lloyd Davis position on a
staying close to the rectum anteromedially. A short beanbag. The right arm is tucked and posi-
possible drawback of the techniques is the tioned alongside the body. The rectum is washed
relatively large pelvic cavity that remains, out with an iodine solution. Prophylactic antibi-
which cannot be adequately filled with the otics are administered.
pouch, resulting (hypothetically) in a larger
presacral cavity. This may prevent a potential Procedure Described for a Single-Team
anastomotic leak from sealing, and it could Procedure
create an opportunity for proximal small Step I. The ileostomy is dissected and provision-
bowel to become entrapped posterior to the ally closed with a running suture to prevent
pouch. Alternatively, a close rectal dissection stool spillage. A single-port laparoscopic plat-
can be applied, which hold the dissection form (GELPOINT Advanced Access Platform,
perimeter away from autonomic nerves, and, Applied Medical, Rancho Santa Margarita,
keeping the surrounding “cushion of mesen- CA, USA) is placed in the stoma site. At the
200 W. A. Bemelman
It was demonstrated that the odds for postopera- pouch advancement – that is, excising the
tive complications were 0.52 times lower for the retained rectum and bringing down the pouch
Ta pouch patients compared to the patients who to an appropriate cuff size (Fig. 20.7).
had undergone a conventional laparoscopic (c) Redundant efferent loop of S-pouch.
pouch. This finding was primarily attributed to S-pouches have an efferent loop (Fig. 20.8).
reduction in surgical site infections. Ta pouches This loop should not be longer than 2 cm,
therefore seem to be a safe and promising alter- because otherwise there is a risk of kinking
native for conventional laparoscopic pouches, but of the efferent loop causing evacuatory dys-
long-term data are still awaited with respect to function. When the dysfunction from evacu-
functional outcomes. ation becomes chronic, the pouch enlarges
and decompensates, as it is unable to build
sufficient pressure to overcome the outlet
a Redo Surgery for Pouch
T resistance. If the pouch is not too large, the
Dysfunction efferent loop can be shortened and a new
hand-sewn anastomosis made. In case the
Pouch dysfunction is a serious long-term compli- pouch is already too large, probably the over-
cation of this restorative procedure. Causes are all size of the pouch needs to be corrected as
often multifactorial and can be medical or surgi- well (Fig. 20.9).
cal in origin. Careful multidisciplinary assess- (d) Mega-pouch: Mega-pouches (Fig. 20.9) can
ment of the pouch is therefore mandatory to find develop as result of chronic outlet obstruc-
the correct cause of the problem and decide on tion and particularly the larger reservoirs are
the appropriate therapy. Cross-sectional imaging sensitive for this (e.g., S-pouches, W-pouches,
and joint endoscopic assessment of the pouch are
essential in decision-making.
than 1 year. These sinuses can be quite clini- The patient is placed in the Lloyd Davis
cally evident and may be the reason that position. A perianal nerve block is done to
prevents closure of a defunctioning ileos- relax the external sphincter muscle. A Lone
tomy; or the sinus(es) can be clinically Star Retractor is secured to expose the
silent causing pouch dysfunction often mis- anorectum.
diagnosed as refractory pouchitis [14].
Cross-sectional imaging is therefore imper- Cuff/efferent loop excision Depending on the
ative in case of chronic pouch dysfunction level of the pouch-anal anastomosis, the rectal
(Fig. 20.11). mucosa is incised just below the ileoanal anas-
(f) The failed pouch. The top three causes for tomosis using either retractors or the TAMIS
pouch failure are Crohn’s disease platform. If the ileoanal anastomosis was
(Fig. 20.12), prior anastomotic leakage/ already at the level of the dentate line (e.g., as
pelvic sepsis, and refractory pouchitis [15]. is the case for an S-pouch), care must be taken
The chronic dysfunctioning pouch can be not to damage the internal sphincter muscle.
diverted with an ileostomy. If symptoms Transection of the muscular layer should be
persist (e.g., severe perianal fistula in done at the level of the ileoanal anastomosis in
Crohn’s disease or uncontrollable anal dis-
charge), it is best if the pouch is excised.
The remaining space within the pelvic cav-
ity must be filled, and typically omentum or
small bowel mesentery is placed in the cav-
ity in order to prevent abscess formation in
the pelvis.
Surgical Approach
Fig. 20.11 Endoscopic image of sinus (left), MRI with sinus (arrow, right)
206 W. A. Bemelman
order to preserve the internal sphincter mus- the retained rectum is dissected until the ileo-
cle. In case of cuffitis, a mucosectomy can be rectal anastomosis is encountered. Thereafter,
done to preserve the internal sphincter muscle. the pouch is carefully mobilized in order to
Careful dissection of the distal pouch or the preserve the pouch. Since the pouch must be
efferent loop is performed. If mobilization of brought down over a considerable distance,
the distal pouch and cuff or efferent loop pro- either laparoscopically or via an open (i.e.,
ceeds successfully (Fig. 20.13), the mobilized Pfannenstiel or low midline) incision, mobi-
portion can be exteriorized via the anus, the lization of the pouch and its mesentery is
cuff or efferent loop can be excised, and a necessary to gain the additional reach
hand-sewn anastomosis can be constructed. If required. After freeing the pouch, including
bottom-up mobilization is insufficient, either the pouch rectal anastomosis and the retained
open or laparoscopic mobilization of the rectum, the latter two are excised. Preferably
proximal part of the pouch and its mesentery a single-stapled, double purse-string ileoanal
must be performed. In the latter case, it is anastomosis is constructed, thereby creating
advisable to defunction the hand-sewn anasto- a union between the pouch and anus. This
mosis (Fig. 20.14). removes another 1.5 cm of rectal cuff. In the
end, a small rim of cuff 1–1.5 cm is preserved
Retained rectum The rectal wall is tran- for better fine continence (Fig. 20.15).
sected 2–3 cm cranial from the dentate line.
( b) Transanal and transabdominal mobilization
Applying a close rectal dissection technique,
of the pouch with revision of the pouch or
new pouch in case of mega-pouch or chronic
pelvic sepsis.
Again, the patient is placed in the Lloyd
Davis position; a Lone Star Retractor is
placed transanally and a perianal nerve
block performed. The TAMIS platform is
also utilized for Ta surgery. Depending on
the type of prior ileoanal anastomosis,
hand-sewn after mucosectomy or double
stapled, the rectal cuff is transected just
below the anastomosis avoiding any dam-
age to the internal sphincter muscle. A
Fig. 20.13 Transanal view on TAMIS mobilized pouch mucosectomy and transection of the muscu-
lar wall at a higher level might be appropri-
ate. The first part of the bottom-up dissection
can be done using retractors or via the
TAMIS platform. The bottom-up TAMIS
dissection proceeds as far proximal as pos-
sible after which the rendezvous is made
with the top-down dissection of pouch and
its mesentery. The completely detached and
mobilized pouch can be remodeled. In case
of revisionary surgery for a mega-pouch,
the pouch must be reduced in size. Care
must be taken in case of reducing the pouch
in size longitudinally, so that the vascular-
ization to the remaining pouch is not com-
Fig. 20.14 Distal part of pouch can be exteriorized for promised (Figs. 20.9 and 20.10).
excision
20 Indications for Benign Disease of the Rectum 207
Fig. 20.15 Schematic
excision of cuff
(Litzendorf et al.) [16]
Dorsal line
Mucosal
proctectomy
Dentate line
Dentate line
208 W. A. Bemelman
In case of pelvic sepsis, the pouch is often Similar to previous approaches, the patient
reduced in size due to fibrosis, and the required is placed in the Lloyd Davis position; a Lone
excision is of this fibrotic distal part of the Star Retractor placed transanally and a peri-
pouch. Quite often, a blind loop is present, anal nerve block performed. The TAMIS plat-
giving the opportunity to enlarge the pouch by form is also utilized for Ta surgery. The
incorporating the blind loop into the lumen of incision is done at the level of the intersphinc-
the pouch using linear staplers. Presacral teric groove. The intersphincteric plane of dis-
sinuses must be carefully debrided to prevent section is followed up to the ileoanal
recurrent abscesses. The ileoanal anastomosis anastomosis. Next, the TAMIS port is inserted
is made using a hand-sewn technique, with and the bottom-up dissection is proceeded via
interrupted 3-0 Vicryl sutures; defunctioning TAMIS. Either via low midline laparotomy or
is routinely performed. A pelvic drain is left in laparoscopy when feasible, the top-down dis-
place for 48 h and 5 days of antibiotics are section is proceeded until the rendezvous is
prescribed in the patients that were operated made. The pouch is excised and an end-loop
on for an index diagnosis of pelvic sepsis. ileostomy is made. If there is sufficient omen-
(c) Transanal and transabdominal intersphincteric tum, a pedicled omentoplasty is created after
excision of the pouch with omentoplasty in case careful debridement of any septic pockets in
of pelvic sepsis or Crohn’s disease of the pouch. the pelvis (Fig. 20.16). If there is no omentum,
Fig. 20.16 Pediculized omentoplasty schematic (left) and in the intersphincteric wound (right)
20 Indications for Benign Disease of the Rectum 209
a close bowel excision of the pouch can be incontinence (7.6%), after initial restorative
done in order to use the pouch’s mesentery to proctocolectomy. This functional deterioration
occupy the pelvic cavity. might be attributable to repeated sphincter
trauma, mucosectomy, hand-sewn anastomosis,
and/or decreased small bowel length; a subset of
Results these patients whose symptoms become clini-
cally significant will ultimately require revision-
The largest series of pouch redo operations origi- ary procedures.
nates from the Cleveland Clinic, Ohio. Remzi TAMIS revisional pouch surgery has only
et al. [17] described over 500 patients who had been reported by Borstlap et al., demonstrating
redo pouch surgery over a 20-year time period. its feasibility and promising feature of more pre-
The main indications for pouch redo surgery cise dissection of the distal pouch [21]. Although
were septic problems of the anastomosis (61%), published reports are sparse, the TAMIS tech-
emptying problems (23%), and pouch vaginal fis- nique to revision is becoming accepted and is
tulae (17%). Success rates were 90% at 5-year commonly utilized by field experts when Ta
and 82% at 10-year follow-up. Independent fac- approach seems logical, as delineated in the pre-
tors of failure of redo surgery were (a) sepsis as vious sections.
indication for pouch revision and (b) postopera-
tive complications after redo pouch surgery.
Smaller series confirmed Remzi’s observation a Completion Proctectomy
T
that results of redo surgery were best in patients in Crohn’s
having mechanical causes of pouch dysfunction
as opposed to those who have inflammatory/sep- Heading
tic causes [18, 19]. Patients with true Crohn’s
disease had less favorable results. It has to be Severe refractory proctitis, anal stenosis, and
stressed that many patients with septic pouch perianal fistulae with chronic sepsis are all indi-
problems are labelled as having Crohn’s disease, cations to remove the rectum in patients with
while they only have a discrete pouch Crohn’s disease. The type of procedure is still a
complication. controversial topic. The rectum can be excised en
In a systematic review by Theodoropoulos bloc with the mesentery or a close rectal dissec-
et al. [20], favorable results were observed, in tion can be done (Fig. 20.17).
terms of (a) redo, (b) revisional, and (c) local/ The resection at the level of the sphincter can
perineal pouch procedures, with healing rates be handled in three ways: (a) full excision of the
reported as 82.2%, 79.6%, and 68.4%, respec- anal sphincter including (parts of) the levator
tively. However, due to the considerably lower muscle, (b) creation of an ultralow Hartmann’s
morbidity rate associated with the performance pouch, or (c) intersphincteric resection. The
of local/perineal pouch procedures, as demon- Achilles heel of the procedures is perineal wound
strated in this review (specifically, 13.6% for healing and local septic complications within the
local procedures vs 44.2% for the revisional sur- pelvis. Intuitively, leaving the smallest dead
gery), some authors have suggested that all revi- space in the pelvis might reduce the risk of pel-
sional surgery should be first attempted vic abscesses and improve wound healing.
transanally, with the aim of avoiding higher mor- However, it seems to indicate that this may not
bidity, when this option is feasible. be true, specifically for Crohn’s disease. De
Theodoropoulos et al. reported functionally Groof et al. [22] compared two groups of
worse outcomes for urgency and nighttime soil- patients, those who underwent close rectal proc-
ing (26% and 38.4%, respectively), compared to tectomy versus those who underwent a more
the reported rates for urgency (7.3%), mild night- standard TME-type resection, and concluded
time incontinence (17.3%), and severe nighttime that the risk of pelvic abscesses was reduced in
210 W. A. Bemelman
Fig. 20.17 TME type of proctectomy (left) and close rectal dissection (right)
the TME-type proctectomy and perineal wound planes. Anteriorly, however, a close bowel dis-
healing facilitated. These clinical findings could section is performed to preserve the autonomic
be correlated with the pro-inflammatory charac- nerves. After extraction of the colorectum, the
teristics of the Crohn’s mesentery, a relatively pelvic cavity is filled with a vascular pedicled
new finding related to the pathogenesis of this omental flap (Fig. 20.16).
disease process. For this reason, in our practice
we perform a TME type of proctectomy for
Crohn’s disease in combination with omento- elvic Sepsis After Low Anterior
P
plasty to limit pelvic dead space. Since in Resection for Rectal Cancer
ulcerative colitis the mesentery is not pro-
inflammatory, a close rectal dissection can be Anastomotic leakage of the ultralow colorectal/
applied. An intersphincteric resection of the coloanal anastomosis is a known complication,
anus removes all the at-risk mucosa and at the which occurs not infrequently. Published rates
same time preserves the integrity of the pelvic in literature differ considerably, mainly because
floor. of differences between studies with regard to
length of follow-up. Most surgeons would
defunction the low anastomosis and would only
Surgical Technique investigate its integrity at the time the closure
of the stoma approaches. Importantly, 30- or
As previously outlined, the patient is placed in 90-day morbidity rates do not capture the clini-
the Lloyd Davis position; a Lone Star Retractor is cally occult, defunctioned leaks. Several
placed transanally and a perianal nerve block per- authors from experienced centers report that
formed. When required, the TAMIS platform is one out of five of the intentionally temporary
utilized for Ta surgery. The incision is carried out ileostomies becomes permanent – and this is
at the level of the intersphincteric groove. The mostly attributed to anastomotic failure.
intersphincteric plane of dissection than proceeds Borstlap et al. [23] clearly showed that overall
along the mesorectum posteriorly. The TAMIS 1-year leak rates amount to 20% for both partial
port is next inserted, and the bottom-up dissec- and total mesorectal excisions. Particularly in
tion advances cephalad following standard TME patients that have had neoadjuvant radiotherapy
20 Indications for Benign Disease of the Rectum 211
a b c
Fig. 20.18 (a) Transection just distal from anastomosis. (b) The leaking anastomosis is pulled out of the Dutch after
TAMIS dissection. (c) TAMIS debridement cavity
212 W. A. Bemelman
In order to redo the coloanal/colorectal anasto- port, the access channel is seated into position
mosis, the afferent colon loop needs to be mobi- and the procedure is continued via TAMIS tech-
lized further to have enough reach. In most of the niques. Mobilization of the left colon and splenic
cases, the left flexure has not been mobilized fully. flexure is not necessary, since the objective of the
Preferably, the left colonic artery is preserved, and procedure is to create an end colostomy.
the inferior mesenteric vein is ligated at the level Furthermore, after resection of the leaking anas-
of the inferior border of the pancreas. The left flex- tomosis, sufficient length remains to make a
ure is fully mobilized to allow the colon to rotate tension-free anastomosis. An omental pedicled
along the middle colic pedicle. Depending of the flap based on the left gastroepiploic artery is
degree of adhesions, the top-down dissection and made and positioned in the pelvis by either via
mobilization of the splenic flexure can be done retrocolic approach (beneath the transverse
with straight laparoscopy, with hand-assist lapa- colon) or via the left paracolic gutter. The omen-
roscopy (using Pfannenstiel extraction incision), tal flap is then used to fill the pelvic cavity after
or using a midline lower straight incision and an extensive debridement of all infectious tissue.
open technique. If the bottom-up dissection via
TAMIS is successful in reaching the anterior peri-
toneal reflection, the top-down dissection can be Preliminary Results
done laparoscopically or via the Pfannenstiel inci-
sion in most cases. The mobilized section of In our unit, a total of 104 patients underwent
bowel, including the segment containing the anas- redo pouch surgery, of which 47 underwent a
tomotic leak, is exteriorized via the Pfannenstiel redo anastomosis (18 conventional; 29 TAMIS)
incision and excised. Extensive debridement of the and 57 underwent ICP (35 conventional and 22
presacral cavity is done by removing all infectious TAMIS). In all TAMIS procedures, the bottom-
and devitalized tissue. If a sufficient rectal cuff up dissection could be completed and connected
remains, a single-stapled, double purse-string with the top-down dissection, with 72% of the
side-to-end anastomosis can be fashioned. If the transabdominal approach after redo anastomo-
rectum is transected within the anal canal, then a sis being completed laparoscopically, versus
hand-sewn anastomosis is performed. 59% of the ICP being performed laparoscopi-
The diverting stoma is left in place. It is advis- cally. However, laparoscopic success was sig-
able to prescribe antibiotics for at least 3 days, nificantly less for the group who underwent
because the most important complication is recur- conventional transabdominal approaches: spe-
rent abscesses at the level of the former presacral cifically, 6% for the redo anastomosis group and
sinus. On day 4, the CRP is measured. In case of 34% for the ICP group (P < 0.001 and P = 0.100).
an elevated CRP or any suspicion of anastomotic In the redo anastomosis group, a stapled anasto-
dehiscence, computed tomography imaging of the mosis could be done in 62% in the TAMIS
pelvis is performed. If work-up reveals no evi- cohort; however, all conventional redo anasto-
dence of a leak, the anastomosis is checked for its mosis were hand-sewn (P < 0.001). There were
integrity within 2–3 weeks. Within 3 weeks, no significant differences in 90-day postopera-
Endo-SPONGE-assisted early closure is still an tive outcome between conventional and TAMIS
effective option for controlled anastomotic leaks. techniques. After redo anastomosis, 11 patients
(61%) in the conventional group and 21 patients
(b) Intersphincteric Resection, End Colostomy, (72%) after TAMIS had their bowel continuity
and Omentoplasty restored at the end of follow-up (P = 0.524).
These data suggest that TAMIS is a valid alter-
The procedure is quite similar to the TAMIS native to conventional top-down redo surgery
redo anastomosis. However, the procedure is for pouch anastomotic leak, with more proce-
started with an open intersphincteric dissection. dures likely to be completed laparoscopically
When there is sufficient space for the TAMIS when this approach is utilized [26].
20 Indications for Benign Disease of the Rectum 213
Miscellaneous Procedures
Fig. 20.20 (Left) Anastomotic defect with connection to the vagina. (Right) Endoscopically, the portion is visualized
via the anastomotic defect
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YS. Intra-operative double-stapled colorectal or 18. Mathis KL, Dozois EJ, Larson DW, Cima RR, Wolff
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for failed restorative proctocolectomy. Ann Surg
Operating Theater Setup
and Two-Team Coordination 21
Aimee E. Gough, Phillip R. Fleshner,
and Karen N. Zaghiyan
Video
2
A1
Video
S1 1
Ba
ck
Ta
bl
e
A2 S2
Back Table
S Surgeon
A Assistant
Fig. 21.3 Operating theater setup for simultaneous abdominal and transanal team operation
their video tower is placed near the patient’s left off the patient’s right and the laparoscopic equip-
shoulder to allow the anesthesiologist access to ment toward the patient’s left. The transanal setup
the patient (Fig. 21.4). At our center, the AirSeal® consists of passing all tubing and power cords
iFS insufflation management system (Conmed over the patient’s left leg secured with a towel
Inc., Utica, NY, USA) is utilized, and it is posi- clamp (Fig. 21.5). The cord of the 3D laparo-
tioned lateral to the patient’s left leg between the scopic camera used for transanal dissection is run
transanal back table and the abdominal team’s parallel to the left and through the pocket of the
laparoscopic tower (Fig. 21.5). Our transanal abdominal drape to reach the video tower near the
back table has a bottom shelf which houses the patient’s left shoulder. It can be helpful to have a
electrocautery unit to help reduce the footprint of Mayo stand near the left foot to rest the 3D cam-
the transanal equipment as the operating room era and other transanal equipment (Fig. 21.5).
quickly becomes very congested.
The patient is given a mechanical and oral antibi- bdominal Team: Abdominal Access
A
otic bowel preparation the day before surgery. and Sigmoid Colon Mobilization
Preoperative heparin subcutaneous is adminis-
tered and sequential compression device is placed The abdominal and transanal teams each consist
in the preoperative care unit. After induction of of one attending surgeon and either a resident,
general endotracheal anesthesia and placement of fellow, physician’s assistant (PA), or surgical
an orogastric tube to decompress the stomach, the scrub (Fig. 21.2). The abdominal team begins the
patient is repositioned from supine to low lithot- operation by achieving pneumoperitoneum and
omy position with supplemental padding lateral placing trocars as one would do for laparoscopic
to the knees to protect from peroneal nerve injury. low anterior resection. Alternatively, as in our
The arms are tucked. Intravenous antibiotic is preferred approach, single-site access is obtained
administered. A urinary catheter is placed and at the future ileostomy site in the right lower
draped over the left leg so that is not in the way of quadrant (Fig. 21.6). At the marked ileostomy
the transanal team. The abdomen and perineum site, the stoma aperture is created per standard
are prepped and draped and an under the buttock technique with splitting of the rectus muscle, the
drape with a pocket is placed. The energy device GelPOINT® Mini Advanced Access Platform
and suction for the abdominal dissection is passed (Rancho Santa Margarita, CA, USA) is prepared
220 A. E. Gough et al.
Fig. 21.4 Operating
theater setup for taTME
with 3D transanal tower
placed near patient’s left
shoulder to allow
anesthesia access to the
patient and video screen
arm extended to allow
the screen to be in the
transanal team’s line of
sight
with three 10 mm ports triangulated placed The small bowel is swept out of the pelvis.
through the cap and placed through the future The dissection of the sigmoid colon is begun in a
ileostomy site, and pneumoperitoneum is medial to lateral fashion. After identification of
achieved. Often an additional 5 mm trocar is the left ureter, the inferior mesenteric artery is
placed in the suprapubic location to aid in trian- divided high on its pedicle near the aorta using a
gulation during splenic flexure mobilization and vessel sealing device (e.g., LigaSure™,
used for a fan retractor which retracts the uterus Medtronic, Inc., Minneapolis, MN) and the retro-
or bladder during the TME dissection. After con- peritoneal dissection carried to the white line of
firming absence of peritoneal or liver metastases, Toldt and inferior border of the pancreas where
the two teams can begin working simultaneously. the inferior mesenteric vein can be divided. Next,
The patient is positioned with the table tilted to the white line of Toldt is divided and the colon
the right and in Trendelenburg position. medialized. As this is being performed abdomi-
21 Operating Theater Setup and Two-Team Coordination 221
a b
c d
Fig. 21.7 Transanal and abdominal teams work simulta- teric artery ligation (a) and sigmoid colon mobilization
neously during the beginning portions of the operation. (c), the transanal team places the transanal purse string (b)
While the abdominal team performs the inferior mesen- and begins the taTME dissection (d)
a b
Fig. 21.8 The abdominal team pulls the rectum upward (a) as the transanal team gets further along in the transanal
dissection (b) to prevent collapse of the mobilized rectum in the limited transanal field
a b
Fig. 21.9 When the rendezvous is achieved, the abdomi- pull the rectum upward into the abdomen and either assist
nal team can retract the peritoneal reflection anteriorly (a), in the dissection or allow the transanal team to completely
place a grasper into the opening to provide retraction, or dismount the rectum from below (b)
by retracting the anterior peritoneal reflection and the pelvis is copiously irrigated from above
upward, placing a retractor through the opening with warm saline or sterile water and allowed to
to facilitate the dissection, or continuing to drain transanally. Next, the distal purse-string
retract the rectum upward and into the abdomi- suture is grasped and the specimen can often be
nal cavity where the dissection can be completed retrieved transanally. In the case of a bulky tumor
by the transanal or abdominal team (Fig. 21.9). or mesentery precluding transanal extraction, a
When the entire rectum is dismounted, the trans- Pfannenstiel incision can be used for specimen
anal cap is removed, the table position is leveled, extraction.
224 A. E. Gough et al.
suprapubic port. As the dissection continues cir- transanal team must adjust accordingly. Early
cumferentially, the abdominal team can fully communication with the team when asking for
deliver and evert the mobilized rectum into the instruments is essential as these cases can become
peritoneal cavity, thereby completing the dissec- overwhelming for the staff. Finally scheduling
tion beyond the reach or vision of the transanal the surgery so that both surgeons are available for
team. the entire duration of the surgery without other
Insufflation pressures during two-team taTME commitments is essential, especially during the
also play a large role in a successful operation. In implementation phase of a taTME program.
the initial portions of the transanal dissection
prior to rectal transection, if using continuous
insufflation platform (AirSeal®), the abdominal References
pressure has little effect on the transanal dissec-
tion. Once the rectum is transected and the TME 1. Lacy AM, et al. Transanal total mesorectal excision
for rectal cancer: outcomes after 140 patients. J Am
dissection has begun, it is our experience that Coll Surg. 2015;221(2):415–23.
maintaining equal abdominal and transanal pres- 2. Penna M, et al. Transanal total mesorectal excision:
sure throughout the latter half of the transanal international registry results of the first 720 cases.
dissection provides optimal transanal view. While Ann Surg. 2017;266(1):111–7.
3. Penna M et al. Incidence and risk factors for anas-
some authors have recommended maintaining tomotic failure in 1594 patients treated by transanal
transanal pressure higher than abdominal pres- total mesorectal excision: results from the interna-
sure [13], in our experience, this can sometimes tional TaTME registry. Ann Surg. 2018. https://doi.
displace the rectum proximally and flatten the org/10.1097/SLA.0000000000002653. [Epub ahead
of print].
TME plane along the sidewall making the dissec- 4. Motson R, Lacy A. The rationale for transanal
tion more challenging. It can also be challenging total mesorectal excision. Dis Colon Rectum.
for the abdominal team to operate at a lower 2015;58(9):911–3.
insufflation pressure. Thus, being mindful of the 5. Benlice C, Gorgun E. Single-port laparoscopic
restorative proctocolectomy with ileal-pouch anal
balance between abdominal and transanal pres- anastomosis using a left lower quadrant ileostomy
sure throughout the case is important, and gener- site – a video vignette. Color Dis. 2016;18(8):818–9.
ally a matched pressure of 12 mmHg works well. 6. de Buck van Overstraeten A, Wolthuis AM, D'Hoore
Lastly, the two teams must be able to work A. Transanal completion proctectomy after total col-
ectomy and ileal pouch-anal anastomosis for ulcer-
together and maximize available resources to ative colitis: a modified single stapled technique.
assure successful and timely surgery. First, train- Color Dis. 2016;18(4):O141–4.
ing and familiarity of the OR team with the pro- 7. Leo CA, Samaranayake S, Perry-Woodford ZL, Vitone
cedure and necessary equipment as well as L, Faiz O, Hodgkinson JD, Shaikh I, Warusavitarne
J. Initial experience of restorative proctocolectomy
having a dedicated team of nurses and surgical for ulcerative colitis by transanal total mesorectal
technicians routinely assigned to taTME cases is rectal excision and single-incision abdominal laparo-
crucial to a successful program. Similarly, dual scopic surgery. Color Dis. 2016;18(12):1162–6.
training of surgeons planning to work together in 8. de Buck van Overstraeten A, Mark-Christensen A,
Wasmann KA, Bastiaenen VP, Buskens CJ, Wolthuis
taTME surgery is important. During surgery, AM, Vanbrabant K, D'Hoore A, Bemelman WA,
compromise between transanal and abdominal Tottrup A, Tanis PJ. Transanal versus transabdominal
teams helps carry the case along. For example, minimally invasive (completion) proctectomy with
the use of a headlight during rectal suturing ileal pouch-anal anastomosis in ulcerative colitis: a
comparative study. Ann Surg. 2017;266(5):878–83.
allows the room lights to be kept dim so the 9. Caycedo-Marulanda A, Jiang HY, Kohtakangas
abdominal operator can continue laparoscopy. EL. Outcomes of a single surgeon-based transanal-
The abdominal operators may need step stools to total mesorectal excision (TATME) for rectal cancer.
compensate for the higher table position when J Gastrointest Cancer. 2017. https://doi.org/10.1007/
s12029-017-9989-7. [Epub ahead of print].
the transanal team is placing the purse string. 10. Burke JP, et al. Transanal total mesorectal excision
When the operating table is tilted to the right to for rectal cancer: early outcomes in 50 consecutive
allow mobilization of the sigmoid colon, the patients. Color Dis. 2016;18(6):570–7.
21 Operating Theater Setup and Two-Team Coordination 227
11. Koedam TWA, et al. Transanal total mesorectal exci- colorectal surgery. Dis Colon Rectum. 2019;62(2):
sion for rectal cancer: evaluation of the learning curve. 203–10.
Tech Coloproctol. 2018;22(4):279–87. 13. Arroyave MC, DeLacy FB, Lacy AM. Transanal
12. Zaghiyan K, Mendelson B, Eng M, Ovsepyan G, Total Mesorectal Excision (TaTME) for rectal can-
Mirocha J, Fleshner P. Randomized clinical trial cer: step by step description of the surgical tech-
comparing laparoscopic vs. ultrasound-guided trans- nique for a two-teams approach. Eur J Surg Oncol.
versus abdominis plane block in minimally invasive 2017;43(2):502–5.
Single-Team taTME
22
Antonio Caycedo-Marulanda, Shady Ashamalla,
and Grace Wai Ma
approach can be feasible in the correct environ- Whether it is a single-team or a two-team pro-
ment and with careful considerations prior to gram does not change the need to follow an
implementation of such a program. A dual-team organized pathway [12, 13].
approach is most likely safer; however this might Seeking institutional support becomes impor-
not be feasible at every center. Perhaps, there will tant to acquire the necessary resources to perform
be institutions that otherwise meet the criteria to the procedure. Having a dedicated team will
perform taTME surgery but lack the resources of enhance the chances of success, which is particu-
having a two rectal cancer surgeons available larly relevant for single-team taTME implemen-
simultaneously [11]. tation. Adequate training and proctorship are also
The single-team taTME approach provides a vital to ensuring its safe introduction [11].
formidable technical and logistical challenge to
surgeons and operating room personnel. Those
situations and all the relevant factors regarding Institution
feasibility and sustainability of a taTME program
should be considered prior to any attempt to There is significant evidence available to support
introduce the technique. Adoption and successful the concept of high-volume rectal cancer institu-
implementation of taTME may prove to be quite tions obtaining better outcomes when compared
difficult, in some situations even prohibitive. with those considered to have low volumes and
In our experience, appropriate implementation suboptimal expertise [14, 15]. It is challenging to
of a single-team taTME program requires an determine a specific number which defines high
insightful assessment of the local patient popula- vs low volume. Concern has risen around the
tion, surgical expertise, availability of institutional increasing complexity of the decision-making
resources, and receptive culture of the team for and surgical technique of rectal cancer which
innovation and learning. Some of the key individ- ultimately led to different organizations and
uals include the following: (a) a colorectal sur- health-care systems to advocate for centralization
geon or gastrointestinal surgical oncologist, (b) a of the management of rectal cancer [16, 17]. The
minimally invasive trained surgical assistant, (c) a advent of taTME has added a new level of com-
specialized nursing team, (d) supportive adminis- plexity; therefore, most experts believe, this tech-
tration, and (e) dedicated surgical equipment and nique should only be considered in high-volume
product specialist support. While these consider- specialized centers.
ations and key elements may coincide with those The institution should be equipped and situ-
described in other chapters regarding the two- ated to enable implementation of advanced surgi-
team approach, the technical and perioperative cal techniques. In general, minimally invasive
considerations that are described herein are surgery requires a longer time than open proce-
unique to the single-team taTME technique. dures, particularly during the learning curve
period, and it is crucial to have administrators
who understand that single-team taTME surgery
Considerations will initially take much longer than the traditional
open or laparoscopic procedure. A progressive
When a surgeon is motivated to introduce and informed administration understands that
taTME surgery at their respective institution, such a venture is worthwhile, since ultimately
they should start by asking themselves several patients benefit through improved oncologic
questions. Am I the right person to do this? Do I outcomes.
have the volume to perform this procedure regu- Some institutions may evaluate current taTME
larly and safely? Is my institution the right place data and opt against a single-team program, due
to do taTME? If the answer to all of those is yes, to unfavorable operating room efficiency. If the
then it is appropriate to consider taking steps institution is not supportive or the infrastructure
toward implementing a taTME program. for surgical innovation or advancement is not
22 Single-Team taTME 231
present, the taTME effort will inevitably fail. ment, and utilization of facility resources – such
This is why it is crucial to ensure the environment as longer initial operative time, additional nurs-
at the local institution is amenable to a single- ing and surgical scrubs for the taTME setup, and
team program prior to advocating for it. Both sur- hospital resources in the case of complications
geon and institution should act with extreme associated with implementation of a novel proce-
caution when considering taTME implementa- dure. While the training of a single surgeon may
tion; this is a particularly sensitive issue in the be easier than coordinating the schedule of two
single-surgeon setting, because operative times high-volume surgeons to train for a procedure,
may be longer and the approach is more chal- advocating for funding of a single-team TaTME
lenging [11]. program is certainly more difficult for the single
surgeon.
The balance between cost, safety, and effec-
pecific Challenges to a Single
S tiveness is a fundamental consideration for suc-
Surgeon cessful adoption of any new procedure [18]. The
frequent lack of supportive evidence for new
dvocating for a Single-Team
A techniques leads to making decisions mainly
taTME Program based on qualitative information [19]. The intro-
It can be quite difficult for a single colorectal sur- duction of new technology is frequently oriented
geon to advocate an ambitious program that toward enhancing existing approaches, either by
requires an important amount of resources, such minimizing the invasiveness of procedures,
as a significant financial investment by the insti- improving clinical outcomes, optimizing cost, or
tution as well as a large quantity of human expanding the number of treated patients [20].
resources dedicated to this operation. The initial cost of a taTME program should
Firstly, a proposal delineating the advantages consider carefully the decision regarding the
of the single-team taTME operation using current selection of the transanal platform. This has a dif-
data from the institution could be created to dem- ferent impact in the short term than it does on the
onstrate the potential benefits for patients as well long term and is largely dependent on economies
as institutional progress and the intangible value of scale, as the different existing options carry dif-
added by innovation. The proposal should con- ferent economic burdens. There are two different
sider the training of the surgeon, the volume of types of platforms, either disposable, single-use
minimally invasive rectal cases at the institution, ones (based on the TAMIS technique) or reusable,
the potential for growth, and the need for contin- multi-use ones (based on the technique of TEM).
uous support for a sustainable program (equip- The latter, so-called “rigid” platforms are manu-
ment maintenance, slow and yet progressive factured by either Richard Wolf™ or Karl Storz™.
learning curve, specialized assistants, alignment Their technology incorporates an insufflating sys-
with goals of administration, and hospital leader- tem that is built-in to the apparatus. The initial
ship). The audience of the proposal should be capital cost can be offset in time depending on the
considered and may include surgical colleagues volume of procedures performed.
and nursing staff, hospital administration, hospi- There are now a variety of TAMIS-based plat-
tal leadership, and community agencies. Once a forms available through various vendors; of
proposal has been created, sources of funding these, the GelPOINT Path Transanal Access
will vary depending on the characteristics of the Platform (Applied Medical™, Rancho Santa
health-care system. Margarita, California) is perhaps most frequently
used for taTME (where available) since it was
ecuring Sustainable Funding
S specifically designed for transanal access and is
The initial implementation of a single-team thus quite versatile and, in the short-term,
taTME program requires an investment in educa- relatively affordable. However, this latter is best
tion and training, purchase of specialized equip- used in combination with a separate and quite
232 A. Caycedo-Marulanda et al.
costly insufflation system (AirSeal® Conmed, procedure. The discussion must include not only
Utica, NY, USA). Thus with TAMIS-based the perceived benefits of the procedure but also
taTME, whether a single- or two-team approach the potential risk specific to taTME, such as ure-
is used, such a system is considered integral to thral injury [24]. In addition, the possible alterna-
the modern taTME since it stabilizes insufflation tives to the procedure are worth including. Ample
in a reduced space. Recently, however, an alter- time should be allotted to the consent process as
native to that has emerged which is a new stabi- the patient’s understanding is crucial. Consent
lizing insufflation bag, which is discussed must include discussing the proficiency of the
elsewhere. operator and the specific innovative technique of
Our experience has been entirely with the the taTME which has the objective of improving
TAMIS-based, GelPOINT Path Platform (aka resection quality and thereby patient outcomes. It
TAMIS platform); initially we introduced it to is relevant to discuss the single-surgeon presence
perform TAMIS for local excision as a segue to and its implications, including how the procedure
taTME [21]. This greatly facilitated the transition is performed in a sequential fashion rather than
to taTME, especially when approaching hospital synchronously. All this will definitively help to
administrators to fund the new program, as the make the consent as informative as possible [23].
value of advanced transanal surgery was already
appreciated.
The importance of teamwork cannot be over- Potential Complications
emphasized. Single-team taTME mandates coop-
eration though all OR channels. This includes Complications specific to taTME include injury
physician leadership, anesthesiologists, nursing to the urethra, the pelvic nerves, and the iliac ves-
and surgical scrubs, intensive care providers, as sels [24–26]. These potential complications are
well as hospital administration. A cost-impact not exclusive of a single-surgeon setting; how-
analysis for the institution should be conducted ever it is possible that they may occur more easily
and should include a realistic understanding of in this type of scenario [11].
case complexity and operative time and, as best The planes of taTME are different than those
as possible, quantify these values into an appro- from a transabdominal approach, and it is much
priate health-care economic model. All of the easier to dissect in the wrong plane from a trans-
above contributed toward helping hospital admin- anal approach [27]. This is due to the improved
istration identify the financial benefits of mini- visualization and superior retraction of the meso-
mally invasive rectal surgery (reduced length of rectum allowing multiple planes to appear avas-
stay, early mobilization, decreased wound com- cular and amenable to safe dissection. This is
plication, and decreased hernia rates) improving particularly risky in a single-team approach;
financial sustainability of our taTME program therefore the single surgeon needs to constantly
[22]. If long-term oncologic outcomes are some- reassess his or her own work and identify when
day proven with the taTME technique (versus he or she is in the wrong plane.
other minimally invasive approaches), then it will
ultimately drive both surgeons and institutions
toward a permanent adoption. Training
surgeons with the skill set necessary to safely training courses as well as integration into a
implement taTME [28]. Despite completion of a taTME proctorship model. Training and acquisi-
didactic component, live case demonstration, and tion of skill has been discussed. The surgeon
cadaver-based training, mentoring and proctoring must be determined, patient, and willing to accept
are crucial to successful implementation of a that initial implementation may be frustrating
taTME program [13, 29]. All of the abovemen- and difficult. In a single-team approach, the sur-
tioned elements are mainly focused on patient geon must be able to deal with challenging situa-
safety [30]. The learning curve of different proce- tions independently but also have the insight and
dures is variable [31], and for taTME it has been wisdom to convert to a conventional approach or
estimated to be around 40 procedures [32]. ask for help from a colleague when necessary. It
In a single-surgeon model, identifying a men- should be understood that the level of difficulty
tor/proctor in the early phases of the process is of an already quite complex operation is substan-
particularly relevant; this relationship should be tially increased when it is performed via the
maintained as long as necessary in order to single-surgeon approach.
achieve proficiency. This will allow the novice
taTME surgeon to gain confidence and expertise
with more complex cases as the experience grows. Specialized Assistant
Identification of an appropriate mentor is dis-
cussed in existing training pathways [12, 33]. In A proficient surgical assistant is a key element of
addition a number of other aids, including elec- the team, since her/his ability to provide traction
tronic tools, such as the D-Live® platform and the and countertraction facilitates exposure, there-
iLapp educational app, are easily available to any- fore enhancing plane recognition by the surgeon.
one interested in adopting taTME [34]. This is imperative in the single-surgeon setting,
for instance, at the rendezvous and then during
the whole process of circumferential detachment
Required Personnel [35] (Fig. 22.1). In this sense, the specialized
assistant functions as a skilled first assistant in a
A standard single-surgeon taTME team is com- manner similar to a resident in surgical training.
prised of six members: a colorectal surgeon, a Not having an experienced assistant in a
surgical assistant, an anesthesiologist, two scrub single-surgeon taTME operation will undoubt-
nurses, and a circulating nurse. Germane details edly have an impact on the performance of the
regarding personnel for single-surgeon taTME procedure, and the authors do not recommend
are discussed in the following sections. single-team taTME without a skilled assistant.
The role of the assistant is thus not limited to
driving the camera; therefore in order to assist in
Surgeon a meaningful manner, it is very important that he
or she has a clear understanding of all the anat-
It is strongly recommended that the surgeon be a omy relevant to the operation and has consider-
high-volume, experienced rectal cancer surgeon able assist experience in advanced laparoscopy
who has completed colorectal fellowship training [9, 10].
[15]. She or he must also be comfortable with
platform-based transanal endoscopic surgery
using either TAMIS (transanal minimally inva- Dedicated Nursing Team
sive surgery) or TEMS (transanal endoscopic
microsurgery) prior to embarking on a taTME A knowledgeable resource nurse is important to
program. the success of the single-team. He or she must be
Training to achieve proficiency is a long pro- cognizant of the case sequence at all times and be
cess. It requires the completion of structured able to troubleshoot equipment as needed with or
234 A. Caycedo-Marulanda et al.
Fig. 22.1 Assistant
on top
without the aid of a product specialist. Due to the for the entire duration of the procedure. One of
many intricate steps and details of the procedure, these nurses serves as a dedicated taTME nurse,
it is necessary to have at least one dedicated nurse who invariably scrubs in during the transanal
who can choreograph all the necessary moves portion of the operation, she/he should be
within the theater and anticipate every potential responsible for orchestrating the surgical equip-
pitfall to facilitate seamless procedural operation. ment and instrumentation, and this individual
We consider it is fundamental to have three serves an assist to the primary surgeon by driv-
nurses available at each taTME case. A mini- ing the camera during the dissection during
mum of two circulating nurses should be present taTME (Figs. 22.2 and 22.3).
22 Single-Team taTME 235
very specific planning and experience. Due to the Familiarity with equipment setup is essential
complexity of devices and the large footprint of to the taTME procedure and can vary largely
instruments and equipment, setup is critical to the depending on the layout of the operating theater.
success of the procedure. Setup for a single- We suggest two equipment setup formats, among
surgeon taTME is no different in that it requires many conformations that exist, as these setups
knowledge of the steps of the procedure and an have worked well at our respective institutions.
understanding of the special limitations that the The specific position of laparoscopic equipment
surgeon may experience throughout the opera- and monitors can be modified to fit the available
tion. It is critical for a single surgeon to ensure infrastructure of the institution (Fig. 22.5. HSN
that the team members know the operative plan taTME room setup).
and are able to set up according to a preoperative Setup 1: The transabdominal laparoscopic
floor plan. tower is set up by the patient’s right shoulder with
The setup for a single-team taTME can be cords draped over the right shoulder. The surgical
divided into the transabdominal equipment and team (both assistant and primary surgeon) stand
transanal equipment: on the patient’s right side, and the abdominal dis-
section is performed from here. The monitor for
Transabdominal: the abdominal surgeon is placed across the oper-
–– Laparoscopic tower with air supply for ating table just beyond the patient’s left hip. The
insufflation abdominal surgical instruments and scrub nurse
–– Additional laparoscopic monitor are also across the operating table on the patient’s
–– Cautery and energy device sources left side.
–– Suction The transanal component is set up with the
–– Equipment tray table with scrub nurse second laparoscopic tower beside the patient’s
Transanal: right leg with cords and insufflation tubing
–– Laparoscopic tower with air supply for insuf- draped along the right leg. The insufflation tub-
flation (may require separate freestanding ing is draped across the pubic symphysis, while
machine) the transanal suction, cautery, and instruments
–– Cautery and energy device sources are laid on a Mayo stand that rests across the
–– Suction surgical field similar to a typical perineal setup.
–– Equipment tray with scrub nurse This tower typically consists of two monitors,
one with the abdominal laparoscopic view and
As a single surgeon, the length of time of the one for the transanal view. The monitors rest on
surgery must also be factored into the operative top of the transanal laparoscopic tower beside
plan and minimized when possible, and therefore the patient’s right leg to enable the transanal
we set up in stages in order to allow for initiation surgeon to visualize both perspectives while
of the procedure. The specimen is then extracted performing the taTME dissection. This also
either through a Pfannenstiel incision or transa- allows the transanal surgeon to monitor the
nally. Pfannenstiel incision extraction of the assistant’s movements and ensure appropriate
TME specimen holds the advantage of limiting traction.
shearing and mesenteric disruption and the Setup 2: The transabdominal laparoscopic
potential for seeding of tumor cells. tower is set up by the patient’s right leg with the
The patient’s abdomen and perineum are then monitor positioned directly between the
prepped extensively. It is important to prep the patient’s legs. The light and camera cords to this
perineum first so that any splashing of contami- tower should be positioned over the patient’s
nant up toward the abdomen will be cleaned with right leg. The additional laparoscopic monitor is
the abdominal prep. We use an alcohol-free solu- positioned above the patient’s left shoulder. The
tion for the perineum and chlorhexidine for the cautery, energy device source, and suction can-
abdomen. ister are placed over the patient’s right shoulder.
22 Single-Team taTME 237
The patient is then positioned in Trendelenburg. • Circumferential TME dissection until the
The order of steps for the single-surgeon approach level of the anterior peritoneal reflection
has been previously described [36]. The transab- • Opening of anterior peritoneal reflection
dominal portion is not different than any laparo-
scopic dissection conducted for a low anterior During the transabdominal approach, while
resection; our preferred technique includes the the team is working toward the pelvis, the assis-
following recommendations: tant is at the patient’s left side facing the monitor
stationed on the patient’s left side. At the next
• Medial to lateral mobilization of the sigmoid point in the procedure, the patient is positioned in
and descending colon with careful identifica- reverse Trendelenburg with the left side up. The
tion and protection of left ureter assistant moves to between the patient’s legs, and
• Medial to lateral mobilization of the splenic the surgeon remains on the patient’s right side but
flexure, careful identification, and protection is now working via the left shoulder monitor for
of the pancreas improved ergonomics. At this stage, the surgeon
• Ligation of the inferior mesenteric vein, close will employ steps to take down the splenic flex-
to the inferior edge of the pancreas ure to obtain adequate colonic length for the con-
• Lateral mobilization of the left colon, including duit. This completes the transabdominal
the lateral attachments of the splenic flexure component and the team then moves to the trans-
• Identifying and maturation of posterior rectal anal component of the surgery.
plan
• Ligation of the inferior mesenteric artery,
proximal to the takeoff of the left colic artery, Transanal Approach
either using clips or an energy device, approx-
imately 1 centimeter distal to the origin at the Once the transanal component is initiated, the
aorta patient is again positioned in Trendelenburg
• Transection of the mesentery of the proximal and the abdominal pressured is decreased. The
margin from the ligated pedicle to the level of assistant is then positioned between the
the colon patient’s leg on the right side and the surgeon is
• Systemic delivery of indocyanine green (ICG) seated centrally between the patient’s legs. In
5 ml to verify point of transection via fluores- this position, the surgeon then employs the fol-
cence angiography lowing steps:
22 Single-Team taTME 239
only conduct one dissection at a time. This makes ever, it strictly depends on the assistant’s ability
the decision to switch between the two approaches to generate adequate traction and countertraction,
more crucial and strategic as it can affect the effi- hence the importance of having an experienced
ciency of the operation. and knowledgeable surgical assistant who can
As previously described, the transabdominal interpret the anatomy as well as the surgeon’s
approach is conducted first, and the upper TME is need for exposure.
dissected prior to moving to the transanal Just prior to peritoneal entry, the assistant may
approach. It is important to employ a “take what pull the specimen upward – this facilitates visual-
is easy” philosophy as a single surgeon. ization of the planes while the surgeon synchro-
Therefore, from the top-down approach, the dis- nously pushes the specimen from below. It is
section is continued until it becomes challenging important to realize, as the surgeon conducts the
as the pelvis narrows; at a minimum the single “bottom-up” portion of the taTME operation, it
surgeon should reach the anterior peritoneal may become more difficult than the two-team
reflection. Once the decision is made to go to the taTME approach; this is the time when the assis-
bottom, it is important to remember to decrease tant’s role is crucial by pulling the rectum up and
the peritoneal insufflation pressure in order to out of the pelvis as the dissection is done
facilitate dissection and avoid billowing. transanally.
Once communication between the two spaces
has been established, the assistant will help by
oles and Assignments
R providing countertraction as needed. Retraction
of the Dedicated Nurse and Surgical can be limited if the surgical assistant is not
Assistant familiar with laparoscopic tissue handling as
excessive or deficient force can compromise the
During the transanal approach, the assistant is integrity of the TME dissection. The point of ren-
standing on the patient’s right side, to the left of dezvous is variable and depends on the location
the seated surgeon, remaining at the top and pre- of the lesion as well as how much dissection from
paring to exert traction and countertraction as above has been performed. If the operation starts
required by the surgeon, with a scrub nurse at the transanally, then the role of the assistant is much
top, holding the camera temporarily. Our prefer- more limited.
ence is to have our dedicated taTME nurse to scrub The assistant remains at the top providing
for the transanal part and hold the camera. The retraction. By looking at both screens (transanal
assistant will stand on the left side of the surgeon; and transabdominal), the primary surgeon utilize
the use of a flexible-tip camera lens prevents any the additional vantage point provided by the dual
interference with the surgeon’s hands. The camera vantage point provided by the laparoscopic video
holder should be familiar with the taTME proce- display. This can significantly help with the intra-
dure, the capabilities of the camera, and the spe- operative decision-making. In addition, the assis-
cific views that facilitate dissection within a tant should ensure the bowel stays properly
narrow field (Figs. 22.3, 22.4, 22.5, and 22.6). oriented and not twisted for the transanal extrac-
tion or the reconstruction.
institution to compare their results against the e ndoscopic microsurgery and laparoscopic assistance.
Surg Endosc. 2010;24(5):1205–10.
standards and outcomes from other 7. Emile SH, de Lacy FB, Keller DS, Martin-Perez B,
jurisdictions. Alrawi S, Lacy AM, et al. Evolution of transanal total
It has been said that for difficult procedures, mesorectal excision for rectal cancer: from top to bot-
the learning curve rises quickly after a critical tom. World J Gastrointest Surg. 2018;10(3):28–39.
8. Lacy AM, Tasende MM, Delgado S, Fernandez-Hevia
number of cases; however this is not accurate for M, Jimenez M, De Lacy B, et al. Transanal total
single-team taTME. The learning curve for mesorectal excision for rectal cancer: outcomes after
single-team taTME is slow with high risk of 140 patients. J Am Coll Surg. 2015;221(2):415–23.
complications during the initial stages of imple- 9. Caycedo-Marulanda A, Jiang HY, Kohtakangas
EL. Outcomes of a single surgeon-based transanal-
menting a program. For this reason, we strongly total mesorectal excision (TATME) for rectal cancer. J
encourage participation in an audit and feedback Gastrointest Cancer. 2017;22(3):277–2.
forum such as a national registry. 10. Deijen CL, Tsai A, Koedam TWA, Veltcamp Helbach
M, Sietses C, Lacy AM, et al. Clinical outcomes
and case volume effect of transanal total mesorec-
tal excision for rectal cancer: a systematic review.
Conclusion Tech Coloproctol. Springer International Publishing.
2016;20(12):811–24.
In summary, the implementation of a single- 11. Caycedo-Marulanda A, Chadi SA, Patel S, Knol J,
Wexner S. Is a taTME programme feasible in a sungle
surgeon institution must be carefully considered. surgeon setting? Colorectal Dis. 2018;20(7):571–3.
The institution, local support, financial sustain- https://doi.org/10.1111/codi.14243.
ability, patient population, and surgeon skills and 12. McLemore EC, Harnsberger CR, Broderick RC,
intent should be aligned to ensure success for a Leland H, Sylla P, Coker AM, et al. Transanal total
mesorectal excision (taTME) for rectal cancer: a
single-team taTME program. We have outlined training pathway. Surg Endosc. 2015;30(9):4130–5.
elements that we consider essential for success at 13. Abbott SC, Stevenson ARL, Bell SW, Clark D,
our institutions; however factors in the local set- Merrie A, Hayes J, et al. An assessment of an
ting (access to equipment, available personnel) Australasian pathway for the introduction of trans-
anal total mesorectal excision (taTME). Color Dis.
may require modification to what has been 2018;20(1):O1–6.
described above. We believe that single-surgeon 14. Borowski DW, Bradburn DM, Mills SJ, Bharathan
taTME is feasible and should be carefully con- B, Wilson RG, Ratcliffe AA, et al. Volume-outcome
sidered at selected institutions. analysis of colorectal cancer-related outcomes. Br J
Surg. John Wiley & Sons, Ltd. 2010;97(9):1416–30.
15. Buurma M, Kroon HM, Reimers MS, Neijenhuis
PA. Influence of individual surgeon volume on onco-
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Transanal Access Platform Options
and Instrument Innovations 23
Giovanni Dapri
three main categories, based on their material rectal ring. The SILS Port has an option to
characteristics. These are as follows: (a) flexible, accommodate three cannulas from 5 mm to
(b) rigid, and (c) semirigid transanal access 12 mm. The SILS Port’s dimensions are 1.5
platforms. (L) × 3.6 (W) × 3.7 (H) cm. This was used to
perform the original series which described
the technique of TAMIS [1]. It is currently
ransanal Flexible Platforms
T FDA approved for use for transanal access
(TAMIS Based) surgery.
(B) The reusable KeyPort (Richard Wolf GmbH,
Flexible, single-use platforms are those utilized Knittlingen, Germany) (Fig. 23.2). It is
by what has been defined as the TAMIS tech- formed by a flexible silicone tube of 55 ×
nique. Most of these platforms were originally 33 cm, a flex mount with an inner lumen of
developed for single-incision laparoscopy (SIL) 24 mm, and a silicone sealing insert with
through the abdomen and were simply adapted three valve ports allowing to accommodate
for transanal access. However, some were three instruments from 5 mm to 15 mm. Two
designed specifically for transanal surgery, additional Luer Lock connectors permit CO2
including for TAMIS and taTME. There are three insufflation and active or passive smoke
main TAMIS platforms and one robotic platform evacuation.
in use currently. (C) The disposable GelPOINT Path Transanal
Access Platform (Applied Medical, Rancho
(A) The disposable SILS Port (Covidien, New Santa Margarita, California, USA)
Haven, Connecticut, USA) (Fig. 23.1). It is a (Fig. 23.3). This FDA-approved platform
malleable port, made of a specialized ther- remains the most common for TAMIS and
moplastic elastomer which allows for an taTME worldwide; it was specifically
atraumatic conforming fit. In most patients designed for transanal use. The apparatus
the inner lip of the port seats above the ano- includes a proprietary GelSeal cap, an access
Fig. 23.1 SILS Port (Covidien, New Haven, Connecticut, Fig. 23.2 KeyPort (Richard Wolf GmbH, Knittlingen,
USA) Germany)
23 Transanal Access Platform Options and Instrument Innovations 247
channel with introducer, three 10 mm The access channel itself includes keyholes
sleeves, and one insufflation stabilization to allow for suture tie placement. This per-
bag. The GelSeal cap provides a flexible ful- mits to the device to be sutured to the skin,
crum for triangulation of standard laparo- whereby it remains securely in position
scopic instruments. Two stopcock valves are throughout the duration of the procedure.
provided for smoke evacuation and insuffla- The GelPOINT Path is currently available in
tion; alternatively, a valveless 5 or 8 mm tro- three access channel lengths: 4 cm, 5.5 cm,
car together with an AIRSEAL® system can and 9 cm. The faceplate (GelSeal) measures
be easily adapted to the TAMIS platform for 40 mm in diameter, and the inner diameter
pneumatic stabilization. A simple clasp of the access channel measures 34 mm. The
device secures the access channel sleeve to sleeves accommodate 5 mm and 10 mm
the GelSeal cap that it can be removed quite instruments. The insufflation stabilization
easily, facilitating the specimen extraction bag stabilizes the surgical space with an
and access to the operative field, if needed. expandable reservoir that dampens the effect
of cyclic billowing [24, 25].
(D) The reusable, rigid platform adapted to the
Flex® Robotic System (Medrobotics,
Raynham, Massachusetts, USA)
(Fig. 23.4a–b). It is the world’s first com-
mercially available robotic-assisted surgical
platform FDA approved for transanal access
that offers surgeons the ability to define a
nonlinear path to a surgical site and achieve
satisfied exposure [26, 27]. The surgeon is
able to sit or stand comfortably as they
choose, while also remaining at the patient
bedside throughout the procedure. The flex-
ible robotic scope is comprised of inner and
Fig. 23.3 GelPOINT Path (Applied Medical, Rancho outer mechanisms, with magnified 3D-HD
Santa Margarita, California, USA) view, and navigation nearly 180°. The total
a b
Fig. 23.4 (a–b) Flex Robotic System (Medrobotics, Raynham, Massachusetts, USA): flexible system (a) and console (b)
248 G. Dapri
a b
Fig. 23.7 (a–b) D-Port or DAPRI Port (Karl Storz Endoskope, Tuttlingen, Germany): the components (a) and the port
once inserted in the anus (b)
250 G. Dapri
cap is secured onto the access channel. The specialized flexible tip or articulating laparo-
reusable silicon cap is formed by three port scopic instruments, or custom-made instruments
orifices (left 6 mm, center 11 mm, right 6 mm) such as those designed specifically for TEM and
aligned in the horizontal axis. It permits the TEO surgery. The dedicated instruments for the
instruments to move freely outside of the port, transanal platforms are:
and the device is designed to function without
securing the shaft to the bedrail (as is the case (A) The reusable BUESS instruments (Richard
with rigid platforms). The orifices allow the Wolf GmbH, Knittlingen, Germany)
introduction of the 10 mm scope in the center, (Fig. 23.9a–g). These instruments are sup-
and of the two ancillaries, 5 mm instruments ported by a straight shaft; however, the distal
are placed into the right and left ports for oper- working end of the effector arm is curved
ation by the transanal surgeon. slightly. A consequent limited space between
(B) The reusable silicon cap modified TEO sys- the surgeon’s hands can be present.
tem (Karl Storz Endoskope, Tuttlingen,
(B) The reusable instruments for TEO (Karl
Germany) (Fig. 23.8). This platform is the Storz Endoskope, Tuttlingen, Germany)
same TEO platform described above, but it (Fig. 23.10a–b). The shaft is curved proxi-
differs in its cap because it is supported by a
silicon flexible cap with four port orifices.
Like standard TEO and TEM, the device is
bedrail mounted for stability. The TEO
scope’s shorted, 7.5 cm shaft allows better
maneuverability of instruments, which is
particularly important for taTME. This sys-
tem allows for the admission of both special-
ized TEO-specific instruments and more
traditional laparoscopic instruments.
Instruments for taTME
Fig. 23.8 Silicon cap-modified TEO system (Karl Storz Fig. 23.9 BUESS instruments (Richard Wolf GmbH,
Endoskope, Tuttlingen, Germany) Knittlingen, Germany)
23 Transanal Access Platform Options and Instrument Innovations 251
mally to the tip and to the handle as well, in preparation for mating with anvil. In the port ori-
maintaining a straight shape in the center. fice at 3 o’clock position (surgeon’s right hand),
This configuration allows a limited freedom five other monocurved, custom-designed instru-
and the absence of conflict between the sur- ments are typically used. They are as follows: the
geon’s hands and the instrument’s tips. needle holder (Fig. 23.12c), the scissors
(C) The reusable WEXNER instruments (Karl (Fig. 23.12d), the coagulating hook (Fig. 23.12e),
Storz Endoskope, Tuttlingen, Germany) the bipolar forceps (Fig. 23.12f), and the bipolar
(Fig. 23.11a–d). Two curves are present on scissors (Fig. 23.12g).
the instrument’s shaft, one at the orifice inser-
tion, allowing a distance with the telescope (E) The reusable Flex Robotic instruments
placed medially, and another one close to the (Medrobotics, Raynham, Massachusetts,
handle, allowing the surgeons to work with- USA) (Fig. 23.13a–h). The diameter of these
out enlarged arms. The main shaft, inside the articulating instruments is 3.5 mm and the
tube and at the extremity tip, is kept straight.
(D) The reusable DAPRI instruments (Karl
a
Storz Endoskope, Tuttlingen, Germany)
(Fig. 23.12a–g). These monocurved instru-
ments are similar and shaped in a semioval
form, allowing a certain degree of freedom b
in intraluminal work, thereby providing an
ergonomic benefit to the surgeon. Because
of the main curve, the surgeon is able to dis-
sect and to suture intraluminally without any
conflict between hands or between the
c
camera- assistant holder’s hand. The sur-
geon’s arms movements are similar to those
observed during conventional laparoscopy.
d
These instruments are inserted through the
D-Port laterally to the main central port orifice used
for the optical system. In the port orifice at 9
o’clock position, one of two monocurved instru-
ments are typically utilized for right-handed sur-
geons: the grasping forceps (Fig. 23.12a) and the
anvil grasping forceps (Fig. 23.12b). This latter is
inserted at the step of circular mechanical colorec-
tal anastomosis, allowing the stapler’s anvil to
Fig. 23.11 (a–d) WEXNER instruments (Karl Storz
remain under control in the pelvis as the arm por- Endoskope, Tuttlingen, Germany): dissector (a), grasping
tion of the circular stapler is introduced transanally forceps (b), scissors (c), needle holder (d)
a e
Fig. 23.12 (a–g) DAPRI instruments (Karl Storz Endoskope, Tuttlingen, Germany): grasping forceps (a), anvil grasp-
ing forceps (b), needle holder (c), scissors (d), coagulating hook (e), bipolar forceps (f), bipolar scissors (g)
c g
d h
23 Transanal Access Platform Options and Instrument Innovations 253
rectal cancer: evaluation of the learning curve. Tech mucosectomy for symptomatic benign rectal stenosis.
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16. Barendse RM, Dijkgraaf MG, Rolf UR, et al.
24. Waheed A, Miles A, Kelly J, Monson JRT, Motl JS,
Colorectal surgeons' learning curve of trans- Albert M. Insufflation stabilization bag (ISB): a cost-
anal endoscopic microsurgery. Surg Endosc. effective approach for stable pneumorectum using a
2013;27(10):3591–602. modified CO2 insufflation reservoir for TAMIS and
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TC, Mancuso PA, Monson JR, Albert MR, Atallah 25. Atallah S, Gonzalez P, Chadi S, Hompes R, Knol
SB. Establishing the learning curve of transanal mini- J. Operative vectors, anatomic distortion, fluid
mally invasive surgery for local excision of rectal neo- dynamics and the inherent effects of pneumatic insuf-
plasms. Surg Endosc. 2018;32(3):1368–76. flation encountered during transanal total mesorectal
18. Martin-Perez B, Andrade-Ribeiro GD, Hunter L,
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Jottard K, Cadière GB. Colorectal anastomotic leak- microsurgery versus transanal minimally invasive
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2016;18(6):O210–3. Colon Rectum. 2017;60(9):928–35.
22. Bravo R, Fernandez-Hevia M, Jimenez-Toscano M, 29. Peters BS, Armijo PR, Krause C, Choudhury SA,
et al. TAMIS a new option for the treatment of post- Oleynikov D. Review of emerging surgical robotic
operative haemorrhage. Color Dis. 2015;17(2):105. technology. Surg Endosc. 2018;32(4):1636–55.
23.
Dapri G, VanGossum M, Muls V, Cadière
GB. Transanal endolaparoscopic circumferential
Intraoperative Decision-Making:
Converting to taTME, When 24
and for Whom?
Isacco Montroni and Antonino Spinelli
“appealing” (otherwise it would have been the Once these clear unmet needs of MIS are
initial option). Surgeons convert to strategies accepted, three more elements should be consid-
that may be suboptimal in regard to modern sur- ered. First, there are significant concerns about
gical principles (e.g., conversions which increase the possible worse outcome for patients requiring
the degree of abdominal wall access trauma) but conversion to open surgery. Second, even after
which carry the advantage of control and converting to laparotomy, performing a good
familiarity. quality TME – in a case of an obese male with a
Since minimally invasive approaches have narrow pelvis and a bulky tumor – may not come
been developed and broadly adopted the word as a simpler task. Third, converting to a different
conversion has been used to describe the shift technique still requires proficiency at the new
from a laparoscopic/robotic approach to open strategy of choice, which may require a different
surgery. With increased experience in minimally skill set by the surgeon.
invasive surgery (MIS), the conversion rate has In order to answer the first question, Yang
been widely reduced, and it is now globally et al. [7] demonstrated that of the many factors
accepted at around 5–6%, in expert hands, for that may lead to conversion including bowel
colonic surgery [4]. Bahma et al. described data injury, bleeding, unclear anatomy, and lack of
from the American College of Surgeons National progression. All of these factors can be classified
Surgical Quality Improvement Project (NSQIP) into two categories: (a) reactive or (b) preemptive
database, and they pointed out that on multivari- conversion [8]. Reactive conversion (RC) has
ate analysis, conversion was higher in patients been defined as one that follows an intraoperative
with advanced age (>80 years old), BMIs classi- complication such as bleeding or organ injury,
fied as overweight or obese, ASA 3 or 4, history whereas preemptive conversion (PC) is defined
of smoking, history of weight loss, and, most sig- as one undertaken to avoid complications. The
nificantly, the presence of ascites. While conver- reasons for PC included poor progression caused
sion rates have been consistently reduced with by unclear anatomy, obesity, or adhesions, inabil-
increased expertise in minimally invasive colonic ity to identify the ureter, and other similar situa-
surgery, a high number of minimally invasive tions. After analyzing a total of 222 laparoscopic
rectal resections still require conversion to lapa- procedures that had been converted to laparot-
rotomy. This appears to be one of the major omy, authors were able to show that patients
unmet needs of laparoscopic or robotic rectal whose conversion was reactive to intraoperative
cancer surgery. The COLOR II randomized con- adverse events were more likely to have a postop-
trolled trial (RCT) showed a conversion rate near erative complication (50% vs 27%; p = 0.02), to
17% [5], while the ROLARR trial reported a non- require a longer time to tolerate a regular diet (6
significant difference in conversion between vs 5 days; p = 0.03), and to have a longer hospital
robotic and laparoscopic TME of one in ten stay (8.1 vs 7.1 days; p = 0.08) than patients who
patients (8.1% for robotic and 12.2% for laparo- underwent a PC. Based on these findings, the
scopic surgery) [6]. Interestingly, the ROLARR authors advocated for not considering conversion
study did not report data about conversion from a “surgical complication” and that an early (pre-
robotic surgery to laparoscopic surgery. Both emptive) conversion should be preferred over a
laparoscopic and robotic cases were more likely delayed laparotomy when major intraoperative
to fail completion in cases of obese, male patients complications have occurred.
undergoing low anterior resection (vs abdomino- In order to address the second and third
perineal resection). The problems associated issues, there are unfortunately very little pub-
with those characteristics are obviously increased lished evidence, but it’s a common experience
by the presence of a large tumor, above all if the that even with the best self-retaining (e.g.,
tumor is located on the anterior side of the rectum Bookwalter, St. Mark’s) retractors in place, it’s
where the very thin mesorectum makes the pro- sometimes extremely complex to access the pel-
cedure far more challenging. vis when conversion to an open approach occurs.
24 Intraoperative Decision-Making: Converting to taTME, When and for Whom? 257
The limited visibility of the lower third of the rec- abdominal approach already facilitated by robotic
tum together with suboptimal access may lead to instrumentation. The only occasion this may pro-
several surgical mistakes, from injuring sur- ficiently happen is when a technical problem is
rounding structures (presacral vessels, prostate, encountered in the robotic system or in case of
vagina, etc.) to performing a suboptimal cancer difficulty mobilizing the splenic flexure and the
operation while tearing the mesorectum or pro- case is switched to standard laparoscopy, often in
ceeding with an intra-mesorectal dissection. In a planned, hybrid, robotic-assisted MIS approach.
addition, when hostile pelvic anatomy is present, Given the paucity of reports in the literature, this
poor access to the most distal margin of the rec- might be considered quasi-anecdotical [10].
tum, below the mesorectal fat, may occur. In On the other end, converting from laparos-
addition, passing a linear stapler distal to the copy/robotic transabdominal approach to taTME
bulky mesorectum down to the pelvic floor and seems to have the potential to fill the gap of about
then safely firing it, at the determined level, could 10% of these rectal cancer cases that are reported
be extremely challenging and lead to suboptimal to be converted to open [6]. This will allow, for
results with the need for multiple firings or inad- the first time, to provide a large number of
vertently firing through the distal tumor. patients with an oncologically appropriate proce-
Nevertheless, this is what most colorectal sur- dure, despite the presence of those challenging
geons have proficiently learned to do over the features that prompted a conversion, without
course of their operative experience, as attested trading the benefits of MIS. Moreover, a trans-
by progressively improved oncologic outcome of anal approach to the pelvis could also be a viable
rectal cancer over time. option in those open cases where laparoscopy
Regarding the third issue previously raised, could not be successfully completed because of a
this is of crucial importance. Converting to a dif- number of reasons (e.g., a history of numerous
ferent approach does require increased confi- previous surgery, inability to maintain pneumo-
dence in the newly adopted strategy, and this can peritoneum, limited access to the pelvic inlet, and
only be achieved with experience. Deciding to so on). All these patients may still benefit from
move from a transabdominal MIS approach to a better visualization and a better dissection of the
taTME approach requires more than a theoretical lower third of the mesorectum, while directly
knowledge of the potential benefit of this tech- visualizing the pelvic autonomic nerves, without
nique. Being proficient at dissecting the rectum “fighting with” and torqueing with significant
from the bottom up in complex cases is abso- force on St. Mark’s retractors.
lutely feasible, as showed by several studies [9], The benefits of the taTME technique are
but specific, advanced skills have to be previ- related to both the dissection and the ability to
ously established. execute a double purse-string, single-stapled
anastomosis. Even in the case that the dissection
is performed with an open approach, but issues
Proficiently Converting are encountered at the moment of the rectal wall
from Minimally Invasive Surgery transection or during the double-stapled anasto-
to Minimally Invasive Surgery mosis (i.e., breakdown of the cross section on the
for the First Time... And What About distal rectum/anal canal), a transanal approach
from Open to a Minimally Invasive could still be utilized. In these cases, performing
Approach? a purse string via the transanal platform (TAMIS
or TEM) as well as the proctotomy could be of
Converting from a robotic procedure to standard absolute value. At the same time, in case of dis-
laparoscopy has been previously described. ruption of the staple line along the anorectal cuff,
Nevertheless, this is rarely performed because being able to perform an anastomosis “taTME”-
abdominal laparoscopy can very infrequently style may help the surgeon overcome this hurdle.
overcome issues not solvable with the same trans- This is probably the first time we can discuss a
258 I. Montroni and A. Spinelli
very likely proficient, nontheoretical, non- particularly bulky uterus that cannot be profi-
fictitious conversion from open surgery to MIS ciently retracted. Extreme cases of disproportion-
for rectal surgery. ally large tumors of the middle/upper rectum in
which the mass is so wide that it impedes access
to the lower third of the mesorectum. In such cir-
Converting Laparoscopy/Robotic cumstances, the approach could be amenable for
to taTME Approach conversion to taTME. Exploiting the utility of a
transanal approach, in those cases, can provide
While discussing conversion from a laparo- clear benefits worth the added effort of
scopic/robotic to a transanal approach, it should conversion.
be kept in mind that performing a taTME should Because an intraoperative conversion is per-
be planned in advance (as a potential alternative) formed in particularly difficult cases, a two-team
since in rectal cancer surgery, there is very little approach might be advisable; and surgeons
room for improvisation. Prerequisite read of the should plan to have this resource available when
pelvic MRI together with an accurate physical conversion to taTME becomes necessary. The
examination of the patient are the key elements to help of a synchronous transanal and transabdom-
reduce to a minimum the risk of inappropriate inal approach, not just in the dissection, but also
surgical planning. Colorectal surgeons should in the specimen retraction and countertraction in
always remember that taTME is a complex oper- the phase of the rendezvous, can allow the most
ation, not just from a technical point of view, and difficult part of the case to become greatly sim-
that it may also require extra equipment (and sur- plified and to be carried out more precisely. This
gical staff preparedness) not routinely available could potentially improve patient short- and
or immediately available in the OR. For this rea- long-term outcomes. No literature is available in
son, a preemptive conversion should be promoted this regard, but it seems logical, in those chal-
over a reactive change of mind in order to reduce lenging cases, to benefit not only from a dynamic
the risks for the patients while giving the OR staff abdominopelvic approach but also to gather
the time to arrange the proper setup. together the experience of two trained colorectal
The reason for converting from abdominal surgeons, one for each team.
MIS TME to taTME is usually when identifying,
for the first time during the surgery, those condi-
tions that are considered the “classic” indications Converting from TAMIS to taTME
for a transanal approach, namely, difficult access
to the distal third of the rectum for the dissection, Over the last 5 years, local techniques to reduce
rectal wall cross-stapling, and/or the safe creation the impact of surgery while effectively treating
of a colo-anal anastomosis. Patients who are rou- rectal cancer have been exponentially growing.
tinely considered at higher risk for conversion Among those, transanal local excision techniques
(obese males with a narrow pelvis and bulky are currently playing a rising role in the arma-
rectal tumor) should rarely surprise the surgeon, mentarium of every colorectal surgeon. First
and evidence is present that a well-planned trans- developed by the precocious Gerhard Buess in
anal approach can reduce the risk of conversion 1983, transanal endoscopic microsurgery (TEM),
to a laparotomy while promoting a good onco- created for higher reach of principally benign
logical operation with extremely low circumfer- neoplasia, almost immediately showed superior-
ential and distal margin cancer involvement [11]. ity over the standard local excision for early-
On the other hand, unplanned anatomical situa- stage rectal cancer [12]. Despite clear advantages
tions can occur, perhaps in the case of the pres- [13], the technique disseminated slowly in the
ence of an unusually narrow female pelvis or a surgical community, because of the steep learn-
24 Intraoperative Decision-Making: Converting to taTME, When and for Whom? 259
ing curve, high upfront cost of the apparatus, and Douglas, during the dissection, which often
the small number of eligible cases. In recent results in loss of pneumatic distention of the rec-
years, a renewed interest for transanal endoscopic tum and which typically requires laparoscopic-
surgery, due to increased knowledge on the assisted sutured closure of the point of peritoneal
natural history of rectal cancer, increasing num- violation.
ber of patient candidates for an organ-sparing Other options include completing the resec-
approach, and development of easy-to-use plat- tion and closing the defect endoluminally, but in
forms which utilize transanal minimally invasive some instances it may be advisable to convert the
surgery (TAMIS) techniques. Among the possi- TAMIS local excision to a standard TME. In
ble indications for TAMIS, large tubulovillous order to complete the resection and stich the gap
adenomas of the rectum are probably the ones closed, the pneumorectum might be safely main-
with the greatest benefit from this approach. tained for a prolonged amount of time. This may
Those lesions would most likely necessitate pro- not be achievable if the dissection is just at the
longed and often piecemeal endoscopic muco- initial step or if the gap is too large, even after
sectomies, while a TAMIS full-thickness excision counterbalancing the abdominal pressure with a
can be achieved in a reasonable amount of time Veress needle or laparoscopic insufflation. If this
and in a single outpatient operation. TAMIS occurs, the surgeon becomes committed to a
allows both the possibility of precisely resecting TME, and conversion to a transanal approach
the neoplasia in one piece and, by establishing appears to be the most logical solution.
full-
thickness dissection, a potential cure Figures 24.1, 24.2, and 24.3 report a case of an
(depending on a number of parameters) in cases anteriorly located large rectal polyp (tubulovil-
where T1 invasive adenocarcinoma is diagnosed lous adenoma at two consecutive biopsy sets).
at final pathology. Because of the growing skill The tumor was considered to be located inside
set of colorectal surgeons, tumor location and the pelvis by two expert radiologists that
extension have been increasingly challenged. described it as below the peritoneal reflection for
While excision of circumferential neoplasia is no its entire extension. The lesion was instead
longer considered a contraindication for TAMIS, located a significant distance above the peritoneal
the distance from the anal verge still is, to some reflection, and the abdominal cavity was entered
degree. In particular, the more proximal the very soon after beginning the transanal dissection
lesion is (especially when positioned anteriorly), with immediate loss of the pneumorectum despite
the greater the challenge for full-thickness local the use of an advanced insufflation device.
excision. This is due to the higher risk of entering Among the advantages of converting to a taTME
the abdominal cavity, above the pouch of are:
Fig. 24.1 Preoperative MRI of a large neoplasia in the mid-rectum, radiological report displayed a T1 N0 rectal mass
260 I. Montroni and A. Spinelli
Fig. 24.2 Intraoperative pictures of the TAMIS procedures; abdominal cavity is entered anteriorly, and the local exci-
sion cannot proceed safely even after insertion of an abdominal trocar and induction of the pneumoperitoneum
Fig. 24.3 Intraoperative pictures of the conversion to taTME from the previously unsuccessful TAMIS attempt. Final
pathology showed a T3 N0 mid-rectum adenocarcinoma with no pathological high-risk features and negative CRM
be a rare event given the recently published 10% 6. Jayne D, Pigazzi A, Marshall H, Croft J, Corrigan N,
Copeland J, Quirke P, West N, Rautio T, Thomassen
conversion rate from reasonably high-quality N, Tilney H, Gudgeon M, Bianchi PP, Edlin R, Hulme
studies. This is the first time we have a reliable C, Brown J. Effect of robotic-assisted vs conventional
option to convert from MIS to MIS and also from laparoscopic surgery on risk of conversion to open
open to a MIS approach. laparotomy among patients undergoing resection for
rectal cancer: the ROLARR randomized clinical trial.
Conversion from TAMIS to taTME might JAMA. 2017;318(16):1569–80.
also become more frequent as the indications to 7. Yang C, Wexner SD, Safar B, Jobanputra S, Jin H, Li
perform TAMIS increase and surgeons are VK, Nogueras JJ, Weiss EG, Sands DR. Conversion
tempted to push the boundaries to treat anteri- in laparoscopic surgery: does intraoperative
complication influence outcome? Surg Endosc.
orly located tumors in the mid-rectum. In these 2009;23(11):2454–8. https://doi.org/10.1007/s00464-
cases, conversion to taTME offers an immediate 009-0414-6. Epub 2009 Mar 25.
and oncologically appropriate restorative 8. Wexner SD. Definitions of conversion—reactive vs
approach. preemptive. Presented at the 8th Annual International
Colorectal Disease Symposium, hosted by the
Cleveland Clinic Florida, Fort Lauderdale, FL in
February. 1997.
References 9. Penna M, Hompes R, Arnold S, Wynn G, Austin R,
Warusavitarne J, Moran B, Hanna GB, Mortensen
1. Cleary RK, Mullard AJ, Ferraro J, Regenbogen NJ, Tekkis PP, TaTME Registry Collaborative.
SE. The cost of conversion in robotic and laparoscopic Transanal Total Mesorectal excision: international
colorectal surgery. Surg Endosc. 2018;32(3):1515– registry results of the first 720 cases. Ann Surg. 2017
24. https://doi.org/10.1007/s00464-017-5839-8. Epub Jul;266(1):111–7.
2017 Sep 15. 10.
Cooper MA, Ibrahim A, Lyu H, Makary
2. de Neree Tot Babberich MPM, van Groningen JT, MA. Underreporting of robotic surgery complica-
Dekker E, Wiggers T, Wouters MWJM, Bemelman tions. J Healthc Qual. 2015;37(2):133–8. https://doi.
WA, Tanis PJ, Dutch Surgical Colorectal Audit. org/10.1111/jhq.12036.
Laparoscopic conversion in colorectal cancer surgery; 11. Penna M, Hompes R, Arnold S, Wynn G, Austin R,
is there any improvement over time at a population Warusavitarne J, Moran B, Hanna GB, Mortensen
level? Surg Endosc. 2018;32(7):3234–46. NJ, Tekkis PP, TaTME Registry Collaborative.
3. https://dictionary.cambridge.org/dictionary/english/ Transanal Total Mesorectal excision: international
conversion. Last time checked 6/3/18. registry results of the first 720 cases. Ann Surg.
4. Bhama AR, Charlton ME, Schmitt MB, Cromwell 2017;266(1):111–7.
JW, Byrn JC. Factors associated with conversion from 12. Buess G, Theiss R, Günther M, Hutterer F, Pichlmaier
laparoscopic to open colectomy using the National H. Endoscopic surgery in the rectum. Endoscopy.
Surgical Quality Improvement Program (NSQIP) 1985;17(1):31–5.
database. Colorect Dis. 2015;17:257–64. 13. Christoforidis D, Cho HM, Dixon MR, Mellgren
5. Bonjer HJ, Deijen CL, Abis GA, Cuesta MA, van der AF, Madoff RD, Finne CO. Transanal endoscopic
Pas MHGM, de Lange-de Klerk ESM, et al. A ran- microsurgery versus conventional transanal exci-
domized trial of laparoscopic versus open surgery for sion for patients with early rectal cancer. Ann Surg.
rectal cancer. N Engl J Med. 2015;372:1324–32. 2009;249(5):776–82.
Key Aspects of the Abdominal
Dissection 25
Masaaki Ito
this layer results in the preservation of the hypo- sacrum) from the promontory angle, it becomes
gastric nerves, the pelvic autonomic nerve plexus, easier to recognize the plane between the fascia
and the paired neurovascular bundles. The pre- and the mesorectum, which is identified as a
hypogastric nerve fascia reaches the anterior wall thick, yellow membrane (Fig. 25.3). If the meso-
of the rectum, where it transitions into the rectum is not identified with absolute accuracy,
Denonvilliers’ fascia. The endopelvic fascia, one cannot guarantee a proper TME dissection
which lies further exterior to the pre-hypogastric layer.
nerve, is present in the posterior wall of the rec- The basic concept of TME is to identify the
tum and covers the blood vessels running in the mesorectum during surgery and then to perform
anterior plane of the sacrum. The anatomical dissection along this fascia. For early-stage
understanding of these fascial layers becomes lesions, such as T1 and T2 rectal cancers, radical
critical during dissection around the rectum
(Fig. 25.1).
While performing the TME procedure from Upward traction by assistant
the abdominal side, the post-rectal space is
entered from the promontory angle to accurately
identify the mesorectum. In this area, there is a
potential space between the mesorectum and pre-
hypogastric nerve fascia, which makes it easy to
identify the mesorectum. As a technique for
expanding the visual field, the vicinity of the sig-
moid colon is grasped with two forceps and
retracted upward, away from the pelvis. By doing
so, the mesentery of the sigmoid colon is pulled
to the peritoneal surface of the anterior abdomi-
nal wall (Fig. 25.2). The mesentery is incised
upwardly, at approximately 1 cm from the root of
the sigmoid mesentery; it is then opened to the
left and right to enter the plane of the post-rectal Counter-traction by operator
space (Fig. 25.2b). By pulling the pre-hypogastric Fig. 25.2 Effective exposure entering the post-rectal
nerve fascia dorsally (at the S2/3 level of the space
Fig. 25.1 Fascias
around the rectum NVB
Seminal vesicle
Denonvillier’s fascia
Lateral ligament
Meso-rectum
Pelvic plexus Prehypogastric
Rectum
fascia
Endopelvic fascia
PSN
Hypogastrin nerve
Fig. 25.3 Identification
of mesorectum
Mesorectum
Prehypogastric nerve
fascia
Fig. 25.4 Identification
of Denonvilliers’ fascia Denonvilliers’ fascia covering
covering the rectum in the seminal vesicle
anterior side of the
rectum
Mesorectum
rately recognizable. When dissection occurs in layer in the posterior wall of the rectum: these are
the layer that includes the hypogastric nerve, the dissection layer of the abdominal side or that
neurovascular bundle (NVB), and pelvic plexus of the posterior side of the endopelvic fascia
in the vicinity of the resection site, caution must (Fig. 25.7). In taTME, due to the presence of
be taken to avoid injury to these structures as uri- recto-sacral ligament with fusion of several fas-
nary and sexual dysfunction may likely be cial layers in the vicinity of the S2–3 sacral verte-
induced postsurgically. brae, then isolation of this ligament is necessary.
However, on the lateral side of the rectum, an In this region, if the dissection proceeds in a
adequate plane between the hypogastric nerve direct line with no change toward the peak of the
and pelvic plexus is acquired by pulling the curve of the L-shaped sacrum, caution is required
mesorectum inward, and cutting that peak yields to avoid injury to the blood vessels located in the
nerve preservation (Fig. 25.6). If the TME proce- anterior surface of the sacrum. The direction of
dure is continued unmodified in the vicinity of the dissection shifts upward after the recto-sacral
the anal canal, which is the endpoint of the TME, ligament is resected; this results in dissection that
the intersphincteric space (ISR) is identified conforms to the shape of the sacrum. In contrast,
behind the NVB, and dissection of the ISR is ini- typical perirectal dissection from the abdomen
tiated (Fig. 25.7). involves the dissection layer between the meso-
If taTME is performed from the anal side, rectum and pre-hypogastric nerve fascia.
there are mainly two choices for the dissection However, as with taTME, resection of the recto-
sacral ligament in the region of the S2–3 verte-
brae is necessary.
Dissection point to preserve Figure 25.8 presents a case where the sur-
nerves
gery was performed from the perineal side,
with the dissection layer lies behind the endo-
Mesorectum pelvic fascia for T3 lesions of the posterior wall
of the rectum. Such difference of the dissection
planes from the abdomen to those from the
perineum is occasionally found in two-team
Pelvic plexus
taTME procedures.
1 2 3
RECTUM
NVB
Recto-sacral fascia
issues in abdominal procedures are (1) preserva- in the pelvic cavity needs to be maintained.
tion of adequate colonic blood flow and (2) mobi- Therefore, it is desirable that the dissection layers
lization of the colon that is long enough to avoid of the abdominal procedures and perineal proce-
tension in the anastomotic site. dures are not connected in the early phase of the
In case of high anastomotic sites following low surgery. In particular, the rendezvous point is
anterior resection (LAR), the branching site of the commonly the peritoneal reflection. Therefore,
left colic artery (LCA) can be easily preserved with during the abdominal dissection with two teams
a comparatively low level of ligation. However, if (top and bottom), it is preferable not to dissect
an anastomotic site is predicted to become a low- the peritoneal reflection located in the anterior
level anastomosis in the vicinity of the anal canal, it wall of the rectum until both teams are ready to
is essential for the abdominal dissection team to carry out the rendezvous. Similarly, during the
perform the mobilization of the splenic flexure, so dissection of the posterior wall of the rectum, it is
as to assure ample length, with care to preserve the better not to connect the dissection plane between
intrinsic vascular arcades to the colon and conduit. the abdominal space and the perineal space just
To accomplish this, three things must be per- close to the recto-sacral ligament. Once the
formed: (1) high division at the root area of IMA, abdominal and perineal sides are connected, the
(2) complete mobilization of the splenic flexure, abdominal air pressure on the perineal side and
and (3) division of the inferior mesenteric vein that on the peritoneal side must be the same; oth-
(IMV) at the inferior margin of the pancreas. By erwise the subsequent abdominal procedures will
completing these three procedures, an adequate be affected.
mobility of the colon can be obtained, and an anas- After all the dissections are completed, the
tomosis using the colon with good blood flow rectal cancer mass (en bloc with the rectum and
becomes possible. Other steps include mobiliza- mesorectal packet) is excised and extracted.
tion of the descending and sigmoid mesentery, Extraction can be done by two different routes –
division of the White Line of Toldt, and intracorpo- transabominal or transanal. Each route has its
real division of the marginal artery at the site own advantages and disadvantages. In patients
selected for proximal bowel division. The latter is whose tumor volume is relatively small, and the
particularly important to perform, especially prior mesentery is not overly bulky, extraction of the
to transanal extraction of the specimen, since the specimen via the anus is a reasonable option.
blood supply (especially the marginal artery) is However, when the tumor size is large or the
prone to shear during this process. mesentery bulky due to visceral obesity, there is a
In particular, the evaluation of blood flow dur- risk of injury to the mesenteric blood vessels and
ing surgery by indocyanine green (ICG) fluores- shearing of the mesentery itself. Hence, a trans-
cence imaging has recently become available. abdominal route is preferred in this setting.
Consequently, through real-time perfusion angi- Another advantage of the transabdominal route is
ography utilizing ICG intraoperatively, it is pos- that the surgeon can check whether the marginal
sible to mitigate the risk of using a colon with vessels are correctly preserved. In particular, for
inadequate blood flow – such as when due to the cases of ISR and in cases of low-level anastomo-
presence of Sudeck’s point which is an anasto- sis, the colon must be fully mobilized so that
motic site in the sigmoid colon susceptible to adequate colon length and good blood flow are
ischemic colitis. preserved.
aution for the Abdominal
C Summary
Dissection Team in the Dual-Team
taTME taTME is a surgery procedure that is performed
from the perineal side, which is the reverse of the
There are several points that the abdominal dis- conventional TME. This technique has demon-
section team of the two-team approach must be strated many advantages compared to conven-
cautious about. In taTME, abdominal air pressure tional TME, especially in the treatment of male
270 M. Ito
patients with a narrow pelvis and in patients with inferiority, randomised controlled trial. Lancet Oncol.
2014;15(7):767–74.
visceral obesity. In properly selected patients, it 3. Stevenson AR, Solomon MJ, Lumley JW, et al.
may be superior to TME in terms of resection Effect of laparoscopic-assisted resection vs open
quality and patient outcomes. resection on pathological outcomes in rectal can-
In this chapter, the salient points pertaining to cer: the ALaCaRT randomized clinical trial. JAMA.
2015;314(13):1356–63.
the abdominal dissection have been highlighted. 4. Fleshman J, Branda M, Sargent DJ, et al. Effect of
The abdominal portion of taTME is critical for laparoscopic-assisted resection vs open resection
assuring safe and proper conduct of the taTME of stage II or III rectal cancer on pathologic out-
operation. Coordination and dual-team orchestra- comes: the ACOSOG Z6051 randomized clinical
trial. JAMA. 2015;314(13):1346–55. Martin-Perez
tion is important, as is the anatomical under- B, Andrade-Ribeiro GD, Hunter L, Atallah S. A sys-
standing of the structure of the membranes tematic review of transanal minimally invasive sur-
surrounding the rectum is necessary. gery (TAMIS) from 2010 to 2013. Tech Coloproctol.
2014;18:775–88.
5. De Lacy AM, Rattner DW, Adelsdorfer C, Tasende
MM, Fernandez M, Delgado S, et al. Transanal natu-
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Group. A randomized trial of laparoscopic ver- Surg Endosc. 2013;27:3165–72.
sus open surgery for rectal cancer. N Engl J Med. 6. Atallah S, Martin-Perez B, Albert M, deBeche-Adams
2015;373(2):194. T, Nassif G, Hunter L, et al. Transanal minimally inva-
2. Jeong SY, Park JW, Nam BH, et al. Open versus lapa- sive surgery for total mesorectal excision (TAMIS-
roscopic surgery for mid-rectal or low-rectal cancer TME): results and experience with the first 20 patients
after neoadjuvant chemoradiotherapy (COREAN undergoing curative-intent rectal cancer surgery at a
trial): survival outcomes of an open-label, non- single institution. Tech Coloproctol. 2014;18:473–80.
Zen and the Art
of the Purse-String 26
Andrew R. L. Stevenson
Retraction can begin with eversion of the distal string whilst seated but raising the operating table
anal canal either with sutures or using proprietary for head-down tilt as required, to gain perfect
retractors such as Lone Star retractor (Cooper access.
Surgical, Incl). Various proctoscopes can then be
employed to demonstrate the lower edge of the
tumour. If the lesion is higher than the anorectal Purse-String Principles
junction, the operating platform anoscope can be
inserted to provide exposure. However, for Generally, the purse-string is placed 1 cm distal
tumours that are close to the anorectal junction or to the lower edge of the tumour, and the rectot-
into the upper anal canal, the purse-string would omy performed 1 cm distal to the purse-string;
need to be inserted using a proctoscope only, thus the rectotomy is created 2 cm distal to the
before insertion of the operating platform and inferior extent of the tumour. Depending on the
endoscopic equipment. Illumination is best pro- height of the tumour and its position in relation
vided by means of a surgeon’s headlight or self- to the anorectal junction, the distance below the
illuminating proctoscope. As the operating tumour at which the purse-string is placed may
theatre becomes crowded with all the equipment be slightly greater to or less than 2 cm. When
required for these complex operations, the use of the purse-string has been tightened and tied, the
a battery-powered headlight can be quite helpful, ideal appearance is a centrally placed knot with
if available. Long needle holder and forceps can a number of shallow radial folds extending out
facilitate access to the distal rectum via the towards the periphery from the central knot
proctoscope. (Fig. 26.1).
For tumours that are situated higher in the The perfect purse-string is achieved by assur-
rectum, it is more desirable to place the purse- ing equal needle placement and taking equal
string endoscopically using the chosen platform size radial bites, typically 8–12 bites depending
for taTME. Good-quality laparoscopic needle on the width of the rectum. It is important that
holders will be required for placement of the the sutures are placed evenly and not too far
purse-string. The preferred suture is an 0-Prolene apart, not too close together, but “just right”.
on a 26 mm, semi-half circle (SH) needle. This is The needle should enter the tissue just a few
less likely to break when tying the suture or dur- millimetres along from where the needle exits
ing the TME dissection, and the smaller-diame- the tissue of the previous bite. When the purse-
ter needle is both easier to use in a small space string is tightened and secured, this will invert
and also less likely to take too much tissue at the rectal wall evenly, providing a good plat-
once. form around which the rectotomy can be made.
If the operation is being performed as a syn- It is vital that the purse-string is centrally secure
chronous procedure with two teams, it is impor- to prevent the egress of bowel content or, or
tant for the perineal surgeon to have good access potentially, exfoliated malignant cells to enter
and appropriate ergonomics to be able to perform the operative field. Whether the purse-string is
the perfect purse-string. It is important for the performed “open” via proctoscope or endoscop-
abdominal surgeon to also appreciate the impor- ically via the chosen platform, it is advisable to
tance of this step of the operation and allow the have minimal amount of the suture within the
position or height of the patient to be adjusted to rectum. This will help to prevent looping and
suit the perineal surgeon. Although I prefer to excess suture affecting visibility or forming
perform the taTME dissection in a standing posi- inadvertent knots.
tion (with elbows slightly extended and assistant There are no hard and fast rules about the best
camera holder standing or sitting comfortably position to start the purse-string (I typically start
next to me), I will usually perform the purse- at the three o’clock position), but it is often useful
26 Zen and the Art of the Purse-String 273
Common Pitfalls
the distal rectum once the dissection has released The Distal Purse-String
the tension on the tissue with dissection in the
intersphincteric plane. For the majority of patients undergoing a restor-
When the purse-string is higher than the sweet ative procedure, a circular-stapled anastomosis
spot, it may become difficult to reach by sur- will be utilized. Unlike the double-stapled tech-
geon’s hand to secure the knot. In this case, it will nique, which closes the distal rectum, by defini-
become necessary to tighten and secure the tion the taTME technique will have an open distal
purse-string and tie it endoscopically. This can be rectal stump. This will then require placement of
quite challenging, especially for surgeons not a further purse-string which is secured to the cen-
familiar with intracorporeal knot tying. An endo- tral spike of the circular stapler. Although this
scopic knot pusher can be employed. will be also addressed in the chapter on anasto-
Alternatively, the formation of preformed loop motic technique, it is again another time where
can facilitate the tightening of the purse-string. the perineal surgeon needs to pay close attention
This can be readily made with the loop 12–15 cms to the formation of the purse-string. This is more
from the needle. The “tail” should only be 3 cm commonly achieved using a handheld procto-
long to make it easier for the surgeon to finish off scope under direct vision, but occasionally this
the tie. needs to be performed endoscopically if the rec-
Once tied, the ends of the purse-string suture totomy has been at a higher level. An 0-Prolene
are often used for retraction during the initial rec- or equivalent heavy-gauge monofilament suture
totomy and dissection. The utility of holding the is also used for the distal purse-string, again start-
tied purse-string ends can be improved by placing ing at the 3 o’clock position. The suture is placed
multiple knots (15–20). This then creates a “han- from the lumen through the rectal wall and con-
dle” for the surgeon to manipulate and improve tinued in an over and over fashion. It may be use-
tissue tension and retraction when performing the ful to use a “boomerang” suture technique going
next step of the operation, the rectotomy. from outside the rectal wall into the lumen. A
The rectotomy should proceed once the sur- “boomerang” suture is where the needle is held
geon is confident that the lumen of the rectum has by the needle holder oriented back towards the
been completely occluded by the creation and surgeon’s hand. This will ensure a full-thickness
tying of the perfect purse-string. This can be bite of tissue and subsequent complete doughnut
tested by using a grasper or suction device, prob- upon completion of the stapled anastomosis.
ing centrally once the pneumorectum has been Focus, or flow, is again needed when tying this
initiated. If the purse-string is tight and complete distal purse-string around the central spike of the
without the formation of a “rose petal”, the sur- circular stapler. Of course, the third time a purse-
geon may then lavage the rectum with a cytocidal string is required in this operation is for the prox-
solution and proceed with the rectotomy and dis- imal colonic conduit for placement of the stapler
section with confidence. If at any stage the purse- anvil.
string should fail during the dissection, either Every step of the operation is equally impor-
through technical failure, inadvertent cutting of tant. Each subsequent step can only proceed
suture or excessive pressure on the specimen, the depending on the success of the preceding step.
surgeon needs to have appropriate skills to rescue The formation of a perfect purse-string in the
the situation. This again may involve placement operation of taTME lays the foundation for a
of further purse-string or figure eight suture good-quality TME and helps assure a negative
endoscopically. Other possible solutions include distal resection margin. It is important for the sur-
using an ENDOLOOP® Ligature (Ethicon, geon to appreciate the importance of the purse-
Somerville, NJ, USA) around the distal divided string and to give all attention – breathe, relax,
rectum followed by copious lavage or bringing have that special Zen moment and slow down – to
the specimen down to the anal canal and suturing be sure to achieve your goal of achieving the per-
under direct vision. fect purse-string.
An Overview of Operative Steps
and Surgical Technique 27
F. Borja de Lacy, María Clara Arroyave,
and Antonio M. Lacy
Positioning the Patient
Once there is enough tissue to close the lumen, should be performed in a standardized laparo-
the purse-string suture is placed to prevent spill- scopic fashion. Once in the perineal phase, the
age of liquid stool and cancer cells. It is possible anus is closed with a purse-string monofilament
to insert the endoscopic platform afterwards, and suture, and the threads might serve as traction. A
the transanal dissection with laparoscopic instru- circular perianal skin incision is made, approxi-
ments can be continued as explained above. mately 2 cm from the closed anus. The incision is
performed along the loose areolar tissue and the
anobulbar or anovulvar raphe. Posteriorly, the
Abdominoperineal Excision incision extends to distal extent of the coccyx.
Laterally, it is dividing the fat from both ischio-
This topic is discussed more completely in a ded- rectal fossae. With taTME for APR, the dissec-
icated chapter. Here, a brief description is pro- tion should start posteriorly to find the presacral
vided. In cases of tumours invading the external plane. Once located, our preference is to utilize
sphincter or when there is a poor bowel function the TAMIS technique with the GelPOINT Mini
expectation after surgery, an abdominoperineal Advanced Access Platform (Applied Medical,
excision is required. The abdominal approach Rancho Santa Margarita, CA, USA). Three can-
nulas should be placed in an inverted triangle
position, and transanal dissection should be con-
tinued as described above (Fig. 27.9).
be found 5 cm below the level of the tumour [7]. Specimen Extraction
This is the reason why, when a partial mesorectal
excision (PME) is intended, the transection of There exist two ways to extract the specimen:
the mesorectum should be at least 5 cm below transanally or transabdominally. The latter has the
the distal edge of the tumour. After occluding the advantage of maintaining the integrity of the
rectal lumen with the purse string, both the rec- abdominal wall and reducing the risk of surgical
tum and mesorectum are transected perpendicu- site infections and incisional hernias while
larly until reaching the proper TME plane. There improving postoperative pain and cosmesis. The
is an increased risk of bleeding while dissecting size of the tumour, the mesorectum, the length of
inside the mesorectum, which can be limited the colon and the width of the pelvis are condi-
using sealing devices, although this could lead to tions that must be considered before a transanal
increased procedure costs. Partial mesorectal extraction is performed (Fig. 27.10). To avoid
excision with the taTME technique is very chal- excessive vascular tension during the specimen
lenging and is only recommended for experi- retrieval, splenic flexure mobilization is recom-
enced surgeons. mended. In case of a circular, endoluminal stapled
(double purse string) anastomosis, the purse string
on the opened distal rectal cuff should be per-
Critical Anatomic Landmarks formed before transanal extraction to prevent any
mucosal retraction that may make this step more
Through the transanal approach, the pelvic anat- difficult post-extraction. For a hand-sewn colo-
omy is novel even for very experienced colorectal anal anastomosis, the transanal extraction must be
surgeons. TaTME carries potential pitfalls, which performed after placing the four cardinal stitches.
could lead to a more difficult dissection or to Transabdominal specimen extraction is a bet-
intra- or postoperative complications. Therefore, ter option than transanal extraction when facing
early recognition of errors is crucial, to be able to large tumours and bulky mesenteric envelopes –
return to the correct plane [8–10].
Anteriorly, the prostate and seminal vesicles
in males can be injured [10]. In females, the
vagina can be opened, although this complica-
tion can be safely repaired intraoperatively. The
most feared complication is urethral injury, typi-
cally when an excessive lateral dissection is
made, followed by prostate mobilization and
putting the urethra at risk during the initial ante-
rior dissection [10, 11]. If in doubt, the endo-
scopic platform should be removed, and the
surgeon should palpate the prostate and urinary
catheter.
Posteriorly, dissection must respect Waldeyer’s
fascia, avoiding the presacral venous plexus
(Fig. 27.12) and minimizing the confusion about
correct versus incorrect plane of dissection when
coming along lateral and anterior sides. Moreover,
when dissecting laterally, neurovascular bundles
must be respected, to decrease the risk of impaired
bowel, urinary and sexual function. Fig. 27.10 Transanal specimen extraction
27 An Overview of Operative Steps and Surgical Technique 283
especially in the setting of android narrow pel- tomoses, the open rectal cuff can be handsewn
vises, where both the specimen and the sphincter (Figs. 27.11 and 27.12). Anastomotic techniques
complex are at risk of damage. A Pfannenstiel are discussed in more detail in a separate
incision can be carried out in most cases, with the chapter.
incision length tailored to the specimen size. The
wound should be protected to prevent wound
infections and cancer cell implantation.
Regardless of which modality is selected for
specimen extraction, an intracorporeal division
of the proximal mesocolon and colon is compul-
sory so as not to shear the marginal artery during
extraction.
Anastomosis
With the advent of modern instrumentation, ating the need for a permanent stoma for many
such as endoluminal surgical staplers developed patients. Increasingly, a rethink of the 5 cm mini-
by Mark Mitchell Ravitch in 1972 [6–8], and mum distal margin requirement shifted the new
with important, new approaches to restorative “safe margin” to just 2 cm [30]. This was partly
proctocolectomy introduced by Sir Alan Parks at based on the earlier work of Golligher and subse-
St. Mark’s Hospital (London, UK) in the late quently others investigators who demonstrated
1970s [9], the concept of total removal of the tumor spread to be rarely distal to the tumor’s
ultralow rectum with maintenance of a func- caudal extent [31–33]. Meanwhile, increasing
tional sphincter mechanism became quite achiev- data suggested that any grossly negative margin
able. While at the time such radical techniques was acceptable [34] and a renewed focus on
were only applied toward removing the at-risk assuring circumferential margin clearance in
rectum and colon for benign pathology (espe- conjunction with resection quality (i.e., TME
cially ulcerative colitis) and, subsequently, for grade) was paramount to all else [35, 36].
premalignant conditions such as familial adeno- In 2005, Rullier et al. (Bordeaux, France)
matous polyposis syndrome [10, 11], the chal- reported the results of 92 patients with invasive
lenge of removal of the rectum for low rectal carcinoma localized to the distal rectum (≤4.5 cm
cancer remained – since cure was difficult and from the anal verge) who underwent curative
local failure rates were quite high. Thus, for this radical resection with ISR [37]. With an 89% R0
subset of tumors, surgical treatment was histori- resection rate, 2% local recurrence rate, and a
cally radical, with complete removal of the ano- 5-year overall survival rate of 81%, it was con-
rectum by APR. cluded that the technique of ISR permits curative
During the 1980s, RJ Heald introduced sur- intent radical resection and sphincter preserva-
geons to the importance of proper embryonic- tion without oncologic compromise, and there-
based resection [12, 13]. Meanwhile, neoadjuvant fore rectal tumor distance from the anal verge
therapy for local control together with the unique should “no longer [be] a limit for sphincter-
perineal techniques proposed by G. Marks was saving resection.” This put an official end to the
combined to, for the first time, provide patients 2 cm rule, without oncologic compromise, thus
with a curative-intent resection for ultralow- creating a new and important axiom in rectal can-
lying, advanced-stage rectal cancer [14–16]. This cer surgery. Namely, candidacy for sphincter
technique is commonly referred to as the “TATA” preservation for patients with ultralow-lying rec-
(transanal abdominal transanal) operation and is tal cancer depends not on the tumor’s distal
a well-known, important prequel to the modern- extent but rather the lateral extent (specifically,
day taTME operation – as it is essentially the first the presence or absence of external sphincter
description of a “down-to-up,” sphincter- invasion).
preserving technique for curative, rectal cancer
surgery. Interestingly, TATA predated TAMIS
[17] and the first report of taTME in a human [18] A Standardized Classification
and the melding of TAMIS and taTME [19–23] System for Low Rectal Cancers
by almost a quarter century.
It was during the 1990s and early to mid- The relationship of low-lying rectal tumors with
2000s that the true maximal distal limits of radi- respect to the anal sphincter complex can be
cal rectal resection and reconstruction were defined in a standardized fashion and is based
finally achieved with acceptable oncologic out- upon the Rullier Classification System for distal
comes [24–29]. By recognizing that a part or all rectal cancer [38] (Fig. 28.1). There are essen-
of the internal sphincter muscle could be sacri- tially four types of ultra-distal rectal cancer
ficed (especially with tumor downstaging), inter- which can be defined in relation to the anorectal
sphincteric resection (ISR) for extremely ring and levator plate muscles. The four types are
low-lying lesions became a feasible option, obvi- as follows:
28 Strategies for Ultralow-Lying Rectal Cancer 287
AR
DL
AV
Type I: Supra-anal, >1 cm from the anorectal ring modifications are possible with TEM but are not
Type II: Juxta-anal, <1 cm from the anorectal addressed. The special application of taTME for
ring APR (such as for extirpation of Rullier Type IV
Type III: Intra-anal, with internal anal sphincter tumors) is addressed in detail elsewhere.
(IAS) invasion or encroachment
Type IV: Trans-anal, with invasion of tumor into
the levator ani muscle or the external anal tandard Educational Programs
S
sphincter (EAS) for taTME
The suggested surgical options for these The introduction of taTME into surgical prac-
tumors are as follows: tice has required specific training programs to
be implemented so as to assure the safe delivery
Type I: (Ultralow) anterior resection of this new kind of surgery [39–46]. Even online
Type II: Partial ISR learning modules and web-based, deffered live
Type III: Total ISR (d-LIVE) surgery are available for taTME edu-
Type IV: Abdominoperineal resection (APR) cation [47–49]. While most courses provide
comprehensive education and practical instruc-
While taTME has been applied to Types I–IV, tion on this novel approach through cadaveric
in this chapter, we examine the technical nuances training session(s), such training primarily
of taTME for Type I, II, and III rectal cancers focuses on taTME as applied to distal rectal
providing a practical approach to the manage- cancer, but not necessarily for extreme distal
ment of these special problems in rectal cancer lesions (Rullier Types I–III). Ironically, it is this
surgery. The technique described herein is with group of ultralow rectal cancers which are best
the utilization of the TAMIS platform; similar suited for the taTME approach, and descriptions
288 S. Atallah and E. Rullier
of this technique are rarely reported in the litera- aroscopic needle drivers and instruments are then
ture [50, 51]. Here, the technical steps necessary used to conduct every step, including securing
to approach Type I–III rectal cancers are the purse string. Knot-tying can be accomplished
delineated. via a knot pusher with handmade extracorporeal
knot creation; however, the entire process of
knot-tying is commonly done by hand using con-
General Technical Principles ventional hand-tying techniques. For these two
common options, the use of a self-retaining ano-
The general approach to taTME for Type I–III rectal retractor (most typically, the Lone Star
rectal cancer (Fig. 28.2) should follow a stan- Retractor System, Cooper Surgical, Inc.) is
dardized protocol. While some authors have optional.
advocated a perineal-first approach [52, 53], it is As a footnote, it should be realized that the
prudent to perform an abdominopelvic oncologic general technique of TAMIS and the design of
survey, such as through diagnostic laparoscopy, the GelPOINT access channel and apparatus
as a first step prior to any radical oncologic sur- were created with the objective of local excision
gery [54]. of higher neoplasia, not low-lying lesions which
For mid-rectal cancers and the majority of low are approachable with the Parks technique [55].
rectal cancers (excluding ultralow-lying Type I– This “higher reach” was precisely the impetus
III tumors), the taTME approach utilizing TAMIS behind the 1984 development of the TEM scope
and specifically the GelPOINT path transanal by G. Buess as well [56, 57]. Furthermore, the
access platform (Applied Medical, Inc., Rancho development of TEM, TEO, and TAMIS all pre-
Santa Margarita, CA, USA) requires the place- dated the evolution of taTME, and, thus, no
ment of the TAMIS access channel with one of transanal access platform has yet been designed
two options utilized. Option 1: The access chan- specifically for the purpose of taTME.
nel is seated in position with its inner lip secured In the following sections, the detailed
just above the anorectal ring. Next, the rectum is approach to taTME for resection of more com-
sutured closed using a handheld, conventional plex, ultralow-lying rectal cancer is discussed.
needle driver, and then the gel cap is secured to taTME for Type I tumors will be discussed sepa-
the access channel. After establishing pneumatic rately from the approach to Type II/III rectal can-
insufflation, the dissection is carried out using cer, as there are important differences.
standard taTME techniques. Option 2: The access
channel is seated in position, and the gel cap is
placed, pneumatic inflow is established, and lap- taTME for Rullier Type I Tumors
a a
Fig. 28.8 (a) With the aid of a Lone Star Retractor and
manual retractors, sharp dissection along the ISR plane is
performed with Metzenbaum scissors or (b) electrocau-
tery; meticulous dissection is crucial
Functional Outcomes
radiation-induced fibrosis, age, gender, local sep-
In the 1950s, J. Goligher and E. Hughes rightly sis, and other factors.
concluded that anorectal function after recon- Despite these challenges, the outcomes after
structive, sphincter-preserving surgery is directly ISR for rectal cancer have been quite acceptable.
related to rectal cuff length [60]. That is, the lon- In a series of n = 101 patients who had undergone
ger the rectal cuff (e.g., distance from the anorec- ISR, although two-thirds reported having <3
tum to the anastomotic line), the more likely bowel movements per day, about half reported
defecatory function will be preserved. Therefore, having defecatory urgency, while one-quarter
even when perfectly executed, taTME for reported difficulty evacuating [61]. Although
ultralow tumors (Types I–III) with reconstruction general data on taTME is now available through
will invariably result in functional compromise. single-center series and registry data [62, 63], the
These effects can be further compounded by functional outcomes specifically for the subset of
patients who have undergone ISR in conjunction
292 S. Atallah and E. Rullier
include the creation of advanced courses for 4. Maunsell HW. A new method of excising the two
upper portion of the rectum and the lower seg-
those who already have clinical taTME experi- ment of the sigmoid flexure of the colon. Lancet.
ence who wish to augment their skill set – with 1892;2:473–6.
the objective of expanding fundamental knowl- 5. Prete F, Prete FP. The pull-through: back to the future.
edge to address ultralow-lying cancers. Specific G Chir. 2013;34(11–12):293–301.
6. Ravitch MM, Steichen FM. Technics of staple
training modules should focus on an understand- suturing in the gastrointestinal tract. Ann Surg.
ing of the ultralow pelvic anatomy, particularly in 1972;175:815–37.
males, and the ability to define the prostatic anat- 7. Fain SN, Patin CS, Morgenstern L. Use of a mechani-
omy is paramount when performing ultralow cal suturing apparatus in low colorectal anastomosis.
Arch Surg. 1975;110:1079–82.
taTME [39, 58, 80]. 8. Lirici MM, Hüscher CG. Techniques and technology
New protocols including the selective use of evolution of rectal cancer surgery: a history of more
radiotherapy [81] which may include systemic than a hundred years. Minim Invasive Ther Allied
chemotherapy as an alternative for (some) locally Technol. 2016;25(5):226–33. https://doi.org/10.1080
/13645706.2016.1198381. Epub 2016 Jul 14.
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therapy (TNT) [84–87] may improve oncologic out ileostomy for ulcerative colitis. Br Med J.
clearance. Moreover, this may obviate the need 1978;2(6130):85–8.
for surgical resection altogether by achieving 10. Madden MV, Neale KF, Nicholls RJ, Landgrebe JC,
Chapman PD, Bussey HJ, Thomson JP. Comparison
mural sterilization–which, at some expert cen- of morbidity and function after colectomy with
ters, is managed with watch and wait protocols ileorectal anastomosis or restorative proctocolec-
and observation alone [88–91]. tomy for familial adenomatous polyposis. Br J Surg.
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11. Nyam DC, Brillant PT, Dozois RR, Kelly KA,
understanding the oncologic outcomes for Type Pemberton JH, Wolff BG. Ileal pouch-anal canal
I, II, and III tumors with taTME (via the anastomosis for familial adenomatous polyposis:
approaches described herein) should be carefully early and late results. Ann Surg. 1997;226(4):514.
assessed. As a cautionary note, taTME does not 12. Heald RJ, Ryall RD. Recurrence and survival after
total mesorectal excision for rectal cancer. Lancet.
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To date, in the largest single-center series on 13. Heald RJ, Moran BJ, Ryall RD, Sexton R, MacFarlane
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Given that this data is from the leading center of 14. Marks G, Mohiuddin M, Masoni L, Montori A. High-
expertise on taTME, great care and careful under- dose preoperative radiation therapy as the key to
standing of the technical steps are necessary. This extending sphincter-preservation surgery for can-
underscores the importance of careful assessment cer of the distal rectum. Surg Oncol Clin N Am.
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28 Strategies for Ultralow-Lying Rectal Cancer 297
Stephen W. Bell
muscle coat of the rectum is in continuity with the little or no mesorectum at this level. The serosa of
internal anal sphincter. The external anal sphinc- the bowel is white and is seen “centrally” in the
ter is in continuity with puborectalis and the pel- dissection. The endopelvic fascia is a fibrous
vic floor muscles. The longitudinal muscle of the structure overlying the skeletal muscle of the pel-
rectum continues rostrally in the intersphincteric vic floor. If the dissection is under the endopelvic
plane, thinning significantly and fanning out in fascia, pink skeletal muscle is visible, and it con-
the lower anal canal to be relatively unrecogniz- tracts when in contact with diathermy.
able. When the rectotomy is positioned above the
anorectal junction, the dissection usually falls
straight on to the cranial side of the endopelvic uminal Anatomy of the Rectum
L
fascia (posteriorly) in the correct plane for further in Relation to the Purse String
dissection. When the dissection starts as a partial
intersphincteric dissection in the mid-to-upper The art of the purse string has been addressed in
anal canal, this can often lead to dissection over detail in Chap. 26. As such this will not be dealt
puborectalis but rostral to the endopelvic fascia. with in great detail here. It is important, however,
In the common situation of the rectotomy being at to note that correct positioning of the purse string
the anorectal junction, it remains important to will lead to a symmetrical indrawing of the rectal
identify the endopelvic fascia and stay on the cra- wall, with the center of the purse string being
nial side of it but not to dissect in the subserosal centrally placed in the lumen of the bowel. This
plane (see Fig. 29.1). There is often very little tis- also distorts the anatomy of the rectal wall and
sue between these two planes as there is usually the angle at which one must dissect to pass
through the wall perpendicularly. It is necessary
to angle outward from the lumen but not at 90
degrees to the lumen. The angle is a little more
subtle than this, and depending on the exact posi-
tion of the rectotomy and the laxity of the bowel
wall, this could be as much as 45 degrees (see
Fig. 29.2).
the extrafascial plane of the mesorectum. It is pletely divided circumferentially, the rectal wall
common to divide each of these layers circumfer- is more mobile and often moves cranially under
entially before proceeding on to the next layer. the force of the pneumopelvis. If this “release”
As such, one would initially mark out with dia- has not been observed, then it may well be that
thermy the planned incision on the mucosa and the muscle layer has not been completely divided
then divide the mucosa/submucosa and finally circumferentially.
divide the muscle layers. The longitudinal fibers
of the muscle layer are relatively easily visible as
white fibers and can commonly be easily distin- he Extrafascial, Subserosal,
T
guished from the underlying fibro-fatty tissue and Sub-Endopelvic Fascia Planes
(see Fig. 29.3). Once the muscle layer is com-
Identification of the extrafascial plane of the
mesorectum (the “Holy Plane” as described by
Bill Heald when dissecting from the abdomen
into the pelvis) is one of the main key anatomical
landmarks of the taTME operation. When dis-
secting from the abdomen into the pelvis, there is
a broad mesorectum separating the extrafascial
plane from the subserosal plane. As described
above, the point at which one performs the rec-
totomy will determine where the extrafascial
plane will be encountered when operating transa-
nally. The mesorectum at this point is usually
either very thin or nonexistent (see Fig. 29.4). As
such there is very little tissue between the subse-
Fig. 29.3 Operative photograph during rectotomy (with rosal plane, the true extrafascial plane, and the
and without annotation). The cut edge of mucosa is seen plane under the endopelvic fascia. The rectotomy
on the left of the image. The extrafascial plane is seen in is most commonly 1–2 cm distal to the lower
the left lower quadrant of the image, and the undivided
margin of the tumor. As such any dissection in
longitudinal muscle fibers are seen in the left upper quad-
rant of the image. These muscle fibers are seen in live tis- the subserosal plane brings one closer to the
sue as whiter than surrounding tissue tumor and therefore a threatened positive mar-
tension from the retraction, and the tissue being oo Deep Posteriorly: Presacral
T
lifted broadens out from this point. Figure 29.8 Veins and the Sacrum
demonstrates this triangle appearance, and in this
example the underlying fascial plane has been Immediately posterior to the deep layer of the fas-
lifted because the dissection has been at the base cia propria is a loose areolar plane with little adi-
of the triangle. The dissection should be at the pose tissue that opens very easily. Posteriorly the
apex of the triangle, allowing the tented tissues to contents of this space are the presacral veins. This
fall away, as opposed to dissection in the deeper is a venous plexus that results from anastomoses
plane as seen in Fig. 29.9. between the lateral and median sacral veins.
These drain into the internal and common iliac
veins and also communicate to the deeper veins
within the sacrum via the sacral foramina. Injury
to these veins can lead to profuse and potentially
catastrophic bleeding as they are large veins. If
the injury involves the region of the sacral foram-
ina, the vein can retract into the foramen making
hemostasis more difficult. As the posterior taTME
dissection extends proximally, it is imperative that
the surgeon anticipates the sacral curvature, exe-
cuting an upward turn before colliding with the
sacrum as it becomes in-line with the plane of dis-
section. Alternatively, this portion of the dissec-
tion (the proximal TME dissection) can be
performed by the abdominal surgeon who likely
Fig. 29.8 Retracting the rectum/mesorectum tents up the has a better vantage point, in most instances.
attached underlying tissues producing a triangle appear-
ance. Dissection should be guided to the apex of the tri-
angle not the base
oo Deep Laterally: Major Vessels,
T
the Ureter, and the “Pelvic Tonsils”
Suggested Reading
Atallah S, Albert M, Monson JR. Critical concepts and
important anatomic landmarks encountered during
transanal total mesorectal excision (taTME): toward
the mastery of a new operation for rectal cancer sur-
gery. Tech Coloproctol. 2016;20(7):483–94. https://
doi.org/10.1007/s10151-016-1475-x. Epub 2016 May
17.
Atallah S, Mabardy A, Volpato AP, Chin T, Sneider J,
Conclusion Monson JRT. Surgery beyond the visible light spec-
trum: theoretical and applied methods for localization
The critical anatomical landmarks encountered of the male urethra during transanal total mesorec-
tal excision. Tech Coloproctol. 2017;21(6):413–24.
when performing taTME have been described. It is https://doi.org/10.1007/s10151-017-1641-9. Epub
important to recognize the variability between 2017 Jun 6.
patients and also pathologies. The effect of radio- Bernardi MP, Bloemendaal AL, Albert M, Whiteford M,
therapy and previous pelvic surgery can either alter Stevenson AR, Hompes R. Transanal total mesorectal
excision: dissection tips using ‘O’s and ‘triangles’.
the anatomy or make the appearance of the anat- Tech Coloproctol. 2016;20(11):775–8. Epub 2016
omy slightly different. Finding the correct plane Oct 1.
and maintaining dissection in the correct plane are Knol J, Chadi SA. Transanal total mesorectal excision:
the cornerstones to performing taTME. Adherence technical aspects of approaching the mesorectal plane
from below. Minim Invasive Ther Allied Technol.
to the principles described in this chapter and this 2016;25(5):257–70. https://doi.org/10.1080/1364570
textbook will help the surgeon maintain a safe dis- 6.2016.1206572.
Urethral Injury: The New
Challenge for taTME 30
Heather Carmichael and Patricia Sylla
alone [1]. This may partially explain the high rate reports a total of 34 urethral injuries that have
of injury noted by Rouanet et al. in their series of occurred during taTME; only 18 of these had
male patients only. The rate of urethral injury in been reported to an international registry and
all patients and in male patients only for large only 5 were included in published series, indicat-
case series (≥ 20 patients) are reported in ing that underreporting of this complication is a
Table 30.1. serious concern (Sylla et al., manuscript submit-
The true incidence of urethral injury may be ted for publication) [15].
underreported in these large case series. Indeed, Furthermore, rates of injury may increase
as many as 18 urethral injuries have been reported with uptake of taTME unless surgeons are spe-
to international registries, according to experts in cifically trained about the risk of male urethral
the field, but only a handful have been docu- injury and how to avoid it. Rates of inadvertent
mented in the surgical literature (Table 30.2) mobilization of the prostate (wrong-plane sur-
[13]. Anonymous feedback from n = 38 surgeons gery) are high in reports on cadaveric trainees,
who had undergone a formal cadaver-based despite the fact that most trainees have extensive
taTME training in North America demonstrated rectal cancer experience. In one study, nearly
that 20% of survey participants had experienced 20% of cadaveric trainees unintentionally mobi-
at least one urethral injury in their experience lized the prostate, and 2 out of 103 trainees acci-
since course completion [14]. A recent interna- dentally completed a pelvic exenteration during
tional survey of urethral injury during taTME taTME training [14]. However, there is evidence
Table 30.1 Large series of taTME with rates of urethral injury when complications were noted
Author Year Country N % male N urethral injury % total injured % male injured
de Lacy [33] 2013 Spaina 20 55.0 0 0.0 0.0
Rouanet [5] 2013 France 30 100.0 2 6.7 6.7
Velthuis [34] 2014 Netherlandsb 25 72.0 N/A
Atallah [35] 2014 USAc 20 70.0 0 0.0 0.0
Fernandez-Hevia [36] 2015 Spaina 37 64.9 0 0.0 0.0
Veltcamp Helbach [7] 2015 Netherlandsb 80 60.0 0 0.0 0.0
Tuech [37] 2015 Franced 56 73.2 0 0.0 0.0
Muratore [38] 2015 Italy 26 61.5 0 0.0 0.0
de Lacy [6] 2015 Spaina 140 63.6 0 0.0 0.0
Perdawood [39] 2015 Denmarke 25 76.0 0 0.0 0.0
Buchs [40] 2015 UKf 20 70.0 0 0.0 0.0
Chen [8] 2015 Taiwan 50 76.0 0 0.0 0.0
de’Angelis [41] 2015 France 32 65.6 0 0.0 0.0
Rink [42] 2015 Germany 24 75.0 0 0.0 0.0
Serra-Aracil [43] 2016 Spain 32 75.0 N/A
Burke [9] 2016 USAc 50 60.0 1 2.0 3.3
Rasulov [44] 2016 Russia 22 50.0 0 0.0 0.0
Buchs [45] 2016 UKf 40 80.0 0 0.0 0.0
Kang [10] 2016 China 20 60.0 1 5.0 8.3
Lelong [46] 2016 Franced 34 67.6 N/A
Perdawood [11] 2017 Denmarke 100 72.0 1 1.0 1.4
Maykel [17] 2017 USA 40 60.0 0 0.0 0.0
Marks [47] 2017 USA 373 68.9 0 0.0 0.0
Caycedo-Marulanda 2017 Canada 27 51.9 0 0.0 0.0
[48]
de Lacy [49] 2017 Spaina 186 63.4 N/A
Penna [12] (registry) 2016 N/A 720 67.9 5 0.7 1.0
Indicate prospective cohorts with likely patient overlap
a–f
30 Urethral Injury: The New Challenge for taTME 313
Table 30.2 Descriptions of urethral injury during taTME reported in the surgical literature
Timing relative
Tumor and patient Management and to surgeon
Series characteristics Type and timing of injury morbidity experience
1 Rouanet Bulky anterior rectal Unspecified Noted intraoperatively, Beginning of
[5] tumor suture repair with experience
TEO, no long-term
morbidity
2 Rouanet Concurrent T4 prostatic Unspecified Noted intraoperatively, Unspecified
[5] carcinoma suture repair with
TEO, no long-term
morbidity
3 Burke [9] Low, anterior rectal tumor Injury to posterior wall Noted intraoperatively, Middle of
(<3 cm from anal verge) of preprostatic urethra managed experience
that occurred during nonoperatively, no
mobilization of rectum long-term morbidity
from prostate
4 Kang [10] Large, circumferential Prostatic and urethral Conversion to Beginning of
tumor 5 cm from anal injury accompanied by laparoscopic assistance experience
verge in a patient with massive hemorrhage
benign prostatic after dissection too far
hypertrophy anteriorly
5 Perdawood Advanced low rectal Unspecified Managed Unspecified
[11] cancer, treated with nonoperatively, no
neoadjuvant long-term morbidity
chemoradiation
bulky T4 anterior rectal tumors. Finally, the sur- extensively in the urologic literature on radical
geon should be able to recognize the cylindrical perineal prostatectomy [20, 21]. During taTME
shape of the prostatic urethra in case the wrong for low rectal tumors (within 5–6 cm of the anal
plane of dissection is entered [13, 16]. verge), the RUM must be divided in order to
Another important anatomic landmark is the access the plane between the anterior rectum and
rectourethral muscle (RUM), and understanding posterior surface of the prostate. The RUM must
the relationship between this muscle, the anterior be divided close to the rectum, as division of this
rectal wall, the posterior prostate, and other mus- muscle too far anteriorly leads to dissection along
cles of the pelvic floor is vital, although underap- the inferior lobe of the prostate in an anterior
preciated until recently (Sylla et al., manuscript direction, toward the membranous urethra [22]. If
submitted for publication) [15]. The RUM is a unaware of these anatomic relationships, the sur-
dense band of smooth muscle fibers that extends geon may mistake the RUM for residual muscu-
from the muscular propria of the rectum anteri- laris propria of the rectum and direct dissection
orly to the external urethral sphincter. The ana- too far anteriorly in an attempt to avoid rectal
tomic significance of the RUM has been described perforation (Figs. 30.1 and 30.2).
a b
c d
Fig. 30.1 Near-miss injury to the prostatic urethra during extended close the apex of the prostate (b, white arrow),
taTME. Transanal TME dissection initiated shortly after but the surgeon quickly realized the error and corrected the
complete intersphincteric resection was completed for a dissection back to the correct plane, more inferiorly and
very low rectal tumor. The anatomically correct plane closer to the anterior rectal wall (b, blue arrow). The pros-
between the anterior mesorectum and posterior prostate tate is finally visualized along its left lateral aspect (area
was difficult to identify. Fibers of the rectourethral muscle between the white and blue arrows, c), and dissection pro-
are seen coursing anteriorly between the anterior rectal ceeds along the correct anatomic plane, close to the ante-
wall and the apex of the prostate and should have been rior rectal wall (c, blue arrow). After taTME is completed,
divided close to the anterior rectal wall (a, blue arrow). the prostatic urethra is visualized along with a small defect
Instead, and out of concern of erring too close to the ante- in the surrounding urethral sphincter muscle (d, white
rior rectal wall and risking anterior rectal wall perforation, arrow). Fortunately in this near-miss case, the urethra
the dissection is inadvertently carried out too anteriorly (a, remains intact, as confirmed with intraoperative cystos-
white arrow). Dissection was erroneous and briefly copy under transanal endoscopic perineal visualization
30 Urethral Injury: The New Challenge for taTME 315
first is the use of simple tactile feedback in the infrared stents can be used at once to improve
form of preoperative digital rectal examination visualization [1]. Because infrared light is uti-
(DRE) [1]. This exam allows for localization of lized, there is minimal heat emission and low risk
the prostate prior to the start of the operation and for tissue damage.
identification of geometry of the anterior dissec- Fluorescence imaging with indocyanine green
tion plane. If the anterior dissection is unclear (ICG) has also been used in taTME to identify
during the course of taTME, the surgeon can also structures using visualization in the near-infrared
use this technique to confirm dissection in the wavelength [25]. The dye can be injected system-
correct plane by removing the transanal access ically to highlight blood vessels in the operative
port and performing DRE. field, and due to the fact that near-infrared wave-
There is some data to suggest that use of a lengths are more translucent through the same
two-team strategy as opposed to a one-team strat- tissue visualized in visible wavelengths, vessels
egy may reduce the risk of urethral injury. In the beneath the operative surface can be effectively
review of 34 urethral injuries by Sylla et al., the identified [26]. Peri-tumoral injection of ICG has
majority of injuries by both inexperienced and been used in taTME to better identify planes of
more experienced taTME surgeons occurred dur- dissection, and ICG has also been used to evalu-
ing operations performed using a one-team ate adequacy of blood supply to the rectal anasto-
approach [15]. The two-team approach may lead mosis [27]. Recently, transurethral injection of
to better visualization and identification of the ICG has been used to visualize the urethra in a
correct anatomical planes during taTME. cadaver model of taTME, demonstrating how this
Finally, in cases of urethral injury, surgeons in technique could be used to provide better identi-
the prior study noted that persisting with a taTME fication of the urethra during taTME to prevent
approach despite difficulties in identifying ana- injury [28].
tomical landmarks and tissue planes was a com- Laparoscopic ultrasound can also be used to
mon reason for injury [15]. It is essential that the identify the urethra during taTME. This tech-
surgeon be prepared to change strategy in the nique is widely used in other surgical disciplines
face of a difficult dissection and complete the for tumor localization and identification of ana-
anterior dissection via either a transabdominal or tomic landmarks [29, 30]. A similar technique
open transperineal approach (similar to the peri- can be used in taTME to visualize the prostate
neal portion of an APR). The surgeon should and detect the urethra by means of color Doppler
have a low threshold to convert in the face of ultrasound imaging and irrigation through a
inability to recognize the correct plane of Foley catheter. This technique has been described
dissection. by Atallah et al. although it is not commonly used
in practice [1].
Finally, the use of real-time stereotactic navi-
Emerging Technologies gation for taTME has been described and used in
a small pilot study of three patients with anterior
New technologies may help prevent urethral rectal cancer [31, 32]. This technique uses spe-
injury, particularly in difficult cases of anatomi- cialized software to integrate preoperative imag-
cal distortion as mentioned above. The use of ing and camera image to locate the position of
infrared-lighted urethral stents (Infravision surgical instruments relative to multi-planar MRI
Imaging System, Stryker, Inc. Kalamazoo, MI) or CT images or a three-dimensional rendering of
placed through a clear Foley catheter has been the operative field. This technique can success-
described as a technique to identify the male ure- fully identify the prostate and urethra and prevent
thra and avoid injury [24, 25]. The stents can be wrong-plane surgery; however, it is limited by its
identified with the use of a special infrared lapa- inability to differentiate between the contiguous
roscopic camera filter and allow for transillumi- planes of the mesorectal envelope and surround-
nation through up to 12 mm of tissue. Multiple ing endopelvic fascia, which puts the nearby
30 Urethral Injury: The New Challenge for taTME 317
autonomic nerves at risk [31]. Furthermore, this 5. Rouanet P, Mourregot A, Azar CC, Carrere S,
Gutowski M, Quenet F, et al. Transanal endoscopic
technique is limited to specialized centers with proctectomy: an innovative procedure for difficult
the required equipment and requires imaging resection of rectal tumors in men with narrow pelvis.
immediately preoperatively, which can lead to Dis Colon Rectum. 2013;56:408–15.
substantial increases in operative time [1]. 6. Lacy AM, Tasende MM, Delgado S, Fernandez-Hevia
M, Jimenez M, De Lacy B, et al. Transanal total
mesorectal excision for rectal cancer: outcomes after
140 patients. J Am Coll Surg. 2015;221:415–23.
Conclusions 7. Veltcamp Helbach M, Deijen CL, Velthuis S, Bonjer
HJ, Tuynman JB, Sietses C. Transanal total meso-
rectal excision for rectal carcinoma: short-term out-
Transanal total mesorectal excision (taTME) is a comes and experience after 80 cases. Surg Endosc.
promising new approach to distal and mid-rectal 2016;30:464–70.
cancer but is associated with a risk for iatrogenic 8. Chen C-C, Lai Y-L, Jiang J-K, Chu C-H, Huang I-P,
injury to the male urethra. Although rates of Chen W-S, et al. Transanal total mesorectal excision
versus laparoscopic surgery for rectal cancer receiv-
injury reported in the literature are low, this likely ing neoadjuvant chemoradiation: a matched case–
underestimates the true incidence of this compli- control study. Ann Surg Oncol. 2016;23:1169–76.
cation. Urethral injury may become more com- 9. Burke JP, Martin-Perez B, Khan A, Nassif G,
mon as use of taTME becomes more widespread. DeBeche-Adams T, Larach SW, et al. Transanal
total mesorectal excision for rectal cancer: early out-
Structured taTME training that incorporates comes in 50 consecutive patients. Colorectal Dis.
extensive didactics on perineal anatomy and 2016;18(6):570–7.
strategies to avoid organ injuries (as well as the 10. Kang L, Chen W-H, Luo S-L, Luo Y-X, Liu Z-H,
ability to promptly recognize and repair them), Huang M-J, et al. Transanal total mesorectal excision
for rectal cancer: a preliminary report. Surg Endosc.
cadaver training, and proctored surgery with a 2016;30(6):2552–62.
mentor surgeon can help minimize urethral injury 11. Perdawood SK, Thinggaard BS, Bjoern MX. Effect
in the future. Additionally, new techniques using of transanal total mesorectal excision for rectal
infrared and near-visual light spectrum imaging cancer: comparison of short-term outcomes with
laparoscopic and open surgeries. Surg Endosc.
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Warusavitarne J, et al. Transanal total mesorectal
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cases. Ann Surg. 2017;266(1):111–7.
13. Atallah S, Albert M, Monson JRT. Critical concepts
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30 Urethral Injury: The New Challenge for taTME 319
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How to Avoid Urethral Injury
in Males 31
Sam Atallah and Itzel Vela
Table 31.1 Patient-related factors which could poten- Table 31.2 Steps to prevent urethral injury during
tially increase the risk of iatrogenic urethral injury in taTME
males undergoing taTME
1. Assess preoperative imaging (midsagittal rectal
Previous nonoperative local therapy MRI); assess the shape and size of the prostate
Prior external beam radiotherapy neoadjuvant gland; recognize which patients may be at
treatment increased risk for urethral injury.
Prior external beam radiotherapy for prostate cancer 2. Prior to initiating taTME, the surgeon should
treatment perform a digital rectal exam; in addition to feeling
Prior implantation of radiation seeds for the tumor in low rectal cancers, the prostate
Prior injection of SpaceOAR® hydrogel (possible) should be examined by palpation, and its size,
shape, and relative position should be noted.
Previous local operations of the anus, rectum, or
prostate 3. When there is uncertainty about the anterior plane
during dissection, the taTME platform should be
Prior radical prostatectomy
removed, and the prostate gland should be
Prior prostate biopsies (multiple) reassessed by palpation.
Prior anterior local excision in the distal rectum (via 4. Utilize the urinary catheter in a way analogous to a
TEM, TEO, TAMIS) ureteral stent. When the prostate gland is
Prior surgical treatment of complex anorectal fistulae inadvertently mobilized, the catheter can be
and abscess palpated once the taTME platform has been
Prior rectourethral fistula repaired via any approach removed.
Prior implantation of artificial urinary or anal 5. Detection of applied vibratory or pulling (tugging)
sphincter motion to urinary catheter, with simultaneous
History of congenital malformations or trauma palpation.
History of pelvic trauma with urethral transection or 6. Use of a lighted, infrared urethral stent placed
urethroplasty through a clear-coated urinary catheter.
History of imperforate anus congenital malformations 7. Use of injected indocyanine green for localization
of the rectum, urethra, and urogenital diaphragm of the male urethra (currently experimental).
History of prior rectourethral fistula repaired via any 8. Critical understanding of the neurovascular bundle
approach of Walsh and its relationship to the prostatic
Factors related to intrinsic disease of the prostatic and capsule.
membranous urethra 9. Critical understanding of the morphology of the
Benign prostatic hypertrophy mobilized posterior lobe of the prostate gland.
Synchronous prostate cancer 10. Critical understanding of the extra-rectal muscle
Urethral stricture(s) structure, including the rectourethralis muscle, the
fibers of Luschka, and the anterior sling of the
Difficult urinary (Foley) catheter insertion at the time
puborectalis.
of surgery
11. Understand the effect of perceptual completion,
Factors related to local sepsis
loss of frame of reference, and human factors that
Prior pelvic sepsis, for instance, related to ileal pouch can predispose to improper plane dissection and
failure injury to the urethra.
Complex, chronic anterior fistulae (e.g., 12. Comprehension that uncertainty about the position
suprasphincteric, extrasphincteric) of the prostate gland and urethra mandates
Recent or active prostatitis discontinuation of taTME and completion of the
Recent or active urethritis operation abdominally.
Factors related to the rectal tumor
Low lying, fixed tumor ≤3 cm from anal verge
Anterior, distal rectal cancer ≤3 cm from the anal
verge tage over taTME in this setting as it is conducted
Tumor abutting the prostate with limited CRM based with constant tactile feedback to confirm the
on imaging position of the prostate gland and urethra.
Nevertheless, with requisite training and expe-
rience, a taTME technique can still be successfully
considered for alternative approaches, including executed, and adjunctive techniques to localize the
laparoscopic and robotic abdominal techniques urethra in an effort to minimize iatrogenic injury
to accessing the deep pelvis. Even the sphincter- can be employed [6, 10, 11]. These are delineated
preserving TATA operation may hold an advan- in Table 31.2, and crucial anatomic pearls and
324 S. Atallah and I. Vela
he Rectourethralis Muscle
T
and the Pre-rectal Muscle
Fibers of Luschka
urethral injury during taTME. As such, it has differences between correct and incorrect plane,
been learned that CBD injury is not most likely to this point of the male taTME dissection is consid-
occur due to challenging body habitus or aberrant ered to be the most stressful point of the entire
biliary anatomy, but rather due to surgeon misper- operation. Particularly for less experienced
ception [28–30]. Thus, through incorrect identifi- taTME surgeons, this psychologic state increases
cation of anatomic structures, which results from anxiety which can diminish judgment and which
a lost frame of reference, and through errors in can lead to operative error. This is one reason that
cognition secondary to visual completion, a sur- taTME surgeon proctorship is vital toward the
geon can be led to make incorrect assumptions safe implementation of this complex procedure
about anatomy within the operative field. [5, 35–38]. It specifically allows the operating
Furthermore, surgeons are less likely to change surgeon to gain confidence until proficiency with
their operative coarse once this has been estab- taTME is established.
lished – a consequence of confirmatory bias [31–
34]. According to Way et al. [28], “once we
commit to a specific judgment, we tend to dis- Methods to Localize the Urethra
count the significance of new dis-confirmatory
evidence and remain in favor of the confirmatory Today, there are essentially three perineal
evidence.” Thus, confirmatory bias can unfortu- approaches to extirpation of the rectum. They are
nately contribute to (rather than minimize) opera- APR, TATA, and now taTME [39]. With APR and
tive morbidity. with the original description of TATA, confirma-
In summary, urethral injury can result from tory tactile feedback allows the operator to con-
the surgeon’s mind incorrectly processing infor- stantly assess the anterior plane, and when the
mation. Leading factors include (a) loss of frame prostate gland is inadvertently mobilized during
of reference (by failing to maintain critical ana- perineal dissection, it is typically recognized and
tomic landmarks in the field of view), (b) percep- the appropriate adjustments made. However,
tual completion (an assumption of anatomic taTME – whether with TEO, TEM, or TAMIS –
relationships “filled in” and assumed to be real in relies on instruments and haptic (not tactile)
the mind of the operator), and (c) confirmatory feedback that does not reliably assess when the
bias, whereby a surgeon is more likely to con- prostate gland has been mobilized. Thus, most
tinue along a perilous plane of dissection than to experts now advocate removal of the platform
process new information that suggests this and direct palpation of the prostate when there is
approach is not correct. uncertainty about the anterior dissection. It is so
important that training courses for taTME now
advise a digital rectal exam with a baseline
Other Human Factors assessment of the prostate gland prior to purse-
string application and introduction of the access
Establishment of the correct anterior taTME dis- channel.
section in males can be one of the most challeng- Additionally, it should be recognized that the
ing aspects of this operation. The increased urethra is effectively stented with a urinary cath-
workload coupled with the high stakes of opera- eter, which allows this structure to be palpated
tive morbidity can dramatically increase the sur- when the posterior lobe of the prostate gland and
geon’s mental stress. In the balance is the risk of pre-membranous urethra are inadvertently mobi-
dissecting too anteriorly with subsequent urethral lized en bloc with the anterior rectum and meso-
injury, while dissection in a plane too dorsally rectum [6]. New approaches for urinary system
can result in violation of the rectal wall and and urethral localization capitalize on the fact
potentially insult to the tumor itself–resulting in that the urethra is stented by a catheter. Effective
an irrecoverable compromise to the oncologic examples of how the urinary catheter can be uti-
integrity of the operation. With only millimetric lized for localization (other than direct tactile
31 How to Avoid Urethral Injury in Males? 329
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A Roadmap to the Pelvic
Autonomic Nerves During 32
Transanal Dissection
Werner Kneist
Table 32.1 Roadmap to the pelvic autonomic nerves – focus on transanal total mesorectal excision
Author Nerves Based on Topography Other aspects
Lacy Autonomic Video endoscopy Excellent visualization, Believe that it allows more
et al. [2] nerves especially in the narrow precise PANP
male pelvis
Atallah IHP and Transanal robotics Clear visibility with the Further refinements necessary
et al. [3] nerves (3D) robotic approach facilitates
PANP
Sylla HN, IHP, Video endoscopy Dissections too close to Excessive retraction and dual
et al. [7] PSN, NVB IHP and NVB may cause use of monopolar diathermy
functional disturbances and bipolar energy can lead to
nerve damage
Bertrand IHP, NVB Fetal and adult Nerves are at risk during 3D reconstruction of fetal
et al. [8] anatomy; CAAD for anterior, lateral, and anatomy gives an idea of the
pelvic anatomy; posterior mesorectal plane for PANP
taTME experience dissection in the lower and
middle thirds
Aigner HN, IHP, Adult anatomy; Nerves are at risk at the The NVB above the levator
et al. [9] NVB, LAN, macroscopic superior aspect of the anal ani muscle serves as a
IASN dissections, caudal to canal; along the “holy landmark
cephalic direction; plane,” at the level of the
taTME experience sacral promontory
Kneist IHP, PSN, Video endoscopy; Five key zones of risk for Intraoperative verification of
et al. [10] NVB, IASN neuromapping pelvic autonomic nerve functional integrity seems
damage (Table 32.2) possible
Atallah IHP Video endoscopy; Insufficient differentiation Helpful for assuring the
et al. [11] real-time image- for separating fascia layers correct plane of dissection
guided from the pelvic nerve
neuronavigation plexus
Chouillard NVB Video endoscopy; Significantly more Specimen quality comparable,
et al. [12] pure NOTES cases frequent nerve including pathohistological
identification, compared to detection of neurovascular
the laparoscopic approach elements
(78% vs. 33%)
Kneist PSN, IRP Video endoscopy; Identification rates Intact neural pathways covered
et al. [13] neuromapping significantly higher with or embedded in the endopelvic
neuromapping compared fascia could be confirmed
to visual assessment alone
Atallah NVB, IHP, taTME experience, S2/S3 IHP routes appear 4 mm vessels of the NVB at a
et al. [14] PSN teaching experience “bow” shaped, approx. 10 o’clock position, superficial
6–8 cm from the anal to the prostate and the
verge; no risk of nerve urethras, serve as a landmark;
injury in the posterior pneumodissection can occur
hemisphere 4–5 cm from deep to the IHP
the anal verge
Kneist IRP Cadaver teaching Identification and Identifying IRP leads to a
et al. [15] course with video preservation of the IRP is significantly higher number of
endoscopy an element of training NVB visualizations
Watanabe PSN (S4), Video endoscopic case Identifying the prostate Avoiding urethral injury
et al. [16] NVB gland, with autonomic
nerves as a landmark
Schiemer PSN, IHP, Robotics; video Surgeon easily Monitoring is integrated at the
et al. [17] IRP, NVB, endoscopy; neuromapped both pelvic surgical console; video
IASN neuromapping sidewalls documentation of the map
HN hypogastric nerve, NVB neurovascular bundles, PSN pelvic splanchnic nerves, IHP inferior hypogastric plexus, IRP
inferior rectal plexus, LAN levator ani nerve, IASN internal anal sphincter nerve, IAS internal anal sphincter, APR
abdominoperineal excision, CAAD computer-assisted anatomic dissection, PANP pelvic autonomic nerve preservation
32 A Roadmap to the Pelvic Autonomic Nerves During Transanal Dissection 337
Table 32.2 Five key zones where autonomic nerves are at risk during transanal approach
Key
zone Level Nerve segments Dissection Depiction
1 Upper anal canal, at Terminal branches of the Intersphincteric
dentate line IASN
IASN internal anal sphincter nerves, IRP inferior rectal plexus, PNS pelvic splanchnic nerves, IHP inferior hypogastric
plexus, NVB neurovascular bundles
during a partial intersphincteric resection. With fatty tissue and tend to course along the internal,
diameters of 0.1 mm, intersphincteric nerves are rather than the external, anal sphincter. Injections
barely visible, even when an incision is performed to enhance tissue volume and careful preparation
at or below the dentate line, during an initially open seem to comprise the method of choice to optimize
approach (Table 32.2). The nerves are embedded in nerve-preserving dissection [10, 18–20].
338 W. Kneist
The risk of injury to the HN and the nerve seg- is even more precise and rapid; this approach
ments above (i.e., the superior hypogastric plexus could be used transanally in the future (Fig. 32.3).
and inferior mesenteric plexus) is lower than the
risk of injury to nerves in the pelvis minor.
Results from the international taTME registry
showed only two (0.1%) HN divisions in 1594
cases, although this may be a gross under estima-
tion and the true incidence remains unknown. On
the other hand, the risk of injury with the abdomi-
nal approach is also low. However, an uncoordi-
nated, simultaneous operation from abdominal
and transanal can pose a risk in the pelvic auto-
nomics. Finally, a well-rehearsed, two-team Fig. 32.2 Left-sided neurovascular bundle (NVB) dem-
approach can provide an additional dimension, onstrated by the proctor and preserved by the participating
by perfecting the traction - countertraction strat- surgeons (taTME in cadaver courses [15])
egy. Hence, autonomic nerve visualization and
preservation at the level of the sacral promontory
might be easier to achieve than it was before
[4, 7, 9, 12, 24, 28].
Mixed reality technology and future develop- total mesorectal excision (TaTME) following the
Second International Consensus Conference. Color
ments in the field will facilitate precision in Dis. 2016;18:13–8.
nerve-sparing surgery. Technological advances 7. Sylla P, Bordeianou LG, Berger D, Han KS, Lauwers
will improve individualized planning, spatial GY, Sahani DV, Sbeih MA, Lacy AM, Rattner DW. A
awareness, navigation, and the simultaneous dis- pilot study of natural orifice transanal endoscopic
total mesorectal excision with laparoscopic assistance
play of rendezvous maneuvers, neuro-monitoring, for rectal cancer. Surg Endosc. 2013;27:3396–405.
and staining results (Fig. 32.4). In addition, better 8. Bertrand MM, Colombo PE, Alsaid B, Prudhomme
visualization, electrophysiological measure- M, Rouanet P. Transanal endoscopic proctectomy and
ments, postoperative specimen immunostaining, nerve injury risk: bottom to top surgical anatomy, key
points. Dis Colon Rectum. 2014;57:1145–8.
MRI nerve status assessment, and retrospective 9. Aigner F, Hörmann R, Fritsch H, Pratschke J, D’Hoore
video analysis can improve quality control proce- A, Brenner E, Williams N, Biebl M, TAMIS TME
dures to confirm the efficacy of PANP [11, 13, Collaboration Group. Anatomical considerations for
17, 29–31]. transanal minimal-invasive surgery: the caudal to
cephalic approach. Color Dis. 2015;17:O47–53.
10. Kneist W, Rink AD, Kauff DW, Konerding MA, Lang
H. Topography of the extrinsic internal anal sphinc-
ter nerve supply during laparoscopic-assisted TAMIS
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Operative Vectors, Anatomic
Distortion, and the Inherent 33
Effects of Insufflation
Sam Atallah, Albert M. Wolthuis,
and André D’Hoore
Fig. 33.1 The actualized workspace volume increases as dent on the phase of dissection. The subperitoneal work-
a function of time during the transanal portion of taTME space is negligible during rectotomy but increases
and then can be mathematically expressed as exponentially during taTME dissection. Finally, upon ren-
∆vtaTME/∆ttaTME or simply dv/dt, whereby ∆vtaTME repre- dezvous with the abdominal cavity, which usually occurs
sents the change in volume and ∆ttaTME equates to dissec- anteriorly along the peritoneal reflection, the abdomino-
tion time. The rate of change in workspace volume (e.g., pelvic cavity becomes one common space
the viewable surgical field) is not constant and is depen-
however, and it is well known that with taTME, operative field’s workspace is a function of time
especially laterally and posteriorly, as the plane is and can be mathematically expressed as
developed by pneumatic dissection, it is possible ∆vtaTME/∆ttaTME or simply dv/dt (Fig. 33.1) [6].
to actualize deep planes that lie beyond the scope
of dissection. When the correct plane is achieved,
however, pneumatic dissection augments sharp Operative Vectors
dissection in the TME plane in accordance to the
standards set forth by Professor RJ Heald. With standard multiport laparoscopy or robotic
In some regards, actualizing the subperitoneal abdominal surgery, gas flow delivery can be
space during taTME is similar to extraperitoneal arranged by connecting inflow tubing to any trocar
surgery – such as for endoscopic totally extra- in any quadrant. Most often the choice of which tro-
peritoneal hernia repair [1, 2]. However, in those car to use is arbitrary, although may surgeons prefer
approaches, typically a balloon is used to actual- to insufflate through a trocar not occupied by the
ize the potential space prior to proceeding with camera lens as this can increase lens fogging lead-
dissection, creating a constant workspace for the ing to diminished optic clarity. Because of the large
entire procedure. In contradistinction, with volume of the abdominal cavity, however, the direc-
taTME, the workspace volume changes in rela- tion of gas flow into the cavity is generally not clini-
tion to dissection time – since this space is not cal relevant. That is, there is no distortion of target
established with balloon dissection but rather anatomy and only symmetric doming of the anterior
with sharp, meticulous dissection in accordance abdominal wall can be appreciated. However, dur-
with the principles of TME surgery [3–5]. Thus, ing taTME, the direction and magnitude of gas flow
the more the dissection progresses, the more the and the resultant effect on the surgical field during
workspace volume (and thus the field of view) operation, including the effect this imparts on the
increases. Therefore, the change in volume of the process of dissection itself, are quite relevant.
33 Operative Vectors, Anatomic Distortion, and the Inherent Effects of Insufflation 345
Pelvic cavity
Fig. 33.2 The insufflation “vector” can be thought of as anatomy, but with taTME, the direction of insufflation has
the force of insufflation together with its direction. With very specific effects on the target anatomy and the fascial
abdominal minimally invasive surgery, insufflation vec- envelopes that surround the rectum and mesorectum
tors have no appreciable effect on the operative field and
With transanal access, insufflation has a spe- (such as exogenous CO2) effect anatomy, and
cific direction and specific force or magnitude. In much of what can be learned is based on observa-
physics, the magnitude of a force together with tional data and known physical principles of con-
its direction defines a vector. Thus the force of tinuum mechanics [7–11].
CO2 gas insufflation plus the direction of gas It is known that, because the insufflated gas is
delivery can be defined as an insufflation vector delivered via a closed cylinder (the transanal
[6]. The insufflation vector achieved with taTME platform’s access channel), that gas flow is gov-
(Fig. 33.2) results in a compounded effect that, erned by laws which define fluid movement in
on the one hand, greatly facilitates sharp dissec- such a cylinder. In particular, there are two impor-
tion by pneumatically delineating surgical planes tant laws pertaining to gas flow. First, the Hagen-
and maintaining what can be a remarkably pris- Poiseuille Law [12] defines the rate of flow of
tine operative view; on the other hand, the taTME CO2 as it is transmitted through the taTME access
insufflation vector poses new challenges. Most channel. Essentially, this states that there is a
notable of these challenges are the following: (a) variable rate of flow through the channel, whereby
exposure of false planes beyond the TME enve- the highest flow velocity is observed at the center
lope, (b) lifting and “standing up” of pelvic auto- of the access channel, while the lowest flow
nomic nerves, creating a potential for their injury velocity is at the periphery. Thus, there exists a
if not recognized, and (c) in the event of pelvic velocity gradient which effects the target anat-
venous bleeding during dissection, introducing a omy is a specific way. Based on observational
vehicle for CO2 venous embolization. data, this tends to create a concavity of the meso-
rectal envelope during the posterior taTME dis-
section, thus contributing the classic anatomic
Gas Flow Mechanics distortion observed. It also produces a central
“forward compression” of the mobilized anat-
Gas kinetics and the physics of Newtonian fluid omy. Second, although of lesser importance,
dynamics within a closed system have been well Bernoulli’s Law [13] states that energy is con-
studied, but not as it pertains to insufflation sys- served, and as CO2 gas is transmitted from the
tems and the effect such systems impart on narrow radius of the insufflation tubing and tro-
human anatomy during operation. Thus, little is car to the much larger diameter access channel,
known about how precisely Newtonian fluids the overall gas rate of flow is constant, although
346 S. Atallah et al.
Ca
nnu
la
A2
V rate 1 = V rate 2 la
Cannu
A1V1 = A2V2 8µLQ
DP =
π R4
π r2V1 = π r2V2 taTME access channel
Bernoulli equation (conservation of energy) Hagen-poiseuille equation
Fig. 33.3 The principles of fluid mechanics that govern tubing) and slower in a large cylinder such as the taTME’s
CO2 flow through the taTME apparatus are illustrated. access channel, but the overall flow rate remains the same
Conceptually, two laws of physics should be understood. due to the larger cross-sectional areal of the apparatus. ∆P
First, the Hagen-Poiseuille Law states that pressure pressure differential; P1, pressure at the outer rim of the
diminishes along the forward direction of gas flow, access channel; P2, pressure at the end of the access chan-
thereby creating a pressure gradient, ∆P (P1 – P2). nel near the surgical field; μ, dynamic (shear) viscosity
Furthermore, this law states that gas flow velocity is high- coefficient; L, cylinder length; Q, volumetric flow rate; R,
est at the center of the cylinder and lowest at its periphery, radius of cylinder; A1, trocar cross-sectional surface area;
thereby creating a velocity gradient. Bernoulli’s Law is A2, taTME access channel’s cross-sectional surface area;
synonymous with the Law of Conservation of Energy, and V1, velocity of CO2 within trocar; V2, velocity of CO2
thus velocity flow rate is constant, as gas flows faster in a within taTME access channel
smaller diameter cylinder (such as a trocar or insufflation
the velocity is decreased (Fig. 33.3). equipment was required [14–16] (as is the case
Understanding gas kinetics helps one to under- with rigid platforms, which have unique and spe-
stand the observed pneumatic effects and the cifically designed insufflation systems as compo-
classic anatomic distortion (see later) that is often nent of the apparatus). While currently TAMIS
evident during taTME dissection. and even taTME can be performed with standard
laparoscopic insufflators, when available alter-
nate modes of insufflation are often advocated to
Cyclic Billowing resolve the nuisance problem of cyclic billowing
and smoke accumulation with loss of visual field
Since the introduction of TAMIS for local exci- stability.
sion via endoluminal surgery [14] and subse- Cyclic billowing is defined as the sudden,
quent use of this technique for taTME [15–19], periodic collapse of the workspace – including
an important operative limitation has been over- the lumen of the rectum in the case of TAMIS and
come. Initially, both TAMIS and TAMIS-based the actualized subperitoneal workspace of the
taTME relied on laparoscopic insufflation sys- pelvis during taTME. Cyclic billowing is some-
tems designed for abdominal access surgery, and times referred to as “pelvic breathing” due to the
not transanal surgery or limited space, subperito- rhythmic collapse of operative workspace during
neal pelvic surgery. This was at the time believed transanal surgery. Advanced transanal surgery
to be an advantage of the technique of TAMIS such as TAMIS and taTME mandates a sustained
and taTME via TAMIS, because no specialized pneumatic dissection that is not volatile and is
33 Operative Vectors, Anatomic Distortion, and the Inherent Effects of Insufflation 347
hand-fashioned apparatus, whereby a surgical access and insufflation are present, and pressure
sterile glove is used as an interposition in the CO2 settings should always be slightly less for abdom-
tubing [26], providing a reservoir that serves as a inal insufflation relative to taTME insufflation.
proxy for operative space, thereby minimizing the This is to maintain a positive down-to-up pres-
effect of billowing, but not necessarily smoke sure gradient, otherwise the actualized work-
accumulation. This makeshift solution is a useful space will collapse. This is true even if there is
construct and represents an important low-cost only one AirSEAL® iFS system in use, and a
alternative to the valveless trocar system. traditional laparoscopic insufflator is being used
Furthermore, in 2018, the manufacturer of the to insufflate the abdominal cavity. In such a set-
GelPOINT Path Transanal Access Platform ting, cyclic billowing can occur at the point of
(Applied Medical, Inc.) began including a reser- peritoneal entry. In general, the peritoneal entry,
voir bag (at no additional cost) which reduces bil- which is most commonly achieved along the
lowing in the same manner [27]. There are other anterior reflection (as this is the shortest distance
options that have recently become available, to the abdominal cavity) should be the last major
including PneumoClear® Insufflation (Stryker, step in the taTME dissection. After this step, even
Inc. Kalamazoo, MI, USA) with TAMIS mode with correct pressure settings, a diminished oper-
that is designed to achieve a more stable pneumor- ative view can often be observed.
ectum and pneumopelvis than standard laparo-
scopic insufflators.
The AirSEAL® iFS system is often incor- Anatomic Distortion
rectly classified as a “high-flow” insufflator. In
actuality, however, in AirSEAL Mode, the typical With abdominal minimally invasive surgery
rate of flow during taTME is quite low at 8 L/ (MIS), whether laparoscopic or robotic, the
min, and pressure limits are set to ~8–12 mmHg. insufflation applied does not substantially distort
The system is designed to respond instantly to the native viscera as the insufflation is evenly dis-
pressure changes by increasing the rate of flow. tributed over a large area, and the only noticeable
For example, if plumes of smoke or blood require distortion is the symmetrical doming of the ante-
ancillary suctioning to clear the field, the process rior abdominal wall. However, during the trans-
of suctioning will result in a quite sudden anal portion of taTME, anatomical distortion can
decrease in the pressure which can threaten the be quite pronounced. This occurs as the operative
stability of the pneumatic distention essential in insufflation vector exerts an effect which aids in
maintaining the operative field of view. To com- establishing the taTME dissection plane but, at
pensate for this, the AirSEAL® iFS system is the same time, creates gross anatomic distortion
designed to increase flow to up to 40 L/min tran- as the mesorectal envelope and rectum proper
siently. This rapid, real-time response is one of become mobilized (Fig. 33.5) [6]. Classically,
the important factors that allows for TAMIS and this produces a concavity of the mesorectal enve-
taTME to be performed with a stable operative lope and also a forward compression of the entire
view that has minimal billowing. Cyclic billow- rectum and mesentery that can sometimes render
ing is also greatly dampened (if not completely the anatomy unrecognizable. During the poste-
eliminated) by the constant sampling of gas pres- rior dissection, the mesenteric distortion creates a
sure by this system. central concavity with a ventral bend to the mes-
Even with AirSEAL® iFS and other advanced enteric envelope (Fig. 33.6a, b). As the lateral and
platforms, during taTME at the point of perito- anterior dissections are completed, the distortion
neal entry, there is potential for loss of the opera- compresses the entire rectum and its mesentery
tive field of view as pneumatic distention cephalad.
diminishes when the taTME insufflation pressure Because of the distortive effects imparted by
“competes” with the abdominal insufflation pres- operative vectors, the mesentery does not
sure. With the two-team approach, laparoscopic typically appear elliptical, and its completeness
33 Operative Vectors, Anatomic Distortion, and the Inherent Effects of Insufflation 349
cannot be assessed until the specimen is extracted. tissue is placed on stretch, and when a lead point
This implies that the operator must instead rely has not been released. Such phenomena are not
on the interpretation of the fusion planes and infrequently encountered during dissection with
must understand and appreciate the typical laparoscopic and robotic colorectal surgery.
appearance of anatomic distortion during the Thus, triangles from tethering of unreleased
transanal portion of the operation. This is one points are not unique to taTME, but tend to be
reason that taTME dissection presents unfamiliar quite pronounced with this operation in particu-
anatomy to the novice surgeon and why signifi- lar. When the point of tethering (usually the ven-
cant experience is required to gain proficiency tral tip of the triangle) is not recognized and the
with this challenging technique. dissection proceeds dorsal to this point, the fas-
cia is violated, and it results in disruption of the
fascia plane. Because the pneumatic force is uni-
Triangles and Halos formly distributed at this point of violation, the
appearance of a linear fascial disruption will
As a result of pneumatic dissection, release along take on the shape of a circle and has thus been
natural anatomical planes of fusion is observed, termed the “halo sign” [28]. Triangles and halos
but occasionally there are tethering points which are important signs in maintaining plane recog-
are adherent and must be released through delib- nition during taTME. Due to the unique fascial
erate sharp dissection. As the tethered point tents layering patterns, entry into false planes is quite
the fascia in the shape of a triangle, this is often typical during the natural course of taTME dis-
recognizable as such, and thus fascial plane “tri- section. Especially along the posterior dissec-
angles” can be an important clue as to the location tion, it is critical that the triangle and halo
of the correct plane. Such triangles occur in all phenomena are recognized and appropriately
aspects of surgical dissection, particularly when managed (Fig. 33.7).
Endopelvic fascia
Fig. 33.7 Triangles and halos are pneumatic phenomena ent, and when the mesentery is projected anteriorly by the
observed during all minimally invasive surgery, but are insufflation vector, the tethered plane “stands up” in the
particularly important with taTME. As originally shape of a triangle. If this or any fascial plane is violated
described by Bernardi and colleagues, triangles are cre- at a point other than its fusion point, a linear cut along the
ated when a tethering point of a fascial plane has not been fascia takes on the appearance of a halo or circle since the
released by sharp dissection. Such a point must be recog- pneumatic force evenly distributes tension. Triangles and
nized and dissected free, thereby releasing the adherent halos are important clues, and taTME surgeons must
fascia. This is of particular importance along the posterior remain vigilant, making plane adjustments accordingly
dissection where the endopelvic fascia tends to be adher-
33 Operative Vectors, Anatomic Distortion, and the Inherent Effects of Insufflation 351
Fig. 33.9 Between 6 and 8 cm from the anal verge at the insufflation vectors creates a misleading, areolar plane of
3 and 9 o’clock position lie avascular fat pads that are dissection that can incorrectly direct the surgeon to this
separate from the TME plane and do not follow its ellipti- lateral plane, which often results in sacral bleeding
cal shape (curved arrow). Pneumatic dissection due to the
352 S. Atallah et al.
Fig. 33.10 Posterior taTME dissection is shown, by dashed purple lines, “stand up” in a vertical orienta-
whereby dashed lines in green delineate the correct plane tion, and they often take on the shape of a bow or shoe
of dissection, while a dashed red line overlies a lateral, strings. It is imperative that taTME surgeons recognize
areolar area that is an incorrect plane. Between the correct these roots and are not drawn to more lateral areolar
and incorrect plane lie the inferior hypogastric nerve roots planes which would result in significant autonomic nerve
from the S2 and S3 tributaries. These nerve roots, denoted injury
‘Areolar’ mesentery
Fig. 33.11 It is classically stated by RJ Heald that the mesentery appears quite areolar and thus dissectable.
correct TME plane is the “innermost dissectable plane.” However, in fact, it is not and instead dissection of this
However, insufflation vectors can dissect the mesentery areolar mesentery has exposed the rectal muscle tube,
itself, giving it the appearance of being correct. Here, the which is clearly visible in this video still frame
posterior TME plane is being dissected. Note that the
formed for cancer). The innermost dissectable point. In surgical practice, this error tends to occur
plane – as described by RJ Heald – can thus give in the initial posterior dissection. It happens not
a false appearance of having yet a more inner dis- only because of the mesentery itself becomes
sectable plane as the mesenteric envelope pres- areolar (Fig. 33.11), but because the m esenteric
ents an areolar appearance due to constant-pressure envelope itself may have a steep posterior slope
pneumatics, delivered from the taTME vantage along the sacrum requiring compulsory steep
33 Operative Vectors, Anatomic Distortion, and the Inherent Effects of Insufflation 353
angulation of the instruments during this portion Paroxysmal and otherwise unexplained altera-
of the operation to accommodate the patient’s pel- tion in end-tidal CO2 (ET-CO2) should immedi-
vic geometry [29]. ately alert the taTME surgeon and anesthesiologist
to the possibility of air embolization. This sudden
change in ET-CO2 is usually the sentinel event
CO2 Entrainment and Embolization detected, heralding the onset of cardiovascular
compromise. In most instances, ET- CO2
CO2 embolization during laparoscopy can be decreases, but an increase in this parameter has
lethal [30, 31]. While most abdominal laparo- also been observed during air embolization.
scopic operations present at least some risk of Treatment of CO2 embolization requires rapid
CO2 venous entrainment and subsequent air intervention and mandates that surgeon and anes-
embolization, this risk is generally nominal, and thetist work in concert to rectify the problem.
the incidence of clinically relevant air emboliza- These steps include the immediate cessation of
tion during such procedures is exceedingly rare CO2 gas delivery, flooding of the operative field
[32]. However, one of the first small series to with saline, or gauze soaked in saline to prevent
report outcomes with taTME by Rouanet et al. further gas entrainment, while controlling ongo-
included CO2 embolism as a morbidity [33], and ing venous hemorrhage. Simultaneously, the
although unreported in the initial registry data anesthetist should perform Durant’s maneuver –
series [34], it has now become apparent that this that is, maintain moderate Trendelenburg (head
risk may be moderately higher than with conven- lower than level of feet) while placing the patient
tional laparoscopy and at the time of this writing in left lateral decubitus position (left-side rota-
is actively being studied [35]. The most likely tion of the operating table); this is believed to
mechanism for this is exogenous gas entrainment decrease or at least limit gas from traveling
into low-pressure venous vessels which may through the right side of the heart into the pulmo-
become injured during the process of taTME dis- nary arterial tree where right ventricular outflow
section [6]. This may be further exacerbated by can become obstructed due to an air lock.
the type of insufflator being used and the insuffla- Furthermore, increasing positive end-expiratory
tor’s operational mode; however, this remains an pressure (PEEP) can decrease the pressure gradi-
area of ongoing investigation. ent between the lacerated venous vessels and the
When the pressure of the venous system is central cardiovascular system, thereby limiting
less than the pneumatic pressure of insufflation, the potential of further gas entrainment [36, 37].
insufflated CO2 gas enters into the venous system Investigation into understanding the process
where it can result in cardiovascular collapse as it of gas embolization during taTME remains an
creates a right ventricular airlock. In the observed area of active research. Alternative exogenous
events, the venous bleeding is not excessive and gases, unfortunately, are not currently feasible
tends to tamponade by the force of pneumatic for use with taTME. For example, helium,
insufflation. Because CO2 entrainment results although essentially inert with no pharmacologic
when the pressure exceeds venous pressure, it is effects and although noncombustible, is rela-
strongly recommended that insufflation pressure tively insoluble in blood and more likely to result
be set to less than normal venous pressure and to in embolization [38], leaving exogenous CO2 gas
the lowest possible setting which allows for as the only practical option at present.
maintenance of the visual field – particularly
when constant flow systems such as AirSEAL®
iFS are employed. Furthermore, it should be CO2 Aerosolization of Bacteria
noted that venous pressure may be decreased by and Tumor Cells
steep Trendelenburg positioning while flow
increases by gravity and via respiration. These Among the pragmatic differences between
are factors which can exacerbate the rate of CO2 taTME and other sphincter-preserving, anterior
gas entrainment into lacerated vessels. operations for extirpation of the rectum is that an
354 S. Atallah et al.
intentional rectal wall violation (rectotomy distal rectal lumen before and after purse-string appli-
to the purse string) is performed [6, 29, 39]. cation and prior to commencing the transanal dis-
Theoretically, bacteria and even live exfoliated section. Next, during the course of taTME
tumor cells can shed [40–45], thereby seeding the dissection, cultures were obtained from the ster-
pelvis during taTME. This could be related to the ile, laparoscopic ports from the four quadrants of
following factors: (a) poor mechanical bowel the pelvis, and later the patients were followed
preparation, or, in the case of invasive cancer, clinically. The data revealed that 39% had posi-
observation of a friable tumor; (b) improper purse tive cultures for enteric microbes (e.g.,
string, or purse string/rectal wall violation during Escherichia Coli). Furthermore, 17% of patients
taTME dissection; and (c) the aerosolization of had localized infections within the pelvis man-
cells by the force of CO2 insufflation during the aged nonoperatively with systemic antibiotics
process of dissection. The theoretical implica- with or without percutaneous drainage. These
tions are, in the immediate postoperative time- data suggest that despite irrigation, contamina-
frame, pelvic sepsis and abscess formation can tion of the sterile abdominopelvic cavity occurs
ensue, and perhaps more importantly, in the long not infrequently during taTME and pneumatic
term, an increased risk of local recurrence due to insufflation with aerosolization of microbes may
tumor cell implantation may be observed. It be a contributing factor in some circumstances,
should be noted that the latter has not been real- although the exact mechanism is not known. A
ized by clinically available data, which, it should powerful tool in the assessment and safe imple-
be c autioned, only includes short- and midterm mentation of taTME has been the registry data,
follow-up. which at the time of this writing includes over
Due to the complexity of metastasis, tumor 3000 cases which have been entered into the
cell deposit volume, and the requirements to suc- European taTME Registry [49]. These data
cessfully implant a viable metastatic focus, it is extracted from this invaluable resource are
probable that even live exfoliated tumor cells that expected to greatly enrich our understanding of
seed the resection bed do not result in cancer this emerging operation in the coming years.
recurrence in most instances. In contradistinc-
tion, bacterial cells are easily able to thrive in the Acknowledgments The authors appreciate the invalu-
abdominopelvic cavity and probably require a able assistance of Stephanie Philippaerts and the iLapp-
Surgery Foundation in the development of the medical
lower inoculum to result in clinically relevant illustrations contained in this chapter.
infection. This is particularly true when the inoc-
ulum is a mixed flora of anaerobes and facultative
bacteria which exhibit a synergistic effect in sep-
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Total Hindgut Mesenteric
Mobilization for taTME 34
J. Calvin Coffey and Rishabh Sehgal
will then include a description of the surgical surgeon, it follows that technical descriptions
technique involved followed by a summary of the related to the mesentery, the peritoneum and
current status of different technical platforms. underlying fascia, lacked a formal anatomical
foundation.
Mesenteric mobilization was dogmatically
History summarized along the following lines. The White
Line of Toldt (if present) was identified and used
Until recently, mesenteric anatomy was consid- as a landmark at which to commence division of
ered complex. As the anatomy of the peritoneum the peritoneum. The mesentery was then
is determined by the mesentery, it follows that “stripped” back to the midline, in order to facili-
peritoneal anatomy was also considered complex tate division of the vessels within it. The mesen-
[12–14]. The main reason for this is that the mes- tery was then divided up to the intestine, which in
entery was described as being made up of multi- turn was divided [16–20].
ple separate regions (or “mesenteries”) Most intestinal surgeons on both sides of the
(Fig. 34.1). This dogma dominated almost all Atlantic were long aware of the importance of
anatomical, surgical, radiological and other mesenteric mobilization. Jamieson and Dobson,
appraisals of mesenteric anatomy [13, 15]. As the in the United Kingdom, emphasised this as far
mesentery is a pivotal structure for the intestinal back as 1909 [14, 21]. In 1942 Congdon et al.
Fig. 34.1 Depiction of classic model of mesenteric and wall. A mesentery was not normally found associated with
intestinal anatomy. According to this model, multiple the ascending and descending colon
mesenteries attached directly to the posterior abdominal
34 Total Hindgut Mesenteric Mobilization for taTME 359
emphasised the importance of the mesentery in a norectal junction [1, 5, 12, 15, 34–40]. This was
saying that American surgeons generally got into followed by an update in Gray’s Anatomy,
a particular plane and mobilized along this, with thereby reversing over 150 years of dogma relat-
minimal blood loss [22]. Still the anatomical ing to the attachment of the small intestinal mes-
foundation remained unchanged in reference lit- entery [41].
erature (Fig. 34.1). The original quote from the textbook that would
The importance of the mesenteric basis of become Gray’s Anatomy (circa 1858) stated:
oncological surgery was identified by RJ Heald “It’s root, the part connected with the vertebral col-
in 1982 [23–25]. Heald spent a considerable umn, is narrow, about six inches in length, and
amount of time convincing the surgical commu- directed obliquely from the left side of the second
nity about the importance of mesenteric, fascial lumbar vertebra to the right sacroiliac symphysis.”
[42] The updated description in the 41st e dition of
and peritoneal anatomy, in describing the tech- Gray’s Anatomy now states:
nique which he called total mesorectal excision
The mesocolon extends along the entire length of
[26–33]. This coincided with the emergence of the colon and is continuous with the small bowel
laparoscopic means of conducting intestinal sur- mesentery proximally and the mesorectum
gery. With this, surgeons were afforded a 20-fold distally… [43].
magnification of anatomical landmarks and high Mesenteric continuity is a simple property
resolution imaging of these. The new degree of with major implications. These are increasingly
separation between surgeon and tissues (i.e. sur- emerging as the systematic characterization of the
geons no longer directly held tissue) meant their mesentery gathers momentum. For example, it is
anatomical approach had to be based on an accu- now recognized that the mesentery is not simply a
rate model. While this was the case, the details of double fold of peritoneum that holds the intestine
one such model remained elusive and, in fact, in place but rather a collection of tissues that
were largely ignored. Surgeons learned how par- maintains all abdominal digestive organs in posi-
ticular patterns of activities permitted good- tion and in continuity with other systems. Once
quality mesenteric-based surgery, without having the mesenteric frame and associated organs adopt
an anatomical correlate for these. their final position, the peritoneal reflection devel-
In 2012 our group clarified the anatomy of the ops around the digestive system to hold all in
mesentery [34]. We showed that it is a continuous position (Fig. 34.2). In addition, certain regions of
structure from the duodenojejunal flexure to the mesentery are anchored to the posterior
a b
Fig. 34.2 The peritoneal reflection: (a) digital depiction posterior abdominal wall and the mesentery. (b) Similar
of the reflection where the small intestinal mesentery view to that presented in (a) of the reflection where the
reaches the posterior abdominal wall and continues as the small intestinal mesentery continues laterally as the right
right mesocolon. The reflection is the translucent mesocolon. The reflection has been partially divided
membrane of peritoneum that bridges the gap between the
360 J. C. Coffey and R. Sehgal
a b
Fig. 34.3 Toldt’s fascia. The fascia has been coloured Image demonstrating Toldt’s fascia after the left colon and
green. (a) Image demonstrating Toldt’s fascia after the mesocolon have been detached from the posterior abdom-
right colon and mesocolon have been detached from the inal wall via mesofascial separation
posterior abdominal wall via mesofascial separation. (b)
abdominal wall, with Toldt’s fascia interposed Such a set of terms was lacking until recently,
between both (Fig. 34.3) [44, 45]. due largely to the erroneous classical model of
Perhaps the most important implication of mesenteric and peritoneal anatomy [5, 13, 15,
mesenteric continuity is that surgeons can for- 38]. Clarification of mesenteric and peritoneal
mally depart from the peritoneal-based model of anatomy has meant that a set of anatomically
surgical anatomy and adopt a mesenteric-based accurate and sensible terms can be generated.
and more accurate model. It is not surprising, that Examples are those described above (i.e. perito-
an appraisal of the technical approach to hindgut notomy and mesofascial separation).
mobilization will reveal that the surgical commu- The terms routinely used throughout the rest
nity had long ago adopted the mesenteric model of this chapter are defined in the next section.
over the peritoneal one. While these may not be widely used throughout
the rest of this book, they are increasing in gen-
eral and international adoption [5, 13, 15, 47, 54].
Nomenclature The set of terms is a utility of considerable impor-
tance as it enables authors and surgeons to accu-
Any textual description of a surgical activity (i.e. rately describe a technical activity. In addition,
taTME with its multiple operative steps) requires the components of the set are intuitive, which
a set of specialized terms. For example, division further improves the ability of the reader to
of the peritoneal reflection is called peritonot- understand the concepts described, by providing
omy. Separation of the mesentery from the under- detail in an entirely anatomic-based manner.
lying fascia is called mesofascial separation [37, Since any operation is made up of multiple indi-
38, 46–53]. vidual activities happening either in sequence or
As the terms describe the surgical disruption in tandem, appropriate terminology enables a
of anatomy, they must be anatomical in their deri- comprehensive description of hindgut mobiliza-
vation and meaning. This in turn requires that the tion in general [8–11, 55]. Adoption of this
anatomical foundation on which they are based anatomical- based approach permits a rigorous
must be accurate. standardization of the operation, irrespective of
the platform used to achieve it.
34 Total Hindgut Mesenteric Mobilization for taTME 361
a b c
Fig. 34.4 The mesentery (current model). (a) Anterior, (b) anterolateral and (c) posterior view
Fig. 34.5 The left mesocolon. (Taken from Chap. 2, “Mesenteric and peritoneal anatomy”. In Mesenteric Principles of
Gastrointestinal Surgery: Basic and Applied Principles)
34 Total Hindgut Mesenteric Mobilization for taTME 363
confined to the posterior and lateral aspects of Centrally, the mesentery is suspended at the infe-
the upper and mid-rectum (Fig. 34.7). At the rior mesentery artery origin. Peripherally, the
level of the distal rectum, the mesorectum con- mesentery is suspended by formation of the
tinues around anteriorly and forms a collar or reflection. In between both, Toldt’s fascia is an
cuff of mesorectum (Fig. 34.8) [1, 5, 9, 12, 15, intermediate mechanism of attachment. These
34, 35, 56–59]. mechanisms of attachment develop during
There are three major mechanisms by which embryological growth and must be disrupted dur-
the mesentery (and hence the abdominal diges- ing colorectal surgery on the hindgut. They are
tive system itself) is maintained in position. separately described in the following [1, 5, 9, 12,
These are central, intermediate and peripheral. 15, 34, 35, 56–59].
White line
of Toldt
Mesorectum
Left iliac
fossa
Waldeyer’s
Anterior collar of mesorectum
fascia
364 J. C. Coffey and R. Sehgal
The mesorectum is attached/anchored to the “leaves it” to reach across to the organ and bridge
pelvic side wall via a continuation of Toldt’s fas- the space between the organ and the posterior
cia between it and the pelvis. The fascia contin- abdominal wall. This is the peritoneal reflection
ues between the mesorectum and adjacent and it is of considerable surgical importance
structures, towards the pelvic floor where it con- (Fig. 34.9) [1, 5, 6, 9, 12, 15, 34, 35, 56–59].
denses to form the so-called Waldeyer’s fascia. The reflection is continuous around the
Waldeyer’s fascia is not a separate fascia, but entirety of the mesentery and intestine. It is pres-
rather it is a continuation of Toldt’s fascia [1, 5, ent at the lateral aspect of the descending colon.
9, 12, 15, 34, 35, 56–59]. It continues from here along the lateral aspect of
Anterior to the mesorectum, the fascia is also the mesosigmoid, in the region where the meso-
interposed between the mesorectum and anterior sigmoid separates away from the posterior
structures. In males, these anterior structures are abdominal wall to become mobile [1, 5, 6, 9, 12,
the seminal vesicles and prostate, while in 15, 34, 35, 56–59]. A reflection of the peritoneum
females they are the cervix and vagina. Toldt’s also occurs at the medial aspect of the mesosig-
fascia continues around the posterolateral aspect moid and left mesocolon, in the region of the
of the mesorectum to occupy the position between abdominal midline (Fig. 34.10). From the duode-
the mesorectum and anteriorly located structures. nojejunal flexure, this reflection continues cau-
This region of the fascia has been called dally along the medial aspect of the left mesocolon
Denonvilliers’ fascia. As with Waldeyer’s fascia, and then along the medial aspect of the mesosig-
Denonvilliers’ is not a separate fascia, but rather moid, to reach the upper mesorectum and rectum
a continuation of Toldt’s fascia [1, 5, 9, 12, 15, [1, 5, 6, 9, 12, 15, 34, 35, 56–59].
34, 35, 56–59]. The reflection at the medial aspect of the
The peripheral mechanism by which the mes- mesosigmoid continues caudally along the right
entery is held in position is the peritoneum. side of the mesorectum where it is termed the
Wherever an organ comes into close contact with right pararectal reflection. The reflection at the
the posterior abdominal wall, the peritoneum lateral aspect of the mesosigmoid continues dis-
Cecum
a b
Ileum
Right
peritoneal
reflection
Right
peritoneal
reflection
Toldt’s fascia
White line
of Toldt
Fig. 34.9 The peritoneal reflection: (a) digital depiction to that presented in (a) in a cadaveric setting. The reflec-
of the reflection where it bridges the space between the tion has been divided sharply using a scalpel. Sub-
posterior abdominal wall and the right side of the colon. mesothelial connective tissue is apparent beneath the
(Taken from Chap. 2, “Mesenteric and peritoneal anat- surface of the reflection. (Taken from Chap. 2, “Mesenteric
omy”. In Mesenteric Principles of Gastrointestinal and peritoneal anatomy”. In Mesenteric Principles of
Surgery: Basic and Applied Principles). (b) Similar view Gastrointestinal Surgery: Basic and Applied Principles)
34 Total Hindgut Mesenteric Mobilization for taTME 365
a b
Sigmoid colon
Fig. 34.10 The peritoneal reflection at the medial border Principles). (b) Digital depiction of the reflection where it
of the mesosigmoid: (a) Digital depiction of the reflection bridges the space between the posterior abdominal wall
where it bridges the space between the posterior abdomi- and the mesosigmoid viewed from above down in the
nal wall and the mesosigmoid viewed from above and midline. (Taken from Chap. 14, “The appearance of the
from left to right. (Taken from Chap. 14, “The appearance mesentery during open surgery”. In Mesenteric Principles
of the mesentery during open surgery”. In Mesenteric of Gastrointestinal Surgery: Basic and Applied Principles)
Principles of Gastrointestinal Surgery: Basic and Applied
tally along the left lateral aspect of the mesorec- Importantly, it is not necessary to excavate
tum where it is termed the left pararectal through the fascia to identify underlying struc-
reflection. In the mid-pelvic region, the right and tures [1, 5, 6, 9, 12, 15, 34, 35, 56–59].
left pararectal regions of the reflection come The final point to be mentioned relates to the
around anteriorly to form the anterior reflection colonic flexures [5, 10, 12]. There are numerous
of the peritoneum. This is true end of the perito- flexures, but the ones that exert the greatest chal-
neal cavity [1, 5, 6, 9, 12, 15, 34, 35, 56–59]. lenge are the hepatic and splenic. The flexures are
The inferior mesenteric artery (IMA) branches best understood as comprising four components
ventrally from the abdominal aorta, proximal to centred on a central mesenteric component
its bifurcation and enters the sigmoid mesentery. (Fig. 34.11). At each flexure, the mesentery
As the IMA enters the mesentery, it is surrounded changes from attached to non-attached and thus
by a sheath of connective tissue that is continuous undergoes considerable conformational changes.
with Toldt’s fascia and that also receives contri- The mesenteric component of the flexures can be
butions from the connective tissue of the considered in terms of a longitudinal component
mesentery into which the vessel is incorporated and a radial component. The radial component of
[1, 5, 6, 9, 12, 15, 34, 35, 56–59]. the splenic flexure extends from the middle colic
As the fascia is located between the mesentery origin. At the middle colic, it is fixed in position
and the posterior abdominal wall, it provides a to the mesenteric root region, and as one extends
useful landmark for the abdominal surgeon. The along the radial axis, the mesentery detaches to
mesenteric domain of the abdomen is located become mobile. The longitudinal axis of the
anterior to the fascia, while the non-mesenteric transverse mesocolon extends from the trans-
domain is located posterior to the fascia. Posterior verse mesocolon (where it is mobile) to the left
to the fascia are retroperitoneal structures such as mesocolon (where it is attached) [1, 5, 10, 12].
the kidneys, the ureters, and gonadal vessels. The other components of the flexures are the
Toldt’s fascia thus separates the mesenteric and peritoneum, colon proper and fascia. The fascia
non-mesenteric domains of the abdomen. is interposed between attached regions of
366 J. C. Coffey and R. Sehgal
a b Intestinal
Intact component
of flexure
Colofascial
c d separation
Fascial
component
of flexure
Peritoneal
Mesenteric component
component
Peritoneal component
of flexure
Peritoneal
component
Mesenteric
component
of flexure
Fig. 34.11 The splenic flexure. (Taken from Chap. 20, left side, after conceptually removing the flexure. The
“Mesenteric component of flexural mobilisation”. In reflection has been divided through to demonstrate the
Mesenteric Principles of Gastrointestinal Surgery: Basic relationship between the peritoneum, colon, mesentery
and Applied Principles). (a) The intact splenic flexure. (b) and fascia. (e) View of the in situ flexure if the non-flexural
Flexure conceptually disconnected from non-flexural regions of the intestine and mesentery were removed. The
regions. (c) View of the remaining non-flexural mesentery view demonstrates the relationship between the colon,
after removal of the flexure. Colic, mesenteric, fascial and mesentery, reflection and fascia
peritoneal components are apparent. (d) View from the
34 Total Hindgut Mesenteric Mobilization for taTME 367
a b
Left peritoneal reflection Descending
colon
Edge of Edge of
peritoneotomy peritoneotomy
Fig. 34.12 The lateral mesosigmoidal reflection at the sigmoid. (Both images taken from Chap. 13, Appearance
lateral aspect of the mesosigmoid. (a) Intraoperative view of mesentery during laparoscopic surgery, in Mesenteric
of the lateral reflection at the left lateral aspect of the Principles of Gastrointestinal Surgery: Basic and Applied
mesosigmoid as it is undergoing division. (b) Digital view Principles)
of the divided reflection at the lateral aspect of the meso-
368 J. C. Coffey and R. Sehgal
a White Line of Toldt and dividing the peritoneum tion, then the mesosigmoid has been fully
just medial to this. We do not advocate relying on detached [5, 8, 9, 12].
this landmark, as its presence and extent are vari- The left mesosigmoidal reflection is then
able. In addition, it also occurs in areas other than divided and the IMA circumferentially isolated
in association with the peritoneal reflection, a by [1] detaching the mesentery around it and [2]
point that can cause confusion if overly relied dividing the fascia that coalesces around the
upon. Where it does occur, the White Line of IMA. The latter is then divided to commence the
Toldt marks the line of intersection of Toldt’s fas- process of disconnection (i.e. where the mesen-
cia, with the peritoneum [1, 9, 15, 54, 58, 59]. tery is entirely freed from the underlying non-
mesenteric domain of the abdomen) [5, 8, 9, 12].
Detachment and Disconnection:
Mesosigmoid – Mesofascial edial to Lateral Detachment
M
Separation of the Mesosigmoid
The aim of peritonotomy is to identify the meso- The technical activities are the same as those
fascial plane. Without peritonotomy (whether of detailed above. The reflection at the left side of
the visceral or parietal peritoneum), one cannot the mesosigmoid is divided. The mesofascial
identify the mesofascial plane. If the mesofascial plane is identified and the mesentery detached
plane is not evident after peritonotomy (which is from the underlying fascia via mesofascial sepa-
common), the surgeon is either supra-fascial (dis- ration. This is repeated circumferentially around
secting directly towards or within the mesentery) the IMA pedicle until the latter has been circum-
or retrofascial (with the dissection proceeding ferentially isolated. Toldt’s fascia coalesces
along a plane too deep, that enters into the retro- around the IMA, and this must be divided to
peritoneum) [1, 9, 15, 54, 58, 59]. complete its isolation for division of the vessel
To identify the correct plane, the mesosigmoid near its point of origin. Once divided, the surgeon
is lifted off the retroperitoneum, thereby placing can then dissect beneath the mesosigmoid, gradu-
the fascia under greater tension via retraction. As ally detaching the latter from underlying fascia
the fascia comes under stretch, the interface until eventually the left lateral reflection is
between it and the mesentery is also placed under reached. This can be divided directly, or alterna-
tension, and the interface between both is appar- tively one can change the direction of dissection
ent [1, 9, 15, 54, 58, 59]. The instruments used to and approach this from inferior to superior, divid-
achieve this are beyond the scope of this chapter, ing the reflection from the left iliac fossa towards
and one is referred elsewhere for a detailed the splenic flexure. In this manner, the mesosig-
description of how to achieve this safely in open, moid becomes fully detached [5, 8, 9, 12, 58, 59].
laparoscopic and robotic contexts [60].
Once the mesofascial interface has been
established, the mesentery is separated from the ateral to Medial Detachment
L
fascia and in this manner detached (but not dis- and Disconnection of the Left
connected). Separation of both is called meso- Mesocolon
fascial separation and is one of the most
important surgical steps in abdominal and intes- The lateral peritonotomy is extended proximally
tinal surgery. Eventually, a limit of mesenteric in the direction of the spleen. The descending
detachment will arise. In this case, the perito- colon is generally fused to the posterior abdomi-
notomy must be extended and another zone of nal wall with Toldt’s fascia, which is interposed
contiguous mesentery identified for detachment. between both of these structures. Lifting the
If this process is continued cephalad and caudad, colon away from the posterior abdominal wall
and, as far medially as the left peritoneal reflec- places the interface between both on stretch, and,
34 Total Hindgut Mesenteric Mobilization for taTME 369
with appropriate tension and counter tension, White Line of Toldt, and it is mentioned here in
these can be sharply separated. As this is cotin- order to emphasise that one should not rely on the
ued medially, the mesentery is encountered and identification of this landmark to guide dissec-
the same principles of reflecting the mesentery tion. Instead one should rationalize the anatomi-
away from the posterior abdominal wall, then cal appearance and landmarks in mesenteric,
separation from underlying fascia, apply. This is fascial and peritoneal terms. As with lateral to
continued medially as far as the medial reflection medial mobilization, further detachment is ulti-
which is then divided. It is also continued as far mately impeded by attachment of the mesenteric
proximally as possible where the attachment of component for the flexure. This must be formally
the mesenteric component of the splenic flexure detached before mobilization can be considered
usually impedes further dissection. The surgeon complete [5, 8, 9, 12, 58, 59].
may elect to disconnect the left mesocolic mes-
entery at this point or formally mobilize the mes-
enteric component of the flexure. The latter is The Splenic Flexure
generally recommended as it is usually required
to provide sufficient reach for an anastomosis in The anatomy of the flexures has always been
the setting of taTME. Either way, mesenteric dis- poorly described. It is likely this was mainly due
connection requires that the mesentery (contain- to the fact that according to the classic model,
ing the inferior mesenteric vein (IMV)) is divided regions of mesentery commenced or ended at the
through to the level of the surface of the intestinal flexures. In other words, anatomical correlates of
wall [5, 8, 9, 12, 58, 59]. start or end structures should be apparent
It is important to note that the IMV is con- (Fig. 34.1) [1, 5, 10, 12]. Mesenteric anatomy is
tained in the mesentery and that it does not con- readily explained by the current mesenteric-
nect the mesentery to the non-mesenteric domain based model of abdominal anatomy. Each flexure
of the abdomen. As a result, it is not included in is comprised of four structures centred on a mes-
mechanisms by which the mesentery is generally enteric confluence. At the splenic flexure, the
maintained in position, but it is important when it confluence is between the distal transverse meso-
comes to disconnecting contiguous regions of colon and the left mesocolon (Fig. 34.11). The
mesentery in order to permit a resection [5, 8, 9, intestine rounds the periphery of the mesenteric
12, 58, 59]. confluence. The upper and lateral aspects of the
confluence are obscured from direct visualization
by the peritoneal reflection. The greater omentum
edial to Lateral Detachment
M fuses with the splenocolic region of the reflection
and Disconnection of the Left to varying degrees. When the flexure is consid-
Mesocolon ered in terms of these components, then flexural
mobilization becomes a matter of disrupting each
Given the continuity of the mesentery, perito- of these components [1, 5, 10–12].
neum and fascia, the technique of medial to lat-
eral detachment involves the same activities with
these being conducted utilizing a medial to lat- plenic Flexure Mobilization: Medial
S
eral approach. In keeping with this method, the to Lateral Approach
medial reflection is firstly divided. The left meso-
colon is lifted away from the fascia placing the If the dissection had commenced from medial to
interface on tension. This helps in identification lateral, then the left mesocolon would be detached
of the interface and separation of its components. as far cephalad as possible, where further detach-
Of note, a white line will often be visualized at ment would be limited by attachment of the
the interface between the mesentery and the mesenteric component of the flexure. It is possi-
underlying fascia. This is also a region of the ble to disrupt the relationship between this, and
370 J. C. Coffey and R. Sehgal
the underlying fascia, until the mesentery is fully fascia. This is then completed to the point where
detached and lesser sac entry is achieved. At this further detachment is impeded by the middle colic
point, the last structures to assist in maintaining vascular pedicle [1, 5, 10–12, 57–59].
the position of the flexure are the greater omen-
tum and the reflection [1, 5, 10–12].
The greater omentum can be divided just out- Future Directions
side the epiploic arcade of the greater curvature
of the stomach and the division continued from Hindgut mobilization for taTME can be achieved
medial to lateral until the spleen is encountered. reliably and safely using the mesenteric-based
At this point, the omentum is fused to the spleno- approach described above. In addition, the termi-
colic reflection, obscuring the latter from view. If nology that has been derived from the mesenteric
the omentum is divided, then the region where it based model, enables one to rigorously stan-
is attached can be retracted infero-medially, dardise mobilization. It also allows the surgeon
thereby exposing the underlying splenocolic repeatedly and reproducibly explain the precise
region of the reflection. This can then be divided anatomical basis to taTME. Furthermore, the
and the division extended towards the left lateral new terminology greatly aids in standardization
reflection at the lateral aspect of the descending of operative documentation and descriptions.
colon. If this is divided, then the mesentery of the This is particularly important for the process of
flexure is fully detached and can be liberated as taTME, because transanal extraction for speci-
far medially as the region where the middle colic men retrieval and generally ultra-low anastomo-
pedicle arises [1, 5, 10–12]. ses mandate careful and complete mobilization
of the hindgut, often in its entirety.
Most debate in rectal surgery at the moment
plenic Flexure Mobilization: Lateral
S centres on which is the best modality to use:
to Medial Approach open, laparoscopic, robotic or (most recently)
taTME. As the anatomical basis of colorectal
If a medial to lateral mobilization was conducted, surgery has only recently been clarified, it has
then the order in which the components of the not been possible to rigorously standardize
flexure are disrupted differs from that described resectional surgery with a view to formally test-
above. Firstly, the left lateral reflection is divided ing how each of these surgical techniques per-
as far cephalad as possible. It is usually impeded forms against each other. The result is that it is
by the region where the greater omentum fuses unlikely we will know which platform is the best
with the splenocolic region of the reflection. At for a long time to come. In that context, it is
this point, the surgeon may begin dividing through probably best that surgeons employ the modality
the omentum to enter the lesser sac, and then con- they feel is best allows them to access the embry-
tinue division of the omentum as far laterally as ological roadmap that is routed in the mesenteric
possible. Then the surgeon can retract the flexure model of abdominal anatomy. That will vary
infero-medially, thereby placing the omentum depending on the surgeon, the patient and the
under gentle tension, and allowing its division in pathology.
this region. As the omentum and reflection have
fused, division of the former is usually associated
with division of the latter. With division of the References
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372 J. C. Coffey and R. Sehgal
The vast majority of surgery takes place in the Fluorophores are compounds that emit energy as
visible ‘white light’ spectrum. Utilizing other fluorescence when excited by light of a specific
areas of the electromagnetic spectrum, in particu- wavelength [1]. As the spectrum of absorption
lar near-infrared (NIR) light, could aid surgical and emission of these substances is commonly
decision-making and ultimately improve patient known, these photophysical characteristics have
outcomes in selected patients. Fluorescence- enabled the use of fluorescence in many indus-
guided surgery incorporates the use of a fluoro- trial applications including selective use during
phore or fluorescent dye to identify anatomical, surgery. The near-infrared (NIR) spectrum (700–
physiological and pathological processes when 900 nm) is most commonly used for intraopera-
injected intravenously or interstitially. This tive applications [2]. This spectrum optimizes the
approach can provide important additional infor- wavelengths in which the common fluorophores
mation to help guide the surgical procedure and present in the human body do not exhibit fluores-
potentially reduce specific complications such as cence [3]. At lower wavelengths the fluorescence
anastomotic leak. In this chapter, we will detail of haemoglobin predominates, and at higher
the theoretical basis of fluorescence-guided sur- wavelengths the fluorescence of water predomi-
gery as well as the clinical applications in nates. These endogenous fluorophores will pol-
colorectal surgery, in particular transanal surgery, lute the signal if wavelengths outside the
and future areas of research. near-infrared spectrum are used intraoperatively.
The ideal fluorophore will have the ability to
clearly fluoresce with minimal distortion from
background signal and have the ability to suffi-
ciently penetrate tissues with increasing depth.
At present, most fluorophores are only able to
fluoresce through a few millimetres of tissue lim-
iting their clinical application.
A. S. Soares · M. Chand (*) Besides the photophysical properties, the
Division of Surgery and Interventional Sciences,
University College London Hospitals, NHS Trusts, pharmacodynamic and pharmacokinetic profiles
GENIE Centre, University College London, are also important as a clinically useful fluoro-
London, UK phore can be given before or during surgery [4].
e-mail: [email protected]; If a fluorophore is administered before surgery,
[email protected]
the ideal situation would be to have a predictable limiting it to preoperative uses, such as with con-
half-life. For fluorophores used intraoperatively, ventional angiograms.
rapid distribution and excretion are more impor- Intraoperative angiography provides the
tant considerations. potential to assess perfusion of organs including
A camera using a special filter needs to be the colon. Colonic perfusion is most important
used to be able to identify light at this spectrum during bowel resection and anastomosis, as this
and several options are available in the market remains one of the key determinants of an anasto-
[5]. There are differences in the specific range of motic leak [10]. Currently, there is no standard-
wavelengths covered by the different equipment ized method to assess colonic perfusion during
[6]. This technology naturally lends itself to the construction of an anastomosis. The common
minimally invasive surgery setting, be it laparo- practice is to check for the pulsation of the mar-
scopic or robotic. ginal artery, to document bleeding from the cut
edges of the bowel, and to assess the colour of the
bowel segments to be anastomosed [7]. But these
Indocyanine Green (ICG) are all subjective methods and lend themselves to
a non-quantified degree of variability.
ICG is the most widely used fluorophore in clini- Furthermore, they rarely provide a clear demar-
cal practice. The compound is a heptamethine cation between well-perfused and non-perfused
cyanine fluorophore. It circulates bound to albu- tissue. ICG can be used during bowel surgery to
min when injected intravenously, due to its provide a more objective assessment of perfusion
hydrophobicity. The half-life in serum is 3–5 min- at the time of anastomosis and can lead to a
utes [7], after which ICG undergoes biliary excre- change in resection margin when compared to
tion. This fluorophore has a peak excitation standard clinical assessment [11, 12]. The role of
wavelength of 807 nm and a peak emission wave- perfusion angiography (PA) is a dynamic one
length of 822 nm [5]. Allergic reactions have with a growing field of applications and rapidly
been described, but the overall frequency is low accruing data on its usefulness.
(0.103%), and they are generally mild [8].
Hypotension may occur in 0.034% of patients.
Due to ICG’s structure containing iodine, patients urrent Status of Perfusion
C
with previously documented iodine allergy (e.g. Angiography in Colorectal Surgery
allergy to CT contrast) should avoid contact with
ICG as there is considerable cross-reactivity. Anastomotic leak (AL) remains one of the most
challenging complications in colorectal surgery.
AL leads to increased morbidity, longer hospital
Definition of Perfusion Angiography admissions and increased use of intensive care
units, incurring additional annual costs of £1.1–
Angiography is a technique used to visualize vas- 35 million in the United Kingdom’s National
cular structures. This was done initially through Health Service alone [13]. The additional cost per
the injection of radiopaque contrast agents into patient with AL is between £3372 and £10,901. In
the vessels followed by X-ray imaging through addition to the financial burden, there is also a risk
the efforts of pioneers like Osborn, Egas Moniz of worse survival outcomes for those patients
and Forssmann in the first half of the twentieth undergoing surgery for colorectal cancer [14].
century [9]. In recent years, there has been Despite advances in perioperative care and
increasing interest in this technique with several surgical technique, the risk of anastomotic leak is
new fluorophores being developed along with still up to 19% in colorectal anastomoses [15].
more complex imaging systems. This has allowed The leak rate is higher in patients who require a
surgeons to use the principles of perfusion angi- low rectal anastomosis which is often seen in
ography in real time during surgery rather than patients undergoing taTME. Indeed, these are up
35 The Role for Perfusion Angiography 375
PA assesses the blood flow to the tissue but does ICG is a nonspecific fluorophore. The knowledge
not consider other factors that might play a causal of cell markers [44] and the improvement of tech-
role in the occurrence of AL. Surgeon prediction nical capabilities have enabled the synthesis of
of AL is not reliable [40]. It seems plausible that targeted fluorophores [45]. The development of
patient factors (nutritional status, previous this new area of fluorescence-guided surgery
chemoradiotherapy, frailty) and technical aspects opens the gateway to tailored fluorescence and
play an important role in AL [41]. Recently, dys- improved benefit for patients. The regulatory
biosis and the impact of the microbiome in anas- pathways for these molecules are not yet stan-
tomotic integrity have been pursued in dardized [46] which is an area of active interven-
mechanistic studies. Surgery represents a major tion by the scientific societies.
physiological stress, and postsurgical recovery is
not fully understood. Recent evidence has shown
that the preoperative bowel preparation, prophy- Conclusions and Future Directions
lactic antibiotics and surgical trauma have a sig-
nificant impact in the microbiological The use of fluorescence angiography has been
environment at the anastomosis. The extent to shown to be promising in observational studies
which these factors shape the microbiome has not in colorectal surgery and especially in the con-
been completely elucidated [42]. This may lead text of colorectal cancer. Lowering the
to a disproportionate increase in bacteria with a Anastomotic leak rate and its attendant conse-
more virulent phenotype [41]. The absence of the quences is of extreme importance. Randomized
normal bacteria may favour the occurrence of trials are underway to better define the contribu-
disseminated infection and sepsis, AL or superin- tion of this technique to patient management. As
fection (e.g. C. Difficile). Preclinical models have data accrues, a rise in dissemination of the tech-
suggested that inflamed and injured intestinal tis- nique is expected. Further work will also be nec-
sues undergoing repair select strains of bacteria essary to elucidate the role of non-vascular
that express a high collagenase-producing pheno- factors in anastomotic leak. The influence of the
type which contributes to anastomotic leak [43]. microbiome might be a relevant factor as pre-
The culture-based methods have been replaced liminary reports have shown.
by RNA sequencing and transcriptomic analysis Fluorescence-guided surgery will continue to
that expands the ability to study the microbio- evolve. Future developments include the defini-
logical environment [42]. Therefore, there is tion of quantitative measures and synthesis of
great potential to explore the microbiome to targeted fluorophores. Aiming to improve patient
improve health and prevent AL, as this becomes a care and outcomes, this field will certainly
more developed area of research. increase the precision of the surgical armamen-
tarium. It is then the job of surgeons, scientists
and healthcare industry to collaborate to intro-
Fluorescence Quantification duce these developments into clinical practice in
an efficient and safe manner.
At present there is no method of quantifying fluo-
rescence in real time in the operating theatre.
Benefits of achieving this include standardization References
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Perioperative Preparation
and Postoperative Care 36
Considerations
Anuradha R. Bhama, Alison R. Althans,
and Scott R. Steele
A detailed obstetric history should also be preference. First, an external inspection of the
obtained for women including assessment of perianal skin should be performed to assess for
number of pregnancies, vaginal deliveries, and fissures, fistulas, abscesses, and skin tags. Patients
any instrument-assisted deliveries; this history is undergoing TaTME for ileal pouch creation in
important for assessing potential sphincter func- ulcerative colitis should have a thorough anorec-
tion. Along these lines, an assessment of preop- tal examination to ensure there are no signs of
erative continence is necessary to determine if a unexpected perianal Crohn’s disease. The patient
coloanal anastomosis will be tolerated. In cases should be asked to squeeze with their sphincter
concerning for possible difficulty with postopera- muscles to assess function of the external anal
tive continence, anal manometry may be utilized sphincter. Next, a digital rectal examination is
to objectively assess sphincter function. essential, as this will provide information regard-
Additional history should include past medi- ing function as well as the extent and location of
cal, surgical, and family history. Past medical his- any malignant disease. The state of the pelvic
tory will often guide further preoperative testing. floor muscles can be evaluated on digital exam as
Assessment of baseline functional and cardiopul- well. In cases of malignancy, the surgeon should
monary status may warrant preoperative evalua- note relation of the tumor to the anal verge and
tion by specialists in cardiology, vascular sphincter complex, possible adherence to of inva-
medicine, pulmonary medicine, or anesthesia. sion of local structures, size of the mass, and
These specialists may also assist in temporarily qualities of the mass such as texture and mobility.
stopping or bridging anticoagulation therapy or TaTME is an especially helpful technique for
determine if an inferior vena cava filter is required obese males with bulky low rectal cancers, as the
preoperatively. Frequently, patients with history transanal approach allows for more direct visual-
of renal impairments undergo optimization and ization and definition of the distal margins, which
coordination with their nephrologists for medica- is typically more challenging in these patients
tion and fluid management, as well as for plan- when utilizing the traditional transabdominal
ning perioperative dialysis. Diabetes, approach [10]. In women, if there is suspicion
immunosuppression, obesity, and smoking must that the tumor invades the vaginal walls, then a
all be addressed and managed preoperatively [9]. vaginal exam should be performed. A bimanual
Consideration should be given to these various exam, with a finger in the rectum and a finger in
comorbidities that may contribute to an increased the vagina, may be helpful in delineating the true
risk of anastomotic leak. extent of invasion. This can be further character-
A thorough physical examination should ized on preoperative staging MRI.
focus on the abdominal and digital rectal exami-
nations. The abdominal examination should
assess for prior scars or hernias that should be Preoperative Testing
taken into consideration for operative planning.
The abdomen should be examined for distension, During the general preoperative evaluation, the
suggestive of partial obstruction, and organomeg- surgeon should always be cognizant of and
aly or masses, suggestive of potential metastatic searching for factors that may influence the risk
disease. Body habitus should be noted as it plays of anastomotic leak. Several studies have identi-
a role in patient positioning and port placement in fied the following as possible risk factors for
the operating room. Obesity also influences leak: male gender, obesity, smoking, chronic
potential sites for stoma marking. immunosuppression, hypoalbuminemia, tumors
Given that the goal of TaTME is sphincter >25 mm, and preoperative steroid and nonsteroi-
preservation, a careful anorectal examination is dal anti-inflammatory drug use [11, 12]. As part
crucial. This examination can be done in left lat- of the preoperative screening evaluation, all
eral position or prone jackknife position, depend- patients undergoing abdominal surgery should
ing on the patient’s tolerance and the surgeon’s generally have routine laboratory tests drawn,
36 Perioperative Preparation and Postoperative Care Considerations 383
including a complete blood count, serum chemis- a pelvic MRI with contrast should be obtained for
try, as well as coagulation studies. Blood should local staging [14]. In patients with a contraindi-
be typed and screened. Testing should also cation to MRI, an endorectal ultrasound can be
include an assessment of the patient’s nutrition utilized for local staging. All patients are pre-
levels and protein stores. In patients with rectal sented at a multidisciplinary tumor board, where
cancer, a baseline preoperative CEA level should the clinical presentation, radiologic findings, and
also be established. Women of childbearing age pathology slides can be reviewed by a multidisci-
must have a urine pregnancy test. Patients may be plinary group of experts to create an individual-
evaluated at a pre-anesthesia clinic, which can ized plan of care for each patient [15, 16]. The
determine the need for any further testing such as principles of neoadjuvant therapy for patients
hemoglobin A1C levels, thyroid function studies, undergoing TaTME are consistent with those
iron studies, electrocardiogram, stress testing, or applied to any other preoperative rectal cancer
other testing. Attention should be paid to nutri- patient. Depending on multidisciplinary tumor
tional status, substance abuse screening, preop- board recommendations, patients will typically
erative opioid utilization assessments, and any undergo short- or long-course chemoradiation
special medications. This may include anticoagu- therapy followed by resection at the appropriate
lation, immunosuppression, and chemotherapy. time interval. PET scans are not routinely indi-
Endoscopic visualization of the lesion is nec- cated and should be reserved for select situations,
essary following the digital rectal exam. This can typically following the guidance of a multidisci-
be accomplished with flexible or rigid proctos- plinary tumor board recommendation.
copy, with or without sedation. In cases of benign
indications, proctoscopy should be performed to
rule out any underlying malignancy. Visualizing Preoperative Stoma Marking
the lesion endoscopically will allow for charac-
terization of the lesion in regard to circumfer- Prior to surgery patients should be marked for
ence, friability, and both distal and proximal ostomy sites. This includes both diverting loop
extent. The level of obstruction of the lumen can ileostomy and end colostomy. Patients who
also be judged during the endoscopic examina- undergo preoperative marking have better results
tion. This will help determine if the patient postoperatively [17]. Patients should always be
requires diversion prior to the initiation of neoad- counseled as to the need for an ostomy. In the
juvant therapy. Biopsies can be taken to confirm case of diverting loop ileostomy, the ostomy does
pathology. If not already done, all patients should not help prevent anastomotic leak but does mini-
undergo a complete colonoscopy to exclude syn- mize the clinical severity if one were to occur
chronous lesions. [18]. In some cases, even with the intention of
Staging is key to the preoperative assessment performing a TaTME with primary anastomosis,
of any cancer patient. In regard to the history and there are situations in which an anastomosis can-
physical, inquiring about systemic symptoms not be performed and an end colostomy must be
such as weight loss and fatigue is important. On created. Patients should be marked and counseled
exam, special attention should be given to signs for this possibility, regardless of the low proba-
such as muscle wasting, abdominal distension, bility of this occurring.
hepatomegaly, and lymphadenopathy [13]. As
mentioned previously, asking questions regard-
ing change in bowel habits and signs of obstruc- Sphincter Evaluation
tion is important. Utilization of ASCRS and
NCCN staging guidelines is necessary for all In addition to a thorough physical examination,
patients with rectal cancer to direct both local and several studies are available to evaluate the func-
distant staging. A CT of the chest, abdomen, and tion and anatomy of the internal and external
pelvis should be obtained for distant staging, and sphincter muscle. Since a transanal approach is
384 A. R. Bhama et al.
Though titled enhanced recovery after surgery, Preoperative evaluation should focus on optimi-
the ERAS pathways include preoperative, intra- zation of the patient’s general condition as well
operative, and postoperative components for as specific presurgical elements. Smoking cessa-
patients undergoing colorectal surgery that allows tion and limiting alcohol consumption have been
for optimization of their entire perioperative care shown to have improved postoperative outcomes
(Fig. 36.1). when carried out for greater than 4 weeks prior to
The preoperative phase includes the initial operation [21]. Optimization of nutritional sup-
evaluation of the patient, patient education, port, through patient education and/or the addi-
mechanical and antibiotic bowel preparation, pre- tional of protein supplements, may improve the
operative analgesia, and fasting prior to the opera- overall status of the patient as well. Evaluation
tion. The intraoperative phase of ERAS includes and optimization of medical comorbidities are
the utilization of minimally invasive approaches, also necessary and may include several evalua-
such as TaTME, intraoperative fluid restriction, tions by subspecialty physicians. Preoperative
analgesia, and venous thromboembolism prophy- evaluation may include utilization of a modified
laxis. The postoperative phase includes early frailty index (MFI) that has been shown to
36 Perioperative Preparation and Postoperative Care Considerations 385
c orrelate with increased length of stay and can decrease the rate of venous thromboembolism [26].
assist in identification of patients who may The use of preoperative intravenous antibiotics
require additional resources. These patients may administered within 60 minutes of the incision, and
be identified to participate in prehabilitation pro- in adherence with SCIP (Surgical Care
grams to further optimize outcomes. Improvement Program) guidelines, has been shown
Along with optimization of the patient, educa- to minimize the risk of surgical site infection [27].
tion is paramount in preparation for surgery. Several antibiotic regimens are utilized (isolated or
Clear goals should be set with the patient in in combination), including cefoxitin, ertapenem,
regard to pain control, diet advancement, patient ampicillin/sulbactam, ceftriaxone, cefazolin,
participation in recovery, and discharge criteria. Flagyl, Cipro, gentamycin, and clindamycin [28].
In preparation for the operation, all patients Administration of IV antibiotics within 60 min
should undergo mechanical bowel preparation. prior to incision has been found to result in a sig-
Though the utility in bowel preparation in pre- nificant reduction in surgical site infection follow-
venting infection or leak remains in question, it is ing colorectal surgery [29, 30]. Anti-nausea
still commonly utilized as it provides several prophylaxis should also be administered. The utili-
benefits in the laparoscopic setting. The decom- zation of alvimopan in minimally invasive surgery
pressed bowel after mechanical bowel prepara- remains controversial, and current indications in
tion allows for easier manipulation and specimen colorectal surgery include open operations without
extraction [22]. The addition of oral neomycin creation of a diverting ostomy [31, 32].
and metronidazole with the mechanical bowel
prep remains controversial, but some studies
have shown a significant decrease in rate of post- Intraoperative
operative surgical site infection when utilized
[23]. Given the transanal nature of the operation, There are several intraoperative elements that
the rectum should be completely cleared of stool are involved in the ERAS guidelines that
for visualization of the rectal mucosa during require participation by both the surgical and
placement of the purse-string suture in the anesthesia teams. First, surgeons should attempt
TaTME approach. Furthermore, colon prepara- to utilize minimally invasive techniques when-
tion can help limit the soiling of bacteria into the ever possible, either laparoscopic or robotic.
surgical field in the event a purse-string failure is Laparoscopy has been shown to have improved
encountered intraoperatively. outcomes including decreased surgical site
Traditionally, patients have remained fasting infection, infectious complications, pain scores,
from midnight the night prior to surgery. Some anastomotic leak, and decreased length of stay
centers have chosen to allow patients to continue [33–38].
to consume clear liquids up until 2 h prior to sur- Long-acting opioids should be avoided as they
gery and/or provide patients with various carbo- contribute to postoperative ileus. In the preopera-
hydrate loading fluids to consume the morning of tive area, patients may be given various nonste-
surgery. The theory behind this strategy is that roidal (acetaminophen, celecoxib) or neuropathic
reduction of insulin resistance may lead to a (gabapentin) pain medications to minimize the
faster recovery [24]. There is no definitive data need for opioids [39]. Another adjunct that may
that this improves surgical outcomes and may in reduce the need for opioids is the transverse
fact increase the anesthetic risks [25]. More abdominus plane (TAP) block [40, 41]. This can
research on this topic is necessary prior to draw- be performed by either the anesthesia or surgical
ing a firm conclusion. teams. This block is designed to anesthetize the
Prior to the operation, patients should be given nerves that supply the abdominal wall (T6 to L1).
venous thromboembolism prophylaxis. 5000 units Studies have shown that TAP blocks improve
of heparin administered subcutaneously prior to immediate postoperative pain outcomes and
the induction of anesthesia has been shown to decrease opiate requirements [42].
386 A. R. Bhama et al.
The routine utilization of nasogastric decom- nasogastric tubes are left in place and patients are
pression postoperatively is no longer recom- advanced on a diet rather quickly. Patients ini-
mended. Patients may forgo the use of gastric tially start on clear liquids and advance to full
decompression altogether, or an orogastric tube liquids and then a low-residue diet within the first
may be utilized during the operation when indi- day postoperatively. Studies have shown that
cated with removal at the end of the operation patients who are provided with a solid diet imme-
[43]. The patient’s body temperature should be diately postoperatively have shorter overall
maintained at normothermic temperatures (36– lengths of stay than those who are started on liq-
38 °C). Methods to achieve normothermia uids [53, 54]. Patients are allowed to self-regulate
include use of warm airflow blankets, warming their diets based upon their own tolerance levels.
the ambient temperature of the operating room, If a nasogastric tube is left for gastric decompres-
and warm intravenous fluids. Maintenance of sion, it is closely monitored for output and qual-
normothermia has been shown to decrease surgi- ity of drainage. The tubes are removed as soon as
cal site infection [44, 45]. Surgical drains should possible, and the patient is advanced on a diet as
also be used judiciously, as the data regarding tolerated. Multimodal analgesia utilizing nonste-
drain placement are conflicting [46, 47]. roidal anti-inflammatory drugs and neuropathic
One of the more controversial intraoperative pain medications helps avoid the need for narcot-
ERAS items is the management of fluid adminis- ics, which decreases ileus and in turn decreases
tration. There are two approaches to intraopera- length of stay. Early mobilization is also a major
tive fluid resuscitation – traditional and restrictive factor in reducing ileus, and patients are encour-
[48]. Traditionally, fluids are given liberally at a aged to ambulate in the hallway of the surgical
maintenance rate with additional fluids given to unit five times per day with assistance. Again,
replenish insensible losses and estimated blood fluid management is judicious, and as patients
loss. Newer data has emerged that demonstrates tolerate oral intake, intravenous fluid rates are
that this liberal approach to fluid resuscitation minimized.
has been associated with adverse postoperative Post discharge planning starts immediately
outcomes [49, 50]. Several randomized control upon admission to the surgical unit. If necessary,
trials have demonstrated mixed results. Some physical therapy evaluations and recommenda-
have shown that a restrictive, goal-directed tions are obtained, and discharge needs are iden-
approach is associated with decreased postopera- tified early. Patients start working with wound
tive complications, earlier return of bowel func- ostomy care nursing on the first postoperative
tion, and reduced length of hospital stay [51]. day to become accustomed to managing their
Other studies, still, have demonstrated that a lib- ostomy.
eralized fluid management approach confers Enhanced recovery after surgery requires col-
improved outcomes [52]. Further randomized laboration and participation from all members of
studies are needed to determine the ideal approach the patient care team. This includes not only the
to fluid management in colorectal patients. surgery team but the preoperative nursing staff,
the postoperative nursing staff, and the anesthesia
teams for management of intraoperative elements.
Postoperative With careful attention to patients’ specific needs,
ERAS can allow patients to successfully be dis-
Postoperative ERAS is essential for patient charge home safely without a risk for readmission
recovery. Over the last decade, there has been a or increased complications. The ERAS protocols
substantial paradigm shift in postoperative care used for traditional laparoscopic and open rectal
in the colorectal surgery patient in regard to cancer surgery should also be applied to those
nearly every aspect of their care. Typically, no patients undergoing the TaTME approach.
36 Perioperative Preparation and Postoperative Care Considerations 387
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Intraoperative Morbidity of taTME
37
T. W. A. Koedam, Jurriaan Benjamin Tuynman,
Sam Atallah, and C. Sietses
specifically on the lateral side wall and ventral to the close the rectum completely (Figs. 37.1 and 37.2).
rectum. Incorrect plane surgery has been described Insufficient closure or disruption of the purse
in the registry in 5.7% of all patients, although this string during dissection might cause contamina-
is likely underreported [5]. Dissection too close to tion of the surgical field (Fig. 37.3) with bacteria
the rectum will result in violating the mesorectum and tumor cells, increasing the risk of infection
or damaging the specimen via injury to the rectal and potentially negatively influencing the onco-
wall proper with perforation, which is known to logical outcome as is observed in patients with a
increase the likelihood of local recurrence [8]. rectal perforation [9]. In addition, if the closure of
Dissection outside the TME plane can, of course, the purse string is not airtight, the lumen of the
result in damage to the neurovascular structures or bowel can become distended during the process
an increased bleeding risk. of taTME, which thereby renders the abdominal
taTME can be broken down in clear steps which portion of the operation more difficult.
should be followed. For each step of the procedure, Infection may be a special problem during
there exists a potential for complications. These are taTME since the rectal wall is intentionally
delineated in the following sections. divided during the course of the operation, which
could negatively impact the sterility of the proce-
dure (i.e., compared to abdominal approaches
Purse-String Application which typically utilize staplers to simultaneously
and Preparation of the Lumen divide and seal the lumen). In a study by Velthuis
et al. [17], 23 consecutive patients underwent
During taTME the rectal lumen is closed using a taTME utilizing the TAMIS approach. Prior to
purse-string suture. and after purse-string application, the lumen was
Both the correct position and quality of this irrigated with a bactericidal agent. During the
suture are essential for a successful dissection and dissection, three samples were obtained sterilely
an adequate distal margin. The purse string should via a swab delivered into the pelvis from the
abdominal laparoscopic ports. This revealed that
39% of the cultures were positive for colonic
flora and, of these, 44% developed pelvic infec-
tion requiring therapy. The authors concluded
that taTME is associated with positive cultures in
more than one-third of patients, and the data sug-
gests that locoregional infectious complications
are more common. Thus, while infection is a
postoperative complication, its incidence may be
increased if during taTME, adequate irrigation
and a properly constructed purse string are not
assured.
Full-Thickness Rectotomy
Fig. 37.1 A purse string has been applied to the distal
rectum, and the rectotomy has been completed circumfer-
entially. While the purse string is intact, note that there is
After complete closure of the rectum, the next step
clearly a defect in the center as the purse string did not of taTME is a full-thickness, circumferential dis-
cinch down completely. The operator should at this point section of the rectal wall. For this step, a sufficient
stop the taTME operation and secure this using a second purse string is essential. Without adequate pres-
stitch, typically in a figure-of-eight fashion. Failure to
close even this small defect can lead to inadvertent spill-
sure it is difficult to find the proper layer of dissec-
age of stool and overdistension of the lumen rendering tion. It is easy to get off-plane in the muscular
further dissection difficult layer of the bowel wall. The consequence of insuf-
37 Intraoperative Morbidity of taTME 393
Fig. 37.2 In this example of a purse-string failure, the exposed lumen is visible. Such a violation to the purse-
purse string itself was intact with a complete seal. string proper occurs when the dissection proceeds in a
However, during the anterior dissection, the purse string plane too close to the rectum or when the purse string is
itself was violated causing it to unravel. Anteriorly, the applied in tissue planes beyond the rectal wall
Fig. 37.4 The left nervi erigentes, a splanchnic nerve before it was transected. Postoperatively, this patient suf-
which provides parasympathetic innervation to the genita- fered from erectile dysfunction. Note the exposed muscle
lia and which is responsible for erectile function in males, laterally signifying that the dissection is too lateral to the
is shown in the grasp of a hook cautery just moments mesenteric envelope
wall can occur. This injury might be less critical be dissection by connecting both the dorsal and
than urethral injury but can and should be avoided anterior plane. In the future, fluorescence with
by digital manipulation of the posterior vaginal indocyanine green could help identify the urethra
wall during taTME dissection along the anterior and prevent dissection in patients who received
plane. Bladder injury is rare (0.1%) and can often neoadjuvant radiotherapy or by surgeon in their
be managed by placement of a urine catheter and learning curve. Currently, this remains investiga-
sutured closure of the defect via transanal access tional with the only data showing feasibility
(Fig. 37.8). Furthermore, cystoscopy may be derived from cadaveric work [10]. Lighted near-
indicated to assess the urinary trigone depending infrared urethral stents appear to represent
on the point of injury [5]. another valid option for urethral localization
This mobilization of the prostate and dissec- [11–13].
tion of the urethra can be prevented by a stepwise
dissection. Before dissecting the lateral plane, the
anterior plane is localized. The lateral plane can The Anastomosis
Fig. 37.7 The close juxtaposition of the prostate gland to gland can become dorsally distracted leading to the pre-
the distal anterior rectal wall makes injury to the urinary prostatic urethra becoming inadvertently drawn into the
system one of the most dreaded complications of plane of dissection. (Photo courtesy of Ichiro Takemasa,
taTME. During the process of dissection, the prostate MD (Japan))
396 T. W. A. Koedam et al.
Fig. 37.8 The bladder can be subject to posterior distrac- and injured. Such injuries may be preventable with a syn-
tion and injury. Here, the anterior dissection proceeded chronous approach as the abdominal team can distract the
anteriorly beyond the prostate gland and seminal vesicles bladder ventrally to expose the anterior reflection at
in the proper plane, but then the bladder was encountered the point of rendezvous
Other Complications
Elisabeth C. McLemore and Patricia Sylla
Table 38.1 Cleveland clinic incontinence index of an anal or anastomotic stricture will hinder the
<1x per 1–2x per Weekly Daily surgeon’s ability to position the operating trans-
Incontinence month (1) month (2) (3) (4) anal access platform.
Gas The coexistence of fecal incontinence or bor-
Liquid
derline continence may alter the operative plan, as
Stool
temporary and permanent fecal incontinence have
Pad usage
Lifestyle been reported with transanal endoscopic microsur-
alteration gery (TEM) [17, 18]. Multiple small TEM studies
Scale of 5–20 have documented a transient decrease in sphincter
Minimal–No fecal incontinence: score of 5 resting pressures on anal manometry that was pro-
Full fecal incontinence: score of 20 portional to the duration of the procedure, with
resting pressures returning to baseline 12 months
functional outcomes after TAMIS and taTME postoperatively [19–22]. Alterations in resting
will be reviewed separately in the remainder of anal sphincter pressures did not translate into any
this chapter. detrimental effects on continence. In a study of 41
TEM cases, Cataldo et al. found no significant
changes in the Fecal Incontinence Severity Index
Functional Outcomes: TAMIS (FISI) or Fecal Incontinence Quality of Life
(FIQL) scores 6 weeks postoperatively relative to
TAMIS [9] is a modern evolution of the transanal preoperative scores [17].
endoscopic microsurgery (TEM) technique pio- A recent study that longitudinally assessed
neered by Gerhard Buess in 1983 [10]. TEM has anorectal function and quality of life in 102 TEM
been a disruptive technique in colorectal surgery. patients preoperatively and at 6, 12, 26, and
The initial results comparing TEM to the stan- 52 weeks postoperatively found that the general
dard of care, transanal excision (TAE) revealed quality of life scores (EQ-5D) were significantly
that TEM was associated with superior quality of lower at 6 and 12 weeks but returned to baseline
resection demonstrated by the higher rate of at 26 weeks. Similar to prior studies, anorectal
achieving negative margins [10, 11]. Long-term function as assessed by colorectal functional out-
results revealed that TEM resection of rectal come (COREFO) was worse at 6 weeks postop-
lesions also resulted in a lower local recurrence eratively but returned to baseline at 12 weeks
rate compared to TAE [12–16]. More recently, postoperatively [23]. However, two TEM series
multiple transanal platforms have been devel- reported persistent sphincter dysfunction follow-
oped, and new techniques and terminology (such ing TEM on long-term assessment using either
as TAMIS) have broadened the utility and appli- St. Mark’s fecal incontinence score or Wexner
cations of the TEM technique. and Kamm incontinence scores [24, 25]. Dafnis
Prior to consideration of any transanal endo- et al. reported a 37% rate of various degrees of
scopic surgical resection technique for removal fecal incontinence in 48 patients at a median fol-
of rectal lesions, patients must first undergo a low-up of 22 months following TEM and found a
systematic evaluation to properly characterize correlation with OR time [25]. Restivo et al. also
and stage the rectal lesion. The history and physi- reported a 28% incidence of variable degrees of
cal examination is the cornerstone of preopera- fecal incontinence at a median follow-up of
tive evaluation prior to considering a surgical 40 months among a cohort of 89 patients who
technique, such as TAMIS. An overall assess- underwent TEM. Preoperative radiotherapy and
ment of the patient’s general health is important perioperative complications were found to be
to determine the ability to tolerate general anes- independent risk factor for functional distur-
thesia and determine the surgical approach. bances [24].
Previous anorectal surgery is an important con- TAMIS is a more recent surgical technique
sideration when planning TAMIS. The presence compared to TEM, and naturally, the reported
38 Functional Outcomes to Transanal Minimally Invasive Surgery (TAMIS) and Transanal Total… 401
functional outcome data after TAMIS is less similar to that of healthy case matched controls at
robust in comparison. Albert and Atallah have 3-year follow-up. There seems to be no associa-
reported their outcomes after TAMIS in their first tion between fecal incontinence scores and
50 cases in 2013 reporting on margin status, reported quality of life. However, the potential
specimen integrity, and postoperative complica- negative impact of TAMIS on fecal continence
tions [26]. The adoption of TAMIS has since then and/or quality of life should not be underesti-
grown, as reflected by several additional midsize mated and should be discussed during preopera-
case series that have been published [27]. tive counseling.” [31]
However, most early TAMIS case series have not There is growing interest in formal evaluation
reported on functional outcomes. In a small pro- of functional outcomes after TAMIS and other
spective study conducted by Schiphorst et al., transanal endoscopic surgical resection tech-
functional outcomes following TAMIS were niques. We eagerly await long-term functional
assessed in 37 patients using FISI score preoper- outcomes following TAMIS in the setting of
atively and at 3, 6, 9, and 12 months postopera- larger multicenter studies. In the meantime, it is
tively [28]. Among 17 patients with decreased advisable to follow the cautionary report by
preoperative fecal continence at baseline, Clermonts and colleagues and continue to coun-
improved FISI scores were noted in 88%, while sel patients preoperatively regarding the potential
among 18 patients with normal continence at impact on social and functional outcomes after
baseline, no change in FISI scores was found in transanal endoscopic surgery using any type of
83%, suggesting preserved long-term anorectal transanal access device.
function following TAMIS procedures.
In 2017, Clermonts et al. published the inci-
dence of impaired fecal incontinence in 42 Functional Outcomes: taTME
patients who underwent TAMIS [29]. The fecal
incontinence severity index (FISI) [30] was uti- With increasing interest in natural orifice surgery,
lized to assess fecal continence over a median the dynamic evolution of transanal and endolu-
follow-up time period of 36 months (range minal surgical techniques continues. These tech-
24–48). The preoperative FISI score was 8.3 niques began with transanal endoluminal surgical
points. One year following TAMIS, the mean removal of rectal masses and have progressed to
FISI score was 5.4 points (p = 0.5). Three years transanal radical proctectomy for rectal cancer.
after TAMIS, the mean FISI score was 10.1 The first case of taTME was performed in 2009
points (p = 0.01). Overall, fecal continence by Sylla, Rattner, Delgado, and Lacy [32]. The
improved in 11 patients (26%) and decreased in improved visibility and working space associated
20 patients (48%) [29]. with the taTME technique are appealing and have
More recently, 37 patients who underwent resulted in many surgeons to return to the cadaver
TAMIS were compared to healthy controls in an lab for additional rectal cancer surgical training
attempt to further evaluate the quality of life in in the taTME technique [33, 34].
patients following TAMIS [31]. The quality of There are several ongoing clinical trials fur-
life outcomes were measured using the Short ther evaluating the safety and efficacy of the
Form 36 health survey (SF-36) questionnaire. taTME technique. Many of these trials are also
The postoperative quality of life scores in the assessing functional outcomes in addition to
TAMIS group were similar to those reported by oncologic outcomes after taTME. A multicenter
Dutch healthy controls. The quality of life scores phase II study of transanal TME (taTME) led by
for the “social functioning” domain were lower Patricia Sylla (Mt. Sinai Hospital, New York
in patients who had undergone TAMIS compared City) is currently enrolling patients with Stage
to healthy controls (84 vs. 100 points, p = 0.03). I–III rectal cancer (NCT03144765, ClinicalTrials.
The authors concluded that TAMIS is a safe tech- gov Identifier). A single-center clinical trial titled
nique with postoperative quality of life scores “Transanal total mesorectal excision for rectal
402 E. C. McLemore and P. Sylla
cancer on anal physiology plus fecal inconti- impact on social and functional outcomes after
nence” led by Dr. Tracy Hull (Cleveland Clinic, TME for rectal cancer using any surgical techni-
Ohio) is also actively enrolling patients for fur- cal approach.
ther evaluation of this technique (NCT03283540,
ClinicalTrials.gov Identifier). The COLOR III,
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Oncologic Outcomes
39
Sharaf Karim Perdawood
Grading of TME Specimen rectal cancer. With no doubt about the short-term
benefits of laparoscopy, the oncologic results con-
Total mesorectal excision (TME) is considered tinue to be questioned [6–12]. In search for the
the gold standard surgical procedure for mid and optimal method to achieve a perfect TME, tech-
low rectal cancer since Bill Heald described it and nological advances like robotic and transanal sur-
showed dramatic improvements in the long-term geries are to be regarded as ongoing efforts to
oncologic outcomes [1–3]. Thus, the goal of the achieve Heald’s TME in a minimal invasive man-
surgery is to achieve a perfect quality TME, where ner, especially where access to the low rectum is
the mesorectum is excised “totally” as the name challenging by other modalities.
implies. This goal is unfortunately not always Regardless of the approach used, surgeons
achievable in every case, especially in challenging must assure that the quality of the TME is as
cases where there are anatomical factors that ren- close to perfect as possible. Fortunately, TME
der the dissection difficult; prototypically this grading is well-standardized for the excised
occurs when the dissection is performed on an specimen. Efforts by pathologists alongside
obese male patient with a narrow pelvic inlet. advances in the surgical technique and the sur-
With the introduction of TME in the era of open geons who help modernize the approach to rec-
surgery, perfect specimens could be retrieved by tal cancer surgery have led to a standard and
well-trained colorectal surgeons in most cases, reproducible description of the excised speci-
and data were reproducible in numerous studies. mens [13–15]. The plane of surgery during
Even recently, data from open surgery show very TME constituted an independent factor for
high rates of satisfactory results [4, 5]. With the local recurrence in a recent analysis of a ran-
available evidence from open surgery, new mini- domized clinical trial (P = 0.002) [16]. While
mal invasive techniques must be rigorously com- rates of “complete” specimens after open TME
pared to these standards, as the oncological are acceptable in most publications from high-
quality should never be jeopardized. Ever since volume centers, laparoscopic surgery seems to
the introduction of laparoscopic surgery, the ques- lag behind. For this reason, taTME (a mini-
tion of whether it can reproduce the results from mally invasive technique with improved
open surgery remains essentially unanswered for access) could show immediate signs of
improvement in the quality of the performed
surgery through an improvement in the rates of
S. K. Perdawood (*)
Slagelse Hospital, Department of Surgery, “complete” mesorectal specimen as defined by
Slagelse, Denmark Phil Quirke [15].
The initial reported cases of taTME demon- modern approach to taTME. Marks et al. [37]
strated a remarkably high rate of “complete” reported results of 370 rectal cancer surgeries
mesorectal envelopes, and some even reported where TME was initiated from below. In 96% of
100% intact TME specimens [17–24]. However, cases, the TME specimen was either “complete”
terms like “satisfactory” or “good” results should or “nearly complete.” In conclusion, taTME
be interpreted with caution of whether the speci- seems to overcome difficulties in the dissection
mens were “complete” or “nearly complete.” of the lowest part of the rectum and may result in
With the increasing adoption of the procedure superior TME quality in select cases, although
and liberal inclusion of difficult cases, a tendency comparative, randomized trials are still lacking.
is seen toward a fall in the rates of specimen “com-
pleteness” [25–28]. These studies have showed
rates of “complete” specimens ranging from 47% Circumferential Resection Margin
to 84%. The largest published series with number
of patients included ranging from 50 to 186 plus One of the most important goals of surgery for rec-
taTME registry data have shown promising results, tal cancer is to achieve a free resection margin,
with rates of specimen “completeness” that are mainly through retrieval of a perfect specimen. The
comparable with those achieved through standard circumferential resection margin of the mesorectal
laparoscopic approach [28–37] . specimen has a great prognostic impact on the local
In the taTME registry study by Penna et al. recurrence and distant metastasis [38, 39]. It is the
[29], the TME specimen was “complete or near circumferential resection that is more frequently
complete” in 96% of cases (85% complete, 11% involved and is one of the more challenging aspects
near complete, 4% incomplete). However, patients of TME surgery. Numerous studies have shown
were registered from several centers, and there is alarmingly high rates of circumferential resection
probably a case selection bias, especially of the margin involvement, worse in tumors located in the
initial cases. The two reports from Barcelona with lowest part of the rectum [40–42]. To date, pub-
140 and 186 patients are probably overlapping; lished series of taTME have shown quite accept-
nonetheless the series of 186 patients is the largest able rates of involved circumferential resection
published to date [30, 31] . The authors reported margins. Even in advanced cases of rectal cancer
rates of specimen “completeness” of 97.1% and selected for taTME, Rouanet et al. [19] reported a
97.5%. These are without a doubt excellent results free margin in 87% of 30 patients with advanced
from experienced team that standardized the tech- rectal cancer. Overall, most studies report no
nique of taTME, which is still considered by most involved circumferential resection margins; this
colorectal surgeons to be a challenging and com- can be partly attributed to selection of less chal-
plex approach. The second largest published lenging cases. The rates of circumferential margin
series from one center to date is from Denmark involvement in the reported series range from zero
[34] and shows a rate of 86% specimen “com- to 11.8% [22, 25, 34, 36, 43–47] . Data from the
pleteness.” Other series have similarly acceptable international registry showed an involved circum-
rates of at least 84% [28, 32, 37] . A comparative ferential margin rate of 2.4%; however as a cau-
study by Velthuis et al. (2014) demonstrated that tionary note, 7.1% of this registry was “not
the TME quality was improved with the taTME reported” [29]. With the largest published number
approach versus the laparoscopic approach (96% of consecutive cases from a single center, De Lacy
vs. 72%, p < 0.05) [37]. et al. have reported a rate of involved margin of
An apparent conclusion of the investigators 8.1% (defined as CRM ≤ 1 mm, excluding T4
has been that to improved surgical access with tumors) [31]. Perdawood et al. [48] have shown
taTME, translated into improved TME quality. comparable rates of margin involvement among
This has been shown to be the case with transanal patients treated by open, standard laparoscopic
dissection in similar fashion without using the and transanal procedures. In analyzing these rates
transanal platforms, prior to the advent of the with those of standard laparoscopic approach, clear
39 Oncologic Outcomes 407
benefits of taTME could be demonstrated, showing study by Fernandez-Hevia et al., the distal resec-
at least comparative rates of involvement of cir- tion margin was longer with the taTME approach
cumferential resection margin [49–52]. Finally, in when compared to the laparoscopic approach
a randomized trial comparing the transanal (2.8 vs. 1.7 cm, p < 0.01). This is not necessarily
approach to radical rectal resection versus laparo- an advantage, and a very low anastomosis can be
scopic surgery by Denost et al., the rate of circum- the end result, which compromises the functional
ferential resection margin was significantly lower outcomes.
with the transanal approach (4% vs. 18%, p = 0.02).
These data suggest that taTME has the poten-
tial to improve rectal cancer care, through lower Local Recurrence
rates of positive circumferential resection mar-
gins when compared to standard laparoscopic The most crucial goal of surgery for rectal cancer
approaches, as realized by most published series is disease-free survival by providing local tumor
to date. However, this must be interpreted with clearance. Local cancer recurrence is therefore an
caution since they are mostly from centers with important parameter of the quality of surgery. In
special interest and experience in taTME surgery. standard laparoscopy, a local recurrence rate of
With appropriate training and experience, the rate 5% was observed in both laparoscopic and open
of circumferential resection margin positivity TME groups in a randomized clinical trial com-
may be lowered by utilizing this novel approach paring the two approaches for rectal cancer [55].
to radical rectal cancer resection. The study had locoregional recurrence at 3 years
as the primary end-point.
While taTME is still a relatively new proce-
Distal Resection Margin dure and long-term results from the largest series
are not yet available, several cases of local recur-
In laparoscopic or open TME, transection of the rences have already been reported. Rouanet et al.
rectum is done without direct view of the tumor [19] reported local recurrence in 1 patient out of
itself and these techniques depending on tactile 30 with an observation period of 21 months. The
assessment of the tumor. Potentially, this can lead circumferential resection margin was involved in
to lower anastomosis than necessary. Even worse, this case. Veltcamp et al. reported two cases of
with such top-down approaches, there exists a local recurrence among 80 (2.5%) patients who
real risk of transecting across the tumor and jeop- underwent taTME [32]. The follow-up time was
ardizing the oncologic outcome of the operation. 30 months. A similar rate of local recurrence rate
This risk can be theoretically eliminated in of 2.3% was reported among 140 patients by
taTME, due to direct visualization of the tumor Lacy et al. where the mean follow-up time was
allowing for a precise transection of the rectal 15 months [30]. One case of local recurrence
lumen with a suitable safe margin. among 32 (3.1%) operated patients was reported
While theoretically the risk of a positive distal by de ´Angelis et al. [56], and here the follow-up
resection margin should be zero, this is not what time was 24 months. Burke et al. [35] reported
has been observed. While registry data suggests local recurrence in 2 out of 50 patients (4%) after
that the distal resection margin positive rate is a median follow-up period of 15.1 months.
quite low (0.3%) [29], other data contradict this After nearly a decade since the introduction of
finding. In fact, the rate of positive distal resec- taTME, more studies to be awaited with special
tion margin has been reported to be as high as focus on the long-term results, including local
8.7% in the center with the most experience with recurrence. The pattern of recurrence is also an
this approach [53]. While positive distal resection interesting subject due to the inherent nature of the
margins are still inexplicably observed with procedure that involves transluminal transection,
taTME for rectal cancer, overall, a longer distal insufflation of CO2, fixation of the anal sphincter
resection margin is appreciated [54]. In a 2015 retractor with traumatic instruments, and transanal
408 S. K. Perdawood
specimen retrieval. All of these can potentially Larson D, Marcello P, Posner M, Read T, Monson J,
Wren SM, Pisters PW, Nelson H. Effect of laparo-
lead to tumor cell implantation and increase the scopic-assisted resection vs open resection of stage
risk of local recurrence. One published case of II or III rectal cancer on pathologic outcomes: the
local recurrence raises the suspicion of implanta- ACOSOG Z6051 randomized clinical trial. JAMA.
tion similar to port-site metastasis [57], which is 2015;314:1346–55.
5. Stevenson AR, Solomon MJ, Lumley JW, Hewett P,
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410 S. K. Perdawood
patients without systemic disease or those with a 8]; however, receiving neoadjuvant therapy has
burden of metastatic disease that would other- been consistently associated with a more comor-
wise preclude an attempt at curative resection. bid postoperative course.
Furthermore, patients who have undergone taTPE Oncologically, surgeons must be confident in
have had underlying tumor extension into the the likelihood of being able to achieve a margin-
prostate gland, the posterior vaginal wall, and/or negative (R0) resection, prior to embarking on
the presacral and lateral sidewall fascia. such an endeavor. As such, it is crucial to involve
Involvement of the levator ani muscles or the colleagues from all appropriate subspecialties –
external sphincters is also amenable to a dissec- which may include urology, gynecology, ortho-
tion under pneumopelvis (taAPR) via an extrale- pedics, as well as plastic surgery for reconstruction
vator approach; this will be discussed in a when necessary in the planning phases. Having
separate chapter. the patient assessed by each subspecialty sur-
Given the early experiences with taTPE, we geon is imperative to ensure specialty-specific
will discuss the various principles of treatment as assessments of resectability and discussions of
well as the operative approaches that have proven the consent and perioperative/postoperative
to be crucial in planning a radical exenteration expectations. Furthermore, a multidisciplinary
under pneumopelvis, focusing on the technical cancer conference (MCC) discussion can allow
aspects of the procedure. The oncologic princi- for further optimization of the approach and
ples of exenterative procedures will be discussed assessment of resectability, as well as determin-
briefly, as they pertain to the technicalities of a ing appropriate adjuvant and/or neoadjuvant
taTPE. protocols.
administration of neoadjuvant therapy [9]. The phase; and it should be noted that the prostatec-
extent of involvement of the external sphincter or tomy was completed from the abdominal phase
levator musculature can be further optimized of the operation as well [11].
with transanal ultrasound which has a higher sen-
sitivity (compared to MRI) for delineating early
T-staging [10]; this may further inform the surgi- Platforms
cal team regarding the potential for sphincter
preservation. The main platforms to consider for taTPE are the
The details of the extent of the oncologic disposable transanal platforms (Gelpoint Mini® and
resection will depend on the preoperative imag- Gelpoint Path®, Applied Medical, Rancho Santa
ing which is best repeated following the comple- Margarita, CA, USA; SILS Transanal port,
tion of neoadjuvant therapy and at the appropriate Medtronic®, Minneapolis, MN, USA; Keyport
time interval. This will vary by institution and by Flex®, Richard-Wolf, Knittlingen, Germany) and
the modality of neoadjuvant therapy that was the fixed or rigid platforms (Transanal Endo
administered. The extent of the resection should scopic Microsurgery, Richard-Wolf, Knittlingen,
be dictated by the consensus decision of the MCC Germany; TEO®, Karl Storz Endoskope, Tuttlingen,
discussion. The ability to salvage other pelvic Germany). Each port has advantages afforded to the
organ structures will depend on the inter-specialty surgeon and procedure. Most surgeons will use the
assessments. Sphincter preservation is not usu- port they are comfortable with during standard
ally possible when there is a resection of the pel- taTME and transanal endoscopic procedures.
vic floor musculature such as in cases of invasion
or sacrectomy. Considerations of sphincter pres-
ervation can be stratified into functional and phincter Preservation or En Bloc
S
oncologic factions. Functional factors are consid- Perineal Resection
ered on an individualized basis and are based on
the patient’s preference, depending on preopera- One of the first decisions that needs to be made is
tive continence as well as postoperative expecta- to determine whether or not sphincter preserva-
tions of gastrointestinal function. Pertinent tion is feasible. If the patient’s sphincter can be
oncologic factors include distance of the tumor preserved, then the dissection can be initiated
from the anorectal junction (ARJ) and, in cases through a standard approach used in taTME. The
of partial or total intersphincteric resections, the details of initiating this dissection will be dis-
clearance of the intersphincteric plane or lack of cussed elsewhere and will depend on the distal
involvement of the external sphincter. extent of the tumor. The modified Rullier criteria,
proposed by Knol and Chadi, can provide a picto-
rial frame of reference to this assessment [12].
Operative Approach Briefly, if the tumor is present more than 2 cm
from the ARJ, the transanal dissection can be ini-
The feasibility of a transanal approach to the tiated under pneumopelvis with the TAMIS port’s
resection has been reported in male patients with access channel seated in place. If it is less than
en bloc prostate and seminal vesicle resections 2 cm from the ARJ, the dissection is often initi-
[3, 4, 11] as well as anecdotal experiences with ated with a non-endoscopically placed purse
resections of the posterior wall of the vagina. string, usually after anal effacement with the
Hayashi and colleagues discuss performing a lat- Lonestar® device, or similar. If a total or partial
eral pelvic node dissection as part of a laparo- intersphincteric proctectomy is planned, the dis-
scopic total pelvic exenteration with taTPE section is often initiated in the appropriate plane
technique for perineal completion and extraction; prior to, or after, which the purse string is formed.
during this technique, the authors performed the The dissection is then transitioned from a tradi-
pelvic sidewall dissection during the abdominal tional transanal approach (often described as the
414 S. A. Chadi and D. Sands
transanal transabdominal or TATA) to one under gland. Options for partial prostatectomy do exist
pneumopelvis when the TAMIS port apparatus although this can be difficult to perform, given
has been docked. This approach is generally difficulties understanding and predicting the
more straightforward to perform (especially for extent of invasion into the prostate during the
surgeons have not performed a taAPR) given the intraoperative dissection. Tumors abutting the
relatively more traditional perirectal anatomy of prostatic fascia can often be approached with an
a taTME. intraparenchymal dissection. This is often more
If sphincter preservation is not possible, sur- straightforward to perform transabdominally
geons should have had some experience with after entering into the plane anterior to the recto-
taAPR as the planes of dissection can be quite prostatic fascia (Denonvilliers’ fascia) allowing
different and require a detailed knowledge of the for a preservation of the seminal vesicles and the
pelvic floor musculature to navigate proximally. urethra.
This will be covered here briefly and in more When deciding to perform a total prostatec-
detail in a separate, dedicated chapter. tomy as part of the procedure, it is prudent to
The decision of an intralevator or extralevator consult with a urologist in the surgical decision-
dissection needs to be made. The extralevator making process, especially for the purpose of
dissection tends to be more amenable to a taAPR operative planning. The resection will often
approach as the fascial planes of the pelvic floor require removal of the seminal vesicles that is
musculature tend to be more straightforward to often approached transabdominally and commu-
follow. The landmark of the coccyx and the glu- nicated with the transanal dissection. During this
teus maximus muscle are identified. The coccyg- process, the vas deferens is identified lateral to
eus and internal obturator muscles are identified the seminal vesicles. The seminal vesicles are
at the ischial spine. The levator ani muscles are identified when the peritoneal reflection anterior
dissected off the attachments of the coccygeus to the rectum is incised. This is often performed
and internal obturator muscles. This provides 10–20 mm anterior to the true reflection.
access to the supralevator space, allowing for a Following the alveolar plane laterally will take
continuation of the dissection along the internal the surgical dissection anterior to the seminal
obturator muscle. This procedure is performed on vesicles so as to ensure they are included en bloc
each lateral aspect of the dissection. The internal with the surgical specimen. When the vas defer-
pudendal artery is also identified and ligated dur- ens is identified, it can often be transected with an
ing the dissection. Anteriorly, the perineal body is energy device. The dissection can then be fol-
identified and dropped posteriorly along the lowed anterior to the seminal vesicles distally to
transversus perinei muscle. In male patients, this communicate with the transanal dissection. Care
guides the surgeon during this anterior dissection must be taken to allow the transanal team to per-
to the level of the membranous urethra at the form the prostatic mobilization.
insertion of the prostate. At this level and under An additional decision integral to operative
direct observation and control, the urethra can be planning for taTPE is to determine whether or not
transected with the distal aspect remaining the bladder must be excised. Fundamental to this is
exposed for considerations of reconstruction in the assessed involvement of the trigone of the blad-
the case of prostatectomy. The details of a female der for tumor extension, which mandates en bloc
dissection will be covered below. cystectomy. The prostatic dissection can be
approached with a combination of a transabdomi-
nal and transperineal approach. Transabdominally,
he Prostate, Seminal Vesicles,
T after the ureters are identified and isolated as close
and Bladder as possible to the bladder, they are transected with
preservation of the peri-ureteric fat for the purposes
Distal rectal tumors may extend into the prostatic of maintaining vascularity. The peritoneum is
capsule or into the parenchyma of the prostate incised lateral to the median umbilical ligaments,
40 TaTME for Radical Exenteration 415
and the space of Retzius is entered with maturation poses as the remainder of the dissection is contin-
of the plane. Transection of the urachus and median ued posterior to the posterior wall of the bladder
umbilical ligaments should be performed with cau- and into the peritoneal cavity. Care must be taken
tion to avoid injury to the inferior epigastric ves- to identify the dorsal venous complex, which lies
sels, especially in cases where a vertical rectus anterior and more proximal to the prostate. Once
abdominus myocutaneous flap will be used for identified the dorsal vein can be divided with a
perineal reconstruction. vessel-sealing device, in conjunction with the rest
The plane in the space of Retzius is developed of the urinary sphincter. If unsure of this plane
until the endopelvic fascia is reached and opened. transanally, it may be safer to perform it during the
The vas deferens is often divided at this level to more familiar transabdominal approach. The ure-
expose the lateral sidewall and the external iliac thra can then be reconstructed through a bladder
vessels and to allow for ligation of the superior and advancement to the distal site of transection
inferior vesicle arteries as well as the vesicopros- through the transanal access platform. The bladder-
tatic artery. The superficial dorsal venous complex urethra anastomosis is constructed over a urinary
is exposed and ligated with an energy device when catheter (which serves as a stent) and is fashioned
adequate proximal and distal control has been with interrupted absorbable sutures. When com-
obtained. This later aspect of the procedure can plete, coloanal reconstruction and anastomosis
often be performed during the transanal portion of with an end-to-end, side-to-end, or colonic-j-
the procedure as well as discussed below. pouch-configuration utilizing either a stapled or
During the perineal component of taTPE, if hand-sewn approach is then fashioned.
sphincter preservation is planned, the surgeon When a cystoprostatectomy is planned, the
begins with a full-thickness rectotomy at the lateral dissection discussed in the above section
desired distal margin. The dissection is followed is continued into the space of Retzius and ante-
along the presacral plane posteriorly after which, rior to the prostate and, more proximally, to the
the dissection is advanced further laterally and bladder. The dissection laterally in the space of
external to the TME plane to include the visceral Retzius can be continued more proximally such
pelvic fascia en bloc with the dissection. This will that it facilitates entry into the space anterior to
guide the surgical team external to the traditional the bladder, thereby dropping it posteriorly for en
TME plane when extending the dissection laterally. bloc exenteration. This dissection will have often
The prostate is kept pedicled anteriorly to the ure- been performed synchronously with transabdom-
thra. The surgical team can follow the extraperito- inal dissection during which the two approaches
neal dissection, lateral to the visceral pelvic fascia. will be communicated at the point of rendezvous.
This is usually the wrong plane of dissection during Ileal conduit reconstruction with ureteric reim-
a traditional taTME as it takes the surgeon in the plantation is then performed during from the
extra-TME plane and eventually into the space of abdominal approach.
Retzius and anterior to the prostate. While entering When anal sphincter preservation is not
into this plane when performing an en bloc prosta- planned, the approach to the prostate and bladder
tectomy, care should be taken to avoid the various remains similar – other than the anterior approach
nerve bundles in the pelvic sidewall which are sus- to the urethra. As the perineal body is dropped
ceptible to injury. Additionally, when preserving posterior to the transversus perinei muscle, the
the bladder, limiting the more proximal dissection dissection is brought proximally to the level of
of the space of Retzius will allow for the bladder to the urethra. The remaining steps of the oncologic
remain adherent anteriorly. As this dissection is resection are performed as described above.
continued anteriorly, the membranous (pre-pros- Perineal reconstruction with biologic mesh or
tatic) urethra is identified. The urethra is next tran- myogenous/myocutaneous flap advancement can
sected along with the urinary catheter; alternatively, be performed when necessary, often in conjunc-
the catheter can be left in place for orientation pur- tion with plastic/reconstructive surgical team.
416 S. A. Chadi and D. Sands
with magnetic resonance imaging and endoluminal section for advanced rectal cancer. Surg Case Rep.
ultrasound after preoperative chemoradiotherapy. Dis 2016;2:1–4.
Colon Rectum. 2014;57(3):388–95. 12. Knol J, Chadi SA. Transanal total mesorectal exci-
11. Hayashi K, Kotake M, Kakiuchi D, Yamada S, Hada sion: technical aspects of approaching the mesorec-
M, Kato Y, et al. Laparoscopic total pelvic exen- tal plane from below. Minim Invasive Ther Allied
teration using transanal minimal invasive surgery Technol. 2016 Oct;25(5):257–70.
technique with en bloc bilateral lymph node dis-
TaTME for Abdominoperineal
Excision 41
Suguru Hasegawa, Tomoaki Okada, Daibo Kojima,
Akira Komono, Ryohei Sakamoto, Naoya Aisu,
Yoichiro Yoshida, and Yoshiharu Sakai
a BS b c
EAS (sc) Prostate
Urethra RUM
TP
Retcum NVB
EAS (s/d) US
Coccyx Tumor
PR
Coccygeal m LA
Fig. 41.1 Anatomy of around the anorectal region. (a) muscle, LA levator ani muscle, NVB neurovascular bun-
External anal sphincter (EAS) level. (b) Puborectal mus- dle, RUM rectourethral muscle, TP transverse perineal
cle (PR) level. (c) Prostate level. BS bulbospongiosus muscle, US urethral sphincter
Operative Procedure the tip of the coccyx. The hiatal ligament, a white
fibrous tissue connecting the coccyx and the rec-
A multimedia manuscript demonstrating our tum, is divided with special care so it does not
technique for TpAPE has been published previ- migrate into the mesorectum or posterior rectal
ously [5]. After positioning, the operation com- wall. Once the mesorectal plane is identified,
mences with a circumferential skin incision division of the levator muscle is extended bilater-
around the anus, with appropriate margins away ally, and the endopelvic fascia covering the leva-
from the tumor. Subcutaneous fat tissue is divided tor ani is also divided to enter the mesorectal
using electrocautery so that the ring portion of plane (Fig. 41.7).
the GelPOINT-mini® device can be accurately Posterior dissection is continued until this
placed. When the skin incision becomes large plane is connected with the laparoscopic dissec-
enough, a purse-string suture is applied, which is tion. The level of division of the levator muscle
beneficial to prevent air leakage during surgery can be determined at the surgeon’s discretion,
(Fig. 41.3). Following the fixation of the mainly depending on the extent of tumor inva-
GelPOINT-mini device, pneumoperitoneum is sion. Here, the roots of the pelvic splanchnic
maintained at 8–12 mmHg, and division of the nerves are identified bilaterally, and special care
subcutaneous and ischioanal fat is performed is taken to avoid injury to the autonomic nerves
(Fig. 41.4). of the pelvis (Fig. 41.8).
One can choose from among several dissec- Next, the anterior dissection is addressed. The
tion planes depending on the extent of tumor anterior dissection is more difficult in male
invasion. This includes the intersphincteric, the patients than in female patients because there is
extralevator, or the ischioanal planes (Fig. 41.5). the potential risk of urethral injury in males.
The tip of the coccyx is identified, and the levator Therefore, we describe here the dissection in
ani is widely exposed bilaterally (Fig. 41.6). The male patients. The transverse perineal muscle is
levator ani is divided posteriorly just anterior to an important landmark as it divides the anterior
a b
c d
Fig. 41.3 Skin incision to GelPOINT placement. (a) extent to place the GelPOINT device. (c) Purse-string
Skin incision can be minimal when skin is spared from suture is useful to keep the surgical field air-tight. (d)
tumor invasion. (b) Subcutaneous fat is divided to some GelPOINT® placement
422 S. Hasegawa et al.
a b
IRA
c d
ACL
Fig. 41.4 Division of the ischioanal fat. (a) Left side. (b) Right side (IRA inferior rectal artery). (c) Posterior side
(ACL ano-coccygeal ligament). (d) Anterior side
Fig. 41.5 Perineal
dissection planes in
APE. (a) Ischioanal
APE. (b) Extralevator
APE. (c) Intersphincteric
APE. (Modified form
Holm et al. [7])
c)
b)
a)
Modified form Holm et al. Surg Oncol Clin N Am. 2014
urogenital area and the posterior anorectal area. landmark at this point to divide the puborectalis
We dissect just behind the transverse perineal and levator ani muscles. The dissection line
muscle, and here the bilateral puborectal sling, should thus be determined based on the extent of
which is oriented along the posterior-anterior tumor infiltration, from extralevator resection to
axis, is identified. There is no clear anatomical standard resection (Figs. 41.9 and 41.10).
41 TaTME for Abdominoperineal Excision 423
a b
LA
LA
c d
TP
PR
EAS
Fig. 41.6 Exposure of the levator ani muscle and verse perineal muscle, EA external anal sphincter). (d)
puborectal muscle. (a) Left side (LA levator ani). (b) Posterior side (PR puborectal muscle). Blue marker indi-
Right side (LA levator ani). (c) Anterior side (TP trans- cates the tip of the coccyx
a b
LA
MR
HL
c d MR
MR
PSN
EPF
Fig. 41.7 Division of the levator ani muscle and entering mesorectum (MR) (LA levator ani muscle). (c) Posterior
into the posterior TME plane. (a) Division of the levator mesorectal dissection (MR mesorectum, EPF endopelvic
muscle (HL hiatal ligament). (b) Exposure of the posterior fascia). (d) Identification of the bilateral pelvic splanchnic
nerves (PSN) (MR mesorectum)
424 S. Hasegawa et al.
a b
LA
MR
c d
PSN PSN
Fig. 41.8 Lateral extension of the dissection plane. (a) cle (LA) to right side (MR mesorectum). (c) Dissection
Connection of the dissection plane with laparoscopic between mesorectum and left pelvic splanchnic nerve
team. (b) Extension of the division of the levator ani mus- (PSN). (d) Dissection between mesorectum and right pel-
vic splanchnic nerve (PSN)
a b
TP
RUM
PR PR
PR
c d EPF
MRA
LA
PR MR
LA
Fig. 41.9 Right anterior-lateral dissection. (a) Surgical Division of the right puborectal sling (PR) and levator ani
field after division of behind the transverse perineal mus- muscle (LA). (d) Surgical field after division of the levator
cle. (b) Division of the right puborectal sling (PR). (c) ani muscle (LA) (EPF endopelvic fascia, MRA middle
rectal artery, MR mesorectum)
41 TaTME for Abdominoperineal Excision 425
a b
PR
RUM PR
LA
c d SV NVB
SV LA
MR
MR
LA
MR
Fig. 41.10 Left anterior-lateral dissection. (a) Division omy (LA levator ani muscle, MR mesorectum, SV semi-
of the left puborectal sling (PR) (RUM rectourethral mus- nal vesicle). (d) After division of the levator ani muscle
cle). (b) Left puborectal sling (PR) and levator ani muscle (LA), dissection between neurovascular bundle (NVB)
(LA). (c) Laparoscopic assistance (right upper window) is and mesorectum is performed under laparoscopic assis-
helpful for better exposure and identification of the anat- tance (SV seminal vesicle)
Once the puborectal muscle sling is divided, specimen is extracted from below, and a perma-
the perineal body or rectourethral muscle, which nent sigmoid colostomy is fashioned.
contains abundant smooth muscle fibers and
fibrous connective tissue, is encountered. There
is no clear anatomical landmark here, and special ow to Avoid Urethral Injury During
H
care should be taken not to injure the urethra, TpAPE
neurovascular bundle, and prostate (see “How to
avoid urethral injury” below). Laparoscopic Urethral injury is a very important and serious
assistance to identify the contour of the prostate complication of this procedure. For male patients,
is beneficial to ensure safe and adequate dissec- the risk of urethral injury is likely increased in
tion in this area (Fig. 41.10). When the apex of TpAPE procedures as compared with TaTME
the prostate is identified, the following step is because the dissection plane easily goes more
almost identical with that of TaTME. Here, the toward the lateral side of the prostate as com-
dissection plane is easy to distinguish between pared with TaTME. Several methods have been
the prostate and the rectum. proposed to prevent this serious complication,
Dissection is widely commenced cranially such as urethral lighted stent placement,
and connected to the space with laparoscopic intraoperative ultrasonography, and stereotactic
dissection. Finally, bilateral mesorectal dissec- navigation [6]. The key anatomic consideration
tion between the mesorectum and pelvic auto- around this area is identification of the apex of
nomic nerves is performed with the assistance the prostate. Assistance with the laparoscopic
of the laparoscopic team (Figs. 41.11 and approach helps to predict the contour of the pros-
41.12). The sigmoid mesentery and sigmoid tate even if it is just the level of the upper border
colon are divided laparoscopically. The resected of the prostate.
426 S. Hasegawa et al.
a b
RUM
Pr Pr
RUM
c d
Pr NVB
MR
NVB
NVB
MR
Fig. 41.11 Dissection of the rectourethral muscle and fibers. (b) Division of the rectourethral muscle (RUM) (Pr
right neurovascular bundle. (a) Dissection between meso- prostate). (c) Dissection between right neurovascular bun-
rectum and inferior part of the prostate (Pr). Rectourethral dle (NVB) and mesorectum (MR). (d) Finally, right lat-
muscle (RUM) can be identified as longitudinal whitish eral attachment is divided, and TpAPE is completed
(NVB neurovascular bundle, MR mesorectum)
a b
c d
Fig. 41.12 Surgical field after specimen extraction. (a) Transanal view. (b) Transanal view. (c) Laparoscopic view. (d)
Resected specimen
41 TaTME for Abdominoperineal Excision 427
Jean-Sébastien Trépanier, F. Borja de Lacy,
and Antonio M. Lacy
recently transanal total mesorectal excision ation is crucial for proper planning. Also, reopera-
(taTME) [22–24], sound proficiency in dissection tive pelvic surgery can place the ureters at risk for
from a bottom-up approach was gained by various injury; therefore, consideration for preoperative
surgeons around the world. In selected cases placement of ureteral stents should be given.
where visualization from a transanal standpoint
would be deemed helpful, a combined transanal-
laparoscopic transabdominal Hartmann’s reversal Operative Setup
(taHR) was proposed as another approach. It has
been previously described by Dr. Antonio Lacy’s For the taHR, we favor a two-team approach. It
team [25–27]. To date, it remains experimental. It allows for performance of the procedure with
should be reserved to medical centers with thor- assistance of a second team for plane dissection
ough expertise in transanal surgery. using the two points of view. Thus, two complete
The expected advantages of this approach teams are operating simultaneously; each one
include (a) transanal dissection through intact, includes a surgeon, one or two assistants, a scrub
virgin planes, (b) improved ability to localize the nurse, and a dedicated set of instruments.
rectal stump (especially when short and covered
by peritoneum), (c) optimal visualization during
surgery in a narrow pelvis, and, finally, (d) the Technique Description (Table 42.1)
advantage of performing a double purse-string
single-stapled anastomosis with rectal tissues taHR: Abdominal Aspects
free of fibrosis or staple lines. This chapter is
intended to describe taHR and share various tech- Whenever possible, a laparoscopic approach is
nical tips and pitfalls. favored for the abdominal portion of the taHR
operation. It should start with the colostomy take-
down, placement of a single-port platform in the
Preoperative Planning
Table 42.1 Steps of a taHR
Patients should be well informed on the innovative
Abdominal steps Transanal steps
aspect of this approach for intestinal continuity
1. Colostomy takedown. 1. Placement of the flexible
reconstruction. Also, it is our opinion that every case transanal platform.
should be included in a prospective registry to mea- 2. Placement of an EEA 2. Evaluation of the rectal
sure outcomes, and, ideally, patients should be part of stapler anvil in the stump.
a study protocol with internal review board approval. proximal colon.
Preoperatively, all patients are evaluated by 3. Single-port device in 3. Choice of the site
stoma site. of rectotomy and
digital rectal examination and endoscopy of both mucosa tattooing.
their rectal remnant and proximal colon. A con- 4. Pneumoperitoneum. 4. Rectotomy.
trast enema of the rectal stump is also performed 5. Placement of trocars. 5. Dissection and
to measure its length and visualize its position in rendezvous. Extraction
the pelvis. Pre-colostomy, baseline anorectal of the resected portion
of rectal stump.
function is determined before proceeding, to pro-
6. Lysis of adhesions. 6. Purse string on the open
vide realistic expectations of functional outcomes rectal stump.
after reconstruction and to exclude candidates for 7. Mobilization of the left 7. Tying of the purse string
whom HR would result in a poor quality of life. A colon and splenic on the EEA anvil.
combined transanal-transabdominal approach is flexure.
8. Identification of the 8. Double purse-string
considered when the rectal stump appears short
rectal stump if single-stapled
(less than 15 cm). Knowledge of the indications possible. anastomosis.
for which the initial Hartmann’s procedure was 9. Anastomosis under
performed and the circumstances of the first oper- laparoscopic guidance.
42 Hartmann’s Reversal by a Combined Transanal-Transabdominal Approach 431
Fig. 42.1 Proposed single-port platform and trocars Fig. 42.2 Transanal flexible platform with an anal
placement retractor
432 J.-S. Trépanier et al.
Fig. 42.3 Rectotomy at the site of stenosis in the rectal Fig. 42.5 Placement of a purse-string running suture on
stump the open rectal stump (from a transanal perspective)
Conclusion
References
1. Hartmann H. Nouveau procédé d’ablation des can-
cers de la partie terminale du colon pelvien. Congrès
Français Chir. 1921;30:411.
2. Schmelzer TM, Mostafa G, Norton HJ, Newcomb
WL, Hope WW, Lincourt AE, et al. Reversal of
Hartmann’s procedure: a high-risk operation?
Surgery. 2007;142(4):598–607.
3. van de Wall BJM, Draaisma WA, Schouten ES,
Broeders IAMJ, Consten ECJ. Conventional and lapa-
Fig. 42.8 Final view of a completed anastomosis roscopic reversal of the Hartmann procedure: a review
of literature. J Gastrointest Surg (Springer-Verlag).
2009;14(4):743–52.
ileostomy is created in the case of a low colorectal 4. Vermeulen J, Gosselink MP, Busschbach JJV, Lange
anastomosis. A closed-suction drain is positioned JF. Avoiding or reversing Hartmann’s procedure
in the pelvis if deemed necessary by the surgeon, provides improved quality of life after perforated
diverticulitis. J Gastrointest Surg (Springer-Verlag).
and it is removed before hospital discharge. 2010;14(4):651–7.
5. Gorey TF, O’Connell PR, Waldron D, Cronin K, Kerin
M, Fitzpatrick JM. Laparoscopically assisted reversal
Results of Hartmann’s procedure. Br J Surg. 1993;80(1):109.
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roscopic colostomy closure. Surg Laparosc Endosc.
Preliminary results from a pilot study of ten 1993;3(1):69–72.
patients showed a 30% complication rate, with 7. Carus T, Emmert A. Single-port laparoscopic rever-
no leak and no conversion to an open procedure sal of Hartmann’s procedure: technique and results.
Minim Invasive Surg. 2011;2011:1–5.
[27]. There was one conversion to a hand- 8. Choi BJ, Jeong WJ, Kim YK, Kim S-J, Lee SC. Single-
assisted procedure to help with the lysis of port laparoscopic reversal of Hartmann’s procedure
adhesions. Three patients had complications: via the colostomy site. Int J Surg. 2015;14:33–7.
one patient with surgical site infection (abdomi- 9. Clermonts SHEM, de Ruijter WMJ, van Loon Y-TT,
Wasowicz DK, Heisterkamp J, Maring JK, et al.
nal wall and pelvic) treated with antibiotics and Reversal of Hartmann’s procedure utilizing single-port
percutaneous drainage and two patients pre- laparoscopy: an attractive alternative to laparotomy.
sented with ileus. Surg Endosc. 2016;30(5):1894–901.
434 J.-S. Trépanier et al.
Fig. 43.1 TME principles for rectal cancer. Meso and its
tail are removed respecting fascial envelop
EXCISION
Middle
Rectal Artery
Denonvillier fascia
Seminal vesicles
Inferior
Hypogastric nerves
bladder
to limit the risk of local recurrence treatment fail- vant RCT. On follow-up, 6 months later, a liver
ure – and it is especially crucial to obtain staging metastatic lesion was detected and promptly
that is as accurate as possible, to avoid underesti- resected. Today, the patient is disease-free with
mation of the tumor’s true stage. good functional results.
Our first complete oncological resection of the For the next patient, we performed another
rectum together with its mesorectal envelope NOTES transanal TME for cancer, but, before
using a purely transanal approach was performed doing the anastomosis, a laparoscopic explora-
in June 2010. The patient was a 55-year-old male tion through a single port introduced in the right
(in fact, a family doctor) who developed a recur- iliac fossa was performed so as to control the
rent mid-rectal lesion after polypectomy with sus- quality of the vascular dissection and, in addi-
pected invasive disease, based on morphology tion, to aid with bowel mobilization and for cre-
(although biopsy revealed only benign neoplasia). ating a diverting ileostomy, as the patient
He refused standard of care, radical surgery (up- received neoadjuvant radiotherapy. Analyzing
to-down TME), because of the risk of bad func- our initial experiences, we standardized the pro-
tional results, and he preferred to have a transanal cedure that now seemed quite reproducible. As
local excision. Due to the characteristics of the this process improved, the operative time has
neoplasm, a pure NOTES transanal TME was per- decreased markedly. Recently, a female (BMI
formed. Finally pathologic examination revealed 29) underwent the pure NOTES approach for
invasive adenocarcinoma, pT2N1 (1/15 lymph rectal cancer, she had no previous abdominal or
nodes positive for metastatic disease). pelvic operations, who had a T2 N0 mid-rectal
It was a pure NOTES taTME with a long oper- tumor (Figs. 43.4 and 43.5). The operation was
ative time (about 6 h), but – except for diffuse completed in approximately 2 h. Thus, we have
emphysema of the retroperitoneum, mediastinal, refined and s tandardized the steps of the proce-
and cervical spaces – the postoperative course dure in a better way; consequently, indications
was uneventful with recovery that was quite are limited in early-stage tumors for this techni-
rapid. This patient subsequently received adju- cally demanding approach.
438 J. Leroy et al.
Patient Selection
Surgical Technique
Armamentarium
Fig. 43.9 MedicalTek® (Taichung, Taiwan). Box for Fig. 43.10 U-shaped articulating arm fixed to the operat-
2D–3D real video conversion (available in 2 K and now in ing table to maintain TEO® device
4 K)
the plumes of smoke, we use a low power (20 and US standard rails, with lateral clamp for
watts) setting and a modern electronic control height and angle adjustment of the articulated
energy generator. stand (Fig. 43.10).
The platform includes a 4.5 mm camera lens, The TEO® faceplate is composed of three
fixed to the device, connected itself to a cold light channels (two 5 mm and one 10 mm) (Fig. 43.11)
source by a fiber-optic cable. The tip of the scope allowing introduction of operating instrumenta-
is a Hopkins® angled 30° downward. There are tion, which can include the same ones used for
two camera lens scope lengths, the 21 cm one is conventional laparoscopic surgery, and in this
adapted to the 7.5 and 15 cm platform and the fashion, TEO® is similar to TAMIS. There exists
28 cm one is for the 20 cm length device. A full- specific instrumentation developed for the TEO®
HD 2 K video laparoscopic camera is connected and the S-Portal® system (Karl Storz, Tuttlingen,
to the scope. Recently we used a 4 K video cam- Germany), long instruments and double-curved
era (Olympus) and tested the 2 K/4 K 3D video instruments with a rotating tip as developed by
convector (Fig. 43.9). S. Wexner and J. Leroy.
For ergonomics, the liquid crystal display Monopolar electrosurgery can be connected to
(LCD) monitor (minimum 35′ diagonal) is posi- any type of adapted laparoscopic instrument. In our
tioned above the pubis. The TEO® is fixed to the experience, the monopolar tool with optimal per-
operating table using a specific holding system, formance characteristics has been the 5 mm HF
U-shaped, autoclavable, with quick release cou- monopolar spoon electrode with smoke evacuation
pling KSLOCK®, consisting of HR Rotation suction channel, designed by Olympus Company
Socket, to clamp to the OR table, for European (Tokyo, Japan) (Fig. 43.12). We also recommend
43 Pure NOTES Transanal TME 441
Setup
a b
Fig. 43.21 Right lateral dissection. Visualization of Fig. 43.23 Full-thickness anterior rectotomy from 10 to 2
nerves plexus branches
Fig. 43.26 Female patient: opening the Douglas pouch Fig. 43.28 Proximal lateral division on left of the root of
the mesorectum
Then, the pelvis is explored and cleansed with irri- Fig. 43.41 Resection: distal margin
gation through the anus. A LoneStar™ retractor is
positioned transanally to expose the anorectum. platform has been reintroduced. If required, further
Intra-abdominal inspection (e.g., to assess for active mobilization of the sigmoid and even descending
sites of bleeding) is done after the TEO® operating colon can be done at this time.
43 Pure NOTES Transanal TME 449
Fig. 43.42 Division of the sigmoid with a linear stapler Fig. 43.43 Exposure with LoneStar® retractor and prep-
aration of a side-to-end manual low colorectal anastomo-
sis with separated stiches
tep 9: Construction of Low Colorectal
S
or Coloanal Anastomosis
The anastomosis may be an end-to-end or a side- pneumoperitoneum. The catheter on the anvil’s
to-end colorectal or coloanal anastomosis. It can be spike is removed, and the spike is grasped with the
stapled or hand-sewn, but it may depend on the aid of Kelly forceps. The arm portion of the circu-
clinical scenario. The side-to-end hand-sewn anas- lar stapler is inserted and mated to the anvil, before
tomosis is the easier technique to perform and is performing the anastomosis and controlling it
done utilizing either the TEO® platform or the endoscopically.
LoneStar® Retractor (Fig. 43.43) depending the
level of the anastomosis. Interrupted sutures (pre-
ferred) or a running suture may be used. Postoperative Care
In a side-to-end stapled anastomosis, a colos-
tomy is performed just distal to a well-vascularized Patients should follow an enhanced recovery
segment of bowel along the antimesenteric border after surgery (ERAS) protocol, and standard
in preparation for the anastomosis [9]. The spike analgesia is offered (paracetamol and oral opi-
of the anvil is delivered through this colostomy ates). Sips of fluid are given on the evening of
and brought out through the antimesenteric side of surgery and diet started the next day. Early patient
the proximal colon. The conduit is then transected mobilization is encouraged.
with a single firing of a linear stapling device, just
distal to the anvil and proximal to the colostomy. A
purse-string suture is placed around the spike of Discussion
the anvil. A catheter is attached over the spike of
the anvil to be used as a handle to prevent exces- hy Pure taTME?
W
sive retraction of the anvil cranially into the abdo- Pure NOTES transanal rectal extirpation has
men. The anvil is pushed back into the pelvis and attracted our attention. By providing superior
the short TEO ® is reinserted transanally. The pel- visualization and more accurate distal TME dis-
vis is inspected for bleeding, and the orientation of section (particularly in early rectal cancer), such
the proximal bowel is controlled to ensure that it is an approach may improve clinical, oncological,
not twisted. A purse-string suture is placed to close and functional outcomes. In particular, a no-scar
the orifice around the spike of the anvil. Prior to radical resection significantly improves healing
cinching the purse-string suture, a drain is briefly and recovery after surgery. Thus, not only can
advanced into the pelvis to evacuate any residual patients return to full activity and function
450 J. Leroy et al.
post-operatively, but, when indicated, they can rectum and sigmoid colon is an operation predi-
receive adjuvant therapy without significant delay. cated upon embryological planes –.
Following the Japanese experience in retroperi- even along the retroperitoneum. All critical
toneal oncologic right and left colectomies [18] blood vessels and relevant autonomic nerves lie
and the experience of pure retroperitoneal lymph- within the retroperitoneal space. The main chal-
adenectomies in gynecologic cancers [19, 20], our lenges for TME are dissection along this plane,
center has replicated these approaches for the rec- whereby preservation of vital vascular and nerve
tum via a transanal access. Our experimental and structures is paramount during the dissection.
clinical experience concluded the feasibility and Today, the pure NOTES down-to-up transanal
safety of pure NOTES taTME. In the literature, rectosigmoid dissection is now well standardized
most of papers report results of hybrid techniques at our center and select centers worldwide. With
with transanal rectal dissection completed from appropriate training and experience, this retro-
below, but not above the level of the S2 vertebra peritoneal approach, particularly for the manage-
[21–30]. Only a few teams have performed pure ment and control of the vascular pedicles, appears
NOTES taTME [31, 32]. As previously stated, to be optimal [6, 8, 9]. Confirmatory data reported
even with proper expertise, only selected patient by other experts subsequent to our published
will benefit of this advanced procedure. findings are also available [33].
should be mastered and perfectly understood before 3. Fleshman J, Sargent DJ, Green E, Anvari M, Stryker
SJ, Beart RW Jr, Hellinger M, Flanagan R Jr, Peters
it is taught to delegate surgeons. Today, substantial W, Nelson H, Clinical Outcomes of Surgical Therapy
experience with pure NOTES taTME (in highly Study Group. Laparoscopic colectomy for can-
selected patients) has been realized and, at our cen- cer is not inferior to open surgery based on 5-year
ter, has become standardized. Most recently, a pure data from the COST Study Group trial. Ann Surg.
2007;246(4):655–62. discussion 662–4.
NOTES taTME for curative-intent rectal resection 4. Heald RJ. A new solution to some old problems:
was completed in 2 h (female patient, T2 mid-rectal transanal TME. Tech Coloproctol. 2013;17(3):257–8.
tumor, long sigmoid loop, with a virgin abdomen https://doi.org/10.1007/s10151-013-0984-0. Epub 2013
(Figs. 43.4, 43.5, and 43.6). Teaching taTME is not Mar 22.
5. Sylla P, Rattner DW, Delgado S, Lacy AM. NOTES
easy. Sam Atallah (2017) demonstrates perfectly in transanal rectal cancer resection using transanal endo-
a recent paper how difficult it can be (35). Training scopic microsurgery and laparoscopic assistance. Surg
in fresh cadaveric model seems for us the best Endosc. 2010;24:1205–10. https://doi.org/10.1007/
approach. Some advanced programs have been s00464-010-0965-6. Epub 2010 Feb 26.
6. Leroy J, Barry BD, Melani A, Mutter D, Marescaux
developed worldwide [35–37]. J. No-scar transanal total mesorectal excision: the last
step to pure NOTES for colorectal surgery. JAMA
Surg. 2013;148(3):226–30. discussion 31.
Conclusion 7. Leroy J, Cahill RA, Perretta S, Forgione A,
Dallemagne B, Marescaux J. Natural orifice translu-
menal endoscopic surgery (NOTES) applied totally to
Performing a pure oncologic transanal TME sigmoidectomy: an original technique with survival
without abdominal scars is feasible. This con- in a porcine model. Surg Endosc. 2009;23(1):24–30.
cept is based mainly on the objective of provid- https://doi.org/10.1007/s00464-008-0102-y. Epub
2008 Sep 24. PMID: 18814015.
ing surgical cure for patients with rectal cancer. 8. Leroy J, Diana M, Barry B, Mutter D, Melani
Patient selection is highly important. The best AG, Wu HS, et al. Perirectal Oncologic Gateway
indications for this approach are currently for to Retroperitoneal Endoscopic Single-Site
early rectal cancers of the mid/high rectum, with Surgery (PROGRESSS): a feasibility study
for a new NOTES approach in a swine model.
or without neoadjuvant therapy. The pure NOTES Surg Innov. 2012;19(4):345–52. https://doi.
taTME can also be applied for rectal extirpation org/10.1177/1553350612452346. Epub 2012 Jul 1.
of carpeting benign rectal tumors for which a PMID: 22751618.
complete endoscopic excision is impossible. In 9. Dapri G, Marks JH, editors. Surgical Techniques
in Rectal Cancer, Chapter 28, Joel Leroy, Usmaan
our primary experience, a diverting stoma may be Hameed, Ntourakis Dimitrios, and Frédéric Bretagnol.
avoided in patients in whom there is no neoadju- Pure Transanal Laparoscopic TME without Abdominal
vant radiochemotherapy. Laparoscopy. Springer Japan 2018. https://doi.org/
Its principle limitations seem to be locally 10.1007/978-4-431-55579-7_28.
10. Marks J, Mizrahi B, Dalane S, Nweze I, Marks
advanced rectal cancer and obesity. G. Laparoscopic transanal abdominal transanal resec-
Up-to-down or down-to-up TME are surgeries tion with sphincter preservation for rectal cancer in
of embryological planes. Before doing down-to- the distal 3 cm of the rectum after neoadjuvant ther-
up pure taTME, it is necessary to memorize the apy. Surg Endosc. 2010;24(11):2700–7. https://doi.
org/10.1007/s00464-010-1028-8. Epub 2010 Apr 23.
technique of up-to-down to perform easier dissec- 11. Marks JH, Myers EA, Zeger EL, Denittis AS,
tion of embryological planes as described above. Gummadi M, Marks GJ. Long-term outcomes by a
transanal approach to total mesorectal excision for
rectal cancer. Surg Endosc. 2017;31(12):5248–57.
https://doi.org/10.1007/s00464-017-5597-7. Epub
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Totally Robotic taTME: Experiences
and Challenges to Date 44
Marcos Gómez Ruiz
postoperative outcomes with the laparoscopic approaches, either open, laparoscopic, or, more
approach [16]. Furthermore, the cost of robotic recently, robotic. Indeed, a laparoscopic low ante-
surgery must also be addressed before it can rior resection (LAR) remains particularly chal-
become the new standard treatment. lenging in adverse anatomical situations, such as
There is a close relationship about the rate of male patients with a narrow pelvis, visceral obe-
CRM involvement and the local recurrence. The sity, prostatic hypertrophy, or neoadjuvant chemo-
impact of robotic-assisted TME on CRM involve- radiotherapy. Exposure, rectal dissection, and
ment, however, remains controversial. Several distal cross-stapling of the rectum can be extremely
studies report no significant differences in CRM challenging in these conditions. Starting with dis-
involvement as compared to laparoscopic- section from the perineum seems to offer advan-
assisted TME [17, 18]. Nonetheless, a few retro- tages, by avoiding distal cross-stapling in a narrow
spective case-matched studies found significantly pelvis. The use of laparoscopic staplers in this situ-
decreased CRM involvement after robotic- ation is difficult as multiple staple firings across
assisted TME [19, 20]. Currently, there is limited the low rectum increase potential for anastomotic
literature dedicated to assessing the quality of leak [23]. The potential anastomotic benefits of a
TME in robotic-assisted surgery [20]. Reviewing transanal approach have been challenged by the
the current literature on CRM, this is reported as recent publication of the International Registry in
a discrete variable defined as <1 mm [21] or which the number of low anastomosis and anasto-
≤2 mm [19] rather than continuous variable in motic leak rate was concerning [24, 25].
mm. Of course, if the tumor (or a positive node) The concept is that a bottom-up (caudal to ceph-
extends to the CRM, this represents not only a alad) or retrograde dissection technique may pro-
positive margin but implies an R1 resection. vide the surgeon some advantages including the
Araujo et al. [22] published a large review of ability to directly visualize and choose the distal
the literature in which they reported the oncologic resection margin. A transanal purse-string suture
outcomes after robotically performed tumor-spe- below the tumor ensures that an adequate oncologi-
cific mesorectal excision for rectal cancer includ- cal distal margin will be achieved; it also allows
ing 1776 patients from 32 reports. The authors using the pneumatic insufflation of the mesorectal
reported no significant differences on pathologi- plane to facilitate rectal dissection. The optimal
cal data such as number of lymph nodes yield and close visualization of the mesorectal dissection
rate of positive CRM. In these series, the mean plane might reduce injury to surrounding structures
number of harvested lymph nodes ranged between such as the vagina, prostate, pelvic nerves, and pel-
10.3 and 20, whereas the total CRM positivity vic vessels. Importantly, from the taTME vantage
varied between 0% and 7.5%. Nevertheless, point, conflicts with the adjacent intra-abdominal
although certain heterogeneity among studies is pelvic structures and viscera are avoided, as they
to be acknowledged, a trend toward lower CRM no longer need to be retracted cephalad for rectal
involvement after robotic resections was noted in mobilization in this unique setting.
comparison to both laparoscopy and open stan- The technique itself demands an understand-
dard surgery. It should be noted that, for rectal ing of pelvic anatomy as well as comfort with
cancer surgery, the quality of the TME dissection currently available surgical equipment including
and the CRM status are far more important vari- the access platforms and insufflation systems that
ables than the number of lymph nodes harvested. make this approach possible. These concepts
have been challenged by the reported urethral
injuries and recent publications in which taTME
Transanal Total Mesorectal Excision had a higher positive distal resection margin
(DRM) when compared with a robotic low ante-
Transanal total mesorectal excision (taTME) was rior resection [26].
developed to overcome the inherent limits of After M. Whiteford first described taTME in a
abdominal approaches, also known as “anterior” cadaveric model in 2007, P. Sylla and A. Lacy
44 Totally Robotic taTME: Experiences and Challenges to Date 457
described the first successful clinical use of taTME The significant rate of taTME-related urethral
in 2010 in a patient with a rectal carcinoma of the injury occurs at the posterior wall of the pre-
middle third [27]. Since 2010, TaTME has had an prostatic urethra in male patients with a distal
important impact worldwide, and there has been a anterior rectal cancer (within 3 cm of the anal
significant increase in the number of publications verge). Atallah [36] has observed in his North
related with taTME over the past 8 years [28]. This American Training Program on taTME that
concept can be further supported by the fact that approximately 20% of cadaveric trainees (all
national training programs are being developed to with considerable rectal cancer experience) will
ensure that there is safe introduction of taTME inadvertently mobilize the prostate and enter the
across Europe, North America, as well as parts of incorrect plane, underscoring the importance of
South America (such as Brazil), and Southeast Asia. adequate training in this technique, which
Several cohort series have been published approaches the rectum from an unfamiliar van-
regarding hybrid endoscopic taTME [29–32]. tage point. Other cautionary points during taTME
These series suggest that taTME is feasible and include meticulous attention to the autonomic
safe regarding short-term outcomes and that it nerve plexi [37] and other anatomic structures
delivers high-quality TME specimens in selected detailed in other chapters.
patients. Wolthuis et al. [33] reviewed 20 stud- With appropriate training, taTME can be con-
ies where 323 patients were included. Most sidered a real advancement in the surgical man-
studies were single-arm prospective studies agement of rectal cancer surgery. However, it is
with fewer than 100 patients. Multiple transanal yet to be seen as to whether or not it will become
access platforms were used, and the laparo- a real scientifically proven advantage [38, 39].
scopic approach was either a multi- or single- Randomized trials have been constructed to chal-
port platform. The procedure was initiated either lenge this issue. There is already an International
by transanal or transabdominal. When a simul- taTME Registry in place with more than 1500
taneous approach with two operating surgeons cases reported so far [24, 25]. In Europe, the
was chosen (Cecil approach), the operative time GRECCAR 11 trial [40], COLOR III trial [41],
was significantly reduced. and in the near future RESET trial have been
This review clearly demonstrated that taTME designed and are being developed to compare
is currently performed in a non-standardized taTME with other existing anterior approaches.
way, which reflects surgeons exploring the tech- In particular, COLOR III and GRECCAR 11 are
nical boundaries of ultralow rectal cancer. prospective, multicenter, randomized trials
The published series that excluded T4 tumors planned to compare taTME with laparoscopic
have demonstrated a promising CRM involve- TME. It will take years before robust data will be
ment of 0–5.4% [33]. The largest series, including available. During this period, care must be taken
140 patients, reported CRM involvement of 6.4% before proposing taTME outside of expert
[34]; however, T4 tumors were not excluded, and centers.
all patients with involvement of CRM were cor-
rectly predicted by MRI [35]. Short-term morbid-
ity and oncological results were comparable to obotic Transanal Total Mesorectal
R
other laparoscopic TME series [33]. Excision (Robotic taTME)
In the largest published taTME series to date
[33], the CRM positivity rates range from 2.5% Clinical experience of robotic taTME started in
to 6.4%. When taTME and robotic LAR have 2013 when Atallah et al. [42] reported the first
been compared in retrospective multicenter stud- clinical case in a patient with familial adenoma-
ies, similar CRM positivity rates have been found tous polyposis and two synchronic tumors. Our
[26]. Long-term follow-up is necessary to assess group published our robotic taTME experience
more accurately these data and validate onco- in a cadaver model [43] using the PAT plat
logic outcomes. form (Developia-IDIVAL, Santander, Spain),
458 M. G. Ruiz
a self-designed platform, and the 80-mm Gel cases, pathological examination of the TME spec-
POINT gel cap (Applied Medical, Rancho Santa imens showed complete mesorectal excision with
Margarita, CA, USA). On August 2013, we per- negative proximal, distal, and circumferential
formed the first clinical case in Europe [44]. To margins. These preliminary results allowed us to
date, very few publications are available on robotic conclude that this technique is feasible, with good
taTME, and all of these only report early experi- pathological results and postoperative outcomes.
ences [45, 46] or short series of cases concluding Currently, Li-JenKuo et al. [50] have published
that this technique is feasible and safe [47]. the largest robotic taTME. Left colon mobiliza-
Atallah et al. published their initial experience tion was performed with a single-site robotic
[48] with three patients that underwent curative- approach. In this series, 15 patients underwent
intent robotic taTME using the da Vinci Si Surgical robotic taTME, with two conversions. Morbidity
System. They performed the abdominal phase of included an injury to the ureter, and one patient
the procedure with a laparoscopic approach and presented a Clavien IIIb complication because of
the taTME with robotic assistance. They used a a small bowel obstruction.
commercially available transanal minimally inva-
sive surgery (TAMIS) port (GelPOINT path trans-
anal access platform) to dock and interface with otally Robotic tATME:
T
the robotic arms transanally. The Santander Experience
In these three patients, the average age was
45 years (range 26–59) with mean BMI of 32 kg/ Surgical Technique
m2 (range 21–38.5). The average tumor size was
2.5 cm. All lesions were in the distal 5 cm of the The following section describes the technique
rectum. Mean operative time was 376 min. DRM used for totally robotic taTME, utilizing the da
and CRM were free of tumor, with the closest Vinci Si Surgical System with dual-docking.
DRM being 1 cm. The resection quality of the With the patient under general anesthesia, a
mesorectal envelope was graded for complete- urinary catheter is inserted, and the patient is
ness by an independent GI pathologist and was placed in the lithotomy position with the use of
found to be near complete in two cases and com- stirrups. Digital examination and rigid proctos-
pletely intact in one case. copy are performed to confirm the tumor location.
We reported the results of our pilot study with Abdominal access is achieved via Veress needle,
our initial five cases of complete robotic taTME which is inserted in the left upper quadrant and
[49]. We used a “transanal access port” procto- the abdomen, and CO2 insufflation commences to
scope (PAT, Developia-IDIVAL, Santander, an average pressure of 12 mmHg. Robotic 8-mm
Spain). PAT was inserted transanally, and a trocars are next inserted in the right upper quad-
GelPOINT gel cap was used to occlude the proc- rant (12–15 mm and 8 mm), right lower quadrant
toscope and for trocar placement. This platform (two 8-mm trocars), and periumbilical region
(which is essentially a hybrid between TEO and (12–15 mm). The patient is positioned in a right
TAMIS) allows for optimal lateral docking of the tilt, and the peritoneal cavity is first inspected
da Vinci Si Surgical System (Intuitive Surgical, through a standard laparoscope. After confirming
Sunnyvale, CA, USA) with unencumbered move- the absence of significant intra-abdominal adhe-
ments of the robotic arms. All patients underwent sions and no evidence of distal tumor extension or
a dual-docking procedure with robotic-assisted cacinomatosis, the da Vinci Si robotic cart is
multiport laparoscopic left colon mobilization, docked from the patient’s left side (Fig. 44.1).
robotic-assisted taTME, ultralow mechanical Monopolar curved scissors are placed in Arm 1, a
colorectal or handsewn coloanal anastomosis, and fenestrated bipolar grasper is placed in Arm 2, and
a diverting loop ileostomy. Four patients with a double-fenestrated grasper is used in Arm 3. A
stage III disease received preoperative long- 30° 12-mm endoscope is employed. The splenic
course chemoradiation before surgery. In all flexure is first taken down with dissection and
44 Totally Robotic taTME: Experiences and Challenges to Date 459
Fig. 44.1 Da Vinci Si System docked from the left lateral Fig. 44.2 Anal exposure for ISR resection or purse-
side of the patient string suture
Table 44.3 TNM distribution model [56], preliminary results of its clinical use
Rate % in three taTME procedures performed by Simon
T 0 8 21.6 Ng, MD at the Chinese University Hong Kong
1 8 21.6 (Hong Kong), seem promising.
2 9 24.3 A new wave of robotic platforms specifically
3 12 32.4 designed for single-port and natural orifice sur-
Total 37 100.0 gery is currently under development and evalua-
N N0 32 86.5
tion. The main advantage of these systems is the
N1a 5 13.5
addition of flexible effector arms and/or cameras
Total 37 100.0
which can be manipulated in part, or completely,
by a master-slave, computer-assisted system
Table 44.4 UICC distribution [57]. Such systems could change our approach to
Rate % complex surgical or endoscopical procedures,
UICC 0 3 8.1 unique to the field of colorectal surgery, but they
I 13 35.1 first require careful assessment and validation.
IIA 9 24.3 In 2017, the Flex® Robotic System and Flex®
IIIA 1 2.7 Colorectal (CR) Drive (MedRobotics, Corp.
IIIB 6 16.2 Raynham, MA, USA), a semi-robotic apparatus
Complete response 5 13.5 for colorectal surgery specifically indicated for
Total 37 100.0
transanal endoluminal applications, as well as
more radical resection (i.e., taTME), was
through improved precision [52–54]. The robotic approved by the US Food and Drug Administration
and fully computerized systems can facilitate the (FDA). This platform has already been used in
implementation of this technology [55]. cadaver model and is currently under evaluation
in a clinical trial [58]. The flexible effector arms
measure only 3.5 mm, but are not robotic assisted,
Future: New Robotics Platforms which is a limitation of the current technology.
Other limitations include suturing at ranges
The widespread of the clinical use of the robotic beyond 15 cm, needle delivery, and retrieval, and
rectal surgery is being limited mainly by the eco- the process of suturing itself can sometimes be
nomic costs and access to clinical experience in encumbered by the Flex® Robot’s convolution
sufficient number. throughout the sigmoidal bends.
Today, the technological progression is expo- Other single incision platforms such as the
nential. Robotic rectal surgery started less than SPORT ® Surgical System (Titan Medical,
10 years ago with the da Vinci Surgical System, Toronto, Canada) [59] or the multi-trocar platforms
and in this period four different systems have pro- like the expected robotic systems from Cambridge
gressively been used: S, Si, X, and Xi. SP plat- Medical Robotics, Medtronic, Medicaroid, or Verb
form has recently achieved the US Food and Drug Surgical are also in the pipeline for robotic
Administration (FDA) approval for its use in uro- taTME. The latter, a joint venture between Google
logical procedures and will probably achieve the and Johnson & Johnson, hopes to digitize surgery,
same approval for colorectal procedures within thereby providing computer- assisted technology
the next 2 years. After initial evaluation in cadaver that can ultimately improve surgical precision.
462 M. G. Ruiz
24. Penna M, Hompes R, Arnold S, Wynn G, Austin R, 186 patients with mid and low rectal cancer. Surg
Warusavitarne J, Moran B, Hanna GB, Mortensen NJ, Endosc. 2017;32:2442. https://doi.org/10.1007/
Tekkis PP, FRCS, on behalf of the TaTME Registry s00464-017-5944-8.
Collaborative. International registry results of the first 36. S A, M A, JR M. Critical concepts and important
720 cases. Ann Surg. 2017;266:111–7. anatomic landmarks encountered during transanal
25. Penna M, Hompes R, Arnold S, Wynn G, Austin R, total mesorectal excision (taTME): toward the mas-
Warusavitarne J, Moran B, Hanna GB, Mortensen tery of a new operation for rectal cancer surgery. Tech
NJ, Tekkis PP, International TaTME Registry Coloproctol. 2016;20(7):483–94.
Collaborative. Incidence and risk factors for anas- 37. Kneist W, Rink AD, Kauff DW, Konerding MA, Lang
tomotic failure in 1594 patients treated by transanal H. Topography of the extrinsic internal anal sphinc-
total mesorectal excision: results from the interna- ter nerve supply during laparoscopic-assisted TAMIS
tional TaTME registry. Ann Surg. 2018; https://doi. TME: five key zones of risk from the surgeons’
org/10.1097/SLA.0000000000002653. view. Int J Color Dis. 2014;30(1):71–8. https://doi.
26. Lee L, de Lacy B, Gomez Ruiz M, Liberman AS, org/10.1007/s00384-014-2026-4.
Albert MR, Monson JRT, Lacy A, Kim SH, Atallah 38. Atallah S. Trasanal total mesorectal excision: full
SB. A multicenter matched comparison of trans- steam ahead. Tech Coloproctol. 2015;19:57–61.
anal and robotic total mesorectal excision for mid 39. Rullier E. Transanal mesorectal excision: the new
and low-rectal adenocarcinoma. Ann Surg. 2018; challenge in rectal cancer. Dis Colon Rectum. 2015;
https://doi.org/10.1097/SLA.0000000000002862. 58:621–62.
PMID:29916871 40. Rouanet P, Rullier E, Lelong B, Maingon P, Tuech JJ,
27. Sylla P, Rattner DW, Delgado S, Lacy AM. NOTES Pezet D, Castan F, Nougaret S, and the GRECCAR
transanal rectal cancer resection using transanal endo- Study Group. Organ preservation for rectal can-
scopic microsurgery and laparoscopic assistance. cer (GRECCAR 2): a prospective, randomised,
Surg Endosc. 2010;24:1205–10. open-label, multicentre, phase 3 trial. Lancet.
28. Pellino G, Warusavitarne J. Medium-term adop-
2017;390(10093):469–79.
tion trends for laparoscopic, robotic and transanal 41. Dejen CL, Velthuis S, Tsai A, Mavroveli S, Lange-de
total mesorectal excision (TaTME) techniques. Tech Klerk ESM, Sietse C, Tuynman JB, Lacy A, Hanna
Coloproctol. 2017;21:911. https://doi.org/10.1007/ GB, Bonjer HJ. COLOR III: a multicentre ran-
s10151-017-1719-4. domised clinical trial comparing transanal TME ver-
29. de Lacy AM, Rattner DW, Adelsdorfer C, Tasende sus laparoscopic TME for mid and low rectal cancer.
MM, Fernandez M, Delgado S, Sylla P, Martinez-Palli Surg Endosc. 2016;30:3210. https://doi.org/10.1007/
G. Transanal natural orifice transluminal endoscopic s00464-015-4615-x.
surgery (NOTES) rectal resection: “down-to-up” total 42. Atallah S, Nassif H, Polavarapu H. Robotic-assisted
mesorectal excision (TME)--short-term outcomes in transanal surgery for total mesorectal excision
the first 20 cases. Surg Endosc. 2013;27:3165–72. (RATS-
TME): a description of a novel surgical
30. Tuech JJ, Karoui M, Lelong B, et al. A step towards approach with video demonstration. Tech Coloproctol.
NOTES total mesorectal excision for rectal cancer: 2013;17:441–7.
endoscopic transanal proctectomy (ETAP). Ann Surg. 43. Gomez Ruiz M, Martin Parra I, Calleja Iglesias A,
2015;261:228–33. Stein H, Sprinkle S, Manuel Palazuelos C, Alonso
31. Burke JP, Martin-Perez B, MD KA, Nassif G, DO Martin J, Cagigas Fernandez C, Castillo Diego J,
dB-A T, Larach SW, Albert AS. Transanal total meso- Gomez Fleitas M. Preclinical cadaveric study of trans-
rectal excision for rectal cancer: early outcomes in 50 anal robotic proctectomy with total mesorectal exci-
consecutive patients. Color Dis. 2016;18(6):570–7. sion combined with laparoscopic assistance. Int J Med
https://doi.org/10.1111/codi.13263. Robot. 2014;11:188. https://doi.org/10.1002/rcs.1581.
32. Veltcamp Helbach M, Deijen CL, Velthuis S, Bonjer 44. Gómez Ruiz M, Palazuelos CM, Martín Parra
HJ, Tuynman JB, Sietses C. Transanal total meso- JI, Alonso Martín J, Cagigas Fernández C, Del
rectal excision for rectal carcinoma: short-term out- Castillo Diego J, Gómez Fleitas M. New technique
comes and experience after 80 cases. Surg Endosc. of transanal proctectomy with completely robotic
2016;30(2):464–70. total mesorectal excision for rectal cancer. Cir Esp.
33. Wolthuis AM, Bislenghi G, van Overstraeten AB,
2014;92(5):356–61.
D’Hoore A. Transanal total mesorectal excision: 45. Verheijen PM, Consten EC, Broeders IA. Robotic
towards standardization of technique. World J transanal total mesorectal excision for rectal cancer:
Gastroenterol. 2015;21(44):12686–95. experience with a first case. Int J Med Robot Comput
34. Lacy AM, Tasende MM, Delgado S, Fernandez-
Assisted Surg. 2014;10(4):423–6.
Hevia M, Jimenez M, DeLacy B, Castells A, Bravo 46. Mendes CR, Valadão M, Araújo R, Linhares E,
R, Wexner SD, Heald RJ. Transanal total mesorec- Jesus IP. Transanal minimally invasive surgery for
tal excision for rectal cancer: outcomes after 140 total mesorectal excision (TME) through transanal
patients. J Am Coll Surg. 2015;221(2):415–23. approach (TATME) with robotic and transanal
35. de Lacy FB, van Laarhoven JJE, Pena R, Arroyave endoscopic operations (TEO) combined access:
MC, Bravo R, Cuatrecasas M, Lacy AM. Transanal step by step surgery. Abcd Arq Bras Cir Dig. 2015;
total mesorectal excision: pathological results of 28:117–20.
464 M. G. Ruiz
assisted rectal surgery was a response to the lapa- 220 degrees in TEM). It modified the laparo-
roscopic technical limitations for TME. Although scopic abdominal single port for transanal use,
the robotic platform is recognized for its improved and, as a result, all standard laparoscopic equip-
visualization and ease of maneuvering, this has ment could be used transanally as well [14].
generally not translated into a measurable improve- The first human case of transanal total meso-
ment in outcomes. Instead, studies reported equiv- rectal excision (taTME) was performed in 2009
alent oncologic and functional outcomes for both by Sylla, Rattner, Delgado, and Lacy [15]. They
approaches raising the question of cost- benefited from the TATA experience and used the
effectiveness [9, 10]. TEM platform (TAMIS was still under develop-
ment at this time). This was followed by a series
of 20 rectal cancer patients in 2013 with promis-
The Evolution of Transanal Surgery ing results, showing safety and feasibility of the
transanal approach to TME. Although taTME is
The classical “top-down” approach to rectal can- increasingly being adopted worldwide and pre-
cer with all it surgical advancements has main- liminary results in case series are encouraging,
tained open TME surgery as the gold standard for large-scale studies, such as COLOR III and the
rectal cancer treatment. Meanwhile, through taTME trial examining the best surgical approach
experimentation with hybrid approaches, Dr. to rectal cancer, are still underway; further, its
Gerald Marks explored a “bottom-up” concept in indications, standardization, long-term out-
1984 by introducing the TransAnal Abdominal comes, and the slope of its learning curve require
TransAnal (TATA) proctosigmoidectomy with further elucidation as well. Precise indications
colo-anal anastomosis as a sphincter-preserving and contraindications for taTME have not been
technique for curative-intent rectal cancer resec- established yet, and formalized NCCN guide-
tion [11]. In various studies, TATA was success- lines and recommendations for the taTME do not
ful in avoiding permanent colostomies for yet exist at the time of this writing.
patients and provided excellent oncological out-
comes for low rectal cancers treated with chemo-
radiation [12]. Initial Progress with Transanal
The introduction of technological instrumen- Robotics
tations began in 1980, with Knight and Griffen
introducing the double-stapling technique for Given the history of laparoscopy and the transi-
low colorectal anastomoses. Two years later, Dr. tion to robotics in abdominal surgery, it seemed a
Gerhard Buess developed transanal endoscopic natural evolution that TAMIS would follow suit
microsurgery (TEM), a device composed of an and enter the robotic era. The robotic approach to
optical stereoscope, operating instruments, and a a transanal operation was originally described for
specialized insufflation system. The implementa- local excision of rectal neoplasia by Dr. Atallah
tion of TEM in surgical care resulted in better and his colleagues using the da Vinci® Surgical
outcomes compared to standard transanal exci- System (Intuitive Surgical, Sunnyvale, CA, USA)
sion as reported in several studies [13]. TEM’s (Fig. 45.1) [16]. It was a natural step to approach
large-scale adoption was hindered, however, by TME of rectal cancers through the robotic plat-
high device cost and steep learning curve. form, which is believed to overcome the limited
In the search for the ideal approach that maneuverability of TAMIS and TEM in transanal
involved a short learning curve, low cost, and operations with these innate and novel
equivalent outcomes, transanal minimally inva- properties:
sive surgery (TAMIS) came to the surgical scene
in 2009 as an alternative to TEM, promising 1. Movement of an EndoWrist® instrument
affordability, accessibility, and perhaps better 2. Arm crossing
visibility within the rectal lumen (360 degrees vs. 3. Dexterity and precision
45 Next-Generation Robots for taTME 467
4. Reassigning left−/right-hand control in the were free, and, based on standard TME grading,
console the total mesorectal excision was considered near
5. 3-dimensional high-definition images, with
complete due to a 1.5-cm defect in the lower sec-
video magnification tion. The patient was discharged on postoperative
day three and remains disease-free 6 years post
The experimentation with the robotic platform resection.
for taTME in the clinical setting has demon- Follow-up case reports with a similar opera-
strated feasibility for distal and mid-rectum tive setup utilizing the GelPOINT TAMIS port
tumors [17]. In the first human case of RATS- and 5-mm instruments have been documented
TME (robotic-assisted transanal surgery for since Dr. Atallah’s group performed the first
TME; synonymous with robotic taTME) proce- RATS-TME. Verheijen et al. performed a RATS-
dure in 2012, Dr. Atallah and his team used the da TME on a 48-year-old female, with a BMI of
Vinci® Robotic Surgical System–Si (Intuitive 23.6 kg/m2 and a preoperative colonoscopy dem-
Surgical, Inc., Sunnyvale, CA, USA). According onstrating a circular rectal tumor 8 cm from the
to the authors, the Single-Site™ da Vinci® port anal verge [18]. The operative time was 205 min-
was not used for RATS-TME because the intralu- utes with an estimated blood loss of 50 cc, and
minal dexterity diminishes with the use of its there were no intraoperative robotic arm colli-
5-mm non-wristed straight instruments. The sions. The patient left the hospital on postopera-
GelPOINT “TAMIS port” was preferred as a tive day three, and the final pathology report
platform due to previous team experience, as it demonstrated a complete mesorectal excision
offers sphincter protection from the robotic arms with negative margins and an intact mesorectal
by the rigid cylindrical access channel, accom- fascia. There were no reported postoperative
modates an 8.5-mm robotic camera and working complications.
arms, and allows the bedside assistant to operate Additional prospective studies have demon-
a 5-mm suction-irrigator device. This index case strated successful use of the da Vinci® Si plat-
of robotic taTME was performed on a 51-year- form for RATS-TME. In a five patient series
old female with a BMI of 35.3 kg/m2 diagnosed including four men and one woman with an aver-
with familial adenomatous polyposis. Her rectal age age of 57 years, an average BMI of 28 kg/m2,
cancer was located 4 cm from the anal verge and and tumors averaging 5 cm from the anal verge,
complicated by a hepatic flexure tumor. The total all margins on mesorectal specimens were nega-
operative time was 381 minutes (total procto- tive, and all patients were disease-free at 3-month
colectomy with robotic taTME). All margins follow-up [19]. The average operating time was
468 J. O. Paull et al.
398 minutes with no intraoperative complica- the da Vinci® Si platform with the previously
tions, and the average hospital length of stay was described GelPOINT TAMIS port operative
6 days; postoperatively one anastomotic leak was setup. The mean operative time was 473 minutes
reported. with an estimate blood loss of 33 cc; mesorectal
Dr. Atallah and his group followed up their specimens had an average of 12 nodes (with a
initial case report by documenting their experi- range of 8–18), and all margins were clear cir-
ence with four additional RATS-TME operations cumferentially. There were no transanal intraop-
performed for select, distal rectal cancers [20]. erative complications; however, there was one
The cohort included three male and one female left ureteric transection which occurred during a
patient with average age of 44 years and a BMI of transabdominal portion of the case. One superfi-
29 kg/m2; tumor locations ranged from 1 to 5 cm cial wound infection occurred postoperatively,
from the anal verge. The operative times aver- and there was no mortality at 1-month follow-up.
aged 376 minutes, and estimated blood loss was While early data is encouraging displaying con-
200 cc. Patients stayed in the hospital an average tinued operative feasibility and satisfactory onco-
of 4 days postoperatively, and all final pathology logic outcomes, it is important to note that, given
reports demonstrated a mesorectal specimen that the novelty of this robotic approach, large-scale
was complete or near complete with an R0 resec- studies have yet to be conducted, demonstrating
tion in all cases; of note, an average of 27 lymph improvement in long-term patient outcomes and
nodes was contained within each specimen the enhanced value to patient care.
(range 15–39). At 9-month follow-up, one patient
experienced a wound hematoma, another patient
was found to have an asymptomatic subsegmen- Flex® Robotic System
tal pulmonary embolism, and a third was read-
mitted for dehydration secondary to high Within the past few years, new robotic platforms
ileostomy output. There was no evidence of designed for natural orifice surgery equipped with
recurrence within this timeframe. An additional flexible effector arms and cameras have been uti-
case series in 2015 performed by Dr. Huscher lized safely and successfully in otolaryngologic
and colleagues demonstrated similar results [21]. and urologic surgeries. Among the more notable
In their series, seven patients (three men, four of these platforms is the Flex® Robotic System
women) underwent RATS-TME with a transab- (Medrobotics, Corp. Raynham, MA, USA)
dominal laparoscopic vessel ligation and colonic (Fig. 45.2). Since the first application of the plat-
mobilization. The average age was 63.2 years, form in transoral robotic surgery (TORS) was
average BMI was 29.9 kg/m2, and the tumors reported in 2015, the safety and efficacy have
were located on average 2 cm from the anal been tested on both benign lesions and carcino-
verge. The operative time for the transanal por- mas [23–26]. The utility of an articulating endo-
tion was 55.5 minutes and resulted in a complete scopic robot to accommodate the nonlinear
mesorectal excision in six cases with one near anatomy of the anorectal region was recognized,
complete; the average lymph nodes collected per and, on May 4, 2017, the US Food and Drug
specimen were 14 (10–20). One patient experi- Administration (FDA) provided Section 510(k),
enced postoperative rectal bleeding on postoper- which added approval for the Flex® Colorectal
ative day two which required transfusion. (CR) Drive, introducing a semi-robotic apparatus
The largest series to date included 15 patients for colorectal surgery specifically indicated for
who underwent RATS-TME in combination with transanal endoluminal applications, as well as
transabdominal single-site radical proctectomy more radical resection (i.e., taTME). As a tran-
[22]. Eight females and seven males with an aver- soral oropharyngeal tool, the platform originally
age age of 60.3 years and an average BMI of lacked a mechanism to maintain a pneumatic seal,
21.97 kg/m2 with lesions an average of 3.3 cm but the technology has been modified to accommo-
from the anal verge underwent RATS-TME using date insufflation through adaption of a valveless
45 Next-Generation Robots for taTME 469
Fig. 45.2 The
Medrobotics Flex®
System. (Photo courtesy
of Sam Atallah, MD)
The da Vinci SP® has been approved for uro- safety and efficacy of the transoral approach to
logic single-port site procedures since 2014 in the nasopharynx, oropharynx, larynx, and hypo-
Europe, demonstrating both technical feasibility pharynx for benign and malignant lesions [37].
and safety in preclinical cadaveric applications In performance comparisons in cadaveric mod-
as well as subsequent phase I human trials [34, els to the da Vinci’s Si® robotic platform, the
35]. Additionally, the platform’s ability to access SP® has proven superior in visualization of,
and visualize the oropharynx has been exhibited access to, and ease of dissection and vessel con-
in cadaveric models [36], and phase I studies trol of the hypo- and oropharynx [38, 39]. While
performed overseas have demonstrated the previously not utilized in the United States, in
472 J. O. Paull et al.
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clinical study. Head Neck. 2018;40(1):16–23.
Video-Based Training Apps
and Deferred Live Surgery 46
Joep Knol
Surgical
technique
Cognitive
skills
Video teaching
Psychomotor
skills
Course Didactic material
attendance
Pre-task training +
Evaluation Informed consent
Cadaveric
course +
Live Transparancy
Pre-course surgery
evaluation
Patient
selection
Proctored
initiation of Monitor
experience personal
outcomes +
data Safe
registration
Post-course
performance
evaluation
a chievable after 10,000 hours of practice – “the tion and images by multi-camera recording that
10,000 hour rule” [8]. Surgery fits this rule. In can be made available in a synchronized fashion,
surgery, it seems reasonable that increase in known as Deferred Live surgery (dLive).
hours of deliberate practice improves perfor-
mance. Since MIS is performed while watching a
video display, optimization of video teaching can Mobile Apps
contribute to improved surgeon performance.
The need to acquire and master the unique skills Mobile apps are applications developed for hand-
required for laparoscopic surgery drove the rapid held devices such as smartphones and tablets.
evolution of simulated-based training and assess- While some mobile apps come preloaded with
ment of technical skills. As part of the surgical smartphones, users can download others from the
training pathway, dry and wet lab models are mobile app store. In June 2007, Apple, Inc.,
most frequently used. Dry labs are working envi- released the first iPhone at the Macworld Expo.
ronments that provide training models, such as The iPhone scaled computing from an activity
box trainers and virtual reality (VR) simulators, previously limited to desktops to one synced with
while wet labs are an animal-based platform [9]. the modern mobile lifestyle and demand for cog-
However, in this digital age, procedural videos nitive capability that enables access to the world’s
will play an increasing role in these simulation- information via the web. In 2008, Google joined
based training sessions [10]. Tools continue to be the market with Android (operating system)-
developed to meet these unique training needs based smartphones, initially with the HTC Dream
and have great promise to meet the changing phone. During this time period, apps and their
environment of surgical training. associated capabilities continued to grow and
In this chapter we will discuss the theory and scale to meet consumer demand. Now, more than
development of novel tools for current surgical a decade later, global mobile Internet user pene-
training. We will focus on the introduction of tration has exceeded half of the world’s popula-
cognitive-task simulation applications (apps) and tion, with an average daily time spent accessing
optimization of use of surgical pattern recogni- online content from a mobile device reaching
46 Video-Based Training Apps and Deferred Live Surgery 477
Fig. 46.3 Cumulative
number of apps
downloadable from
Apple and Google store
categories to its users. The most popular apps, as can provide content to allow for a rapid review of
defined by downloads, are games (25.04%), busi- critical steps and pearls for surgical procedures
ness (9.88%), educational (8.47%), and music shortly before a planned operation [20].
(2.49%). Medical apps comprise 1.84% of the The introduction of minimal invasive surgery
total market share for all app users. In a recent (MIS) has furthered the progress of apps for surgi-
study by the Accreditation Council of Graduate cal teaching. As MIS is performed utilizing a liq-
Medical Education (ACGME), the most fre- uid crystal display, with the increasing ability for
quently requested medical app types were text- video teaching, and increased focus on teaching
book/reference materials, classification/treatment pathways for more advanced surgical techniques,
algorithms, and guides for focused general medi- the time has come to implement video textbooks
cal knowledge [17]. in a dynamic format. Therefore, the development
While the popularity of medically related apps of apps with an adaptive content, consisting of
continues to grow, there is still a lack of high- expert opinions, surgical videos, medical illustra-
quality apps available. Payne et al. performed a tions, 3D animations, and an up-to-date library-
search on the Apple App Store in 2012, reporting like resource, is a logical next step.
relatively few physician-orientated apps at that
time, which did not address or meet the needs of
the [British] junior doctors [18]. The authors obile App Development
M
were convinced that currently high-quality medi- in Surgery
cally orientated apps are scarce both in Apple and
Google store. The use of apps in surgical education and specifi-
In a recent survey of medical students, findings cally to teach complex surgical procedures is a
were that, after having tried a prototype of an edu- recent development that is rapidly evolving.
cational app on general practice, students signaled Cognitive-task simulation apps currently avail-
their interest in further development and they able include iLappSurgery™ and dLive™ in
highlighted the potential of the app prototype over addition to Touch Surgery™ (Digital Surgery,
medical textbooks for both education and medical London, UK), which offer real-time, easy access
practice [19]. Advantages associated with the use to facilitate effective learning without traditional
of smartphones, as listed by medical students and bounds.
residents, were portability, efficient use of time, The health technology app Touch Surgery was
flexible communications, powerful applications, the trailblazer. In 2013, the Touch Surgery app
access to multimedia resources, and fast access to was introduced and represented the first high-
reliable medical information. In addition, apps quality teaching app made globally available to
46 Video-Based Training Apps and Deferred Live Surgery 479
surgeons, healthcare practitioners, and patients all of the technical steps related to this procedure
through their smartphones. The Touch Surgery and recognizes its pitfalls and troubleshooting to
app digitized procedure-specific surgical routes – successfully overcome obstacles.
3D CGI renderings of patient anatomy and surgi- For a nominal fee, additional content is avail-
cal workflows – as a cognitive training tool able to users for further focused learning. Since
(further information available at www.touchsur- the inception of the app, Professor RJ “Bill”
gery.com). This company has recently released Heald was one of the mentors of this project and
their newest product, GoSurgery, a cognitive tool kindly shared his experience on TME, history of
that supports surgical teams in the delivery of rectal cancer surgery, and importance of embry-
coordinated workflows that can help disseminate ology. His presentations were recorded with a
the right procedural and instrumentation infor- green screen background, and, after keying, his
mation to the right team member, at the right slides were projected in the background to
time – so as to work in a coordinated manner, achieve a more dynamic effect. The same kind of
aiming to produce the most beneficial patient recording and keying was done for many other
outcomes. world-known experts who lent their time and
expertise for the iLapp initiative. In addition,
unique illustrations concerning all the steps and
iLappSurgery and The taTME App pitfalls of taTME were drawn by a medical illus-
trator, and 3D animations were developed on
The iLappSurgery Foundation (www.ilappsur- patient installation and OR setup. Color grading
gery.com) was founded in 2015 as a not-for-profit effects, as first described by our group in a video
organization with the goal to develop educational manuscript on splenic flexure mobilization, were
material concerning advanced techniques in lapa- also used in procedural videos of the taTME pro-
roscopic surgery (Fig. 46.4). In June 2016, iLapp- cedure and included in the app [21].
Surgery launched the taTME App as a pilot After launching the iLapp taTME app, there
project to explore the need for teaching of a more was a steep increase in the number of subscribers,
advanced technique (Fig. 46.5). The iLappSur- with metrics showing 100, 500, 1500, and 2500
gery™ Foundation’s freely available download- subscribers after 2 weeks, 6 weeks, 6 months,
able app “taTME” details the history of TME and and 24 months after launch, respectively
Fig. 46.9 Video-in-Picture (VIP) image of dLive mainframe and aspects of the program
procedure, while mitigating most of the ethical gical demonstrations). Additionally, users from
and moral challenges of conventional live presen- virtually any point on Earth can have access, with
tation techniques. The original procedure can be the unique ability to switch between various case
performed with all the aforementioned recording presentations to demonstrate specific points in
equipment, without concerns of affecting patient- different cases.
centered outcomes of surgery. Furthermore, the The use of dLive technology has been and will
procedure can be performed at the usual pace of continue to be even more advantageous in
the surgeon without any need for time constraints. increasingly complex, multi-team procedures,
Intraoperative adverse events can also be man- such taTME. In such procedures, the entire oper-
aged, recorded, and subsequently used as an edu- ating room is of critical importance to demon-
cational tool for members of the audience. strate to the audience. Currently, taTME
Additionally, the high-quality recording and the procedures are recorded with seven synchronized
multiple intraoperative vantage points allow the cameras, all in 4K quality, including a 360° cam-
surgeon to pause, zoom in, and focus on specific era that provides an overview of the entire operat-
parts of the procedure of particular interest to the ing room. The positions of the various nursing
audience, while being able to switch between the and surgeon teams, the anesthesiologist vantage
various views in the operating room (Fig. 46.10). point, and location of the different intraoperative
This technique also allows the surgeon to narrate towers and equipment all contribute to the safe
various specifics to the audience, without the execution of these complex procedures.
concern of loss of intraoperative focus or atten- Furthermore, the coordination between the peri-
tion during otherwise critical steps of the proce- neal and transabdominal teams can be presented,
dure (the time when questions tend to most providing views of their individual hand motions
commonly be asked during non-deferred live sur- used to achieve specific intraoperative maneu-
46 Video-Based Training Apps and Deferred Live Surgery 483
Disclosures Joep Knol is co-founder of the 14. Ozdalga E, Ozdalga A, Ahuja N. The smartphone
iLappSurgery Foundation, which is a non for in medicine: a review of current and potential use
among physicians and students. J Med Internet Res.
profit organization. 2012;14:e128.
15. Trelease R. Diffusion of innovations: smartphones
and wireless anatomy learning resources. Anat Sci
Educ. 2008;1(6):233–9.
16. Reavley NJ, Mackinnon AJ, Morgan AJ, et al. Quality
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Navigation for Transanal Total
Mesorectal Excision 47
Luis Gustavo Capochin Romagnolo,
Arthur Randolph Wijsmuller,
and Armando Geraldo Franchini Melani
Fig. 47.1 A stereoscopic infrared emitting optical system an additional screen which is connected to the navigation
continuously tracks the patient and instrument by detect- platform, the location of the tip of the instrument is dis-
ing infrared light which is reflected by marker spheres played in the image data set
affixed to a patient tracker and an instrument tracker. On
Fig. 47.2 Several fiducials are placed on the skin anteri- the position of the fiducials/markers by using a calibrated
orly to the pelvic area. After a CT scan has been made just instrument (with marker spheres fixed to it) of which the
preoperatively with these fiducials in situ, this image data position of the tip is recognized by the infrared optical
set is uploaded to the navigation system. These sterile system. Additionally, the patient tracker (with marker
fiducials can then be changed for sterile skin markers after spheres fixed to it) can be recognized which is fixed to the
marking. Subsequently, the position of the patient in the patient or OR table
OR can be determined via recognition and registration of
488 L. G. C. Romagnolo et al.
Fig. 47.3 The tip of a surgical instrument can be tracked by means of an instrument tracker which is fixed to the instru-
ment. It can be attached to an energy device or a regular surgical instrument
a b c
Fig. 47.4 The position of the tip of the surgical instru- are located (b). During a transanal endoscopic approach,
ment is displayed in the image data set. Using an abdomi- the border of the mesorectum is located (c)
nal approach, the aortic bifurcation (a) and the left ureter
three-dimensional position of the patient in the nal organs. However, pelvic surgery is associated
OR to the preoperative images which will be used with additional challenges as compared to surgi-
for navigation. cal navigation in other contexts such as neurosur-
Three surgical infrared optical navigation plat- gery and orthopedic surgery. Rectal surgery is
forms were reported to have been used for stereo- performed in patients with variable degrees of
tactic soft-tissue pelvic navigation (StealthStation lithotomy, a position which is different from the
®S7 Surgical Navigation System, Medtronic Inc., supine position used for acquisition of preopera-
Louisville, USA; Stryker Navigation, Kalamazoo, tive imaging. This positional change could alter
MI, USA; CURVE Navigation System, Brainlab, the patient anatomy and subsequently render ste-
Feldkirchen, Germany) [1, 3, 17]. All systems reotactic pelvic navigation using preoperative
rely on a stereoscopic camera emitting infrared imaging inaccurate. Additionally, the motion of
light, a computer platform, a patient tracker, and the skin reference points with their fiducial mark-
an instrument tracker. ers by means of positional change may hamper
patient position registration in the operating room
(OR) to begin with. To assess these challenges, a
pecific Pelvic Surgery-Related
S study was undertaken to determine the difference
Challenges in patient anatomy, sacral tilt, and fiducial marker
position between these different patient positions
Since anatomical structures at risk during rectal and to investigate the feasibility and optimal
surgery are fixed retroperitoneally, they seem to setup for stereotactic pelvic navigation [3]. Four
be less affected by pneumoperitoneum and respi- consecutive human anatomical specimens were
ratory movements as compared to upper abdomi- submitted to repeated CT scans in a supine and
47 Navigation for Transanal Total Mesorectal Excision 489
several degrees of lithotomy position. Patient sight between the infrared camera of the naviga-
anatomy, sacral tilt, and skin fiducial position tion system and the patient and instrument
were compared by means of an image computing tracker. This line of sight can be hampered by the
platform. In two specimens, a 10-degree wedge patient’s legs which are placed in lithotomy and
was introduced to reduce the natural tilt of the the surgeon who is positioned between the
sacrum during the shift from a supine to a lithot- patient’s legs. Another limitation is that stereo-
omy position. A simulation of laparoscopic and tactic navigation relies on preoperative images
transanal surgical procedures was performed to for accurate navigation. As a result, real-time
assess the accuracy of stereotactic navigation. geometric changes in pelvic anatomy caused by
An up-to-supracentimetric change in patient tissue dissection and traction are known to affect
anatomy was noted between different patient the accuracy of stereotactic navigation.
positions. This observation was minimized Other factors which should be considered
through the application of a wedge. When switch- based on earlier studies on pelvic organ motion
ing from a supine to another position, sacral ret- are the following: rectal and bladder volume
roversion occurred irrespective of the use of a should be equal during the scans which are used
wedge. There was considerable skin fiducial for registration/ navigation, as well as intraopera-
motion between different positions. Accurate ste- tively. Consequently, the bladder should be emp-
reotactic navigation was obtained with the least tied before scanning as well as intraoperatively
registration error (1.9 mm) when the position of via the placement of a urinary catheter. The rec-
the anatomical specimen was registered in a tum should be emptied by means of an enema. In
supine position with straight legs, without pneu- case of transanal TME, the rectum should be emp-
moperitoneum, using a conventional CT scan tied just before closing the purse string. The pel-
with an identical specimen positioning. vic diaphragmatic muscle tension should be equal
The authors concluded that the change in during the scans, as well as intraoperatively.
patient anatomy is small during the sacral tilt
induced by positional changes when using a
10-degree wedge, allowing for an accurate ste- Clinical Application
reotactic surgical navigation when certain pre-
requisites are taken into account. The following Stereotactic soft-tissue pelvic navigation has
aspects should be considered and included in the reported to have been used in vivo for laparoscopic
protocol for an optimal setup of point-merge ste- and transanal approaches for locally advanced and
reotactic navigation in pelvic surgery. Patient recurrent rectal cancer cases [2, 17]. Atallah et al.
position registration should be performed with- used image-guided real-time navigation in four
out pneumoperitoneum in a patient position patients with anteriorly located locally advanced
which is similar to the position during preopera- rectal cancer [1, 2]. They used it during the trans-
tive CT scanning with fiducials. This is because a anal portion of the operation and reported radical
changing patient position results in skin fiducial resections for all patients without any intraopera-
motion, which hampers accurate patient position tive complications. At a median follow-up of
registration. A supine position with straight legs 18 months for three patients, there was no evi-
is the preferred position. The patient tracker dence of locoregional recurrence of distant meta-
should be fixed into the anterior superior iliac static disease [1]. Atallah et al. also used it during
spine to integrate the change in the sacral tilt a laparoscopic approach for a mixed cystic and
angle into the surgical navigation system, since a solid neoplasm in the left perirectal space of which
change is expected to occur when switching posi- they performed a complete excision without any
tions. Finally, a forced sacral tilt seems to mini- perioperative complications [18]. Kawada et al.
mize the change in patient anatomy. reported the performance of stereotactic naviga-
Limitations related to stereotactic navigation tion during a laparoscopic Hartmann’s operation
include the need for maintaining a direct line of with distal sacrectomy for a recurrent rectal cancer
490 L. G. C. Romagnolo et al.
[17]. A radical resection was performed without such as taTME. The challenges related to optimal
any perioperative complications. patient setup combined with the navigation sys-
tem need to be assessed in in vivo studies.
Shlomo Yellinek and Steven D. Wexner
The CLASICC trial [10] was conducted to technique. The benefits of taTME include direct
assess the long-term results of laparoscopic ver- visualization and transection of the DRM and
sus open surgery for colon and rectal cancer. superb visualization of the dissection undertaken
Both the 5-year and 10-year analyses confirmed to achieve the CRM and complete TME speci-
oncological safety of laparoscopic surgery for men. Some of the results are reviewed in this
both colonic and rectal cancer [11, 12]. section.
In a meta-analysis from 2016, Ma et al. [19]
reviewed seven studies including 573 patients
omparison Between Laparoscopic
C (taTME group = 270; lap TME group = 303). No
and Robotic Approach differences were observed regarding oncologic
results including harvested lymph nodes and pos-
In a meta-analysis from 2017, Li et al. [13] itive distal resection margin between the two
reviewed 17 case-control studies, which included groups. However, the taTME group showed a
3601 patient, 1726 patients underwent robotic higher rate of achievement of complete mesorec-
TME, and 1875 laparoscopic TME for rectal can- tal quality, a longer CRM, and less involvement
cer. There were no statistically significant differ- of positive CRM.
ences in oncologic results including positive In another meta-analysis from 2016, Xu et al.
circumferential resection margins, local recur- [20] reviewed seven studies including 209
rence rate, and overall 3-year survival rate. patients who underwent taTME and 257 patients
In a meta-analysis from 2014, Xiong et al. who underwent laparoscopic TME. There were
[14] reviewed eight studies, which included 1229 no significant differences in the outcomes of the
patients in total, 554 in the robotic TME, and harvested lymph nodes and distal resection mar-
675 in the laparoscopic TME. There were no sig- gin. However, compared with laparoscopic
nificant differences in the oncologic radicality of TME, taTME showed a longer CRM, lower rate
resection or local recurrence between the two of positive CRM, and higher rate of complete
groups. Colombo et al. [15] compared 60 laparo- TME.
scopic TME with 60 robotic TME. There were no M. Fernández-Hevia et al. [21] reviewed 140
significant differences in conversion rate, lymph patients who underwent taTME for low- and
nodes yield, positive DRM, or positive CRM. mid-rectal cancers. Macroscopic quality assess-
Recently, the results of the ROLARR random- ment of the resected specimen was complete in
ized clinical trial [2] were published. The authors 97.1% and nearly complete in 2.1%. At a mean
randomized patients to robotic-assisted TME follow-up of 15 months, a 2.3% local recurrence
(n = 237) or conventional (n = 234) laparoscopic rate and a 7.6% rate of systemic recurrence were
TME. There was no significant difference in pos- reported.
itive CRM between laparoscopic TME On behalf of the International TaTME Registry
(14/224,6.3%) compared to robotic TME Collaborative, Penna et al. [26] reported on 720
(12/235, 5.1%). consecutive patients from 66 registered units in
23 countries, comprising 634 patients with rectal
cancer and 86 with benign pathology. Abdominal
omparison Between Laparoscopic
C or perineal conversion was 6.3% and 2.8%,
and taTME Approach respectively. Intact (complete) TME specimens
were achieved in 85%, with minor defects (near
TaTME evolved from a pure NOTES application, complete) in 11% and major defects (incomplete)
initially described by M. Whitford [16] and sub- in 4%. R1 resection rate was 2.7%. Postoperative
sequently P. Sylla [17] to one seen as a gateway mortality and morbidity were 0.5% and 32.6%,
to improved access to the distal rectum, thereby respectively.
overcoming the technical challenges of pelvic Collectively, these data suggest that taTME is
surgery and TME. A. Lacy, P. Sylla, S. Atallah, a promising technique which may indeed improve
and others [18–25] subsequently popularized this surgical resection quality when performed by
496 S. Yellinek and S. D. Wexner
qualified and appropriately trained surgeons. 3. van der Pas MH, Haglind E, Cuesta MA, Fürst A,
Lacy AM, Hop WC, Bonjer HJ, COlorectal can-
Long-term data is still being collected, and this cer Laparoscopic or Open Resection II (COLOR
will remain crucial to the overall success and II) Study Group. Laparoscopic versus open sur-
adoption of this innovative technique. gery for rectal cancer (COLOR II): short-term out-
comes of a randomised, phase 3 trial. Lancet Oncol.
2013;14(3):210–8.
4. Bonjer HJ, Deijen CL, Abis GA, Cuesta MA, van der
Challenges Pas MH, de Lange-de Klerk ES, Lacy AM, Bemelman
WA, Andersson J, Angenete E, Rosenberg J, Fuerst A,
It is incumbent upon the surgical team wishing to Haglind E, COLOR II Study Group. A randomized
trial of laparoscopic versus open surgery for rectal
perform taTME to adhere to appropriate training cancer. N Engl J Med. 2015;372(14):1324–32.
guidelines including cadaver work, viewing vid- 5. Boutros M, Hippalgaonkar N, Silva E, Allende D,
eos, watching live surgery, and being proctored. Wexner SD, Berho M. Laparoscopic resection of
While each one-team and two-team approaches rectal cancer results in higher lymph node yield and
better short-term outcomes than open surgery: a large
each have advantages, most surgeons prefer the single-center comparative study. Dis Colon Rectum.
two-team approach both to facilitate mid-rectal 2013;56(6):679–88.
dissection and to expedite the length of the proce- 6. Vennix S, Pelzers L, Bouvy N, Beets GL, Pierie JP,
dure. Like any new technology, the results of Wiggers T, Breukink S. Laparoscopic versus open
total mesorectal excision for rectal cancer. Cochrane
taTME will be dependent upon appropriate case Database Syst Rev. 2014;15(4):CD005200.
selection and the judgment and technical prowess 7. Martínez-Pérez A, Clotilde Carra M, Brunetti F,
of the surgeons performing the procedure. de’Angelis N. Pathologic outcomes of laparoscopic
Fortunately, thus far, the results of taTME appear vs open mesorectal excision for rectal cancer: a
systematic review and meta-analysis. JAMA Surg.
quite laudable, and we expect that, with time, this 2017;152(4):e165665.
technique will continue to show increasingly salu- 8. Fleshman J, Branda M, Sargent DJ, Boller AM,
tary results with expanded worldwide penetration George V, Abbas M, Peters WR Jr, Maun D, Chang G,
and utilization. The surgical team planning to Herline A, Fichera A, Mutch M, Wexner S, Whiteford
M, Marks J, Birnbaum E, Margolin D, Larson D,
embark upon the adoption and subsequent prac- Marcello P, Posner M, Read T, Monson J, Wren SM,
tice of taTME should undergo extensive training, Pisters PW, Nelson H. Effect of laparoscopic-assisted
as outlined by McLemore and coworkers [23]. resection vs open resection of stage II or III rectal can-
Specifically, a staged training including didactic, cer on pathologic outcomes: the ACOSOG Z6051 ran-
domized clinical trial. JAMA. 2015;314(13):1346–55.
cadaver, and proctor levels is advisable. Moreover, 9. Fleshman J, Branda ME, Sargent DJ. Disease-free
all data should be captured in a meaningful ulti- survival and local recurrence for laparoscopic resec-
mately externally peer-reviewed registry. At pres- tion compared with open resection of stage II to III
ent, both North American and European taTME rectal cancer: follow-up results of the ACOSOG
Z6051 randomized controlled trial. Ann Surg. 2018;
registries are available for enrollment. https://doi.org/10.1097/SLA.0000000000003002.
[Epub ahead of print].
10. Guillou PJ, Quirke P, Thorpe H, Walker J, Jayne DG,
Smith AM, Heath RM, Brown JM, MRC CLASICC
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National Accreditation Program for Rectal Cancer. randomised controlled trial. Lancet. 2005;365(9472):
https://www.facs.org/qualityprograms/cancer/naprc. 1718–26.
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Copeland J, Quirke P, West N, Rautio T, Thomassen JM, Guillou PJ. Five-year follow-up of the Medical
N, Tilney H, Gudgeon M, Pietro Bianchi P, Edlin R, Research Council CLASICC trial of laparoscopically
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open laparotomy among patients undergoing resection 12. Green BL, Marshall HC, Collinson F, Quirke P, Guillou
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trial. JAMA. 2017;318(16):1569–80. Medical Research Council CLASICC trial of conven-
48 Current Controversies and Challenges in Transanal Total Mesorectal Excision (taTME) 497
tional versus laparoscopically assisted resection in 20. Xu W, Xu Z, Cheng H, Ying J, Cheng F, Xu W, Cao
colorectal cancer. Br J Surg. 2013;100(1):75–82. J, Luo J. Comparison of short-term clinical out-
13. Li X, Wang T, Yao L, Hu L, Jin P, Guo T, Yang K. The comes between transanal and laparoscopic total
safety and effectiveness of robot-assisted versus lapa- mesorectal excision for the treatment of mid and
roscopic TME in patients with rectal cancer: a meta- low rectal cancer: a meta-analysis. Eur J Surg Oncol.
analysis and systematic review. Medicine (Baltimore). 2016;42(12):1841–50.
2017;96(29):e7585. 21. Fernández-Hevia M, Delgado S, Castells A, Tasende
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laparoscopic total mesorectal excision for rectal can- J, Lacy AM. Transanal total mesorectal excision in
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15. Colombo PE, Bertrand MM, Alline M, Boulay E, laparoscopic surgery. Ann Surg. 2015;261(2):221–7.
Mourregot A, Carrère S, Quénet F, Jarlier M. Robotic 22. Wexner SD, Berho M. Transanal total mesorectal
versus laparoscopic Total Mesorectal Excision (TME) excision of rectal carcinoma: evidence to learn and
for sphincter-saving surgery: is there any difference in adopt the technique. Ann Surg. 2015;261(2):234–6.
the transanal TME rectal approach?: a single-center 23. Lacy AM, Tasende MM, Delgado S, Fernandez-
series of 120 consecutive patients. Ann Surg Oncol. Hevia M, Jimenez M, De Lacy B, Castells A, Bravo
2016;23(5):1594–600. R, Wexner SD, Heald RJ. Transanal total mesorec-
16. Denk PM, Swanström LL, Whiteford MH. Transanal tal excision for rectal cancer: outcomes after 140
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surgery. Gastrointest Endosc. 2008;68(5):954–9. 24. Wexner SD, Berho M. Transanal TAMIS total meso-
17. Sylla P, Willingham FF, Sohn DK, Gee DW, Brugge rectal excision (TME)--a work in progress. Tech
WR, Rattner DW. NOTES Rectosigmoid resection Coloproctol. 2014;18(5):423–5.
using Transanal Endoscopic Microsurgery (TEM) 25. McLemore EC, Harnsberger CR, Broderick RC,
with transgastric endoscopic assistance: a pilot study Leland H, Sylla P, Coker A, HF F, Jacobsen GR,
in swine. J Gastrointest Surg. 2008;12(10):1717–23. Sandler B, Attaluri V, Tsay AT, Wexner SD, Talamini
18. Atallah S. Transanal total mesorectal excision: full MA, Horgan S. Transanal total mesorectal excision
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Transanal Total Mesorectal
Excision: The Next 10 Years 49
Ronan A. Cahill
In a world of change, the learners shall inherit the struggling in a field without a clear gold standard.
earth, while the learned shall find themselves per-
fectly suited for a world that no longer exists.
In fact, surgery for colorectal cancer is one of the
Eric Hoffer most standardized and understood areas in all of
the areas related to cancer and surgery.
Just before taTME’s emergence, the operative
approach to this disease had been scrutinized to a
eflections on the Evolution to Date
R higher degree than any other major malignancy
of Transanal Total Mesorectal or indeed common operation and its common
Excision approaches had been the subject of randomized
trials with forensic examination of their method-
This book contains many very focused discourses ology and results. Nor is taTME the result of any
and much expert technical data on specific areas new, cool, breaking technology looking to be
of real relevance to the operative performance of applied or indeed one capable of adding extraor-
transanal total mesorectal excision (taTME). dinary new technical capability and in doing so
However, right now, zoom out and look over the opening up a new frontier for surgical interven-
table of contents from a highline perspective. tion. The instruments used, in fact, are often less
What has been achieved over the past decade is sophisticated than those commonly employed in
the imagination, description, development and open and laparoscopic surgery comprising at
validation of an entirely new surgical approach core diathermy hook and graspers and sutures.
for a common cancer within an existing specialty There was no big med-tech industry looking to
that had already a clear oncological framework exploit and profit from a step-advance in excision
governing its address. This isn’t a new disease quality; and no commercial model realized an
variant or one that was being poorly treated or un-met need. In point of fact, high-end equip-
neglected imposing little constraint for surgeons ment for transanal access has existed for quite
some time as part of the catalogue of two major
R. A. Cahill (*) surgical technology companies with global reach
Department of Surgery, Mater Misericordiae (the TEM and TEO devices of Wolf and Storz,
University Hospital (MMUH), Dublin, Ireland
respectively). However, these advancements
Section of Surgery and Surgical Specialities, School were siloed away from the greater mainstream of
of Medicine, University College Dublin,
Dublin, Ireland
laparoscopic access. Furthermore, a highly
e-mail: [email protected] resourced new company (Intuitive Surgical, Inc.)
did emerge in the early 2000s with an incredible technique including in the broad authorship of
piece of electromechanical engineering (the da reports quite different to previous times when
Vinci Robotic Surgical System), but it concen- single institutions vied to be the first to claim a
trated its use just as an exact replicator of existing new procedure. Industry has supported surgery in
ways to perform total mesorectal excision and it this effort and watched – with some amazement –
has, to this day, still really failed to provide much to see how their instruments designed for other
advance in patient outcome. Lastly, while the purposes were creatively applied to a new area
field was opened up through the emergence of and a brand new kind of surgery. So where next
Natural Orifice Transluminal Endoscopic Surgery can this evolution go?
(NOTES), its concepts progressed into reality
against the expectations of many – gastroenter-
ologists backed away from the large intestine as a What’s Best When and by Whom?
target and no disruptive technology toolboxes
were developed (despite considerable investment Notwithstanding the realization of taTME as a
by all major medical technology companies valid operative access that can be safely learnt
including Johnson & Johnson /Ethicon and and performed, further work needs to be done to
Medtronic). NOTES though didn’t disappear (as verify its place in practice and specifically exam-
many indeed thought happened), but its concep- ine if it can displace any of the current approaches
tual foundations were realized and, in fact, are to become the preferred approach for the major-
central to the technique of taTME. Neither was ity. Multicentred trials (including with random-
there any new genomic insight, biomolecular dis- ization) are planned (e.g. COLOR III [1],
covery or biological revelation. Simply (although, ETAP-Greccar 11 [2] among others) and need to
of course, nothing truly creative is simple), sur- be advanced to conclusion. The role of random-
geons iterated their surgery knowing that better is ized trials in surgery has long been discussed and
always possible and true advancement relates to indeed continues to be debated [3, 4]. This is per-
expert effort not bright, shiny gadgets. The main haps unsurprising, given that previous studies
driver of taTME so has been the intelligent per- have often been underwhelming in their conclu-
ception of some exceptional surgeon leaders, sions related to new technologies and surgical
many of whom are authors in this book, who advances. This statement remains valid whether
understood fully the problems of contemporary by reason of non-inferiority design or by their
approaches and who could see the established performance being undermined by long study
oncological framework of rectal cancer as an times. The latter is an important consideration
enabling environment rather than a barrier for because surgical procedures are constantly evolv-
innovation and who allowed the operative appli- ing both technically and technologically and so
cation of their imagination, courage and exper- an evolved landscape and practice standard has
tise. The pioneers of this operation individually developed within the time between study design
and collectively have done an incredible job in and commencement and publication most espe-
the realization of an operation that they invented cially when oncological follow-up is included
and which now has been delivered to such a stan- making the proposed evaluation somewhat
dard and indeed steady state that it can now be redundant.
described in a dedicated textbook. To get here, More recently some have questioned not the
much use has been made of communicative tech- general academic dearth (because this has much
nologies including video, apps and social media improved in terms of quantity and quality) and
to allow concerted efforts synergize and diffuse known pitfalls in construct considerations [5],
widely and to be communicated effectively pro- but actually the applicability of this trial method-
moting education and research regarding ology to surgical access examination [6]. As sur-
taTME. Registries have allowed many groups gical procedures are highly skill and volume
collaborate and share “ownership” of the dependent, it’s difficult for any surgeon to be
49 Transanal Total Mesorectal Excision: The Next 10 Years 501
truly equally adept and practiced at any two dif- ing the subsequent Hartmann’s procedure and in
ferent approaches done for the same disease. whom the rectal remnant may then be very
While, of course, competency is expected no shrunken and inaccessible in any easy way from
matter what the access, most if not all surgeons above [10]. Additional avenues for specialty
have a preferred approach that works “best” for advance raised from increasing and improving
them. The notion of equipoise has led some to taTME experience include topics such as whether
question whether such trials can really be all colorectal anastomosis should be formed by
expected to reliably show anything more than double purse-string rather than by the double-
equivalence. One suggested proposal to consider stapled technique.
is methodological evolution such as randomiza-
tion to expert in a technique before, rather than
after, selection of surgeon/unit. It is, however, Educational Advances
undeniably important for taTME to meet the
same burden of proof as the procedures it com- The proponents of taTME have adopted new edu-
petes against and also to truly reassure against cational formats, including video-based learning
concerns of new problems related to the new and interactive social media, in conjunction with
access. Particularly, urethral injury [7] risk, its inclusion in traditional professional con-
which is specific to this approach, and genitouri- gresses. While societies like the European
nary dysfunction whether better, due to more pre- Endoscopic Association of Endoscopic Surgeons
cise dissection, or worse, due to its propensity for (EAES) and its United States counterpart, the
excision anterior to Denonvilliers’ fascia [8] need Society of American Gastrointestinal Endoscopic
to defined. Surgeons (SAGES) along with specialty con-
With reassurance of safety, effectiveness and gresses like the European Society of
advantage, the next points to clarify relate to Coloproctology (ESCP) and the American
which particular patients (including male vs. Society of Colorectal Surgery (ASCRS) have
female but also those with anterior vs. posterior included taTME almost from its onset with
tumours) are best suited for taTME – as well as podium presentations, they also adopted early
some consideration as to whether it’s even possi- hands-on skills sessions (including high fidelity
ble at all to stratify those cancer patients who models and cadaver training) along with expert-
would best benefit from this novel approach. This led sessions. In addition, surgical educationalist
has implications not alone for whether rectal sur- groups such as IRCAD/EITS have advanced
gery might differentiate as a specialty from colon understanding and knowledge of the approach
surgery but whether low rectal surgery differenti- via theoretical sessions and laboratory courses.
ates from mid-rectal operations, with abdomino- Video capture and editing has been a terrific
perineal resection being perhaps a separate advance and, alongside WebSurg, journals such
category altogether. If any such strategy can be as Colorectal Disease have adopted open-access
shown advantageous in very large centres, the video forum in order for surgeons to investigate,
onus is naturally for smaller centres to coalesce learn and comprehend surgical techniques. The
or refer between each other so that patients, the taTME playlist on the YouTube and Vimeo
specialty and society as a whole receive a return Channels of Colorectal Disease has 25 videos of
on investment in the developmental work related user submitted content ranging from didactic dis-
to operative skill and technical advance. Aside cussion to tips and tricks sessions as well as com-
from cancer, additional evidence is emerging for plication management and advanced technique
the role of taTME in restorative surgery outside illustrative case edits (with its most watched
of cancer (e.g. ileal pouch-anal reconstruction video now comprising over 43,000 views total-
[9]) and in those suffering complications of ling over 125 days of watch-time in total). Other
colorectal surgery such as anastomotic failure journals, including Techniques in Coloproctology
who then later return for reconstruction follow- and Diseases of the Colon & Rectum, have also
502 R. A. Cahill
regularly included open-access videos featuring tion – principally for transanal and robotic sur-
advancements in taTME. The viewing of live gery. If a better means of gaseous expansion
unedited surgery has been taken to new broadcast then fixed volume, variable flow insufflators
standards by the Advances in Surgery group who (similar in concept to neonatal ventilators which
have found and grown a global audience for their need to act similarly to avoid barotrauma but
outstanding and comprehensive sessions in oper- use considerably less sophisticated technology)
ative surgery [11]. Furthermore embrace of social should become more available and more wide-
media, including Twitter [12], along with dedi- spread, including in use for flexible endoscopy
cated smart phone/tablet technology applications and all laparoscopy.
(eg iLAPP [13]), has done much to embed under-
standing of the technique within the minds of a
younger generation surgeons who then can dis- Instrumentation Advances
cuss, debate and disseminate material via peer to
peer sharing networks. Such broad dissemination The general trend since the introduction of
has been a great learning support for those inter- taTME has been simplification with respect to
ested in transanal access and will go on to further operating instrumentation with hook diathermy
advance the technique of taTME and the applica- becoming preferred over vessel-sealing devices
tion thereof. for the transanal portion of the operation. Most
expert taTME surgeons still prefer straight, rigid
instrumentation although curved instrumentation
Platform Advances is becoming more widely available and may offer
some advantages [15]. The main paradigm
There has been little advance in the access equip- remains through application of standardized and
ment now most employed for taTME and indeed known laparoscopic techniques (as applied via
perhaps little needed in keeping with the general utilization of the TAMIS platform), since so
paradigm of simplicity of approach. Transanal many surgeons favour the familiarity principle
access systems are already simple and neat (even over diversity of instruments in their operative
if relatively somewhat over-priced) but could tactics.
perhaps be better adapted to ensure easy fitting
and/or softness against the anal canal. While flex-
ible tubing may allow for a secure fit without risk Visualization Advances
of overstretch or stercoral injury, other intriguing
suggestions due to advanced material manufac- Most helpful in the propagation of taTME has
turing include the manufacture by 3D printing of been the generally high standard of camera visu-
the rectal access tube by customizing their length alization systems. In line optical cabling with
and diameter, based perhaps on measurements respect to the camera head is an advantage in the
from preoperative MRI. relatively confined access of the pelvis and,
Aside from access capture of the anal canal, indeed, for the lithotomized patient. Furthermore,
insufflation systems are the other means of some surgeons have found benefit in the use of a
opening access space both intraluminally and bariatric length camera for the transanal portion
extraluminally. The AirSEAL® Insufflation of taTME, as it can serve to offset instrument
System (ConMed, Inc., Utica, NY, USA) has shaft lengths, resulting in less camera-to-
been very useful for taTME [14] both in terms instrument collisions.
of smoke evacuation and continuous pressure The high-definition quality of most camera
maintenance (when compared to traditional lap- optics greatly enables the appreciation of planar
aroscopic insufflation system that only monitor access and, of course, provides a quality archive
CO2 rate of flow and pressure intermittently). for education and reflective audit. 4K and higher
Today, AirSEAL® remains a niche applica- resolution will better the view further, and while
49 Transanal Total Mesorectal Excision: The Next 10 Years 503
3D seems to have a useful application in this approach transanally, but this still requires com-
approach [16], its overall relative lack of penetra- plete comprehension of the new environment and
tion broadly within theatre systems has hindered new dangers of transgress from below and so we
its implementation. More truly impactful visual- still don’t have a robot that can add value to the
ization technology is however likely emerging in cognitive interpretation related to plane finding,
the form of image-guided surgery (see below). marginal radicality and normal anatomic struc-
ture delineation. These crucial aspects of safe and
effective surgery still depend on the surgeon hav-
aTME: A Killer Robot Application
T ing learnt experientially most often over some
or Robot Killer? considerable timeframe. While clearly only those
who can afford robots can use them, the taTME
Presently, robotic assistance with the Da Vinci conventional approach has the global market
series of machines is increasing with proponents advantage that it can be utilized anywhere with
advocating improved reach into the male pelvis laparoscopic equipment; although, some suggest,
and better specimen results. taTME conceptually this access advantage can be detrimental to prog-
presents the same advantages without the need ress with taTME, since it allows potentially
for multimillion dollar capital investment in tro- unskilled practitioners to “give it a go”, some-
phy technology and subsequent high procedure thing much harder to do with a robotic system
costs, albeit with the need to learn not just a new given their still relative exclusivity and thus gen-
approach but also a new perspective on anatomy. eral lack of availability.
Most robotic and taTME experiences however
compete with laparoscopic or open experience
and not directly with each other (Table 49.1). In Image-Guided Surgery
general, there hasn’t been much published com-
ment to date on the fundamental differences in Where technological progress will really be valu-
these technical sets [17]. Practitioners have able is in the field of surgical guidance or deci-
tended to instead apply the robot to the transanal sion support whether for taTME or other complex
approach in an effort to improve dexterity and endo-laparoscopic intervention. Optical interpre-
precision alone. The anticipated da Vinci SP sys- tation is a foundational cornerstone of all image-
tem should be better equipped again to enable the based surgery, and all contemporary systems now
create a digital video image on a screen that has
been created via fibre-optic energy assimilation
Table 49.1 Comparison between robotic TME and that has been passed through a computer before
taTME its display. While pixel quality and quantity can
Robotic add visual clarity, the viewer still has to interpret
TME taTME
the meaning of the image and look for visual
Availability + +++
clues as to the anatomic and pathologic impor-
Cost +++ +
Evidence base ++ ++
tance of what is being seen.
Accuracy ++ +++ Confidence and accuracy of interpretation
Distal margin identification +++ +++ depends to some degree on the individual’s eye-
Circumferential margin identification − +++ sight including red-blue-green sensitivity and the
Anastomotic construction catalogue of experience of the observer (surgeon)
Skills transferability versus ++ ++
as much training is still time-based. Assistance in
laparoscopic/open
Educational opportunity: via industry +++ ++ early and accurate identification of structures could
Educ. via peers and professional ++ +++ help expedite operative flow, improve precision of
bodies dissection and increase safety of surgery as well as
Registry opportunity ++ +++ improve oncological outcomes through accurate,
Credentialing opportunity ++ + rapid lesion localization, margination and planar
504 R. A. Cahill
Fig. 49.1 Intraoperative photographs showing rectal can- (c) shows thresholding capability, assigning different
cers identified by fluorescent tagged using indocyanine colours to different levels of fluorescence intesnity and
green (ICG) and near-infrared endoscopic (PINPOINT Image (d) shows a near-infrared microscopic view of the
Endoscopic System, Novadaq/Stryker Corporation) in same cancer showing specific depots of fluorescence
both (a) near-infrared and (b) false coloured view. Image related to cancer crypts in high-powered views
506 R. A. Cahill
tance in assigning levels of confidence. This is ablation can easily be envisaged and activated in
particular true for NIR given that many agents in the near term as a challenge to intraluminal
development may present high false- positive transanal access approaches. Increased accuracy
rates and prolonged timeframes and thus delayed of image and therefore target identification and
observation windows. comprehension allows diagnostic detection of
Alongside pixel analysis and feature engi- lesions at colonoscopy in addition providing a
neering (such as texture recognition), mathemat- useful niche for mucosal surveillance and
ical algorithms can helpfully provide profiling colonic topography mapping.
information regarding the nature of the lesion
under observation, most especially if kinetic
analysis is built into the profiles in combination Specializing Specialists
with contrast agents and disclosing dyes. Added
data, additional dyes, spectra or offset cameras The procedure detailed in this book on taTME has
(such as 3D scopes) can allow fluorescence developed to a mature state within about a decade.
tomography modelling of the lesion to depth This has been helped by a variety of technologies
(avoiding the predominance of superficial reflec- that allows surgeons to collaborate and gather evi-
tance in current NIR displays). This would allow dence more easily than before and disseminate
for rapid lesion recognition by the surgeon as concepts and outcomes both within and without
well as a variety of offshoot capabilities such as traditional routes rapidly and widely. This broad-
3D rendered image presentation. It is interesting cast capacity can be equally applied to other areas
that da Vinci robots include a module for fluores- in clinical practice behoving the clinical expert to
cence capacity and Medtronic has recently update and upskill continuously during a standard
acquired a specialised fluorescence company career-duration. Techniques and technologically
(Visionsense) although presently the informa- advances can move forward quickly, and patients
tion is like standard laparoscopic systems, pre- deserve to be able to benefit from useful advances
sented for human interpretation alone. That being applied to their disease without unnecessary
recently an autonomous suturing machine experimentalism but equally also without undue
deployed similar technology to reliably perform delay. This is part of the modern world, and prac-
a tissue anastomosis under hands-off human ticing physicians and surgeons must stay abreast
supervision points the way to an interesting near- of the emerging capabilities in surgical principle
term future. and practice. In the words of Stewart Brand, “Once
a new technology rolls over you, if you’re not part
of the steamroller, you’re part of the road”.
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2015;17(11):O265–7. 599–600.
Index
Health Insurance Portability and Accountability Act Intersphincteric dissection, 193, 281
(HIPAA) compliant, 480 Intersphincteric resection (ISR), 212, 436
Heparin subcutaneous, 219 Intersphincteric space (ISR), 267, 269
Heptamethine cyanine fluorophore, 374 Intestinal continuity, 429, 430, 433
Hindgut mobilization, definition of, 357 Intraoperative angiography, 374
Holy plane, 280 Intraoperative complications
Horizontal pelvic floor, 303 bleeding, 119
Hypogastric nerve (HN), 339, 340 peritoneal entry, 117, 118
rectal lumen, closure of, 119
rectovaginal fistula, 118
I vaginal entry, 118
Iatrogenic urethral injury, 323 Ischioanal fat, division of, 421, 422
iLappLiver logo, 480
iLappSurgery™, 478–480
Ileal pouch-anal anastomosis, see Total J
proctocolectomy Japanese Society for Cancer of the Colon
Ileo-anal pouch assessment, 198, 377 and Rectum (JSCCR), 24
Ileoanal pouch surgery, 198, 199
Image-guided surgery, 503, 504, 506
Immediate salvage surgery, 44, 45 K
Incising a fascial layer, 303 Kanizsa triangle, 327
Indocyanine green (ICG), 374–376, KeyPort, 62, 246
378, 432, 447, 504, 505
Inferior hypogastric plexus (IHP), 339
Inferior mesenteric artery (IMA), 268, 279 L
Inferior mesenteric vein (IMV), 269 Laparoscopic approach
Inferior rectal plexus (IRP), 338 open approach, 494, 495
Inflammatory bowel disease, 198 robotic approach, 495
pouch dysfunction, Ta redo surgery for, 203, 205 taTME approach, 495
pouch redo operations, 209 Laparoscopic colorectal surgery, 455
single-team procedure, 199–202 Laparoscopic hook cautery, 84
surgical approach, 205 Laparoscopic insufflator, 82
cuff/efferent loop excision, 206 Laparoscopic low anterior resection (LAR), 456
retained rectum, 206 Laparoscopic needle holders, 82
transanal and transabdominal Laparoscopic rectal surgery, 391
intersphincteric excision, 208 Laparoscopic suction/irrigation set, 82
transanal and transabdominal Laparoscopic surgery, 405, 407, 419, 420
mobilization, 206, 208 Laparoscopic TME (lapTME), 188
Ta proctectomy and ileoanal pouch Laparoscopic total pelvic exenteration, 413
surgery, 198, 199, 209 Laparoscopic ultrasound, 316
TAMIS revisional pouch surgery, 209 Lateral mesosigmoidal reflection, 367
Infrared-lighted urethral stents, 316 Left pararectal reflection, 365
Insufflation Local cancer recurrence, 407, 408
AirSeal® Insufflator System, 72, 73 Local excision (LE)
compliance, 66, 67, 69, 70 benign neoplasia, 12
control algorithm, 68, 69 benign pathology, 135
delivery and sensing cycle, 68, 70 contraindications, 13
EPIX, 74, 75 defects, 94
hazards, 75, 76 early-stage rectal cancer
insufflated rectum, 67 algorithm, 25–27
ISB, 73–75 diagnosis, 17
non-compliant space, 66 intramural spread, 19
normal laparoscopy, 66 lymph node dissection and removal, 17
physical laws, 65 national guidelines, 24
TEM, 71, 72 NCCN guidelines, 24
volume of gas, 66, 67 oncologic outcomes, 21
Insufflation stabilization bag (ISB), 73–75, 82, 91 patient-related factors, 17, 24
Insufflation system, 347 risk factors, 19, 20
Insufflation vector, 345 salvage, after local recurrence, 25
Internal anal sphincter nerves (IASN), 335, 337, 338 T1 rectal cancers, 20–22
Index 513
Transanal total mesorectal excision (taTME) (cont.) laparoscopic colectomy and assessment of pouch
standard educational programs for, 287, 288 reach, abdominal team, 224
transected urethra during, 330 pouch, anastomosis and final steps, transanal team/
for type I–III rectal cancer, 288 abdominal team, 225
uptake of, 321 transanal proctectomy, transanal team, 225
urethral injury during, 313 upper rectal mobilization, abdominal team, 225
taTME App, 479, 480 Touch SurgeryTM, 478
taTPE, see Transanal total pelvic exenteration TpAPE, see Transperineal abdominoperineal excision
Tension-free anastomosis, 431 Transabdominal single-port platforms, 200
TEO® platform, 438–443, 445–450 Transanal abdominal transanal (TATA), 286, 322, 328
Toldt’s fascia, 360, 361, 363–365, 368, 370 Transanal access port proctoscope, 458–460
Top-down approaches, 407, 466 Transanal back table, 217, 219
Top-to-bottom transfers, 240, 241 Transanal endoscopic microsurgery (TEM), 5, 6, 43, 59,
Total hindgut mesenteric mobilization 60, 165, 245, 248, 429
anatomy, 361, 363–365, 367 economics, 180
Denonvilliers’ fascia, 364 fecal incontinence, 178, 179
inferior mesenteric artery branches, 365 peritoneal entry, 176–178
intermediate mechanism, 363 technical limitations, 176
left mesocolon, 361, 362, 365 telescope, 59
left pararectal reflection, 365 unusual applications, 180
mesenteric component of flexures, 365 use of, 179
mesorectum, 363, 364 Transanal endoscopic operation (TEO), 6, 175, 248, 250
mesosigmoid, 361, 364, 365 Transanal endoscopic surgery (TES), 192, 193
peripheral mechanism, 364 Transanal excision (TAE), 400
right pararectal reflection, 364 Transanal inferior mesenteric artery, 173
splenic flexure, 366 Transanal laparoscopic stapling device, 118
Toldt’s fascia, 364, 365 Transanal microscopic surgery (TEM), 399, 400
Waldeyer’s fascia, 364 Transanal minimally invasive surgery (TAMIS), 6–8,
attachment, 361 166, 167, 175, 245
detachment, 361 applications of, 245
disconnection, 361 circumferential lesions, sleeve resections for, 179
hindgut, 361 economics, 180
history, 358–360 fecal incontinence, 178, 179
lateral to medial detachment and disconnection functional outcomes, 400, 401
of left mesocolon, 368, 369 local recurrence and use of, 175, 176
medial to lateral detachment and disconnection partial-vs. full-thickness resections and risk of
of left mesocolon, 369 stenosis, 180
medial to lateral detachment of peritoneal entry, 176–178
mesosigmoid, 368 series and rates of peritoneal entry, 177
mesentery, 361 technical limitations with, 176
mesofascial plane, 361 unusual applications, 180, 181
mesofascial separation, 361, 368 Transanal minimally invasive surgery (TAMIS)
nomenclature, 360 techniques, 259
obtain unimpeded mesenteric access, 367 Transanal nerve-sparing mesorectal dissection, 335
peritoneal reflection, 361 hypogastric nerve, 339, 340
peritonotomy, 361, 367, 368 IHP, 339
plane, 361 internal anal sphincter nerves, 335, 337, 338
splenic flexure, 369 IRP, 338
lateral to medial approach, 370 NVB, 338
medial to lateral approach, 369, 370 PSNs, 339
Toldt’s fascia, 361 Transanal operating endoscope (TEO), 59, 60, 251
Total mesorectal dissection (TMD), 436 Transanal platforms, 245
Total mesorectal excision (TME), 4, 5, flexible, 246–248
17, 43, 98, 165, 187, 359 rigid, 248
abdominal dissection semirigid, 248–250
NVB, dissection in, 268 Transanal proctectomy, 225
perirectal fascia structure, 264–267 Transanal purse-string suture, 456
Total mesorectal resection (TMR), 98 Transanal retractors, 60
Total neoadjuvant therapy (TNT), 33, 293 Transanal robotic surgery, 165
Total proctocolectomy current applications and outcomes, 167
Index 519
Transanal total mesorectal excision (taTME) (cont.) critical anatomic landmarks, 282, 283
purse string, 392 partial mesorectal excision, 281, 282
purse-string application, 392 triangles and halos, 350
intraoperative prevention strategies, 315, 316 tumor-related factors
introduction and adoption of, 255 local stage, 191
killer robot application/robot killer, 503 tumor height, 191
laparoscopic approach, 495 urethral injury, 311–313, 457
laparoscopic staplers, 456 vagina, prostate and urethra, 307, 308
multi- or single-port platform, 457 vessels, the ureter, and pelvic tonsils, 304–306
new disclosing dyes, 506 visualization advances, 502, 503
oncologic outcomes (see Oncologic outcomes) workspace volume increases, 344
one vs. two teams, 277, 278 See also Radical exenteration
operating theater setup, 217, 219 Transanal total pelvic exenteration
operative approach (taTPE), 411–416
abdominal TME, 187, 188 Transanal transabdominal (TATA) bottom-up
transanal TME, 188, 189 approach, 150
operative vectors, 344, 345 Transanal transabdominal proctosigmoidectomy (TATA),
patient counselling, 193, 194 165, 436
patient indications for, 190 Transanal-laparoscopic transabdominal Hartmann’s
patient, positioning, 278 reversal (taHR), 430
patient selection and counselling, 194 advantages, 430
patient-related factors hand-assisted procedure, 433
narrow pelvis, 192 operative setup
obesity, 191 abdominal aspects, 430–431
patients at risk, 315 steps of, 430
pelvic floor anatomy, variations in, 302 transanal aspects, 431–433
peritoneal cavity, 308 preoperative planning, 430
platform advances, 502 Transperineal abdominoperineal excision
preoperative assessment (TpAPE), 419, 427
history and physical examination, 381, 382 anatomical considerations, 419, 420
preoperative stoma marking, 383 avoid urethral injury, 425
preoperative testing, 382, 383 operative procedure, 421–426
sphincter evaluation, 383, 384 patient positions and operative setup, 420
preoperative preparation, 277 rectovaginal septum, dissection along, 427
presacral veins and sacrum, 304 Transverse abdominus plane (TAP), 385
procedure-related factors Transverse perineal (TP) muscles, 419
abdominoperineal resection, 193 Transversus abdominis plane (TAP) block, 224
intersphincteric dissection, 193 Tumor budding, 20
local excision with TES, 192, 193 Tumor diffusion depth, 99
low/ultra-low anterior resection, 193 Two-team coordination
protocol, 190 advantageous aspects of, 225
Quirke grading system, completeness, 189 insufflation pressures during, 226
rectal cancer resection, gold standard for, 194 low anterior resection
rectal wall, 300, 301 abdominal access and sigmoid colon mobilization,
rectum, luminal anatomy of, 300 abdominal team, 219, 221, 222
reflections on evolution, 499, 500 rectal transection and mobilization, transanal
single-team and two-team, 217 team, 221
specializing specialists, 507 rendezvous, 222, 223
specimen extraction, 282, 283 specimen extraction and anastomosis, transanal
subperitoneal space, operation in, 343, 344 team, 224
superior and inferior pubic symphysis and sacral splenic flexure and upper rectal mobilization,
promontory, 192 abdominal team, 222, 223
surgeon training and experience, 194 TAP block and ileostomy creation,
surgical approach, classification of low rectal abdominal team, 224
tumors with, 193 total proctocolectomy with ileal pouch-anal
total hindgut mesenteric mobilization (see Total anastomosis
hindgut mesenteric mobilization) laparoscopic colectomy and assessment of pouch
transanal approach reach, abdominal team, 224
abdominoperineal excision, 281 pouch, anastomosis and final steps, transanal
with bowel restoration intent, 279–281 team/abdominal team, 225
Index 521
transanal proctectomy, transanal team, 225 prostate gland and urethra, morphology of, 324, 325
upper rectal mobilization, abdominal team, 225 puborectalis muscle, anterior exposure of, 325
risk of, 321
significant risk, 322
U surgeon misperception and visual
Ulcerative colitis, 198 completion, 327, 328
Ultralow-lying rectal cancer during taTME, 313, 323
functional outcomes, 291, 292 urinary system, injuries to, 330
ISR, development of, 285, 286 Urinary system, injuries to, 330
perineal techniques, 285
Rullier type I tumors, taTME for, 288–290
Rullier type II and III tumors, taTME for, 290–292 V
standardized classification system for, 286, 287 Vagina, taTME, 307, 308
taTME, standard educational programs for, 287, 288 Vaginal access minimally invasive surgery
technical expertise, 285 (VAMIS), 144, 145
technical principles, 288 Vaginectomy, 416
Up-to-down approaches, 343 Vector, definition of, 345
Ureter, 304, 306 Vertical pelvic floor, 303
Urethra, 307, 308, 322 Vessel sealing device, 220
morphology of, 324, 325 Vessels, 304, 306
theoretical techniques, localization, 329 Video-in-Picture (VIP), 481–483
Urethral catheters, 219, 329, 416 Visual completion, 327, 328
Urethral injury, 312, 425, 457
APR, 322
Denonvilliers’ fascia, 325, 326 W
during distal anterior dissection, 322 Waldeyer’s fascia, 364
human factors, 328 “Watch and wait” strategy (WW), 32
incidence of, 311–313, 321 Wexner Continence Scale, 124
Luschka, rectourethralis muscle and pre-rectal muscle WEXNER instruments, 251
fibers, 324, 325 Wolf TEM system, 248, 249
management, 330
methods to localization, 328, 329
NVBW, 326, 327 X
patient risk, assessment of, 322 Xi® system, 159, 160
patient-related factors, 323