Tamis 2019

Transanal Minimally
Invasive Surgery (TAMIS)

and Transanal Total
Mesorectal Excision (taTME)
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
ISBN 978-3-030-11571-5 ISBN 978-3-030-11572-2 (eBook)

https://doi.org/10.1007/978-3-030-11572-2
© Springer Nature Switzerland AG 2019

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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.
Upon writing this, I finally understood the true meaning of the

expression “labor of love.” And it’s with deep love that I
dedicate this book to the people who made me who I am today.
To the surgeons who have mentored me throughout my arduous
years of training and, most of all, to my mother Areej, my
father Bisher, my brother Asa, and my wife Michelle. To my
four children, whom I love more than they can possibly
imagine – Olivia, Andrew, Sidney, and Addyson.
Sam Atallah
Foreword
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
Moreover, transcontinental registries have been established to assure respon-

sible and safe implementation.
This book captures the cornerstone developments in a new body of knowl-
edge. Like fabric, it encompasses content woven together by leading TAMIS
and taTME authorities from across the globe, thereby assuring a collective
representation. It is through this circle of pioneers, who reside in the four
corners – Asia, Europe, Australia, and the Americas – that this book is able to
deliver enriching perspectives.
Soon, we will embark upon a new journey, with 2030 visible on the hori-
zon. What new challenges and discoveries lie ahead? With finite and precious
time on Earth, fulfillment comes from knowing our collective contributions
will remain indefinitely – and may provide the foundation for what transpires
next. I consider myself truly fortunate to be part of a group shaping the future
of surgery. To be able to ride atop this epic wave of innovation has been the
stuff of dreams.
Orlando, FL, USA Sam Atallah

Contents
Part I Transanal Minimally Invasive Surgery (TAMIS)
1 Historical Perspectives and Rationale for Development�� 3

Sergio W. Larach and Beatriz Martín-Pérez
2 TAMIS: Indications and Contraindications�� 11
Uma R. Phatak and Justin A. Maykel
3 An Algorithm for Local Excision for
Early-Stage Rectal Cancer�� 17
George J. Chang and T. Paul Nickerson
4 Complete Clinical Response in Rectal Cancer
After Neoadjuvant Therapy: Organ Preservation
Strategies and the Role of Surgery �� 31
Laura Melina Fernandez, Guilherme Pagin São Julião, Bruna
Borba Vailati, Angelita Habr-Gama, and Rodrigo O. Perez
5 Salvage Surgery After TAMIS Excision of
Early-Stage Rectal Cancer�� 43
Sook C. Hoang and Charles M. Friel
6 Organ Preservation and Palliative
Options for Rectal Cancer�� 49
Nienke den Dekker, Stefan Erik Van Oostendorp, and Jurriaan
Benjamin Tuynman
7 Operative Equipment and Insufflator Options �� 57
William Frederick Anthony Miles, Muhammad Shafique
Sajid, and Eleni Andriopoulou
8 Operating Theater Setup and
Perioperative Considerations�� 81
Teresa H. deBeche-Adams, Raymond Yap, and George Nassif
9 Surgical Technique for Local Excision of
Rectal Neoplasia �� 89
Matthew R. Albert and Paul Kaminsky
10 Pyramidal Excision for Early Rectal Cancer and
Special Closure Techniques �� 97
Giovanni Lezoche, Mario Guerrieri, and Emanuele Lezoche
xv
xvi Contents
11 Closure Versus Non-closure After Local Excision�� 113

Dieter Hahnloser
12 Operative and Perioperative Outcomes �� 117
Elena A. T. Vikis, Anne-Marie Dufresne, and George Melich
13 Functional Outcomes After Local Excision
for Rectal Neoplasia �� 123
Elizabeth R. Raskin
14 Oncologic Outcomes for Local Excision of
Rectal Neoplasia �� 133
Lawrence Lee, Nathalie Wong-Chong, and John Monson
15 Applications Beyond Local Excision�� 143
Deborah S. Keller
16 The Evolution of Robotic TAMIS �� 153
Sam Atallah, Nicolas C. Buchs, and Seon-Hahn Kim
17 Transanal Robotic Surgery and Future Directions�� 165
Kevin M. Izquierdo, Thushy Siva, Jean Salem, Brigitte
Anderson, and John Marks
18 TAMIS: Current Controversies and Challenges�� 175
Heather Carmichael and Patricia Sylla
Part II Transanal Total Mesorectal Excision (taTME)
19 Indications for Malignant Neoplasia of the Rectum �� 187

Reagan L. Robertson and Carl J. Brown
20 Indications for Benign Disease of the Rectum�� 197
Willem A. Bemelman
21 Operating Theater Setup and Two-Team Coordination�� 217
Aimee E. Gough, Phillip R. Fleshner, and Karen N. Zaghiyan
22 Single-Team taTME�� 229
Antonio Caycedo-Marulanda, Shady Ashamalla, and Grace
Wai Ma
23 Transanal Access Platform Options and
Instrument Innovations �� 245
Giovanni Dapri
24 Intraoperative Decision-Making:
Converting to taTME, When and for Whom?�� 255
Isacco Montroni and Antonino Spinelli
25 Key Aspects of the Abdominal Dissection�� 263
Masaaki Ito
26 Zen and the Art of the Purse-String�� 271
Andrew R. L. Stevenson
Contents xvii
27 An Overview of Operative Steps and

Surgical Technique�� 277
F. Borja de Lacy, María Clara Arroyave, and Antonio M. Lacy
28 Strategies for Ultralow-Lying Rectal Cancer�� 285
Sam Atallah and Eric Rullier
29 Critical Anatomical Landmarks in
Transanal Total Mesorectal Excision (taTME) �� 299
Stephen W. Bell
30 Urethral Injury: The New Challenge for taTME�� 311
31 How to Avoid Urethral Injury in Males �� 321
Sam Atallah and Itzel Vela
32 A Roadmap to the Pelvic Autonomic Nerves
During Transanal Dissection�� 335
Werner Kneist
33 Operative Vectors, Anatomic Distortion,
and the Inherent Effects of Insufflation�� 343
Sam Atallah, Albert M. Wolthuis, and André D’Hoore
34 Total Hindgut Mesenteric Mobilization for taTME �� 357
J. Calvin Coffey and Rishabh Sehgal
35 The Role for Perfusion Angiography�� 373
António S. Soares and Manish Chand
36 Perioperative Preparation and Postoperative
Care Considerations�� 381
Anuradha R. Bhama, Alison R. Althans, and Scott R. Steele
37 Intraoperative Morbidity of taTME�� 391
T. W. A. Koedam, Jurriaan Benjamin Tuynman, Sam Atallah,
and C. Sietses
38 Functional Outcomes to Transanal Minimally
Invasive Surgery (TAMIS) and Transanal
Total Mesorectal Excision (taTME) �� 399
Elisabeth C. McLemore and Patricia Sylla
39 Oncologic Outcomes�� 405
Sharaf Karim Perdawood
40 TaTME for Radical Exenteration�� 411
Sami A. Chadi and Dana Sands
41 TaTME for Abdominoperineal Excision�� 419
Suguru Hasegawa, Tomoaki Okada, Daibo Kojima, Akira
Komono, Ryohei Sakamoto, Naoya Aisu, Yoichiro Yoshida,
and Yoshiharu Sakai
xviii Contents
42 Hartmann’s Reversal by a Combined

Transanal-Transabdominal Approach �� 429
Jean-Sébastien Trépanier, F. Borja de Lacy, and Antonio M.
Lacy
43 Pure NOTES Transanal TME�� 435
Joel Leroy, Frédéric Bretagnol, Nguyen Ngoc Dan, Hoa
Nguyen Hoang, Truc Vu Trung, and Chuc Phan Ngoc
44 Totally Robotic taTME: Experiences and
Challenges to Date�� 455
Marcos Gómez Ruiz
45 Next-Generation Robots for taTME�� 465
Jessie Osborne Paull, Abdullah I. Alalwan, and Vincent Obias
46 Video-Based Training Apps and Deferred
Live Surgery �� 475
Joep Knol
47 Navigation for Transanal Total Mesorectal Excision�� 485
Luis Gustavo Capochin Romagnolo, Arthur Randolph
Wijsmuller, and Armando Geraldo Franchini Melani
48 Current Controversies and Challenges in
Transanal Total Mesorectal Excision (taTME) �� 493
Shlomo Yellinek and Steven D. Wexner
49 Transanal Total Mesorectal Excision:
The Next 10 Years�� 499
Ronan A. Cahill
Index�� 509
Contributors
Naoya Aisu, MD, PhD Department of Gastroenterological Surgery,

Fukuoka University Hospital, Fukuoka, Japan
Abdullah I. Alalwan, MD The University of Toledo, Department of General
Surgery, Toledo, OH, USA
Matthew R. Albert, MD Center for Colon and Rectal Surgery, Department
of Colon and Rectal Surgery, Florida Hospital, Orlando, FL, USA
Alison R. Althans, BA Case Western Reserve University School of
Medicine, Cleveland, OH, USA
Department of Colorectal Surgery, Digestive Disease and Surgery Institute,
Cleveland Clinic Foundation, Cleveland, OH, USA
Brigitte Anderson Colon and Rectal Surgery, Lankenau Medical Center,
Marks Colorectal Surgical Associates, Wynnewood, PA, USA
Eleni Andriopoulou, MD DEA Department of Digestive Disease, The
Royal Sussex County Hospital, Brighton and Sussex University Hospitals
NHS Trust, Brighton, UK
María Clara Arroyave, MD Department of Surgical Oncology, Clinica
Somer, Rionegro, Colombia
Shady Ashamalla, MSc, MD, FRCSC Sunnybrook Health Sciences Centre,
Department of General Surgery, Toronto, ON, Canada
Odette Cancer Centre, Toronto, ON, Canada
Sam Atallah, MD, FACS, FASCRS AdventHealth Orlando, Oviedo
Medical Center, and University of Central Florida College of Medicine,
Orlando, FL, USA
Stephen W. Bell, MBBS, FRACS Cabrini Monash University Department
of Surgery, Malvern, VIC, Australia
Alfred Hospital, Melbourne, Australia
Willem A. Bemelman, PhD Department of Surgery, Amsterdam University
Medical Center, Amsterdam, The Netherlands
Anuradha R. Bhama, MD Rush University, Chicago, IL, USA
xix
xx Contributors
Frédéric Bretagnol, MD, PhD Digestive Surgery—University Louis

Mourier Hospital (APHP), Paris, France
Carl J. Brown, MD, MSc, FACS, FRCSC St. Paul’s Hospital, Department
of Colorectal Surgery, Vancouver, BC, Canada
Nicolas C. Buchs, MD-PD University Hospitals of Geneva, Department of
Surgery, Geneva, Switzerland
Ronan A. Cahill Department of Surgery, Mater Misericordiae University
Hospital (MMUH), Dublin, Ireland
Section of Surgery and Surgical Specialities, School of Medicine, University
College Dublin, Dublin, Ireland
Heather Carmichael, MD Department of Surgery, University of Colorado,
Aurora, CO, USA
Antonio Caycedo-Marulanda, MD, MSc Health Sciences North,
Department of Surgery, Sudbury, ON, Canada
Colorectal Surgery North, Sudbury, ON, Canada
Sami A. Chadi, MD, MSc, FRCSC, FACS University Health Network and
Princess Margaret Hospital, University of Toronto, Toronto, ON, Canada
Manish Chand Division of Surgery and Interventional Sciences, University
College London Hospitals, NHS Trusts, GENIE Centre, University College
London, London, UK
George J. Chang, MD, MS The University of Texas MD Anderson Cancer
Center, Department of Surgical Oncology, Houston, TX, USA
J. Calvin Coffey, MB, BSc (Hons), Phd, FRCS University Hospital
Limerick and University of Limerick, Department of Surgery and Graduate
Entry Medical School, Limerick, Ireland
Nguyen Ngoc Dan, MD Hanoi High Tech & Digestive Center, St Paul
Hospital, Hanoi, Vietnam
Giovanni Dapri, MD, PhD, FACS Saint-Pierre University Hospital,
European School of Laparoscopic Surgery, Department of Gastrointestinal
Surgery, Brussels, Belgium
Teresa H. deBeche-Adams, MD Florida Hospital, Center for Colon and
Rectal Surgery, Orlando, FL, USA
F. Borja de Lacy, MD Gastrointestinal Surgery Department, Hospital
Clinic, University of Barcelona, Barcelona, Spain
Nienke den Dekker, BSc Department of Surgery, Amsterdam University
Medical Center, location VUmc, Cancer Center Amsterdam, Amsterdam, The
Netherlands
André D’Hoore, MD, PhD University Hospitals, Abdominal Surgery,
Leuven, Belgium
Contributors xxi
Anne-Marie Dufresne, MD, FRCSC Royal Columbian Hospital,

Department of Colorectal Surgery, New Westminster, BC, Canada
Laura Melina Fernandez, MD Angelita & Joaquim Gama Institute, Sao
Paulo, Brazil
Phillip R. Fleshner, MD, FASCRS Cedars-Sinai Medical Center, Division
of Colon & Rectal Surgery, Los Angeles, CA, USA
Charles M. Friel, MD, FACS, FASCRS Department of Surgery, University
of Virginia Health System, Charlottesville, VA, USA
Aimee E. Gough, MD Cedars-Sinai Medical Center, Division of Colon &
Rectal Surgery, Los Angeles, CA, USA
Mario Guerrieri, MD Università Politecnica delle Marche, Ancona, Italy
Angelita Habr-Gama, MD, PhD Angelita & Joaquim Gama Institute, Sao
Paulo, Brazil
Colorectal Surgery Division, University of São Paulo School of Medicine,
Sao Paulo, Brazil
Dieter Hahnloser, MD University Hospital Lausanne, Department of
Visceral Surgery, Lausanne, Switzerland
Suguru Hasegawa, MD, PhD, FACS Department of Gastroenterological
Surgery, Fukuoka University Hospital, Fukuoka, Japan
Hoa Nguyen Hoang, MD, PhD Thai Binh Medical University, Thai Binh,
Vietnam
Hanoi High Tech & Digestive Center, St Paul Hospital, Digestive Colorectal
Department of Minimally Invasive Surgery, Hanoi, Vietnam
Sook C. Hoang, MD Department of Surgery, University of Virginia Health
System, Charlottesville, VA, USA
Masaaki Ito, MD National Cancer Center Hospital East, Department of
Colorectal Surgery, Kashiwa, Japan
Kevin M. Izquierdo, MD Lankenau Medical Center, Division of Colorectal
Surgery, Wynnewood, PA, USA
Paul Kaminsky, MD, PhD Center for Colon and Rectal Surgery, Department
of Colon and Rectal Surgery, Florida Hospital, Orlando, FL, USA
Deborah S. Keller, MS, MD Division of Colon and Rectal Surgery,
Department of Surgery, New York–Presbyterian, Columbia University
Medical Center, New York, NY, USA
Seon-Hahn Kim, MD, PhD Korea University Anam Hospital, Colorectal
Division, Department of Surgery, Seoul, South Korea
Werner Kneist, MD University Medicine of the Johannes Gutenberg-
University Mainz, Department of General, Visceral and Transplant Surgery,
Mainz, Germany
xxii Contributors
Joep Knol, MD Department of Abdominal Surgery, Jessa Hospital, Hasselt,

Belgium
T. W. A. Koedam, MD Amsterdam UMC, Department of Surgery,
Amsterdam, Noord-Holland, The Netherlands
Daibo Kojima, MD, PhD Department of Gastroenterological Surgery,
Akira Komono, MD Department of Gastroenterological Surgery, Fukuoka
University Hospital, Fukuoka, Japan
Antonio M. Lacy, MD, PhD Gastrointestinal Surgery Department, Hospital
Clinic, University of Barcelona, Barcelona, Spain
Sergio W. Larach, MD, FASCRS Endosurgical Center of Florida, Orlando,
FL, USA
Lawrence Lee, MD, PhD Department of Surgery, McGill University Health
Centre, Montreal, QC, Canada
Center for Outcomes Research and Evaluation, McGill University Health
Centre Research Institute, Montreal, QC, Canada
Joel Leroy, MD, FRCS (Honorary, London) Hanoi High Tech & Digestive
Center, St Paul Hospital, Digestive Colorectal Department of Minimally
Invasive Surgery, Hanoi, Vietnam
Emanuele Lezoche, MD, FACS, HF, ASCRS Università di Roma
“SAPIENZA”, Rome, Italy
Giovanni Lezoche, MD Università Politecnica delle Marche, Ancona, Italy
Grace Wai Ma, MD Health Sciences North, Department of Surgery,
Sudbury, ON, Canada
Colorectal Surgery North, Sudbury, ON, Canada
John Marks, MD Colon and Rectal Surgery, Lankenau Medical Center,
Marks Colorectal Surgical Associates, Wynnewood, PA, USA
Beatriz Martín-Pérez, MD Hospital Clinic, Barcelona (Spain),
Gastrointestinal Surgery, Barcelona, Spain
Justin A. Maykel, MD Division of Colon and Rectal Surgery, Department
of Surgery, University of Massachusetts Medical School, University of
Massachusetts Memorial Medical Center, Worcester, MA, USA
Elisabeth C. McLemore, MD Colon and Rectal Surgery, Los Angeles
Medical Center, Kaiser Permanente, Department of Surgery, Los Angeles,
CA, USA
Armando Geraldo Franchini Melani IRCAD Latin America, Barretos,
Brazil
Americas Medical City, Rio de Janeiro, Brazil
Contributors xxiii
George Melich, MD Royal Columbian Hospital, Department of Surgery,

New Westminster, BC, Canada
William Frederick Anthony Miles Department of Digestive Disease, The
Royal Sussex County Hospital, Brighton and Sussex University Hospitals
NHS Trust, Brighton, UK
John Monson, MD Florida Hospital Medical System, Orlando, FL, USA
Center for Colon and Rectal Surgery, AdventHealth Orlando, Orlando, FL,
USA
Surgical Health Outcomes Consortium (SHOC), Orlando, FL, USA
University of Central Florida, College of Medicine, Orlando, FL, USA
Isacco Montroni, MD, PhD, FASCRS Colorectal Surgery, AUSL-
Romagna, Ospedale per gli Infermi- Faenza, Faenza, Italy
George Nassif, DO Florida Hospital, Center for Colon and Rectal Surgery,
Orlando, FL, USA
Chuc Phan Ngoc Hanoi Medical University, Hanoi, Vietnam
Hanoi High Tech & Digestive Center, St Paul Hospital, Digestive Colorectal
Department of Minimally Invasive Surgery, Hanoi, Vietnam
T. Paul Nickerson, MD The University of Texas MD Anderson Cancer
Center, Department of Surgical Oncology, Houston, TX, USA
Vincent Obias, MD, MS George Washington University Hospital,
Department of Surgery, Washington, DC, USA
Tomoaki Okada, MD Department of Surgery, Graduate School of Medicine,
Kyoto University Hospital, Kyoto, Japan
Jessie Osborne Paull, MD Walter Reed National Military Medical Center,
Department of General Surgery, Bethesda, MD, USA
Sharaf Karim Perdawood, MD Slagelse Hospital, Department of Surgery,
Slagelse, Denmark
Rodrigo O. Perez, MD, PhD Angelita & Joaquim Gama Institute, Sao
Paulo, Brazil
Colorectal Surgery Division, University of São Paulo School of Medicine,
Sao Paulo, Brazil
Ludwig Institute for Cancer Research São Paulo Branch, Sao Paulo, Brazil
Uma R. Phatak, MD, MS Section of Colon and Rectal Surgery, Surgery
Department, Boston University Medical Center, Boston, MA, USA
Elizabeth R. Raskin, MD, FACS, FASCRS Loma Linda University, Loma
Linda, CA, USA
VA Hospital Loma Linda, Department of Surgery, Loma Linda, CA, USA
Reagan L. Robertson, MD, MSc, FRCSC St. Paul’s Hospital, Department
of Colorectal Surgery, Vancouver, BC, Canada
xxiv Contributors
Luis Gustavo Capochin Romagnolo, MD IRCAD Latin America, Barretos,

Brazil
Department of Surgery, Barretos Cancer Hospital, Barretos, Brazil
Marcos Gómez Ruiz, MD, PhD, FEBS, Coloproctology Hospital
Universitario Marqués de Valdecilla, IDIVAL, Servicio de Cirugía General y
Aparato Digestivo, Unidad de Cirugía Colorrectal, Santander, Spain
Eric Rullier, MD Department of Colorectal Surgery, Haut-Levèque, Pessac,
France
Muhammad Shafique Sajid, MBBS, MSc, MBA, FCPS, FRCS
(GEN) Department of Digestive Disease, The Royal Sussex County Hospital,
Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
Yoshiharu Sakai, MD, PhD, FACS Department of Surgery, Graduate
School of Medicine, Kyoto University Hospital, Kyoto, Japan
Ryohei Sakamoto, MD Department of Gastroenterological Surgery,
Jean Salem, MD Lankenau Medical Center, Division of Colorectal Surgery,
Wynnewood, PA, USA
Dana Sands, MD, FACS, FASCRS Department of Colorectal Surgery,
Cleveland Clinic Florida, Weston, FL, USA
Guilherme Pagin São Julião, MD Angelita & Joaquim Gama Institute, Sao
Paulo, Brazil
Rishabh Sehgal, MB, MD University Hospital Limerick, Department of
Surgery, Limerick, Ireland
C. Sietses, MD, PhD Gelderse Vallei Hospital, Department of Surgery, Ede,
Gelderland, The Netherlands
Thushy Siva, MBBS Easton Hospital, Department of Surgery, Easton, PA,
USA
António S. Soares Division of Surgery and Interventional Sciences,
University College London Hospitals, NHS Trusts, GENIE Centre, University
College London, London, UK
Antonino Spinelli, MD, PhD, FASCRS Division of Colon and Rectal
Surgery, Humanitas Clinical and Research Center, Milan, Italy
Department of Biomedical Sciences, Humanitas University, Milan, Italy
Scott R. Steele, MD Department of Colorectal Surgery, Digestive Disease
and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
Andrew R. L. Stevenson, MBBS, FRACS, FASCRS University of
Queensland, Brisbane, QLD, Australia
Colorectal Surgery, Royal Brisbane Hospital, Herston, QLD, Australia
Contributors xxv
Patricia Sylla, MD, FACS, FASCRS Division of Colon and Rectal Surgery,

Icahn School of Medicine at Mount Sinai, New York, NY, USA
Jean-Sébastien Trépanier, MD Maisonneuve-Rosemont Hospital, General
Surgery Department, Montréal, Québec, Canada
Truc Vu Trung, MD Hanoi Medical University, Hanoi, Vietnam
St Paul Hospital, Digestive Colorectal Department of Minimally Invasive
Surgery, Hanoi, Vietnam
Jurriaan Benjamin Tuynman, MD, PhD Department of Surgery,
Amsterdam University Medical Center, location VUmc, Cancer Center
Amsterdam, Amsterdam, The Netherlands
Bruna Borba Vailati, MD Angelita & Joaquim Gama Institute, Sao Paulo,
Brazil
Stefan Erik Van Oostendorp, MD Department of Surgery, Amsterdam
University Medical Center, location VUmc, Cancer Center Amsterdam,
Amsterdam, The Netherlands
Itzel Vela, MD Instituto Nacional de Cancerología, Mexico City, Mexico
Elena A. T. Vikis, MD, Med, FRCSC Royal Columbian and Eagle Ridge
Hospitals, Department of Surgery, New Westminster, BC, Canada
Steven D. Wexner, MD, PhD(Hon) Digestive Disease Center, Weston, FL,
USA
Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL,
USA
Arthur Randolph Wijsmuller, MD, PhD Department of Surgery,
University Medical Center Groningen, Groningen, The Netherlands
Albert M. Wolthuis, MD University Hospitals, Abdominal Surgery, Leuven,
Belgium
Nathalie Wong-Chong, MD Department of Surgery, McGill University
Health Centre, Montreal, QC, Canada
Raymond Yap, MBBS, BMedSCi, MSurgEd Florida Hospital, Center for
Colon and Rectal Surgery, Orlando, FL, USA
Shlomo Yellinek, MD Department of Colorectal Surgery, Cleveland Clinic
Florida, Weston, FL, USA
Yoichiro Yoshida, MD, PhD Department of Gastroenterological Surgery,
Karen N. Zaghiyan, MD, FACS, FASCRS Cedars-Sinai Medical Center,
Division of Colon & Rectal Surgery, Los Angeles, CA, USA
Part I
Transanal Minimally Invasive Surgery
(TAMIS)
Historical Perspectives
and Rationale for Development 1
Sergio W. Larach and Beatriz Martín-Pérez
Introduction principles with conventional laparoscopic instru-

mentation, creating an important new option for
Rectal lesions, whether of benign or malignant appropriately trained minimally invasive colorec-
histology, present a special challenge for surgeons tal surgeons.
because of the difficulty of access and exposure to
the rectal lumen. Traditional transanal methods,
such as Parks transanal excision (TAE), have been rom Miles Resection
F
associated with a high incidence of local recur- to Parks Excision
rence, thus unleashing the development of newer
approaches. Heralding the era of the expansion of Surgical management of rectal lesions represents a
endoscopic surgery, transanal endoscopic micro- challenge for the colorectal surgeon. Through the
surgery (TEM) represented a milestone in the twentieth century, the approach to rectal cancer has
approach to rectal lesion excision, as it achieved largely evolved from invasive radical resections to
minimally invasive access to the upper rectum, a organ-sparing techniques. Jacques Lisfranc de St.
better quality of excision with improved likeli- Martin (1790–1847) pioneered transanal rectal
hood of achieving negative resection margins. As cancer excision, when in 1826 he described the
a result, decreased recurrence rates and improved removal of the anus and rectum through the
disease-free survival were observed, all due to perineum, resulting on a perineal colostomy [1]. In
improved access and the concomitant improve- 1875, Kocher and Verneuil tried to improved rectal
ment of visual field and dissection quality. Despite access and described the posterior approach includ-
these advantages, TEM use was limited, ing coccygectomy; this was subsequently refined
mainly due to a steep learning curve, complex sur- by Paul Kraske (1851–1930) [2]. Abdominoperineal
gical setup, and cost of instrumentation. It was resection (APR) for rectal cancer was later
with this pretext that transanal minimally invasive described in 1908 by Dr. Ernest Miles, reducing
surgery (TAMIS) was born, combining TEM local recurrence rates from 100% to 30% [3].
However, the morbidity associated with APR was
high, ranging from 15% to 61% [4–7].
Surgeons continued to search for less-invasive
S. W. Larach (*) options to manage rectal cancer, particu-
Endosurgical Center of Florida, Orlando, FL, USA larly within the distal one-third of the rectum.
B. Martín-Pérez The objective would be to develop sphincter-
Hospital Clinic, Barcelona (Spain), Gastrointestinal preservation techniques that could spare patients
Surgery, Barcelona, Spain
© Springer Nature Switzerland AG 2019 3

S. Atallah (ed.), Transanal Minimally Invasive Surgery (TAMIS) and Transanal Total Mesorectal
Excision (taTME), https://doi.org/10.1007/978-3-030-11572-2_1
4 S. W. Larach and B. Martín-Pérez
from the high morbidity of APR while maintain-

ing acceptable oncologic outcomes. In the case of
premalignant lesions including carcinoma in situ,
the benefits of local operations for tumor removal
present a significant advantage, as such less-
invasive surgery by this modality avoids the mor-
bidity of radical surgery with virtually no
oncologic compromise.
In the early twentieth century, screening and
endoscopic techniques were less developed than
at present, for which these group of patients with
benign neoplasia or T1 cancers were subjected to
a radical surgery, permanent colostomy, and a
Fig. 1.1 Parks anal retractor
high rate of morbidity. Despite radical surgery,
patients had a high rate of local recurrence even
for early-stage rectal cancer [4, 6]. In this quest
for better approaches, local excision for rectal Despite these limitations, early series from
lesions was born as an organ preservation surgery the 1970s were able to demonstrate that local
for suitable lesions. excision for early-stage rectal cancer with favor-
The pathway for management of early-stage able histopathological features had equivalent
rectal cancer followed the treatment model of oncologic outcomes when compared with radi-
early-stage breast cancer – which was treated cal resection. In a landmark study by Morson
with either (a) breast-conservation surgery and et al., the data for local excision revealed a fail-
radiotherapy or (b) radical mastectomy alone [8]. ure rate (as defined by locoregional recurrence)
Local excision for premalignant and early-stage that measured 8.4%, which was felt to be quite
rectal cancer (predominately via Parks transanal acceptable [9].
excision, TAE) aimed to offer patient an improved In the 1990s, the results of a prospective,
quality of life, through stoma-free surgery and multi-institutional study from the Cancer and
maintenance of normal bowel and urogenital Leukemia Group B (CalGB) reinforced the idea
function, while obtaining similar disease-free of local excision and organ preservation for
survival and cure rates to those observed with select, early-stage rectal cancer [10]. Fifty-nine
radical resection. This technique was performed cases of T1 were treated with local excision alone
with transanal retractors, which provide subopti- and 51 cases of T2 undergoing adjuvant external
mal exposure of the rectal lumen (Fig. 1.1). beam radiotherapy after local excision (local
Electrocautery and conventional surgical instru- excision was performed utilizing the conven-
ments were used for the local excision of rectal tional Parks TAE technique). The 6-year over-
neoplasms, and the full-thickness defects were all survival of 85% and disease-free survival rates
closed with suture. Illumination of the rectal of 78% for this treatment seemed promising, par-
lumen and overall operative field exposure was ticularly when compared to the 20–30% failure
limited by external field lights (headlights rates after standard oncologic resection prior to
only modestly improve visualization, and are dif- the era of TME surgery [5, 6]. These encouraging
ficult to direct and maintain onto targets). Due to early results were very well received by the surgi-
these constraints, only low-lying rectal lesions cal community, which resulted in an overall
(i.e., palpable lesions, whose upper edge does not increased rate of local excision as a modality of
extend beyond <7 cm from the verge) were acces- treatment [11]. Unfortunately, subsequent series
sible by this approach, and complete, margin- published inferior results even in the same selec-
negative excision of specimens could be quite tion of T1 patients, whereby the observed local
challenging due to this limited exposure. recurrence rate increased from 8% to 18% for T1
1 Historical Perspectives and Rationale for Development 5
lesions and, even a more alarmingly, from 18% to

37% for the T2 cancers treated in this fashion
[12–14]. Parallel to these results, the technique
for radical surgery was evolving. Lead by RJ
Heald, total mesorectal excision (TME) was
being implemented around the globe. It was
learnt that through proper sharp dissection along
the embryonic plane of the TME envelope, local
recurrence for stage I rectal cancer could be
reduced to 7.1% [15]. Parks TAE had inferior
oncologic results compared to new-era TME sur-
gery [12, 16]. The awareness that the improve-
ment on patient’s quality of life with local
excision and organ-sparing surgery was at the
expense of worse oncologic outcomes resulted in
an overall decrease on the use of local excision
for invasive lesions [17].
Transanal Endoscopic
Microsurgery (TEM)
Surgical evolution has been largely influenced by

instrumentation development, and the advances
in the technique of local excision would undoubt-
Fig. 1.2 Transanal endoscopic microsurgery (TEM)
edly come from creative applications of these equipment. Developed in 1983 by Gerhard Buess, It
advancements. The discovery of the first rigid allowed for high definition access to the rectal vault for
endoscopes presented by Desormeaux in 1865 the purpose of performing local excision
later would evolve into the first fiberoptic endo-
scopic procedure in 1957 [18], heralding the new of the mid and upper rectum [21]. TEM consists of
era of laparoscopy and minimally invasive sur- a rigid transanal platform, which allows insufflat-
gery, which would find fitting applications in the ing of the rectal cavity, creating a pneumorectum.
late 1980s toward a multitude of common abdom- TEM has three working channels, one for a fixed
inal operations [18–20]. camera and other two for working instruments
In such a way, the design of an advanced (cautery, suction, suture, etc.). The improved visu-
endoscopic transanal platform with an endo- alization from a stereoscopic magnified view in
scopic camera and laparoscopic-style surgical the pneumatically distended rectum allows for
instruments would yield access to the rectal cav- precise excision in an operative space that would
ity with superior visibility when compared to the be otherwise difficult to reach. Initially, Buess
traditional Parks approach and even provided designed TEM for local excision of nonmalignant
access to more proximal lesions that were not lesions not within reach of conventional transanal
accessible before with conventional techniques methods, addressing the limitations of the Parks
for local excision. excision. It was not designed with the purpose of
In 1983, predating the first laparoscopic chole- performing higher-quality excision. However, the
cystectomy by a few years, Dr. Gerhard Buess platform was soon utilized also for resection at any
designed transanal endoscopic microsurgery level of the rectum and for early malignant lesions,
(TEM) (Fig. 1.2). It was a platform that, for the since TEM became increasingly recognized as the
first time, allowed for excision of benign neoplasia better platform for this [22].
Since its first description, the use of TEM has

proven to result in high-quality excisions with
outcomes that were more favorable than standard
transanal techniques for local excision, with a low
recurrence rate [23–29]. Winde et al. [22]
described no difference in disease-free and over-
all survival for patients with T1 rectal cancer
operated with local excision via TEM versus radi-
cal resection. A 10-year single center experience
demonstrated that for 70 patients who underwent
TEM for T1 rectal cancer, a local recurrence rate
of 8.5% was observed [30]. Furthermore, data Fig. 1.3 Transanal endoscopic operation (TEO) plat-
surmised from other studies, indicated that local form. (Reproduced with permission of Karl Storz SE &
Co.)
excision via the traditional (Parks) approach has
inferior 5-year survival rates compared to anterior
resection for patients with T1N0M0 disease; ransanal Minimally Invasive
T
while, when local excision of T1 lesions was per- Surgery (TAMIS)
formed with TEM, the oncologic results were
comparable to those achieved with radical surgery The beginning of the twenty-first century was
for early rectal cancer [16, 31, 32]. marked by further evolution in abdominal lapa-
For 25 years, TEM was the only available roscopy and abdominal access strategies.
advanced transanal platform. However, this Meanwhile, the concept of natural orifice translu-
advanced transanal platform required specific minal endoscopic surgery (NOTES) emerged in
instrumentation (with associated higher cost), 2004. This led to the idea of consolidating laparo-
posed ergonomic difficulties, and resulted in a scopic trocars into a combined port that could be
steep learning curve for even experienced train- delivered through the umbilicus (an embryonic
ees [33, 34]. The economic pressure for cost con- natural orifice). Thus, the birth of the “single port”
tainment in the healthcare system limited the was based on (a) decreased abdominal wall access
investment in TEM, and few institutions could trauma and (b) the ability to provide a minimally
afford the TEM apparatus, as a high volume of invasive route via an embryonic natural orifice.
cases was necessary to amortize the price of the Although the concept of single-wound minimally
platform [20]. For these reasons, widespread invasive access was reported by Pelosi et al. in
adoption was limited, and TEM for local excision 1992 as a transumbilical approach for appendec-
remains, to this day, an operative technique pri- tomy [38], it was not until the mid-2000s, in the
marily performed by a small number of high- wake of NOTES, that single ports were manufac-
volume specialists in referral centers [35, 36]. tured, and this approach was subsequently applied
Over the decades, the system’s design has not to a broad range of abdominal procedures includ-
been significantly modified, and it is essentially ing colonic resection [39, 40].
unchanged since its development by G. Buess. Although not intended by design to be used
Transanal endoscopic operation (TEO) (Fig. 1.3) for transanal access, the single port seemed ideal
emerged as a similar platform to TEM, with anal- for this purpose. In 2009, this was performed for
ogous principles, indications, and results [37]. the first time, giving birth to a new operation for
Together, TEO and TEM are considered advanced rectal surgery. The new approach would have a
transanal platforms capable of performing high- profound effect on how colorectal surgeons
quality excision of rectal neoplasia. They are would operate within the rectum. The technique
often referred to as “rigid platforms.” In general, was termed transanal minimally invasive surgery
most experts believe the quality of excision (TAMIS) by its founders S. Atallah, M. Albert,
achievable with TEM and TEO is the same. and SW. Larach [41].
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
Fig. 1.4 Shown is a Single-Incision Laparoscopic (SILS)

Port. Although it was not intended to be used transanally, it Fig. 1.5 Transanal minimally invasive surgery (TAMIS)
was used to develop the TAMIS technique. The SILS port was platform, or TAMIS Port. This device was developed spe-
used for all cases published in the first series on TAMIS and cifically for transanal access and was created and designed
predated the creation of TAMIS-specific ports with the aid of the surgeons who developed the technique
Evolution and Milestones in Rectal Surgery
TEM TEO Transanal minimally

Transanal Transanal Invasive Surgery
Endoscopic Endoscopic (TAMIS)
Local Excision
Transanal excision Microsurgery Operation Dr. Larach, Dr. Atallah

Dr. Parks (9) Dr. Buess (23) (25, 26) & Dr. Albert (54)
’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)
Fig. 1.6 Evolution and milestones in rectal surgery
4. Rosen L, Veidenheimer MC, Coller JA, Corman

odern day transanal total mesorectal excision.
m ML. Mortality, morbidity, and patterns of recurrence
From a technical standpoint, further instrumenta- after abdominoperineal resection for cancer of the
tion and platform refinements will likely contrib- rectum. Dis Colon Rectum. 1982;25(3):202–8.
ute to the advancement of TAMIS. Next-generation 5. Gastrointestinal Tumor Study G. Prolongation of the
disease-free interval in surgically treated rectal carci-
flexible robotic transanal systems are poised to be noma. N Engl J Med. 1985;312(23):1465–72.
part of the future evolution of TAMIS. 6. Luna-Perez P, Rodriguez-Ramirez S, Vega J, Sandoval
Figure 1.6 shows the evolution and milestones E, Labastida S. Morbidity and mortality following
in rectal surgery. abdominoperineal resection for low rectal adenocar-
cinoma. Rev Investig Clin. 2001;53(5):388–95.
7. Wang YW, Huang LY, Song CL, Zhuo CH, Shi DB,
Cai GX, et al. Laparoscopic vs open abdomino-
Conclusion perineal resection in the multimodality manage-
ment of low rectal cancers. World J Gastroenterol.
2015;21(35):10174–83.
TAMIS arose serendipitously and represents an 8. Fisher B, Anderson S, Redmond CK, Wolmark N,
amalgam of innovations in laparoscopy, single- Wickerham DL, Cronin WM. Reanalysis and results
port surgery, NOTES, and TEM. The impetus after 12 years of follow-up in a randomized clinical
behind its development was the need for improved trial comparing total mastectomy with lumpectomy
with or without irradiation in the treatment of breast
access to the rectal lumen, thereby providing a cancer. N Engl J Med. 1995;333(22):1456–61.
practical and effective alternative to TEM. 9. Morson BC, Bussey HJ, Samoorian S. Policy of local
excision for early cancer of the colorectum. Gut.
1977;18(12):1045–50.
10. Steele GD Jr, Herndon JE, Bleday R, Russell A,

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TAMIS: Indications
and Contraindications 2
Uma R. Phatak and Justin A. Maykel
Introduction sal equipment availability, the relatively faster set

up time, and potential decreased risk of inconti-
Transanal minimally invasive surgery (TAMIS) nence as it utilizes a 34 mm malleable access
was first reported in 2010 as a technique for per- channel compared to the rigid 40 mm access
forming natural orifice surgery [1]. This was channel (shaft) of the TEM scope [5]. Similar to
quickly identified as a cost-effective alternative TEM or perhaps more so, TAMIS requires
to transanal endoscopic microsurgery (TEM) advanced laparoscopic skills with in-line instru-
which was pioneered in the 1980s [2]. The prin- ment manipulation in a tight operative field.
ciple advantage of TAMIS is similar to TEM in Since TAMIS represents an alternate method for
that it provides the ability to perform high-quality transanal excision, the indications are similar to
local excision of rectal lesions, thereby avoiding TEM. In certain cases, the TAMIS platform can
the morbidity of abdominopelvic surgery. TAMIS be more versatile and able to reach and visualize
has a higher rate of margin-negative excision lesions which may be impossible to access due to
compared to traditional transanal excision; it also inability to maneuver a long, relatively wide and
has decreased rate of specimen fragmentation. It rigid TEM scope beyond rectal valves or angula-
is believed that, for these reasons, TAMIS-based tions at the sacrum or rectosigmoid junction.
local excision results in a lower rate of local
recurrence compared to patients who undergo
conventional traditional transanal excision for Indications
early-stage rectal cancer [3, 4]. Other advantages
that separate TAMIS from TEM are more univer- The indications for TAMIS range from benign to
malignant disease and mirror historical indica-
tions for transanal excision and for TEM [2, 6].
U. R. Phatak (*) The traditional indications for transanal excision
Section of Colon and Rectal Surgery, were for lesions within 8 cm of the anal verge,
Surgery Department, Boston University Medical less than 3 cm in size, and occupying less than
Center, Boston, MA, USA
e-mail: [email protected] 40% of the circumference of the rectum [2, 6].
These were practical parameters given the limita-
J. A. Maykel
Division of Colon and Rectal Surgery, Department of tion of the instrumentation at the time. However,
Surgery, University of Massachusetts Medical surgeons have pushed the limits of TEM and
School, University of Massachusetts Memorial TAMIS to far beyond what is feasible by tradi-
Medical Center, Worcester, MA, USA
tional transanal access. TAMIS is best suited for
e-mail: [email protected]

12 U. R. Phatak and J. A. Maykel
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 distant 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
Contraindications While the idea of transanal excision for rectal

cancer is not new, much controversy remains
Definitive contraindications to TAMIS are the regarding proximal tumors, T2 tumors, and those
same as for any transanal excision. Fixed masses, with a complete pathologic response following
when malignant, should not be locally excised – neoadjuvant treatment (ypT0N0). Full-thickness
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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26. Kidane B, Chadi SA, Kanters S, Colquhoun PH, Ott 31. Perez RO, Habr-Gama A, São Julião GP, Proscurshim
MC. Local resection compared with radical resection I, Scanavini Neto A, Gama-Rodrigues J. Transanal
in the treatment of T1N0M0 rectal adenocarcinoma: endoscopic microsurgery for residual rectal can-
a systematic review and meta-analysis. Dis Colon cer after neoadjuvant chemoradiation therapy is
Rectum. 2015;58:122–40. associated with significant immediate pain and
27. Read TEMD, Andujar JEMD, Caushaj PFMD,
hospital readmission rates. Dis Colon Rectum.
Johnston DRBA, Dietz DWMD, Myerson RJMD, 2011;54:545–51.
An Algorithm for Local Excision
for Early-Stage Rectal Cancer 3
George J. Chang and T. Paul Nickerson
Background function and low anterior resection syndrome [6].

Finally, patient factors such as the growing obe-
In 2018, an estimated 49,000 new cases of rectal sity epidemic in the United States [7] increase the
cancer were diagnosed in the United States, and risk for overall mortality, need for colostomy, and
colorectal cancer remains the third most common morbidity following proctectomy [8]. Thus, for
newly diagnosed cancer in both men and women patients with early-stage rectal cancer without
[1]. The standard surgical approach to most sphincter involvement, concern for the morbidity
patients with rectal cancer includes radical resec- risk and quality of life impact of radical surgery
tion with total mesorectal excision. Total meso- has led to increased consideration of local exci-
rectal excision (TME), originally described by sion strategies that are associated with substan-
Heald and colleagues in 1982, has been widely tially lower operative risk and provide potential
established as the gold standard surgical treat- for organ preservation [9].
ment of rectal cancer [2]. In combination with
stage-appropriate neoadjuvant chemoradiation
therapy (CRT), the TME technique has dramati- Techniques for Local Excision
cally lowered the traditionally high rates of local
recurrence in rectal cancer [3]. However, com- Local excision (LE) via the conventional trans-
plete dissection and removal of the lymph node- anal excision (TAE) approach has historically
bearing mesorectum, combined with low pelvic been utilized to excise distal rectal tumors
anastomoses often in the setting of an irradiated directly through the anus. Traditional local exci-
field, have been associated with up to 40% rate of sion via TAE is limited to tumors smaller than
perioperative morbidity [4]. Despite the advan- 4 cm located within ~7 cm from the anal verge so
tages of minimally invasive surgery, patients that they can be visualized and accessed using
undergoing radical resection even at high-volume traditional anal retractors [10]. The poor visibil-
centers are still at significant risk for complica- ity of the anal canal and limited standard trans-
tions [5]. Radical resection for rectal cancer is also anal instrumentation contribute to high rates of
associated with a significant risk for bowel dys- specimen fragmentation and specimen margin
positivity [11]. Despite these limitations, TAE
G. J. Chang · T. P. Nickerson (*) procedures potentially offer lower complication
The University of Texas MD Anderson Cancer rates when compared to radical surgery.
Center, Department of Surgical Oncology, Additionally, transanal excision is almost univer-
Houston, TX, USA sally associated with sphincter preservation and

18 G. J. Chang and T. P. 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 complication [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
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
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
Denotes disease-free survival

b
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
(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].
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 outpatients 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 distin (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
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
Besides tumor location and primary characteristics

NCCN and National Guidelines that can be used to determine oncologic feasibility
of local excision of early rectal tumors, patient-
A number of organizations have published guide- related factors should be taken into consideration.
lines regarding the management of early rectal For patients with significant comorbidity or limited
cancers. The 2018 guidelines for the manage- life expectancy, optimizing oncologic control
ment of rectal cancer set forth by the National should be balanced with risk for surgical or func-
Comprehensive Cancer Network state that trans- tional morbidity. Often these early rectal tumors
anal excision (TAE) is only appropriate for T1 N0 being considered for local excision are low lying,
early-stage rectal cancers without evidence of and radical resection would result in loss of sphinc-
high-risk features: small tumors (<3 cm) located ter function or resection of the sphincter complex
within 8 cm of the anal verge, occupying <30% entirely (abdominoperineal resection, APR). When
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
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
* Radical resection may be considered based on surgeon/patient discussion

** May consider neoadjuvant CRT with intersphincteric resection for low rectal cancer desiring sphincter preservation
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
these high-risk features can be safely observed, Conclusions

with an expected local recurrence rate of approxi-
mately 4%. Often these patients are candidates for Although safety and efficacy of local excision of
minimally invasive surgical resection with sphinc- rectal neoplasia via TES has been demonstrated
ter preservation and are willing to undergo radical in multiple studies, the surgeon must take into
surgery up front. Those patients who elect local account tumor characteristics, patient concerns,
excision should be carefully counselled about the and feasibility of safely performing a radical
risks of subsequent salvage surgery or unresect- resection with sphincter preservation. We reserve
able recurrence. Patients who are unwilling to local excision as the primary oncological man-
accept this slight risk of local recurrence and the agement strategy for low-lying rectal tumors with
morbidity of subsequent salvage surgery or favorable features.
unknown lymph node status, or patients in whom
the primary tumor can be safely removed via radi-
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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
Introduction through an endoscopically placed cecostomy as

the last resource to avoid a definitive stoma [3].
Surgical management of low rectal cancer is Even though definitive colostomy rates have been
associated with a significant rate of postoperative reported to be ≤10% in dedicated centers for the
complications. Even mortality may be quite sig- management of rectal cancer, long-term colos-
nificant, depending on patients’ age and comor- tomy rates may increase to ≥22% due to anasto-
bidities [1]. In addition, even after an uneventful motic failures related to poor function, leaks, or
recovery, patients may still have to deal with sig- even local recurrence [4]. Finally, patients who
nificantly negative functional consequences. A underwent a radical surgery for rectal cancer
major proportion of patients will develop fecal have more than twofold increased risk for being
incontinence and considerable rates of low ante- out of work, despite being recurrence-free. The
rior resection syndrome [2, 3]. These symptoms risk increased according to the type of operation
may be so significant that a proportion of these performed (higher for APR compared to AR) and
patients will require antegrade enemas performed to the presence of surgical/postoperative compli-
cations [5].
L. M. Fernandez · G. P. São Julião · B. B. Vailati Neoadjuvant CRT may lead to significant
Angelita & Joaquim Gama Institute, tumor regression of rectal cancers that can be
Sao Paulo, Brazil observed not only in the primary tumor but also
A. Habr-Gama in perirectal nodes, setting the “perfect” scenario
Angelita & Joaquim Gama Institute, for organ preservation strategies such as trans-
Sao Paulo, Brazil anal excision (TAMIS) of small and superficial
Colorectal Surgery Division, University of São Paulo residual tumors [6, 7]. In addition, the observa-
School of Medicine, Sao Paulo, Brazil tion that this effect may be so intense leading to
R. O. Perez (*) complete tumor regression in up to 30% of
Angelita & Joaquim Gama Institute, patients [pathological complete response (pCR)]
Sao Paulo, Brazil
prompted surgeons to an attempt in the identifica-
Colorectal Surgery Division, University of São Paulo tion of these patients before surgical resection,
School of Medicine, Sao Paulo, Brazil
known as complete clinical response (cCR) [7].
Ludwig Institute for Cancer Research São Paulo These patients with complete tumor regression to
Branch, Sao Paulo, Brazil

32 L. M. Fernandez et al.
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
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
Radiological Assessment
Radiological studies are also essential for the

assessment of response not only to confirm clini-
cal and endoscopic findings of a cCR but also
provide additional information of the mesorec-
tum compartment unavailable to the finger or the
endoscope. High-resolution magnetic resonance
(MR) is routinely used for the assessment of
tumor response. The ability to discriminate
between fibrotic changes and residual disease has
improved with advances in technology, placing
MR as an integral part in the assessment of
Fig. 4.1 Typical endoscopic findings of a cCR with whit- response to nCRT [43]. Typical findings of com-
ening of the mucosa and the presence of telangiectasias.
No ulceration or evident mass is present. cCR complete plete tumor regression include the presence of
clinical response low-signal intensity areas in the area previously
harboring the rectal cancer with multiple patterns
[43] (Figs. 4.3 and 4.4). MR may estimate the
pathological tumor regression grade (TRG) by
providing a similar radiological scoring system
(mrTRG) and therefore able to identify patients
with poor or good response prior to surgical treat-
ment and with a significant correlation between
response and survival [33, 44].
Diffusion-weighted magnetic resonance imag-
ing (DWI-MR) may provide additional informa-
tion to standard MR imaging. The properties of
Fig. 4.2 Endoscopic findings consistent with incomplete

clinical response including the presence of an obvious
ulcer and significant amount of fibrin covering it (yellow
arrows)
response) is rarely associated with no residual

cancer. Most of these patients will have residual
viable cancer in nearly 80% of the cases despite a
negative endoscopic biopsies [41] (Fig. 4.2). An
interesting study has revealed that after nCRT,
the mucosa is the layer of the rectal wall less
likely to harbor residual cancer cells [42].
Therefore, the presence of a negative biopsy
Fig. 4.3 Radiological assessment of tumor response with
should not be interpreted as a complete clinical high-resolution magnetic resonance showing findings of
response or as an accurate marker of a complete complete response with the presence of low-signal intensity
pathological response. signal in the area harboring the original tumor (yellow arrow)
tumor response to nCRT [49]. Performance of

transanal local excision with the use of transanal
endoscopic platforms (TEMs or TAMIS) will
provide an ideal specimen with lower risk of pos-
itive margins (in the case of residual cancer) and
specimen fragmentation when compared to stan-
dard transanal surgical techniques, often associ-
ated with poor illumination and exposure of the
surgical field [50]. In addition, appropriate patho-
logical information and resection margins of the
tumor may aid in the decision regarding the need
for additional TME. Otherwise, in the case of a
complete pathological response, it could be used
as an objective confirmation of pCR (ypT0) and
obviate the need for additional TME.
However, these attractive advantages should
be balanced against by several potential disad-
Fig. 4.4 Radiological findings consistent with incom-
vantages. First, healing of the rectal defects cre-
plete response in magnetic resonance indicated by the
presence of a mixed signal intensity area (yellow arrow) ated by local resection after nCRT may be quite
challenging. In the setting of a dehiscence, pain is
frequently quite significant, and it could take as
water molecule diffusion may vary within areas of long as 8 weeks to completely heal. Although,
tissue necrosis, high cellularity (commonly Grade III or IV postoperative complications are
observed within residual tumor) or fibrotic scar- not usually observed, pain is a common cause for
ring. This could be used to improve the identifica- readmission to the hospital [51]. As a result of
tion of responders and represent an additional tool difficult healing, scarring with significant distor-
during assessment of tumor response [45, 46]. tion and irregularities may occur within areas of
Finally, the addition of PET/CT by providing the rectal wall previously resected. This may ulti-
an estimate of tumor metabolism could be used to mately also contribute to difficulties in differenti-
help assess tumor response to nCRT. The varia- ating postoperative fibrosis or local recurrences
tion in mean standard uptake values (SUV) and during follow-up of these patients by clinical,
metabolic tumor volume reduction between pre- endoscopic, and radiological surveillance studies
and posttreatment scans was found to be one of [52]. Secondly, sphincter preservation may be
the best predictors of response to nCRT among significantly compromised after a FTLE. When
patients with rectal cancer [47]. patients with cCR and non-operative manage-
In fact, it has been suggested that the combi- ment were compared to patients with “near-
nation of all these studies (including clinical, complete” response and FTLE following nCRT,
endoscopic, and radiological) may increase the functional outcomes were significantly better
accuracy in the detection of complete tumor among patients under WW [53]. In this setting,
response to nCRT [48]. even though organ preservation has been achieved
with FTLE, anorectal function may be far from
normal in these patients.
ransanal Full-Thickness Local
T Even if patients are found to have incomplete
Excisions (FTLEs) pathological response, FTLE may significant dis-
advantages. Patients that required additional TME
Definitive information on pathological response after FTLE (due to the presence of unfavorable
including final ypT status, TRG, lymphovascular/ pathological features) frequently ended up with an
perineural invasion placed excisional biopsies as APR, despite the fact that they originally were can-
an attractive tool for the assessment of primary didates for a sphincter-preserving strategy [54, 55].
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
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].
Even though there are very few series looking at

oncological outcomes after local excision after uture Perspectives in Organ
F
ypT0, the available data is excellent [61]. Long- Preservation
term oncological outcomes appear to be similar
between patients undergoing watch and wait With the increasing interest of organ preservation
strategy after a cCR following nCRT and patients strategies and the use of nCRT regimens to inten-
managed by TME in the presence of a pCR [8]. tionally develop complete clinical response,
Additional retrospective studies further sup- accurate prediction of tumor response with
ported this similar oncological outcomes between molecular biology studies will become increas-
these subgroups of patients [62, 63]. ingly relevant. Identification of ideal candidates
Local recurrences after WW are still a concern for non-operative management would allow bet-
and have been considered a significant limitation ter selection of patients who would benefit the
in widespread implementation of such strategy. most from nCRT and avoidance of potentially
However, considering that the majority of local unnecessary treatment to poor responders [17,
recurrences appears to develop within the first 68]. However, the presence of significant inter-
24 months of follow-up and nearly all of them and intratumoral heterogeneity observed in rectal
(90%) have an endoluminal component, a strict cancer may have contributed for the lack of clini-
follow-up and simple clinical assessment may cally useful gene expression signatures in pre-
allow early detection of regrowths without com- dicting tumor response [68–70]. Considering this
promising oncological outcomes [64, 65]. intratumoral heterogeneity within a single rectal
Patients with more advanced cT stage at baseline cancer, the coexistence of subpopulations of can-
staging appear to be at greater risk for local recur- cer cells resistant and sensitive to treatment may
rence after initial cCR and should be carefully render that gene signatures derived from single
monitored [16]. Ultimately, the pooled local biopsy specimens may not work simply because
recurrence rate including all published series these fragments are not representative of the
analyzed in a systematic review suggested to be entirety of the tumors. Instead of prediction of
around 16–22% [62, 63]. tumor response, introduction of liquid biopsies
Systemic recurrences may also develop after for the assessment and monitoring of tumor
non-operative management of patients that achieve response may also represent a clinically useful
a cCR. A recent meta-analysis reported similar tool for the management and surveillance of
incidences of systemic recurrence among patients patients during this approach [71].
managed non-operatively with a cCR and patients
with pCR after radical surgery [63]. Curiously, Conflicts of Interest The authors have no conflicts of
overall survival among these patients with cCR interest to declare.
was 93% without the use of adjuvant chemother-
apy. These rates compare favorably with the 90%
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Salvage Surgery After TAMIS
Excision of Early-Stage 5
Rectal Cancer
Sook C. Hoang and Charles M. Friel
Introduction TME. Initially, local excision was performed via

a transanal approach using anal retractors.
Radical resection with a total mesorectal exci- However, there are now more elegant options to
sion (TME) is the gold standard for mid and low a transanal excision (TAE) which include trans-
rectal cancers. Utilizing these techniques there anal endoscopic microsurgery (TEM) and trans-
has been substantial improvement in rates of anal minimally invasive surgery (TAMIS) using
local control and in some studies overall survival either a laparoscopic or robotic platform. These
over the last several decades. However, these newer techniques allow for improved visibility
procedures are associated with considerable resulting in surgical specimens that are more
morbidity and, in some series, a 1–2% rate of likely to remain intact with negative margins.
mortality. Furthermore, many patients will However, despite improvements in imaging and
require either a permanent or a temporary stoma. surgical techniques and our understanding of
Understandably, while recognizing the impor- rectal cancers, local excision for a T1 rectal can-
tance of a TME for patients with locally advanced cer, independent of approach, still has a local
rectal cancers, many investigators have ques- recurrence rate of approximately 10%.
tioned the need for such an aggressive approach Furthermore, once a tumor is completely excised
for patients with an early (T1) rectal cancer. and analyzed pathologically, there will be some
Under these circumstances the rate of lymph patients with tumors who have aggressive patho-
node metastases can be less than 10% which logical features that mandate an immediate
begs the question of whether a TME is oncologi- TME. In both circumstances surgeons must now
cally necessary. Because of this, local excision is perform a radical proctectomy with a TME in an
very appealing for the treatment of early-stage attempt to salvage the initial failed local exci-
rectal cancer. In principle, if the tumor can be sion. It is critical, therefore, for surgeons to
completely excised and the surgeon is confident understand the outcomes of these salvage proce-
there is no lymph node metastases, patients can dures so that patients are fully informed of
be saved from the considerable morbidity of potential outcomes. For the purpose of this dis-
cussion, salvage proctectomy will be classified
as delayed, when it is done for a locally recurrent
cancer, or immediate, when performed for unex-
S. C. Hoang (*) · C. M. Friel pected aggressive pathological features. The out-
Department of Surgery, University of Virginia Health comes will focus on both local control and
System, Charlottesville, VA, USA surgical morbidity.
e-mail: [email protected]; [email protected]

44 S. C. Hoang and C. 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.
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
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
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Organ Preservation and Palliative
Options for Rectal Cancer 6
Nienke den Dekker, Stefan Erik Van Oostendorp,
and Jurriaan Benjamin Tuynman
Introduction risk tumors in the rectum is not without risks. The

relatively high recurrence rate within 2–3 years is
Local excision is a well-accepted organ preserving a substantial problem, since recurrences are often
method for early rectal cancer with substantial symptomatic. Combining local excision with radi-
lower morbidity and impact on quality of life com- ation for palliative reasons could be an option, but
pared to radical surgery. However, only rectal can- unfortunately data to support this theory are scarce.
cers staged as a T1 tumor limited to the superficial Other organ-preserving strategies after local
third of the submucosa (sm1) and less than 3 cm in excision of high-risk lesions are being investi-
diameter without signs of poor differentiation, gated in prospective cohorts and randomized tri-
lymphatic or vascular invasion, budding, or clus- als. A potential curative option is adjuvant
tering in the final pathology are oncologically chemoradiation (CRT) following local excision,
safely treated with radical local excision [1]. These which has proven to decrease local recurrence
tumors have local recurrence rates of less than 5%. rates and offers acceptable morbidity with organ
Small locally excised lesions with more risk fac- preservation. The other option is no further ther-
tors as budding, poor differentiation, and lympho- apy but instead offer close surveillance with sal-
vascular invasion or even T2 lesions have been vage radical surgery if a local recurrence presents
associated with relatively high recurrence rates itself (about 20%).
[2–4]. Due to the increased recurrence rate, most Several combinations of local excision, radio-
guidelines recommend completion radical surgery therapy, chemotherapy, and/or close observation
after local excision of high-risk lesions [5]. are being investigated for treatment of higher-
Local excision for palliation could be consid- staged tumors. The aim of this chapter is to sum-
ered in patients who are either too fragile for or marize data of organ preservation options with a
who refuse radical surgery. This seems to be a focus to palliative options.
valuable option for those that have symptomatic
bleeding, changed defecation, or even inconti-
nence. However, local excision alone for higher- Treatment Options
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

50 N. den Dekker et al.
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.
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].
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
Radical Surgery Local excision is associated with low morbidity

rates, but when compared to radical resection,
Currently, radical surgery following the principal local excision has inferior oncological outcome
of total mesorectal excision (TME) remains the for rectal tumors other than low-risk T1. Although
best available treatment of rectal cancer, in terms theoretically attractive, addition of neoadjuvant
of oncological outcome. However, the risk of (chemo)radiation results in relatively high mor-
anastomotic leakage is substantial with 3–10%, bidity. Local excision with tailored adjuvant
which might be catastrophic, particularly in frail, treatment seems to be a promising option for T1
elderly patients [35]. Therefore, resection with and T2 tumors. Local excision alone for tumors
creation of an end colostomy (Hartmann’s proce- staged T2 or higher stage seems to be associated
dure) might be a valid option in this setting. with unacceptably high recurrence rates that
From an epidemiological standpoint, the could be very symptomatic. Therefore, local
majority of patients diagnosed with rectal cancer excision is not advised as part of palliative
are older than 75 years of age. Therefore, a sig- treatment.
nificant subset may be considered for palliative The best treatment should be highly tai-
treatment rather than curative-intent therapy due lored to each individual patient and discussed
to frailty, severe comorbidities, and/or reduced with the patient, the family, and a multidisci-
life expectancy. A systematic review by Manceau plinary tumor board. If it is only for short-term
et al. concluded that severity of comorbidities symptom relief, short course radiotherapy
had more influence on postoperative complica- might be the best option. If next to low mor-
tions than advanced age [35]. This suggests that bidity, a recurrence-free period is also of rele-
age on its own should not be a discriminator. vance; a more invasive treatment strategy
Unfortunately, few studies report exclusively might be the best option. This could include
on this older, comorbid population. Postoperative local excision with adjuvant therapy for T1–2
30-day mortality in patients with colorectal cancer tumors. As an alternative, endoluminal brachy-
aged between 75 and 84 years is approximately therapy with or without external beam radio-
9%. For patients older than 85 years of age, 30-day therapy could be administered for palliative
mortality is 20%, which increases when surgical treatment of rectal cancer. For patients who
intervention is performed in the emergent setting are deemed medically fit to tolerate radical
[36, 37]. Mamidanna et al. described a higher surgery and want optimal oncological control,
30-day mortality of 31% which increased to 51% then radical surgery seems to be the best
at 12 months follow-up in patients older than option. For patients where the risk of anasto-
80 years [38]. However, this data includes proce- motic leak is unacceptably high, rectal extir-
dures with restoration of bowel continuity. Survival pation without configuration of an anastomosis
rates in younger patients are more promising. For (with permanent end colostomy) seems to be a
T1 rectal cancer, 5-year overall survival is approx- valid option with the best oncological control
imately 80% and for T2 tumors 77% [6, 20, 39]. and a relatively good quality of life.
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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

58 W. F. A. Miles et al.
istory of Transanal Access

H CO2. Operative instruments introduced via one or
Excluding Endoscopy two operating channels allowed both biopsy and
snare excision. The operating instruments are
The development of transanal access can be “steered” by manipulation of the tip of the instru-
divided into two streams; open access using a ment and advancing or retracting the instruments.
mechanical retractor to hold the anus open, and The development of flexible endoscopy has con-
operative sigmoidoscopies which use a tubular tinued in parallel to operative transanal access
device to form a gastight seal while the operation with some degree of crossover [13]. There have
is performed via the lumen of the tube [9]. Open been a number of advances in the use of flexible
access has the advantage of direct vision and endoscopes including endoscopic mucosal resec-
external illumination to allow resection of tion (EMR) and endoscopic submucosal dissec-
lesions. However, this approach is only suitable tion (ESD) [14] which have broadened the scope
for lesions in the lower rectum, and even then the of flexible endoscopy. More recently it has
restrictions of illumination, view, and access of become possible to perform full-thickness dis-
the operating instruments mean that local recur- section of the rectum using a flexible endoscope
rence rates for both polyps and cancers are pro- [15]. Figure 7.1 shows an Olympus-OSF-2 flexi-
hibitively high [10, 11]. ble sigmoidoscope, Olympus UK and Ireland,
Historically, operations performed via an KeyMed House, Stock Road, and SS2 5QH
operating rigid sigmoidoscope had the advantage
of superior access in the upper rectum. The
design of the instrument allowed the rectum to be
insufflated with air while the sigmoidoscope was
being advanced giving excellent access to the
upper rectum and the distal sigmoid colon.
Because of the design of the instrument, it was
not possible to operate via the lumen of the tube
while maintaining insufflation. This limited the
possibility of dissection under vision, and while a
simple snare biopsy of lesions could be com-
pleted, more complex procedures and excisions
could not be performed in this fashion. In Europe
and the United States, this type of operating sig-
moidoscope has largely been consigned to the
museum although it may still be in use in other
more rural health care systems.
Flexible Sigmoidoscopy
The introduction of flexible sigmoidoscopes in

the late 1950s [12] represented the first real
change in the way that the rectum could be
accessed. The vision obtained and the operations
that could be performed were changed forever.
Vison and illumination were provided via fiber-
optic bundles, and the tip of the instrument could Fig. 7.1 Olympus-OSF-2 flexible sigmoidoscope,
be maneuvered in every plane. The lumen of the Olympus UK and Ireland, KeyMed House, Stock Road,
rectum and colon could be insufflated with air or SS2 5QH Southend-on-Sea
7 Operative Equipment and Insufflator Options 59
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.
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].
igid Access Channels

R TEO
with Insufflation
In the case of the TEO device, the telescope is mon-
The two current rigid access devices have a rigid, ocular, and the single eyepiece is mounted above
operating table mount to support a rigid tube the axis of the access tube. This is of some advan-
(access channel) introduced into the rectum via tage as it reduces clashing between the instruments
the anus. The distal end of the tube is closed with and the eyepiece of the monocular scope. The eye-
a gastight end plate through which the endoscope piece is designed to allow a standard laparoscopic
and instruments are introduced via gastight ports. camera to be mounted. The TEO equipment is
The whole device forms a gastight seal between used, in most cases with standard laparoscopic
the tube and the anus, and so the rectum can be equipment including the insufflator. One of the
insufflated. most significant problems with the TEO equipment
when used for taTME is the possibility of billowing
of the rectum [40]. The phenomenon of billowing
TEM will be discussed later in the chapter.
Some surgeons prefer the TEM apparatus,
The endoscope in the case of the TEM equip- while others prefer TEO. In terms of its technical
ment is a precision binocular operating micro- complexity, the TEM equipment is certainly the
scope with a 70-degree field of view which is more challenging to use and maintain. However,
directed inferiorly by 50° in relation to the long the trade-off for this effort is an extremely stable
axis of the scope. The scope is mounted in a platform, with stable insufflation, lumen visibil-
fixed channel within the access tube. This allows ity, suction, and irrigation. Comparative trials
the scope to be advanced and retracted and have shown no measureable difference in patient
rotated about its length. The scope however outcomes between TEM and TEO. Despite the
remains coaxial to the access tube at all times. TEM equipment having been used for the first
The TEM telescope has a third optical channel to taTME, it is not well suited for this operation in
allow a laparoscopic camera head to be attached. our opinion. This is principally because of the
This is below the binocular eyepieces and gives limited utility of the video optics, since only the
a very slightly different field of view. This is operating surgeon maintains the benefit of the
suitable for teaching and allows the surgeon to binocular vision and it can be difficult to operate
operate either via a television monitor or by in a 360-degree field when using the binocular
using the binocular stereoscopic eyepieces, microscope.
depending on surgeon preference. The TEM TEO equipment is less challenging. it its set
device is mounted on the operating table via a up utilizing a standard laparoscope, laparoscopic
lockable arm. Richard Wolf manufactures and instruments, and insufflator. Its simplicity is also
supplies complete sets of instruments designed its limitation as unstable insufflation can make
to be used with the TEM equipment. This anything more than very simple surgery chal-
includes angled graspers, needle holder, and dia- lenging. The TEO equipment can however be
thermy needle knives. The equipment is reuse- used in the full 360° of the rectum, and as the
able apart from parts of the end plate and the monocular operating images are displayed on a
connecting tubing. The connecting tubing pro- video screen, it is possible for an assistant to take
vides insufflation, continuous suction, continu- part in the surgery. TEO equipment has been used
ous pressure monitoring, and a lens washing by a number of centers to perform taTME [41].
channel which allows the telescope to be cleaned Following a consensus meeting in St. Gallen in
without removing it from the access channel. In 2016, where a group of invited experts drew con-
use the patient must be placed on the operating sensus via a Delphi process [42], 59.5% s upported
table so that the lesion to be removed is in a the use of the TEO equipment and 40.5% the use
dependent position [4]. of the TEM equipment.
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].
Fig. 7.3 GelPOINT path Fig. 7.4 SILS port (Covidien)

rent limitation to the utility of transanal surgery.

While clashing can be avoided with experience,
this forms a significant part of the learning curve
and adds to the fatigue of the operators. The
development of a robotic device with stereo-
scopic, 3D optics and articulating effector arms
specifically for transanal surgery is likely to be
the next significant step change in the advance-
ment of transanal surgery [51]. For the time
being, however, it is possible but not common to
Fig. 7.5 D-port manufactured by Karl Storz (KARL use a robot to perform transanal surgery.
STORZ Endoscopy (UK) Ltd. 415 Perth Avenue, Slough,
Berkshire, United Kingdom)
Transanal Instrumentation
Ordinary Laparoscopic Instruments
With utilization of the TAMIS technique, the

majority of transanal surgery can be completed
with normal laparoscopic instruments on stan-
dard laparoscopic colorectal tray. Additional
instruments might include two needle holders,
curved graspers, and various curved instruments,
but these are considered optional.
Fig. 7.6 KeyPort flex Richard Wolf (Richard Wolf
GmbH, Pforzheimer Strasse 32, 75,438, Knittlingen, Modified Instruments
Germany) There are a number of modified instruments
which have been developed by Richard Wolf spe-
Robotic-Assisted TAMIS cifically for use with the TEM equipment. These
include right- and left-handed angled graspers
There is very limited data regarding the use of and needle holders which make suturing more
any form of robotic assistance to perform TAMIS straightforward. Instruments with angled shafts
or taTME surgery although it has been shown to designed for single-incision laparoscopic surgery
be possible to perform transanal surgery with the (SILS) have not generally found favor among the
assistance of a robot [44, 45]. The current genera- majority of transanal surgeons who use the
tion of surgical robots are bulky, and their multi- TAMIS approach. However, the use of angled
arm instruments and mounting systems are not instruments may in some circumstances make
well suited to transanal surgery. There are, how- performing certain tasks less arduous. Likewise,
ever, indications that a wristed or flexible robotic articulated instruments are not in general use
instrument may improve the utility of transanal with TAMIS as, for the most part, straight instru-
surgery. Furthermore, the current design of the ments are sufficient for local excision.
available robots makes docking in the transanal
position difficult. Notwithstanding, there are pio-
neering centers which have shown that robotic Suturing Devices
TAMIS can be achieved [46–50]. In the future,
robotic access may offer a number of significant There have been a number of automated suturing
advantages specifically the elimination of clash- devices which have been developed which accel-
ing of the camera and instruments which is a cur- erate the suturing process when closure is performed
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].
Insufflation and Billowing pressure within the abdomen would be directly

related to the volume of gas insufflated. This is
The Gas Laws not the case within the human body as many of
the tissues have a degree of elasticity and the
In order to understand insufflation, it is important structures are compliant. It is important to under-
to understand the basic physical laws that apply stand compliance in relation to insufflation.
to the gas which is used and the materials which
form the walls of space into which the gas is
insufflated. CO2 is by far the most commonly Compliance
used insufflation gas, and the remainder of this
chapter assumes that this is the gas being used. In the previous section, we have discussed the
For the purpose of this discussion, we will con- relationship between K the amount of gas, its
sider CO2 as an ideal gas [55]. pressure P, and the volume within which it is con-
There are a number of physical laws which tained V as being a constant linear relationship.
apply to gasses, and perhaps one of the most This is true when there is no compliance. It is pos-
important of these is Boyle’s law [56] which is sible to draw the relationship between different
stated as follows: pressure and volume when gas is introduced into
K = P×V spaces of different volumes (Fig. 7.7) [57]. The
tissues of the body are, however, compliant (i.e.,
Whereby, P represents the pressure of the gas, they exhibit elasticity). This means that the rela-
and V is the volume within which it is contained tionship between the pressure of the gas in the
and K the amount of gas (the number of mole- abdomen and volume of the abdomen at the
cules of the gas). We must also be careful to beginning of insufflation is different to the rela-
understand the difference between what we mean tionship between the pressure of the gas and the
when referring to the insufflation rates and the volume of the abdomen at the end of insufflation.
volume of gas within the abdomen. One liter of At the beginning of insufflation, the abdomen
CO2 delivered by the insufflator at atmospheric is very compliant in that with the addition of an
pressure (1020 cm of water) has a slightly lower amount of gas (K) there will be a very small
volume when compressed within the abdomen at change in the pressure within the abdomen and a
a pressure of 20 cm of water (atmospheric pres- very large change in the volume of the abdomen.
sure + 20 cm water).
One liter of CO2 at atmospheric pressure
Pressure volume non-compliant
becomes 1020/1040 x1 liters = 0.98 liters of CO2
16
when compressed within the abdomen with a
pressure of 20 cm of water. For the purposes of 14
Pressure in cm of water
this chapter, we will ignore temperature as the 12

changes to volume or pressure which occur over 10
a physiological temperature range are small 8
enough to be considered negligible.
6
Because the changes in pressure δP are very
4
small and so the changes in volume with pressure
δV are also very small, it is reasonable to assume 2
that 1 liter of gas delivered to by the insufflator is 0

0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5
equal to 1 liter of gas within the abdomen or rec- Insufflated volume
tum. During insufflation when gas is added to the
High volume Low volume Very low volume
abdomen, both the pressure and the volume
change. The abdomen does not behave like a box Fig. 7.7 Linear pressure-volume graphs for high- and
of a fixed volume – if it were as such, then the low-volume non-compliant spaces
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
ficient distension of the abdomen to create a

working space [61] and a flow rate which
replaces any lost gas at a rate which is greater
15 than the rate of loss. The increasing volume of
the abdomen is resisted by the weight of the
abdominal wall (or its nonelastic compliance)
and the elastic tension of the abdominal wall
structures.
Volume There is a very complex relationship between
the amount of gas introduced into the abdomen,
Fig. 7.8 Pressure-volume graph for a non-compliant
the working volume, the tension in the abdominal
space during insufflation
wall, and the compliance of the abdominal wall.
The walls of the abdominal cavity are not uni-
Volume pressure curve compliant form; parts of the abdominal wall are more elas-
tic than others. The abdominal wall is also
30
dynamic and may contract if the patient is not
Pressure in cm water
completely paralyzed [62, 63]. Because of this,

the physical equations which govern the relation-
ship between the volume, pressure, and tension
15 are complex. This complex relationship has been
explored by Becker et al. [57], who have shown
that the pressure-volume relationships vary from
patient to patient. The compliance curve for nor-
mal laparoscopy should appear as shown in
Volume Fig. 7.10. In Fig. 7.10, the insufflation pressure is
within the compliant phase of the distension of
Fig. 7.9 Pressure-volume curve during insufflation of a
compliant space (the abdomen) to the point of
the abdomen, and so an increase in the volume of
non-compliance gas produces a modest increase in pressure. This
diagram could be redrawn to show the volume of
the abdomen in relation to the volume of gas
However at the end of insufflation the addition of added (Fig. 7.11).
the same amount of gas (K) will produce a very
large change in the pressure within the abdomen Volume pressure curve normal laparoscopy
Intra-abdominal pressure in cm water
for only a very small change in the volume [57].

30
If the abdomen was non-compliant, then the
Non compliant
pressure-
volume curve might look like that phase of
shown in Fig. 7.8. However, since the abdominal inflation
wall is compliant, then the pressure-volume Normal working pressure

15
curve will look like that shown in Fig. 7.9. Deflation Inflation
Insufflation Compliant phase of inflation
Volume of isufflated gas within the abdomen

The insufflator increases the amount of gas in the
abdomen until the required pressure is reached Fig. 7.10 Compliance curve for normal laparoscopy
Volume pressure curve normal laparoscopy Volume pressure curve for the rectum
30
Volume of the rectum

Deflation
Volume of the adomen
Non compliant Non compliant

phase of Compliant phase of inflation phase of
inflation inflation
15
Normal working pressure
Normal working pressure
Compliant phase of inflation
Inflation / deflation
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
30 ment of the purse string [40]. Figure 7.12 can

Non compliant also be redrawn to show the change in volume of
phase of
inflation
the rectal working space for a given change in
volume of gas added (Fig. 7.13).
15
Normal working pressure At this point, the insufflated volume is less
Inflation / deflation than 200 ml and may be as small as 62 ml (e.g.,
this is the baseline internal volume of the
GelPOINT path platform prior to initiating insuf-
Compliant phase of inflation flation). The compliance of the system is very
low as the access channel is rigid and only the gel
Volume of isufflated gas within the rectum
cap and the closed rectum are elastic. If it were
Fig. 7.12 Volume-pressure curve of the insufflated rec- assumed that both the sutured rectum and the gel
tum, a small volume of insufflated gas leads to a high cap of the GelPOINT path TAMIS port were
pressure in the rectum rigid, then the pressure in the rectum would rise
in direct proportion to the amount of gas added (a
The situation in the pelvis is more complex. non-compliant system). In this situation the rise
The bony anatomy of the pelvis forms a solid in pressure can be calculated. If it is assumed that
truncated cone with either end of the cone cov- the whole system does not exhibit elasticity and
ered by an elastic membrane. It is bound by the the total volume of the system is 100 ml, then, for
pelvic floor inferiorly and the abdominal perito- each 100 ml of gas at atmospheric pressure
neum and pelvic contents superiorly. The dynam- added, the pressure will increase. As an example,
ics of insufflation are quite different in this when P = 1 and V = 100 ml and K = amount of
situation. As a smaller proportion of the inflated gas in the rectum equates to 100 ml of CO2 at
volume of the pelvis is compliant and the volume atmospheric pressure.
of the pelvis is very small, the rate of change of Expressed mathematically: 1(atmospheric
pressure for a given amount of insufflated gas pressure) × 100ml (rectal volume) =100 ml CO2
will be greater (Fig. 7.12). at atmospheric pressure. This can be rewritten as
As the insufflated volume decreases and the P = amount of CO2 added in ml at atmospheric
overall compliance of the insufflated volume pressure divided by rectal volume in ml or
decreases, the change in pressure for any volume P = 100/100 = 1. If a further 100 ml of CO2 at
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
Fig. 7.14 The delivery Delivery sensing cycle

and sensing cycle of the
most simple insufflator Average pressure Gas delivery Collapsing pressure
control system
Luminal pressure
Delivery Sensing Delivery Sensing Delivery Sensing

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
Fig. 7.15 Diagrammatic Simplified insufflation control after Semm

representation of the
control systems of a Primary
simple laparoscopic pressure reduction valve Insufflation control valve
insufflator
Outflow to
patient
Emergency over pressure

vent
Insufflation control and Pressure sensor

emergency venting
High pressure CO2
Fig. 7.16 Delivery and Delivery sensing cycle

sensing cycle during
abdominal laparoscopy Average pressure Gas delivery Collapsing pressure
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).
Fig. 7.17 Intraluminal Delivery sensing cycle

pressure in the rectum
during billowing Average pressure Gas delivery Collapsing pressure
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
Fig. 7.18 Simplified Simplified Wolf insufflation system

diagram representing the
type of control system Primary
employed by the TEM pressure reduction valve Insufflation control valve
insufflator
Outflow to
patient
Insufflation control
Emergency over pressure vent
Pressure sensor
from patient
High pressure CO2

Controlled smoke evacuation
from patient
gas from the system is controlled, it is possible,

once the rectum is inflated, to maintain almost
absolute stability of the inflation pressure. One of
the great advantages of the TEM system is this
method of insufflation which allows very accu-
rate dissection under very controlled conditions.
AirSeal® Insufflator System
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).
Fig. 7.20 Constant Simplified constant circulation insufflation system

circulation and pressure
measuring system Primary
similar to the AirSeal pressure reduction valve
Insufflation control valve High capacity pump
system
Outflow to
Filter patient
Insufflation control
Return from
patient
Emergency over pressure vent
Pressure sensor
from patient
High pressure CO2
Fig. 7.21 The constant Continuous sensing

sensing system of the
Wolf insufflator or the Average pressure Gas delivery Collapsing pressure
AirSeal device gives a
very stable insufflation
Luminal pressure
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
Fig. 7.22 A standard Simplified insufflation with ISB

insufflator control Primary
system with the ISB in pressure reduction valve Insufflation control valve
place
ISB device
Outflow to
Emergency over pressure patient
vent
Insufflation control and Pressure sensor

emergency venting
High pressure CO2
Fig. 7.23 ISB device connected to the GelPOINT path

and the insufflation stabilization bag (ISB) (Applied
Medical)
Fig. 7.24 Custom large bore connector to link the ISB
device to the GelPOINT path
insufflation port allows instantaneous equilibra-
tion between the rectum and the ISB device. The
ISB device is more compliant than the rectum,
and so movement is seen in the ISB but not in the
rectum. This creates a more stable pressure with
variation in the amount of CO2 in the ISB caused
by gas loss or suction. The EPIX probe (Fig. 7.25)
is designed to work in conjunction with the ISB
to provide smoke evacuation without loss of pres-
sure. This is achieved by ensuring that the flow
rate in the EPIX probe is less than the deliverable
flow rate from the insufflator.
Experimental, dry lab, cadaveric, and early
clinical experience with the ISB-EPIX combina-
tion indicates that it provides a stable insuffla-
tion of the rectum during TAMIS for local Fig. 7.25 The EPIX probe, (Applied Medical)
excision of neoplasia and for taTME. Figure 7.26 luminal pressure in an experimental taTME

depicts lab experience testing the EPIX probe model. With a constant loss from the system to
and the ISB device in a bovine colon model. The imitate smoke evacuation and the insufflation
stabilizing effect of the ISB on a sensing/deliv- pressure set at 12mmhg, the pressure reading
ery system is demonstrated in Fig. 7.27. Waheed from within the rectum ranged from 0.72 mmHg
et al. also showed a considerable variation in to 28.24 mmHg (mean 14.6 mmHg SD ± 4.27)
using a standard insufflator without stabilization.
With the ISB in place, the pressure readings
within rectal lumen were significantly lower
ranging from 8.73 mmHg to 14.52 mmHg (mean
11.84 SD ±1.66) P < 0.001 [64].
Hazards of Insufflation
CO2 embolization is probably a common occur-

rence in laparoscopic surgery however micro-
scopic bubbles of CO2 traveling through the heart
are occult, without clinical sequelae [70].
Problems do occur however if a macroscopic
bubble of CO2 enters the heart and 600 ml bolus
of gas will cause fatal cardiac arrest in an adult
pig. It has been found that an intravenous insuf-
flation pressure of 20 cm H20 was sufficient to
cause an “airlock” in the heart and lead to fatal
circulatory collapse. Insufflation at 15 cm H2O
was better tolerated [71–73]; CO2 embolus is a
recognized complication of laparoscopic surgery
and has an incidence ranging from 0.0016% to
Fig. 7.26 Lab experience testing the EPIX probe and the 100% depending on the method of detection [74,
ISB device in a bovine colon model 75] of CO2.
Fig. 7.27 The ISB device in circuit

stabilizing effect of the
ISB on a sensing/ Average pressure Gas delivery Collapsing pressure
delivery system
Luminal pressure

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
Introduction descriptions of the recommended equipment that

the authors regularly use.
With any new technique, careful consideration
should be given to the equipment required, the
setup of the operating theater, as well as ensuring Essential Equipment
that the patient is properly prepared for the case and
the relevant personnel informed (surgical assis- The key piece of equipment for transanal surgery
tants, anesthesiologists, and nursing staff). This is an access device. In the authors’ institution, the
chapter will look to cover these areas for TAMIS, preferred port is the GelPOINT path (Applied
much of which can also be applied toward the setup Medical, CA, USA, Fig. 8.1) [3]. This is com-
for taTME which is discussed separately in a dedi- posed of three components: an access channel
cated chapter. Since there is considerable overlap made of molded plastic which comes in three
between these two techniques, this chapter will lengths (4 cm, 5.5 cm, and 9 cm), a gel cap which
cover what is required for both procedures, with seals the system to allow pneumorectum and
notes on where TAMIS or taTME setup differs. which serves as a faceplate for admission of can-
nulas – up to four 10 mm cannulas (one of which
can be substituted for a trocar) can accommodate a
Equipment variety of laparoscopic instruments. The gel cap
has two stopcocks which allow smoke evacuation
An important distinction between TAMIS and and connection of insufflation tubing. Depending
TEM is that TAMIS can be performed with
equipment that most standard laparoscopic oper-
ating theaters possess [1, 2]. However, there has
been the development of specialized equipment
that will make the procedure technically less
demanding. First, the essential equipment for
these procedures will be described, followed by
T. H. deBeche-Adams (*) · R. Yap · G. Nassif

Florida Hospital, Center for Colon and Rectal
Surgery, Orlando, FL, USA Fig. 8.1 GelPOINT path device. (Taken with permission
e-mail: [email protected] from Applied Medical, CA, USA)

82 T. H. deBeche-Adams et al.
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
GelPOINT path port.

Note that the average
flow rate with and
without the ISB is the 0 0
same, but the Time Time
fluctuations in flow are
much reduced
with an ISB
Luer lock connection ISB trocar delivers
CO2 to rectum via
Gelpoint Path
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
satisfactory manner. This assists in the placement

of the transanal access port and also improves Recommended
access to the lower rectum when the purse-string
suture is secured under direct vision. This retrac- The majority of high-volume TAMIS (or
tor comes either as disposable or reusable sets, taTME) surgeons advocate the use of the AirSeal
and alternative brands are available. insufflator (Fig. 8.5) for TAMIS and TaTME
Fig. 8.6 Epix electrosurgical probe. (Taken with permis-

sion from Applied Medical, CA, USA)
precision, and, if dissection along embryonic

fusion planes is maintained, the need for more
advanced vessel sealers for hemostasis is obvi-
ated. For dissection, the authors recommend
the use of a monopolar electrocautery device
and prefer a hook tip over pinpoint or spatula
tips, although these are all valid options. A lap-
aroscopic hook cautery with a fine smoke evac-
Fig. 8.5 AirSeal device uator which is operator-controlled at the trigger
handle is preferred. When activated, the smoke
cases [6]. This system allows for continuous evacuation can be done in a gradual fashion to
pressure sensing as well as continuous insuffla- minimize insufflation loss. This can be accom-
tion resulting in a stable platform during the plished with standard suction irrigators with
operation. The ISB can alternatively be used to cautery attachments. Alternatively the Epix
maintain a more stable pneumorectum com- electrosurgical probe (Applied Medical, CA,
pared to standard insufflation alone, though it USA, Fig. 8.6) has an angled L-shaped tip that
does not provide any additional smoke evacua- allows for instruments to be directed toward the
tion. Standard laparoscopic smoke evacuators operative field at a different angle to the laparo-
often are insufficient for TAMIS, and it is noted scope, reducing clashing and optimizing view.
that the AirSeal usually provides a clear field Others have found the SILS™ hook (Medtronic,
due to its optimized smoke evacuation capabili- MN, USA) useful due to its flexible angled tip
ties [8]. An important limitation of AirSeal for though it does not have a built-in smoke
insufflation is that it requires a conventional evacuator [9].
“long” 5 mm versus 8 mm trocar designed for The confined space of the rectum with the
laparoscopy and adapted to TAMIS. This valve- close placement of ports makes tying knots
less trocar makes fixed-angled instruments dif- extremely difficult, and therefore traditional
ficult to use in this port and reduces the surgeon’s suture closure is technically demanding. The
flexibility in port placement. The manufacturer authors prefer to close TAMIS defects with an
is redesigning the port to be more suitable for automatic suturing device to reduce operative
transanal access and to be better adapted to the times and assist in an aligned closure.
TAMIS port. Alternatively, standard absorbable suture may be
Although advanced hemostatic devices such used for a running closure. This is further facili-
as ultrasonic dissectors and vessel-sealing tated by use of barbed sutures that obviates the
coagulators can be used, the authors prefer low- need for knot tying and prevents sliding of the
wattage monopolar cautery for its increased wound edges during closure.
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 Monitor Top

scrub
Bottom Team
Bottom Scrub
Boom 2
Bovie
Bipolar
Camera
Perioperative Considerations fecal matter. Giving full bowel preparation has

also been described in the literature [11], however,
Patient Selection is unnecessary in the authors’ opinion and may
create a more difficult operative field to control
TAMIS with the presence of liquid stool. However, for
Patient selection for TAMIS is detailed elsewhere taTME, consideration should be given to full
in this textbook. Briefly, all prospective patients mechanical bowel preparation if diversion is
must be able to tolerate muscle-relaxing general planned, and ostomy evaluation and marking
anesthesia. The Society of American Gastrointestinal should be undertaken preoperatively if required.
and Endoscopic Surgeons (SAGES) recently pub- Appropriate prophylaxis includes single-dose sys-
lished a guideline that recommended the follow- temic antibiotics administered 30 minutes prior to
ing for TAMIS cases [10]: incision (our preference is ertapenem 1gm IV).
A general anesthetic with muscle paralytics is
• Anatomically accessible lesions localized to required to ensure that the pneumorectum is not
the bowel wall, either benign polyps or Tis/T1 overcome with any increase in intra-abdominal
lesions pressure due to contraction of the abdominal
• Well- or moderately differentiated lesions wall, as well as diaphragmatic excursion which
• Lesions without lymphovascular and/or peri- occurs with negative pressure respiration. The
neural invasion patient is placed in lithotomy position with slight
• Lesion <4 cm Trendelenburg to facilitate access to the perianal
region. Ensuring the patient is on a nonslip mat is
Some caveats need to be included with these essential to prevent any movement of the patient
recommendations. T1 lesions with deeper sub- intraoperatively. An anorectal field block with
mucosal invasion (sm2 or sm3) should be treated bupivacaine can be performed prior to introduc-
as T2 lesions, as the surgeon must consider the ing the TAMIS port to relax the sphincter com-
risk of lymph node metastasis in these patients. plex and to reduce pain postoperatively.
T2 and T3 lesions may be excised when patients
are considered to be medically unfit for radical
resection. These should be discussed at a multi- Postoperative Care
disciplinary tumor board to confirm mutual
agreement of all treating physicians prior to pro- Patients are often discharged on the same day of
ceeding. In addition, in experienced hands, exci- surgery without dietary restrictions. Antibiotics
sion of lesions >4 cm or > 50% of the after TAMIS local excision is no longer recom-
circumference of the bowel lumen is also possi- mended, and analgesics are not warranted.
ble with TAMIS. Restrictions on physical activity are not imposed.
Patients typically follow up for clinical
re-evaluation within 14 days. Clinical examination
Other Considerations typically includes bedside proctoscopy to assess
healing. For patients in whom the excision was
Before TAMIS, the patient should undergo a time-intensive, complicated by bleeding or perito-
cathartic bowel preparation. The authors place the neal entry, inpatient observation is indicated.
patient on a clear fluid diet the day before, with the
patient taking one bottle (296 ml) of magnesium
citrate the afternoon prior to their scheduled sur- Conclusion
gery. On the day of their procedure, the patient is
given two, 250 ml saline laxative enemas prior to Careful preparation before any case will alleviate
arrival at the hospital. This is to ensure that the left many of the potential technical problems that
side of the colon is sufficiently cleared of solid may arise during TAMIS. Although much of the
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
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2017;21(11):897–900.
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Surgical Technique for Local
Excision of Rectal Neoplasia 9
Matthew R. Albert and Paul Kaminsky
Introduction sexual and bladder dysfunction, and permanent

stoma [3]. The treatment of malignant neoplasia
The treatment of rectal neoplasms has evolved of the rectum is a balance between the morbidity
greatly over the last four decades. of classical radical surgery with the increased
In addition to an aging population, the increas- risk of recurrence with local excision.
ing implementation of screening programs Since the introduction of TAMIS in 2010,
worldwide, as well as improvements in the radio- which utilized a single-incision laparoscopic sur-
logic evaluation, has led to an increasing inci- gery port, flexible access devices specifically
dence of early rectal neoplasms amenable to local FDA approved for transanal surgery have been
excision. designed and are commercially available. The
More importantly, surgical techniques and commonest of these “TAMIS ports” used today is
transanal access platforms, initially TEM (trans- probably the GelPOINT path transanal access
anal endoscopic microsurgery) and subsequently platform (Applied Medical, Rancho Santa
TAMIS (transanal minimally invasive surgery), Margarita, CA, USA). Widespread availability,
have evolved to permit high-quality resection of shorter learning curve, and easy training and
rectal tumors. Compared to tradition local exci- implementation have led to extensive adoption of
sion utilizing rectal retractors, both TEM and TAMIS compared to other modalities in the last
TAMIS have consistently and unequivocally decade. TAMIS is a valuable technique for local
demonstrated improved outcomes with decreased excision of lesions in the rectum that can be per-
margin positivity, less tumor fragmentation, formed using readily available equipment and a
lower local recurrence rates, and higher long- minimally invasive skillset.
term survival [1, 2]. Conversely, radical resection
(low anterior resection and abdominoperineal
resection) provides excellent oncologic out- Patient Selection
comes, but these approaches are associated with
significant morbidity and mortality, including As cure rates for early rectal cancer are excellent
anastomotic leak (5–15%), septic complications, with radical surgery, local excision must offer
cure rates comparable to radical surgery while
M. R. Albert (*) · P. Kaminsky allowing for improved functional outcomes and
Center for Colon and Rectal Surgery, Department of reduced morbidity. The main disadvantage of
Colon and Rectal Surgery, Florida Hospital, local excision compared to radical surgery is the
Orlando, FL, USA inability to properly assess for lymph node basin

90 M. R. Albert and P. 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
Fig. 9.1 Intraoperative setup for TAMIS showing patient

in lithotomy, surgeon and assistant operating position, and
the placement of the monitor
AMIS Equipment and Setup

T
Basic laparoscopic instruments (including grasp-
ers, monopolar cautery, and needle drivers) can
be used and are all that is required to perform
Fig. 9.2 GelPOINT path with cap and trocars - FDA-
TAMIS local excision of neoplasia. A 5 mm approved platform designed specifically for TAMIS and
angled (30–45 degree) scope is preferable as it other transanal applications
offsets the operating surgeon’s hands and mini-
mizes instrument collision as well as displays a
more circumferential view of the rectum com- including AirSeal® insufflation system (ConMed,
pared to a non-angled camera lens. An angled Inc., Utica, NY, USA) and Stryker PneumoClear
camera lens also facilitates assessment of the lat- with TAMIS mode (Stryker Endoscopy, San Jose,
eral and proximal margins and can improve visu- CA, USA), have dramatically improved the sta-
alization around the angulations of the rectal bility of pneumorectum. The development of an
valves. Simple monopolar cautery, as well as insufflation stabilization bag (ISB) used in con-
energy devices, can all be utilized for dissection junction with the GelPOINT path provides a
and hemostasis. Monopolar cautery is preferable, cost-effective alternative to newer insufflators
providing greater precision, and is more cost- [13]. Traditional laparoscopic instruments are
effective than alternatives such as vessel sealers then introduced through the TAMIS port for
and harmonic scalpels. A suction device is most dissection.
commonly used to facilitate smoke evacuation, in
addition to controlling minor bleeding or removal esion Assessment and Excision Level
L
of fecal contents. Combined suction and monop- Complete assessment of the tumor is performed
olar devices designed for TAMIS are highly ben- with any bleeding from port insertion trauma
eficial in providing both functions. gently irrigated. Precise extension of the lesion,
Following a perianal block and dilatation of especially in large carpeting adenomas, is easily
the anal canal, the access port is inserted and assessed with a high-definition laparoscope. A
secured, and the gel cap (which contains three quality excision, defined as a non-fragmented,
cannulas) is placed (Fig. 9.2). Pneumorectum is full-thickness, margin negative tumor resection,
created with carbon dioxide insufflation kept at is mandatory for the treatment of early rectal can-
15–18 mmHg and can be increased up to 20 mm cer by local excision regardless of the technique
Hg if required. Next-generation insufflators, used. However, for benign neoplasia, a submuco-
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 maring 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.
Fig. 9.4 Full-thickness excision. Note the mesorectal fat underneath the lesion, signifying that the entire rectal wall has
been transected
verted to formal radical surgery. For benign dis-

ease, margin positivity does not guarantee
recurrence, and these patients can be followed
with routine proctoscopy. Small, benign recur-
rent polyps can be removed with snare polypec-
tomy or other endoscopic means as long as these
patients are enrolled in a surveillance program
post TAMIS excision.
anaging the Ultralow Rectal Lesion

M
Lesions that are located within 3 cm of the anal
verge may be difficult to fully access by TAMIS
due to the length of operating port (37 to 44 mm
in length), which may obscure the distal extent of
the lesion. For these cases, a hybrid approach in
Fig. 9.5 Specimen removed by TAMIS is pinned and which dissection of the distal-most aspect is
oriented begun transanally is used. Once the distal dissec-
tion is completed, then the TAMIS port can be
Following resection, the specimen should be introduced to complete the majority of the dis-
immediately retrieved and oriented (Fig. 9.5). It section. This approach allows for the advantages
should be pinned out and sent to the pathologist of the advanced endoscopic platforms to be
as a fresh, non-preserved specimen to facilitate applied for lesions that would otherwise be at
improved margin evaluation. A positive margin high risk of R1 resection and fragmentation by
for rectal cancer should be re-excised or con- conventional transanal excision.
anagement of Defects After

M between closed defects and those that were left
Local Excision open [15]. A rigid or flexible sigmoidoscope can
Following TAMIS local excision, it is our prac- be used to assess luminal diameter and patency, if
tice to irrigate the defect with betadine to mini- a concern about narrowing has been raised.
mize bacteria and tumor contamination. Rectal
wall closure is then performed; full-thickness
defects are reapproximated transversely with Conclusions
interrupted or continuous suturing to avoid nar-
rowing the lumen. The pneumorectum is TAMIS relies on fundamental minimally invasive
decreased to 7–8 mmHg to reduce tension on the surgical skill and equipment. With proper TAMIS
suture lines. A running closure beginning in the technique and for carefully selected patients,
lateral portion of the incision can be achieved but high-quality local excision of rectal neoplasia is a
is technically more challenging. The use of a valid option with low morbidity that maintains
V-Loc™ suture (Covidien, Mansfield, MA) or the advantages of organ preservation.
other commercially available types of self-
locking, barbed absorbable suture can expedite
continuous closure by maintaining tension and References
negating the need for endoluminal knot tying
(Fig. 9.6). Conversely, closure can be performed 1. Clancy C, Burke JP, Albert MR, O’Connell PR,
Winter DC. Transanal endoscopic microsurgery ver-
in an interrupted fashion with knot tying facili- sus standard transanal excision for the removal of rec-
tated by laparoscopic knot pushers. In some tal neoplasms: a systematic review and meta-analysis.
cases, automated suturing devices – such as the Dis Colon Rectum. 2015;58(2):254–61.
combination RD180/TK device (LSI Solutions, 2. Kidane B, Chadi SA, Kanters S, Colquhoun PH, Ott
MC. Local resection compared with radical resection
Victor, NY) or the Endo Stitch™ suturing device in the treatment of T1N0M0 rectal adenocarcinoma:
(Medtronic, Minneapolis, MN) – can be utilized a systematic review and meta-analysis. Dis Colon
to expedite the closure process but may not be Rectum. 2015;58(1):122–40.
available, and such devices increase per-case 3. Lu ZR, Rajendran N, Lynch AC, Heriot AG, Warrier
SK. Anastomotic leaks after restorative resections for
costs as well. rectal cancer compromise cancer outcomes and sur-
Alternatively, defects which do not violate the vival. Dis Colon Rectum. 2016;59(3):236–44.
peritoneum can be left to heal with expectation of 4. Glasgow SC, Bleier JI, Burgart LJ, Finne CO, Lowry
a minimal scar within 4–6 weeks and few com- AC. Meta-analysis of histopathological features of
primary colorectal cancers that predict lymph node
plications. Hahnloser et al. reported outcomes metastases. J Gastrointest Surg. 2012;16(5):1019–28.
from 75 TAMIS excisions performed at three 5. Saraste D, Gunnarsson U, Janson M. Predicting
centers and found no difference in complications lymph node metastases in early rectal cancer. Eur J
Cancer. 2013;49(5):1104–8.
6. Han J, Hur H, Min BS, Lee KY, Kim NK. Predictive
factors for lymph node metastasis in submucosal
invasive colorectal carcinoma: a new proposal of
depth of invasion for radical surgery. World J Surg.
2018;42:2635.
7. Oka S, Tanaka S, Nakadoi K, Kanao H, Chayama
K. Risk analysis of submucosal invasive rectal car-
cinomas for lymph node metastasis to expand indi-
cation criteria for endoscopic resection. Dig Endosc.
2013;25(Suppl 2):21–5.
8. Okabe S, Shia J, Nash G, Wong WD, Guillem JG,
Weiser MR, et al. Lymph node metastasis in T1 ade-
nocarcinoma of the colon and rectum. J Gastrointest
Surg. 2004;8(8):1032–9; discussion 9–40
9. Nascimbeni R, Burgart LJ, Nivatvongs S, Larson
Fig. 9.6 Rectal wall defect being closed using continu-
DR. Risk of lymph node metastasis in T1 carci-
ous V-Loc suture
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
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JL. Comparison of transanal endoscopic microsur- 14.
deBeche-Adams T, Nassif G. Transanal mini-
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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,
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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

98 G. Lezoche et al.
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
Fig. 10.1 Five different

1 -Mucosectomy
levels of excision
possible with TEM or
2 –Inframuscular layers
TAMIS
excision
3 –Full thickness excis.
4 – Full thickness excis.

+ resection of upper part
of mesorectum
5 –ELRR: Endolumen
Loco-Regional Resection
TEM : 5 different levels of bottom xeresis

10 Pyramidal Excision for Early Rectal Cancer and Special Closure Techniques 99
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.
The inadequacy of conventional full-thick- 95–04), radiotherapy reduces the percentage of

ness local excision for T1 cancers is clearly local recurrences by one-half (from 11.4 to
demonstrated by available data. In fact, the
5.8%). These positive results combined with the
percentages of recurrence in pT1 patients observation that after NT, the number of lymph
reported by three institutions are significantly nodes detectable in the mesorectum is signifi-
different. However, despite the utilization of cantly lower when compared with untreated
advanced instrumentation (TEM), the opera- patients – suggesting that NT can also sterilize
tions performed in each institution are hetero- metastatic lymphatic nodes.
geneous, as illustrated in Fig. 10.2. The Dutch Furthermore, NT has the advantage that it can
group [4] examined 88 pT1 treated with full- significantly shrink the tumor mass, making local
thickness local excision and reported an unac- excision more feasible; for this reason, standard
ceptably high recurrence rate of 20.5%. long-course radiotherapy is preferable to short-
Comparatively, other investigators [5] who course XRT that is less effective in tumor mass
performed full-thickness excision combined reduction.
with the resection of the upper part of the meso- On the bases of these clinical observations, a
rectum reported percentages of local recurrences protocol to treat small (diameter <3) iT2N0M0
that were significantly lower – approximately rectal cancer performing ELRR after completion
12% – for 86 patients who underwent transanal of long-course therapy with 50.4 GY (lcNT) was
local excision for pT1 rectal cancer. developed.
In our experience, ELRR utilizing the TEM With encouraging clinical results as well as
apparatus was successfully performed on 270 confirmatory 5-year follow-up data, our center
patients with pT1 rectal cancer. On follow-up, the developed a protocol for a prospective random-
local recurrence rate measured less than 3%. ized trial on T2 rectal cancer, entitled the “Urbino
The literature reports that administration of Trial” – named after the renaissance city where
neoadjuvant treatment (NT) reduces the risk of the meeting to design this protocol was held. The
local recurrence and probably increases survival results of the Urbino Trial are detailed in the last
rate. According to the Dutch Trial (CKVO section of this chapter.
Fig. 10.2 Markedly Outcome of 3 different TEM procedures

different rates of local pT1 local recurrence
recurrence, based on
three different levels of
local excision
performed using an pT1 n.pts LR
advanced transanal %
platform
Doornebosch et al. Dis Colon Rectum 88 20.5

2010
Stipa et al. Dis Colon Rectum 2012 86 11.6
lezoche 245 3.2
20.5
11.6
2.96
Patient Selection in our protocol, we consider it mandatory to

remove all the area where the neoplasia was
Patient selection is fundamental. Although dis- located prior to NT.
cussed elsewhere in this textbook, the protocol • Rigid rectoscopy is extremely useful in identi-
followed at our center is briefly delineated. fying circumferential tumor location (i.e.,
anterior vs. posterior, right or left lateral) and
consequently the appropriate patient position
Index Staging (Pre-NT) on the operative table, which is relevant for
the rigid TEM scope (with the TAMIS tech-
• Digital rectal examination (DRE). The fixity nique, patients can be positioned dorsal lithot-
and the distance of the tumor margin from omy for the vast majority of lesions, but
the anal ring must be registered and docu- information from rigid proctoscopy is still
mented by DRE. Sphincter tone must be invaluable).
carefully assessed, and if indicated, formal • Macro-biopsies. Utilizing the rigid rectosig-
pelvic floor testing, including manometry, moidoscope, it is possible to perform macro-
should be performed to determine baseline biopsies using the conventional forceps
function. (Fig.10.3) that can remove a substantial
• Flexible endoscopy and biopsy. It is advisable amount of tissue, allowing pathologists to bet-
to use dye to identify tumor limits especially ter assess the histological tumor grade and, in
for flat lesions or adenomas with ambiguous case of T1 cancers, a correct sm depth assess-
margins. In our protocol it is always manda- ment which is critical to determining the opti-
tory to take 5–6 biopsies, circumferential to mal therapeutic strategy.
the tumor at 1 cm distance from the lesion’s • Imaging. Advancements in magnetic reso-
perimeter, on what appears to be normal, nance imaging (MRI) including stronger
native rectal mucosa. Every biopsy must be magnets (3-Tesla), diffusion-weighted imag-
identified by a number corresponding the ana- ing, and new MRI-compatible contrast agents
tomic position and sent to pathology for care- have significantly improved the diagnosis of
ful histologic examination. The rationale for metastatic nodes (N) and the more precise
this is to exclude or confirm the presence of tumor (T) stage. It is our preference to per-
malignant histology. form rectal protocol MRI for all stages of rec-
• Tattooing. We consider it mandatory to per- tal cancer.
form tattooing at each biopsy site in order to
reduce the risk of an incomplete excision of Endorectal ultrasound (EUS) is useful to dif-
the lesion during ELRR. The excision line ferentiate T1 vs. T2 but is unable to evaluate the
must include all the tattoo spots to avoid this submucosal infiltration despite the remarkable
and to assure tumor-free margins. Surprisingly, technological improvement of 3D ultrasound
incomplete local excisions are not infre- instrumentation. Therefore, macro-biopsies
quently reported and measure as high as 22%
in some series [1]. In this regard, it is crucial
to understand that after NT, the tumor borders
are generally not clearly identifiable.
Furthermore, when the tumor is downsized
from the effect of NT, clusters of neoplastic
cells can still be identified in the area where
the cancer was present prior to treatment-
induced regression. The meaning and the evo-
lution of these persistent neoplastic cell
clusters remain elusive; therefore prudentially, Fig. 10.3 Conventional forceps for “macro-biopsies”
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.
TME : Morbidity & Mortality
Neoadjuvant Therapy (NT) • Morbidity 20–30%

• Mortality 2–5%
NT is generally considered mandatory for in high risk pts ~ 10%
advanced tumors. However, in recent years the • Local recurrence 5–15%
realization that early T-stage rectal cancer (e.g., • Metastatic disease > 30%
T1sm3 and T2) can harbor occult metastatic
Funtional sequalae
nodes has improved our understanding of the
possible effect of full-dose NT (fdNT) in treating • Urinary dysfunctions 10%
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
Fig. 10.5 The stoma Stoma acceptance

acceptance is strictly Strictly related to the geografic area
related to the geographic
area. In Mediterranean
countries, it is not 70
infrequent that patient
refuses operation for the
60
risk of stoma. (Kuzu
et al. [6]. https://link.
springer.com/
50
article/10.1007/
s10350-004-6425-4.
Data only) 40
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
20 Fig. 10.7 Combining conventional, full- thickness LE

with NT does not significantly increase local recurrences
15
T2
10
ably survival rate. These data are another indi-
5
cation that the clinical results of local treatment
0 depend on complete tumor excision with nega-
tive margins (R0) and, in addition, the com-
1989 2003
plete removal of the lymphatic tissue
T1 T2
surrounding the segment of bowel containing
Fig. 10.6 Number of local excision performed in the the neoplasm.
USA in 1989 and 2003 for T1 and T2 rectal cancer
atients’ Eligibility for ELRR

P cT2 Exclusion Criteria:
(Pyramidal Local Excision) • Non-responders to NT: Tumor mass reduction
<50%.
Basic Exclusion Criteria • High undifferentiated or mucous rectal
cancer.
1. Histologically high-risk tumors (undifferenti- • Tumor diameter >4 cm after NT.
ated and mucous histology). • Tumor located in the intraperitoneal rectum.
2. Tumors with highly suspicious metastatic
• MR and CT imaging suspicious nodes (>5 mm,
lymph nodes (identified on imaging before not iso-echogenic, irregular shape) after NT.
initiation of NT). • Tumor is fixed (nonmobile by palpation).
3. Tumors with lymphatic, neuronal, and vessel • Patient refuses to accept a program of close
infiltration (not responsive to NT). follow-up and informed consent.
4. T4 cancers.
5. T2 and T3 cancers which are not responsive to c T3
NT. cT3 Inclusion Criteria:
• High-risk patients: age over 80 yo, comorbid
c T1 conditions (ASA 3 or 4), and/or patients who
cT1 Inclusion Criteria: refuse permanent or temporary stoma.
• sm1 and sm2: without histological high-risk • Patients who underwent NT with good
features, response (downstaged >50%).
• Rectal Protocol MRI negative nodes, diameter • Tumor diameter <4 cm.
<5 mm, iso-echogenic, with smooth, regular • Tumor located in the extraperitoneal rectum.
shape. • MR- and CT-negative nodes (<5 mm, iso-
• Located in the extraperitoneal rectum. echogenic, regular shape).
• cT1sm3, treated with NT. • Tumor is non-fixed (mobile on palpation).
• Patient accepting close follow-up and
informed consent.
cT1 Exclusion Criteria:
• sm3, in patients refusing NT,
• Tumor located mainly in the intraperitoneal cT3 Exclusion Criteria:
rectum. • Non-responders to NT: Tumor mass reduction
• Mucinous or undifferentiated cancer. <50%.
• Patient refusing close follow-up and informed • High undifferentiated or mucinous rectal
consent. cancer.
• Imaging suspicious for nodal disease. • Tumor diameter >4 cm.
• Tumor located in the intraperitoneal rectum.
c T2 • MR and CT imaging reveal suspicious nodes
cT2 Inclusion Criteria: (>5 mm, not iso-echogenic, irregular shape)
• Patients who completed NT with a good after NT.
response (downstaged >50%). • Tumor is fixed.
• Tumor diameter <4 cm. • Patient refuses to accept a program of close
• Tumor located in the extraperitoneal rectum. follow-up and informed consent.
• MR- and CT-negative nodes (<5 mm, iso-
echogenic, non-spiculated appearance).
• Tumor is non-fixed (mobile on palpation). Informed Consent
• Patient accepting close follow-up and The informed consent form will include all the
informed consent. possible options possible in relation to the
Fig. 10.8 Geometric C Circular free margin

model to standardize
B Basic plane
endoluminal
locoregional resection L lateral margin
(ELRR)
CC
L/C angle L
B L
C
L
120° B “holy plane”
Multiple running sutures to close

135°
…Extent of circular free margins attempting ELRR, it is advisable to have performed

T at least 50 standard full-thickness excisions and
Radial margins have gained experience in TEM or TAMIS suturing.
geometric model Furthermore, an appropriate background in open
and laparoscopic rectal surgery is required.
Amount of removed tissue (cc)

Identification of residual lymphatic Surgical Dissection
tissue (NUCLEOTIDE-GUIDED MESORECTAL
EXCISION ) As in every surgical procedure, it is strongly rec-
ommended to standardize the ELRR technique.
Fig. 10.9 Criteria to standardize endoluminal locore-
gional resection (ELRR) To this purpose, as in TME, we have considered
the following parameters:
patient general conditions. Patients who undergo
ELRR must agree to be enrolled into a strict 1. Extent of circular free margins (indicated as C
follow-up program. in Fig. 10.8).
2. Extent of radial free margins.
3. To be sure that all the lymphatic structure,
Anesthesia which drains the tumor, has been removed, the
bottom dissection must follow as in traditional
General anesthesia is not mandatory for TEM/ surgery the “holy plane” (indicated as B in
TAMIS procedures, when the lesion is located in Fig. 10.9).
the posterior circumference of the rectum and the 4. The lymphatic drainage of the tumor has a
procedure is presumably short. pyramid shape, and the tip is represented by
the first locoregional lymphatic station, and
for a correct tumor staging, it is mandatory
Pyramidal Excision or ELRR to remove this station. As already men-
tioned, lymphatic metastasis of rectal can-
To perform this type of operation, it is necessary cer do not present skip phenomena. To be
that the surgeon be skilled in TEM or TAMIS. Before sure that the specimen includes this station,
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.
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.
Intraoperative Histological nucleotide is injected behind and around the

Assessment of the Cranial and Caudal lesion through an anoscope or a rectoscope utiliz-
Margins ing a spinal needle. Once pyramidal excision has
been completed, the specimen has been removed,
Before suturing the defect, two half rings of rec- and the lavage of the rectum has been performed
tal wall (obtained from the cranial and caudal (before suture reapproximation), the TEM recto-
margins after the excision of the specimen) are scope is left in situ, and through this point of
removed and sent intraoperatively to the patholo- access, a gamma camera (encased in a sterile
gist. Both of the half rings are marked with blue package) is inserted to explore accurately the
dye at the side of the defect. In this way, the sur- defect created by ELRR, in order to detect any
geon is able to assure an R0 resection. The prin- area of residual radioactivity. In case of local
ciple objective of this protocol is to avoid an activity at least ten times the baseline radioactiv-
incomplete excision of the tumor. ity, the high-activity tissue is marked with a
metallic clip. Once the wall of the defect has been
checked, the optics and TEM faceplate are
Nucleotide-Guided Mesorectal replaced, and the tissues where the metallic clips
Excision (NGME) have been placed are resected and sent to pathol-
ogy for frozen section evaluation of the removed
Basic considerations: lymphatic nodes [8]. The same technique could
• The histologically high-risk tumors (muci- also be adapted to the TAMIS platform.
nous or undifferentiated) are an absolute con-
traindication to any type of local treatment. In
the literature, except for histologically high- Suture Closure of the Defect
risk rectal cancer, cases that present skip
metastasis overpassing the first lymphatic Suturing is one of the most difficult parts of
node station are not reported. ELRR for several reasons:
• The ELRR generally removes a large amount
of mesorectum adjacent to the tumor, and con- • The space in which the needle is moved is
sequently the first lymphatic station is very narrow.
removed with reasonable certainty. • The needle must go through not only the rectal
• However with the delivery of NT, which uti- wall but also the mesorectum.
lizes a higher dose of radiation to the primary • Depending on the level (distance from the
tumor, first nodal station sterility can be anorectal ring) where the ELRR has been per-
observed, a phenomenon less likely in more formed, a discrepancy generally occurs in the
peripheral locales. length of the caudal and cranial edges of the
defect. If the tumor is located very close to the
On the bases of these considerations, we were anal canal, the proximal edge will exceed sig-
interested in developing a methodology able to nificantly the length of the caudal edge; the
detect the nodal disease within the non-excised opposite happens in case of tumors located in
portion of the mesorectum after ELRR. NGME is the upper rectum.
an in-house technique developed by E. Lezoche,
designed with the purpose of increasing the num- Typically, the defect created by the ELRR is
ber of removed nodes during ELRR, in order to quite large and deep, as shown in Fig.10.10.
have a correct staging of the cancer. Therefore, to close the defect, several stitches are
NGME is a technique which is fairly rapid and required. Suturing the defect, a double-zero
simple to perform. After induced general anes- polydioxanone suture (PDS) with a half-ring
thesia, and immediately prior to ELRR, the radio- (SH) needle is usually utilized. The narrow space
Oral rim
Caudal rim
Fig. 10.10 The defect created by the ELRR is very large

and deep. In the pelvic floor are easy recognizable mus-
cles, levator ani of both sides
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.
1. If the defect of the ELRR is very wide, it is

advisable to place a first stitch in the middle of
the cranial edge and then pass the needle to
the corresponding level of the middle of the
caudal edge. This stitch must not be tightened
but rather should be left loose to allow reap-
proximation by another, separate running
stitch. When the running suture reaches the Fig. 10.12 The suture starts from the right side of the
defect (for right-handed surgeon)
midline, the stitch is removed (Fig. 10.11). First passage: the needle at the first stitch must be placed
2. For right-handed surgeons, the suture starts 1 cm laterally to the defect, and then the needle tip must
from the right side of the defect (right to left appear inside the defect
closure). Second passage: the needle crosses the cranial rim enter-
ing at the level of the holy plane and coming out on the
3. The needle of the first stitch must be placed mucosal surface
1 cm lateral to the defect, so that at the first Third passage: the opposite cross must be made in the
passage, the needle tip must appear inside the caudal rim, so the needle crosses the mucosa and exits at
defect (Fig. 10.12). the bottom of the perirectal fat
4. Then, the needle crosses the cranial edge

entering at the level of the holy plane and exit-
ing along the mucosal surface.
5. An opposite cross must be made in the caudal
edge, so the needle crosses the mucosa and
exits at the bottom of the perirectal fat.
6. The needle enters at the level of the meso-
rectal fascia crossing the residual mesorec-
tum and the rectal muscle tube and finally
exits at the level of the cranial edge of
mucosa.
7. This step is repeated several times to utilize
entirely the suture. Correct Wrong
8. For large defect closure, the rectoscope posi-
tion inside the rectum must be continuously
90°
moved, in order to find the most convenient 45°
position for the suturing motion.
9. The most difficult part of the suture is at the Fig. 10.13 If one of the two rims is wider, the needle
level of the terminal part of the defect (left must move with an angle at least of 45° instead of 90°
side in this case), when the suture must be per-
formed at 10–12 o’clock position, relative to We observed two different possibilities of
the operative field. This is related to the fact dehiscence of the suture line after pyramidal
that, at level of the left upper part of the opera- excision, which can be classified as early and
tive field, the instruments, due to the tight late and which are characterized as follows:
space, conflict with one another and with the
optical lens, as well. Early Dehiscence: The first type occurs in
the first 7–10 days postoperatively. This
adverse event is generally related to the exis-
Important Tips tence of tension on the suture line, often
caused by reapproximation of large defects,
• Due to the length discrepancy of the two edges, whereby the gap between the cranial and
the plane on which the needle moves drawing caudal edge is considerable, even after appro-
the curvilinear line cannot be the same. For priate mobilization. Dehiscence is often her-
example, in the case that the cranial edge is alded by tenesmus, sentinel bleeding, and
wider (as in the case with low rectal cancers), pelvis pain. DRE, when within reach, will
at this upper side, the needle must advance often confirm the partial dehiscence of the
along with an angle of at least 45° with respect suture line.
to the mucosal surface. Conversely, at the level Late Dehiscence: The second type of dehis-
of the typically shorter caudal edge, the needle cence occurs much later, 30–60 days postop-
must advance orthogonally (90°) relative to the eratively, and the etiology is related to the
mucosal surface (Fig. 10.13). In this manner, it fluid collection within the dead space that
is possible to compensate for the discrepancy after suturing is created by the lack of tissue
in length of the two rims and to obtain a good apposition (i.e., the local mesorectal defect
reapproximation of the proximal and distal left after pyramidal excision). As clearly
margins, avoiding the formation of weak points shown in Fig. 10.10, the defect created by
along the closure line. ELRR is quite wide, and the specimen has an
• Filling of the residual defect with glue. average volume of ~40–50 ml. The creation
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-
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Such limitations have led to the development of Balla A, Lezoche E. A modified sentinel lymph node
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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
Introduction Lesions in the distal rectum removed by trans-

anal excision are easily amenable to closure using
Closure of the rectal wall defect after transanal open instruments and anal retractors. This is in
excision is controversial. Closing defects can be contrast to higher lesions in the rectum after TEM
technically difficult and may significantly or TAMIS where closure is technically more
increase operative time without a clear benefit. challenging. Endoscopic suturing is difficult and
The current literature suggests that there is no can be time-consuming.
difference in morbidity and functional outcome Many authors have recommended suturing of
between closure and non-closure of the rectal the defect on the basis of improved wound heal-
defect. However, more bleeding complications ing, better bleeding control, and a reduction in
may occur in open defects. Defect closure is the risk of stenosis of the lumen. Closing the
clearly necessary if the abdominal cavity has defect may provide a hemostatic advantage as the
been opened. In the absence of clear data favor- mesorcetum is highly vascularized. Another, the-
ing closure or non-closure, the management of oretical advantage of adapting the mucosa is pre-
the rectal wall defect after TAMIS is left to the serving rectal compliance as only little scaring
surgeon’s discretion and skill set. occurs and regrowth of the mucosa is not neces-
sary. However, compliance after defect closure
versus non-closure has not yet been studied.
To Close or Not to Close Because endoscopic suturing is technically
difficult, some surgeons leave full-thickness
Once the specimen is excised, the question arises defect open, when the defect lies in the subperito-
whether to close or not to close the defect in the neal rectum and in the absence of peritoneal
rectal wall. There is currently no consensus among entry. The rectum and its surrounding mesorec-
surgeons, and nearly all studies state that the deci- tum are well vascularized, which provides an
sion to close or not to close the defect was made excellent medium for granulation tissue and
individually at the surgeon’s discretion. This is not recannulization of the rectal wall. Signs and
very helpful in the daily clinical setting. symptoms of infection including pain, fever, and
elevated white blood cell count can be observed
after TAMIS as inflammatory reaction of the sur-
D. Hahnloser (*) rounding mesorectum. Not closing the defect
University Hospital Lausanne, Department of may increase the risk of infection. However, the
Visceral Surgery, Lausanne, Switzerland mesorectum is also a barrier to infection, as

114 D. Hahnloser
itnessed in the literature by the low incidence of

w suture obviates the need for knot-tying, and the
pelvic sepsis even with open defects. Prolonged use of mechanical suturing devices can expedite
antibiotics are not necessary and do not change the process of defect closure but can add substan-
the infection rate (6% non-closure vs. 10% in the tial per-case costs as well. It is recommended to
closure group; p = 0.2) [1]. close the defect completely “watertight” to avoid
Finally, defect closure may also not always be abscess formation. However, after radiotherapy
feasible because of the potential for rectal lumen and transanal excision, it is not recommended to
narrowing or the difficulty of endoluminal sutur- close subperitoneal defects, as wound dehiscence
ing. For all these reasons, closure of the defect can be as high as 47% [10].
after excision remains a controversial point.
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
Recommendations and Conclusions functional alterations after local excision of rec-

tal tumors with transanal endoscopic microsurgery
(TEM). Int J Color Dis. 2016;31(2):257–66.
The current literature suggests that there is no 5. Bignell MB, Ramwell A, Evans JR, Dastur N, Simson
difference in morbidity and functional outcome JN. Complications of transanal endoscopic micro-
between closure and non-closure of the rectal surgery (TEMS): a prospective audit. Color Dis.
2010;12(7 Online):e99–103.
defect after transanal excision. Furthermore, ben- 6. Atallah S, Albert M, Larach S. Transanal minimally
efits of closure remain unclear. However, no invasive surgery: a giant leap forward. Surg Endosc.
study was specifically designed to answer this 2010;24(9):2200–5.
particular question. Therefore, the decision to 7. Lorenz C, Nimmesgern T, Back M, Langwieler
TE. Transanal single port microsurgery (TSPM) as a
close rectal wall defects may be left to the sur- modified technique of transanal endoscopic microsur-
geon’s preference and skills. gery (TEM). Surg Innov. 2010;17(2):160–3.
We recommend to close all large full-thickness 8. Ragupathi M, Haas EM. Transanal endoscopic video-
defects if possible. It might be sometimes neces- assisted excision: application of single-port access.
JSLS. 2011;15(1):53–8.
sary to further mobilize the rectal wall to allow a 9. Lim SB, Seo SI, Lee JL, Kwak JY, Jang TY, Kim
tension-free closure. In large defects we start CW, et al. Feasibility of transanal minimally inva-
suturing laterally on both sides joining in the mid- sive surgery for mid-rectal lesions. Surg Endosc.
dle. If the defect cannot be closed “watertight,” 2012;26(11):3127–32.
10. Perez RO, Habr-Gama A, Sao Juliao GP, Proscurshim
we recommend to leave it open. Marsupialization I, Scanavini Neto A, Gama-Rodrigues J. Transanal
stitches of the rectal wall to the mesorectum are of endoscopic microsurgery for residual rectal cancer
little use. Early endoscopy after 6–10 weeks after neoadjuvant chemoradiation therapy is associ-
might be indicated to exclude or treat narrowing ated with significant immediate pain and hospital read-
mission rates. Dis Colon Rectum. 2011;54(5):545–51.
of the lumen by balloon dilatation. Medium-sized 11. Ramirez JM, Aguilella V, Arribas D, Martinez

and small full-thickness defects as well as all par- M. Transanal full-thickness excision of rectal
tial-thickness excisions are left open as they will tumours: should the defect be sutured? A randomized
granulate rapidly and be relined with neomucosa; controlled trial. Color Dis. 2002;4(1):51–5.
12. Lee L, Althoff A, Edwards K, Albert MR, Atallah
stricturing and stenosis are extremely rare. Results SB, Hunter IA, et al. Outcomes of closed versus
from the ESD (endoscopic submucosal dissec- open defects after local excision of rectal neoplasms:
tion) literature with comparable wounds to par- a multi-institutional matched analysis. Dis Colon
tial-thickness excisions demonstrate that stenosis Rectum. 2018;61(2):172–8.
13. Noura S, Ohue M, Miyoshi N, Yasui M. Significance
never occurred in cases with <90% circumferen- of defect closure following transanal local full-
tial extent of mucosal defect [18]. Because post- thickness excision of rectal malignant tumors. Mol
TAMIS excision bleeding can occur when the Clin Oncol. 2016;5(4):449–54.
excision defect is left open, keeping the patient 14. Brown C, Raval MJ, Phang PT, Karimuddin AA. The
surgical defect after transanal endoscopic microsur-
in-house for observation is encouraged. gery: open versus closed management. Surg Endosc.
2017;31(3):1078–82.
15.
Menahem B, Alves A, Morello R, Lubrano
References J. Should the rectal defect be closed following
transanal local excision of rectal tumors? A system-
atic review and meta-analysis. Tech Coloproctol.
1. Hahnloser D, Cantero R, Salgado G, Dindo D, Rega
2017;21(12):929–36.
D, Delrio P. Transanal minimal invasive surgery for
16. Herman RM, Richter P, Walega P, Popiela T. Anorectal
rectal lesions: should the defect be closed? Color Dis.
sphincter function and rectal barostat study in patients
2015;17(5):397–402.
following transanal endoscopic microsurgery. Int J
2. Molina G, Bordeianou L, Shellito P, Sylla P. Transanal
Color Dis. 2001;16(6):370–6.
endoscopic resection with peritoneal entry: a word of
17.
Valsdottir EB, Yarandi SS, Marks JH, Marks
caution. Surg Endosc. 2016;30(5):1816–25.
GJ. Quality of life and fecal incontinence after trans-
3. Rimonda R, Arezzo A, Arolfo S, Salvai A, Morino
anal endoscopic microsurgery for benign and malig-
M. TransAnal Minimally Invasive Surgery (TAMIS)
nant rectal lesions. Surg Endosc. 2014;28(1):193–202.
with SILS Port versus Transanal Endoscopic
18. Hayashi T, Kudo SE, Miyachi H, Sakurai T, Ishigaki
Microsurgery (TEM): a comparative experimental
T, Yagawa Y, et al. Management and risk factor
study. Surg Endosc. 2013;27:3762.
of stenosis after endoscopic submucosal dissec-
4. Restivo A, Zorcolo L, D'Alia G, Cocco F, Cossu A,
tion for colorectal neoplasms. Gastrointest Endosc.
Scintu F, et al. Risk of complications and long-term
2017;86(2):358–69.
Operative and Perioperative
Outcomes 12
Elena A. T. Vikis, Anne-Marie Dufresne,
and George Melich
Introduction Intraoperative Complications
Traditionally, rectal neoplasms that were not Peritoneal Entry

resectable by colonoscopy required segmental
oncologic resection, either via abdominoperineal One of the complications of TAMIS is potential
or low anterior resection. These procedures come abdominal entry, particularly for rectal lesions
with a high risk of operative and postoperative located above the peritoneal reflection [3–5]. In
complications that can result in significant patient the literature, peritoneal entry ranges from 10%
morbidity as well as significant perioperative to 28% [4, 6, 7] and has been described in trans-
costs. Transanal minimally invasive surgery anal endoscopic microsurgery (TEM) as an
(TAMIS) emerged in 2009 [1], as there was a expected event for high-risk lesions [8]. In the
need for a more widely accessible (easier setup, authors’ (unpublished) experience, there were
easier to learn, less expensive) approach to trans- nine cases of unplanned intraperitoneal entry out
anal endoscopic excision that was safe and equiv- of 230 (3.9%). Abdominal entry has been
alent to transanal endoscopic microsurgery described as primarily in woman of small body
(TEM) for removal of rectal lesions [2]. TAMIS habitus with low peritoneal reflections and gener-
is now a well-established technique for removal ally in anterior lesions above 10 cm from the anal
of benign lesions and select early rectal cancers verge. Our data suggests a relatively equal distri-
(T1) not resectable by endoscopy. This chapter bution of males and females (five males and four
describes the operative and perioperative out- females) and generally anterior or lateral lesions
comes associated with TAMIS, emphasizing the ranging from 8 to 12 cm from the anal verge [5].
technique and complications of this procedure. Options for repair include transanal repair via
the TAMIS platform, laparoscopy, or laparotomy.
Occasionally, large defects can even require seg-
E. A. T. Vikis (*)
Royal Columbian and Eagle Ridge Hospitals, mental resection if the defect is not amenable to
Department of Surgery, simple local closure. Generally, the defect can be
New Westminster, BC, Canada closed via the TAMIS platform using laparoscopic
A.-M. Dufresne needle drivers and a 3-0 barbed self-locking absorb-
Royal Columbian Hospital, Department of Colorectal able suture. This requires a stable pneumoperito-
Surgery, New Westminster, BC, Canada neum and the conversion to general anesthesia if
G. Melich the procedure is initiated under spinal anesthesia.
Royal Columbian Hospital, Department of Surgery, Though local repair is the ideal approach, if unable
New Westminster, BC, Canada

118 E. A. T. Vikis et al.
to maintain stable pneumorectum, consideration

can be given to laparoscopic transabdominal repair
either via direct closure of the defect or segmental
resection of the rectum. Generally, given the rela-
tive ease of adoption of TAMIS suturing techniques
for those who have mastered laparoscopy, closure
of the defect should be done routinely, so that in
more challenging closures such as peritoneal
breach, conversion to laparoscopy can be avoided.
Caycedo et al. [7] describe five peritoneal vio-
lations in 50 cases (10%). All peritoneal viola-
tions were repaired using the TAMIS platform
and AirSeal® Insufflation System (ConMed,
Fig. 12.1 Intraoperative view of the rectal polyp being
Inc., Utica, NY, USA). The authors of this article stapled with a laparoscopic Echelon stapler
recommended not operating on anterior lesions
suspected to be above the peritoneal reflection if
the surgeon is not facile at laparoscopic suturing, complete excisions of the rectal lesions (see
as they carry a high risk of peritoneal entry. Our Figs. 12.1, 12.2, and 12.3).
current data suggests an unplanned intraperito- Diverting ileostomy has also been described
neal entry rate of 3.9%, where repair was primary [10] but is generally not advised if no major fecal
performed by intracorporeal suturing via the contamination has occurred and primary repair is
TAMIS platform (6 of 9 patients), while 2 patients successful.
required conversion to laparoscopy to close the
defect and 1 necessitated a laparoscopic low
anterior resection, as the defect was too large to aginal Entry and Rectovaginal
V
close primarily. Subcostal needle catheterization Fistulae
using a 14-gauge needle in the left upper abdo-
men at Palmer’s point was used to evacuate the Vaginal entry can occur for anterior lesions in
intra-abdominal CO2 and facilitate transanal women. Infiltrating the rectovaginal septum with
repair, with successful completion of the surgery local anesthetic and digitizing the vagina during
in 3 of the 6 patients who had repair transanally. dissection can help to define the planes and pre-
Interestingly, one patient who sustained a perito- vent vaginal trauma. Keller et al. [10] describe an
neal violation went on to have two further TAMIS electrocautery injury to the vaginal wall that
procedures for recurring adenomas in the same healed with conservative measures. Very early in
position (despite clear circumferential margins our own TAMIS experience, we described one
on previous TAMIS excisions), and these two case of vaginal entry that occurred for removal of
further TAMIS local excisions were not compli- an anteriorly located neuroendocrine tumor. This
cated by peritoneal entry, likely secondary to was recognized intraoperatively and primarily
scarring from the initial procedure [5]. repaired but recurred within 30 days with a clini-
In a series (pending publication), the applica- cally apparent rectovaginal fistula. The approach
tion of a transanal laparoscopic stapling device is to wound care was irrigation with daily enemas
described that could circumvent this complica- and broad-spectrum oral antibiotics to encourage
tion by simultaneously removing lesions while healing as per treatment of other traumatic recto-
closing the defect that are suspected to be above vaginal injuries. The fistula was deemed closed at
the peritoneal reflection [9]. This article exam- 60 days and has remained closed. Of course, if
ines TAMIS operations for local excision rectovaginal fistula occurs, other operative
whereby a laparoscopic stapler is used to define, techniques can be employed as described in the
remove, and seal the defect, all with full-thickness section below on long-term complications.
12 Operative and Perioperative Outcomes 119
Fig. 12.2 End result of the closure of the rectal defect with a laparoscopic stapler
dissection (nb: care must be taken to assure the

gauze sponge does not “drift up” due to the active
pneumorectum, as this has been described by
TAMIS surgeons). Retrieval of this sponge after
suturing of the defect confirms an open lumen. In
addition, if there is any doubt, or the sponge was
not utilized, a patent lumen can be confirmed with
a rigid proctosigmoidoscope in the operating room
or by simply advancing the camera lens (used for
TAMIS) beyond the area of local excision.
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
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
Urinary retention is a frequent postoperative Postoperative Pain

complication of anorectal procedures and cer-
tainly can occur after TAMIS. Generally, urinary For most patients, pain is minimal after TAMIS. It
catheter insertion is not required for a short oper- is a concern mostly for lesions below or near the
ation with no hospital stay. When utilized, cathe- dentate line. A common practice with other ano-
ters increase the risk of urinary retention and rectal procedures is to prescribe metronidazole to
infection. In TAMIS, it has been suggested that patients to reduce postoperative pain. A meta-
circumferential lesions predispose patients to uri- analysis in 2018 [23] demonstrated that both topi-
nary retention [7] and replacement of the Foley cal and oral metronidazole were effective in
catheter for urinary retention has been shown to managing postoperative pain after hemorrhoidec-
increase the incidence of urinary tract infection tomy. Given its anti-inflammatory effects and
[18]. Urinary retention is reported to occur from proven safety in other anorectal procedures, met-
2% to 19% of patients after TAMIS [7, 12, 18]. ronidazole can be prescribed for a total of 5–7 days
Our data suggest a rate of 7% with 13 men and 2 as an efficient and cost-effective treatment for
women, having clinically significant urinary post-TAMIS pain, particularly for patients who
retention. Of these 15 patients, 8 had anterior have undergone ultra-low-lying excisions [24].
12 Operative and Perioperative Outcomes 121
Fecal Incontinence strictures can be treated with endoscopic dilata-

The equipment for TAMIS includes an access tion or Hegar dilators as outpatients, particularly
channel that is placed into the anal canal for the for low-lying strictures [29].
duration of the procedure. This sustained anal
dilatation could potentially be a concern for con-
tinence after the surgery. A descriptive, prospec- Rectovaginal Fistula
tive study was published in 2015 studying the
impact of an anal port on anorectal function dur- The distal two thirds of the rectum anteriorly lie
ing TEM/TEO procedures [25]. The baseline and in close proximity to the posterior vaginal wall.
the voluntary contraction pressures were The identification of the vagina, as well as the
decreased at 1 and 4 months after the surgery. rectovaginal septum, is essential when operating
However, there was no correlation with clinical on an anterior rectal lesion transanally. Any
incontinence. The TEM/TEO instrumentation is trauma to these structures can potentially result
rigid at 40 mm in diameter, compared to 30 mm in a rectovaginal fistula. Keller [10] described
for the flexible TAMIS port [26], suggesting that one case of rectovaginal fistula (1.3%) in TAMIS
there would be less influence on continence with secondary to electrocautery injury. It was man-
the TAMIS procedure. aged conservatively, as previously described in
Schiphorst and Clermonts [27, 28] examined the section on vaginal entry.
long-term functional outcomes post TAMIS, and, A surgical approach may be required if con-
ultimately, there was no clinically significant servative management fails. Transanal or trans-
impact on continence. Schiphorst’s study mea- vaginal operations are options for local repair.
sured functional results after TAMIS. While 51% Depending on the location of the defect, consid-
of the patients had normal continence prior to the eration could be given to transanal repair with
surgery, 17% (3/18) of those had worse continence endorectal advancement flap, which can be cre-
after TAMIS. Interestingly, in the remaining 49% ated using the TAMIS platform [5]. Generally,
of patients with previously impaired continence, endorectal advancement flaps are effective in
continence was seen to improve in 88% of patients, about 50% of patients with previously normal
likely secondary to removal of the inciting lesion sphincter function [29]. At our center, six patients
causing poor preoperative anorectal function and have undergone successful endorectal advance-
symptomology consistent with outlet obstructive ment flap repair of rectovaginal fistulae via
defecation due to the mass effect of the lesion prior TAMIS. Other local repairs would include endo-
to excision. In conclusion, short-term functional vaginal advancement flap, fibrin glue, mesh inter-
results are good, with the majority of patients pre- position, or sphincteroplasty. Complex cases that
serving their continence. fail local repair may require more aggressive
options, such as a pedicled muscular flap
interpostion, low anterior resection, or, very

Long-Term Complications rarely, abdominoperineal resection.
Rectal Stricture
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Functional Outcomes After Local
Excision for Rectal Neoplasia 13
Elizabeth R. Raskin
Introduction Preoperative measurement, both with qualitative

and quantitative tools, is critical to establishing a
The transanal approach can be a viable surgical baseline from which to assess the effect of trans-
option for most benign and select malignant rec- anal surgery on function. This chapter aims to
tal neoplasms. The decision to proceed with define anorectal function, elucidate preoperative
transanal surgery is typically based upon the size and intraoperative factors that contribute to func-
of a lesion, its location within the anorectal canal, tional outcomes, and compare postoperative out-
and its particular pathologic characteristics. comes after traditional transanal (TA) surgery,
Advances in technology, such as the advent of transanal endoscopic microsurgery (TEM), and
transanal endoscopic microsurgery (TEM) and transanal minimally invasive surgery (TAMIS).
transanal minimally invasive surgery (TAMIS),
have allowed for improved optics and access
within the anorectum, translating into superior Anorectal Function
surgical margins and enhanced oncologic out-
comes [1, 2]. While a large focus has been Normal anorectal continence involves complex
placed on the safety, feasibility, and oncologic contributions from the pelvic and perineal mus-
soundness of transanal techniques compared to culature, rectal compliance and capacity, as well
traditional proctectomy, functional outcomes as neuronal pathways which potentiate various
following transanal surgery have received much reflexes.
less attention.
Postoperative anorectal functional outcomes
can be summarized as gas and stool continence, Anatomy of Anorectal Continence
fecal frequency/urgency, and quality of life fol-
lowing surgery. Multiple factors play a role in The pelvic floor – or levator ani, perineal body,
postoperative function, such as preoperative and the internal and external anal sphincter mus-
baseline function, tumor characteristics, surgical cles – comprises the muscular framework for the
technique, and the extent of resection. continence mechanism. Parasympathetic inner-
vation of the pelvic floor arises from S4, while
S1–S3 and S2–S4 innervate the internal and
E. R. Raskin (*) external sphincter, respectively. These branches
Loma Linda University, Loma Linda, CA, USA
of the pelvic plexus help coordinate activity of
VA Hospital Loma Linda, Department of Surgery, both the striated and smooth muscle of the pelvis
Loma Linda, CA, USA

124 E. 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)
Intraoperative Factors Interestingly, the loss of function was not

associated with a decrease in QOL. They
Transanal Excision (TAE) postulated that the maintenance of QOL may be
attributed to the fact that small changes in conti-
Anal dilatation and the utilization of an ano- nence did not significantly change FIQL scores.
scope present the first potential impacts on the Symptoms, such as obstruction, bleeding, mucus
sphincter mechanism during transanal surgery. production, tenesmus, and urgency, may have
The duration of anoscopic use and the degree of been alleviated, leading to an improvement in
stretch depend upon the size, location, and QOL. Alternatively, some patients may have
complexity of the rectal tumor, to allow for ade- experienced psychological relief following tumor
quate exposure. Uncontrolled manual anal dila- excision, despite the decline in sphincter
tation has been associated with loss of function.
continence in close to 27% of patients undergo-
ing anorectal excisional surgery [12]. Stretch of
the internal anal sphincter or excision of a por- Transanal Endoscopic
tion of IAS may contribute to postoperative loss Microsurgery (TEM)
of function [13].
van Tets et al. looked at the effect of utilizing The development of transanal endoscopic micro-
the Parks’ anal retractor for non-sphincter dividing surgery (TEM) by Buess in 1983 expanded the
procedures, studying both preoperative and post- capacity for transanal excisional surgery, espe-
operative manometric readings [14]. Postoperative cially for tumors in the mid and upper rectum
mean resting pressures at 6 weeks decreased by [16]. While TEM has allowed for more precise
23% after the use of the anal retractor compared excisions of rectal lesions, the effect of the tech-
with 8% when the retractor was not used (p > 0.05). nology on anorectal function warrants close
After 12 weeks, the mean resting pressure attention.
remained significantly lower in the group where
the retractor was utilized (p = 0.01). This suggests
a negative effect by the anoscope on the IAS, as Effect on Sphincter Complex
the IAS is largely responsible for resting pressure.
Fenech and colleagues studied 84 patients Utilizing a 4-cm wide specialized rectoscope, the
with benign and malignant tumors, evaluating TEM procedure produces a sustained and con-
continence status and health-related quality of trolled anal dilatation to allow for insufflation
life after TAE [15]. Utilizing preoperative endo- and visualization of the rectal vault. Although the
anal ultrasonography, Wexner Continence insertion of the device entails a gradual dilatation
Scale, and FIQL, the authors found that conti- of the sphincter complex, several studies have
nence status significantly worsened after demonstrated that significant changes to the
TAE. Unfortunately, postoperative ERUS was width and length of the sphincter muscle occur
not performed to indicate whether injury to the following the use of the TEM rectoscope [9]. In a
sphincter mechanism occurred. Patients who had study of 106 consecutive patients undergoing
undergone preoperative radiation therapy TEM for both benign and malignant rectal
experienced the worst changes in continence,
lesions, endoanal ultrasound (EUS) was used to
resulting in similar postoperative symptoms to preoperatively and postoperatively evaluate the
those undergoing low anterior resection. sphincter complex. Injuries were noted in 29.2%
However, some patients experienced an of patients at 1 month following surgery. It is
improvement in continence after excisions of unclear whether the injuries were due to recto-
large villous tumors, as these lesions created par- scope use or the extent of resection. A significant
tial obstruction (i.e., outlet dysfunction) and change in IAS width was noted 1 month from
often exhibit increased mucus production. surgery (p = 0.0008), although it appeared to
128 E. R. Raskin
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
[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
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Oncologic Outcomes for Local
Excision of Rectal Neoplasia 14
Lawrence Lee, Nathalie Wong-Chong,
and John Monson
Introduction TME because of the benefits of decreased post-

operative morbidity and faster recovery, superior
The treatment of rectal cancer with total meso- functional outcomes, and avoidance of a stoma.
rectal excision (TME) represents the best chance However, the indications for local excision are
of cure; however, it is associated with significant expanding, especially with the addition of neoad-
morbidity and poor functional outcome [1]. Local juvant or adjuvant chemoradiotherapy. This
excision is ideal for benign pathology, such as chapter will review the oncologic outcomes of
adenomas that are otherwise endoscopically local excision for benign and malignant rectal
unresectable, thus avoiding the need for radical neoplasms.
resection. Curative-intent local excision can also
be performed for patients with early rectal cancer
without adverse pathologic features. Local exci- Local Excision for Benign Pathology
sion has emerged as an appealing alternative to
Outcomes after local excision for large rectal pol-
yps are highly dependent on margin status
(Table 14.1). Recurrence rates are minimal in the
L. Lee (*)
Department of Surgery, McGill University Health presence of an R0 resection and may be as high
Centre, Montreal, QC, Canada as 40% if there is residual disease. There is still
Center for Outcomes Research and Evaluation, debate in the literature regarding the need for par-
McGill University Health Centre Research Institute, tial- versus full-thickness local excision for
Montreal, QC, Canada benign pathology [10]. It is the authors’ practice
e-mail: [email protected] to routinely perform full-thickness excision
N. Wong-Chong regardless of indication due to the important per-
Department of Surgery, McGill University Health centage of patients that will have unexpected
Centre, Montreal, QC, Canada
pathology that upstages lesions from premalig-
J. Monson nant to malignant. Bach et al. reported that an
Florida Hospital Medical System, Orlando, FL, USA
initial partial-thickness excision was indepen-
Center for Colon and Rectal Surgery, AdventHealth dently associated with positive margins [11].
Orlando, Orlando, FL, USA
Furthermore, full-thickness excision can be cura-
Surgical Health Outcomes Consortium (SHOC), tive if malignancy is found in the specimen, as
Orlando, FL, USA
long as there are no adverse pathologic features.
University of Central Florida, College of Medicine, There are few large studies that have reported
Orlando, FL, USA

134 L. Lee et al.
Table 14.1 Outcomes after local excision for rectal adenomas

Study N Mean FU R1/2 rate Recurrence Mean time to recurrence
Allaix et al. (2012) [2] 233 Median 110 11.1% Overall: 5.6% Median 10 mos (range
mos + margin: 23.1% 4–33)
– margin: 3.4%
Barendse et al. (2018) [3] 89 24 mos 34% Overall: 11% Median 12 mos (IQR
(R1 16%, 7–21)
Rx 18%)
Guerrieri et al. (2006) [4] 530 Median 44 NR Overall: 4.3% 13% after 3 mos
mos 34.8% after 6 mos
43.5% after 21 mos
8.7% after 18 mos
Amann et al. (2012) [5] 103 21.8 mos NR Overall: 6.8% NR
Tsai et al. (2010) [6] 120 24.5 mos NR Overall: 5.0% NR
McCloud et al. (2006) [7] 75 Median 31 37.3% Overall: 16.0% NR
mos + margin: 35.7%
– margin: 4.3%
Ramirez et al. (2009) [8] 149 43 mos 5.8% Overall: 6.0% 20.8 mos (range 12–112)
+ margin: 28.2%
– margin: 4.3%
Whitehouse et al. (2006) [9] 146 39 mos 4.5% Overall: 4.7% 23.3 mos (range 5–48)
+ margin: 40.0%
– margin: 4.4%
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
Study name Statistics for each study OR nd 95% Cl
OR Lower Upper Z Valuee p Value

limit limit
Han Y (16) 0.282 0.088 0.903 –2.132 0.033
de Graaf E (17) 0.127 0.047 0.345 –4.047 0.000
Lebedyev A (18) 0.526 0.044 6.293 –0.507 0.612
Christoforidis D (19) 0.527 0.203 1.368 –1.316 0.188
Moore J (8) 0.139 0.046 0.421 –3.490 0.000
Langer C (20) 0.272 0.108 0.689 –2.745 0.000
0.248 0.154 0.401 –5.690 0.000
0.01 0.1 1 10 100
TEM TAE
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])
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
1.0 pT1 ocal Excision for More

L
Local recurrence-free survival
pT2
0.9 pT3 Advanced Tumors
0.8 With the limitations in T staging with the current

locoregional imaging modalities, there may be an
0.7
important percentage of patients that will be
0.6 understaged or will have adverse prognostic fea-
tures on final pathology. Completion radical exci-
0.5 sion should be performed for these cases within a
0 12 24 36 48 60 72
Time after surgery (months)
short interval of the initial local excision. The
ideal time interval for completion surgery is not
Fig. 14.2 Kaplan–Meier estimates of local recurrence-free clear [49]. It is generally recommended to per-
survival in 361 patients after transanal endoscopic microsur- form the completion surgery within 30 days. It
gery for rectal cancer. P < 0·001, logrank test. pT pathologi-
cal tumor stage. (Adapted from Bach et al. 2009 [11])
may be important to wait for endoscopic healing
prior to excision, but an interval more than
7 weeks may also be associated with worse TME
included three high-volume centers, one that resection quality [50]. Perioperative outcomes
used TAMIS and two that used TEM [13]. Of 428 appear to be similar between completion TME
match patients, TAMIS was associated with after local excision and up-front TME [51, 52],
shorter operative time and length of stay. and oncologic outcomes have not been shown to
However, margin positivity (7% vs. 6%, p 0.65), be compromised [42, 53]. In a systematic review
lesion fragmentation (4% vs. 3%, p = 0.25), of 10 studies with 262 completion TMEs, local
5-year disease-free survival (78% vs. 80%, recurrences occurred in 6%, which compares
p = 0.82), and local recurrence (7% vs. 7%, favorably with up-front TME [49]. Redo local
p = 0.86) were similar regardless of approach, excision is not recommended in this setting and is
TAMIS vs. TEM, respectively [13]. This study associated with local recurrence rates up to 18%
demonstrated that high-quality local excision [49]. However, certain select patients that refuse
with excellent oncologic outcomes for early rec- more invasive surgery or who are medically unfit
tal cancer can be equally achieved using either can be considered for adjuvant chemoradiother-
TAMIS or TEM. apy, although there are no level I data to support
138 L. Lee et al.
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)
[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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Applications Beyond
Local Excision 15
Deborah S. Keller
Introduction postoperative anorectal function [1, 2, 4, 6–8].

With experience, the platform evolved beyond rec-
Transanal minimally invasive surgery (TAMIS) is tal mass excisions, and the utility continues to
an advanced videoscopic endoluminal platform grow. In this chapter, we review several applica-
that blends single-incision laparoscopy with local tions of TAMIS beyond local excision, for per-
excision techniques. TAMIS was first introduced forming established procedures in a minimally
by Sam Atallah et al. in 2009 as an alternate trans- invasive transanal approach, facilitating new tech-
anal endoscopic platform to transanal endoscopic nology and the development of new approaches,
microsurgery (TEM) [1, 2]. Since its inception, and managing complications.
TAMIS has been used increasingly worldwide as
an alternative to traditional transanal excision and
transanal endoscopic microsurgery for local exci- AMIS for Colorectal and Pelvic
T
sion of benign and early-stage rectal cancers in the Procedures
distal and mid rectum [3]. The TAMIS platform
offers specific value of a superior magnified high- The improved visualization, access to the pelvic,
definition 360° view of the rectum with stable and minimally invasive approach are a catalyst to
insufflation for more precise dissection and resec- expand the TAMIS approach to perform procedures
tion. For rectal cancers, these benefits translated to other than simply excising rectal lesions. Safety is
greater resection precision, a higher rate of nega- always paramount, and the risks and benefits of a
tive margins, lower rates of specimen fragmenta- new approach are carefully weighed before entering
tion, and lower lesion recurrence compared to into safety and feasibility trials. In innovative hands,
traditional transanal excision [4, 5]. TAMIS also the applications of TAMIS are nearly limitless.
has benefits over other advanced videoscopic plat- Here, we describe the use of TAMIS to perform
forms, such as transanal endoscopic microsurgery specific colorectal and pelvic procedures.
(TEM), in that there is no capital investment for
equipment, specialized instruments, set-up time,
learning curve, and device-related risk of anal The TAMIS-Ileal Pouch-Anal
sphincter trauma that could negatively impact Anastomosis (TaIPAA)
D. S. Keller (*) The TAMIS-ileal pouch-anal anastomosis

Division of Colon and Rectal Surgery, Department of (TaIPAA) is an ideal procedure for extending the
Surgery, NewYork–Presbyterian, Columbia bounds of the TAMIS platform past rectal tumor
University Medical Center, New York, NY, USA

144 D. S. Keller
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
Proctectomy Rectal prolapse is a relatively common condi-

tion with no accepted standard surgical approach
A completion proctectomy can be performed in described to repair, as all have considerable
patients without restoring continuity, as well. recurrence rates [20]. Current management fol-
Atallah et al. described the TAMIS proctectomy lows the basic approach that frail, elderly
in a patient with symptomatic ulcerative colitis in patients are dispositioned to undergo a perineal
her rectal stump after prior subtotal colectomy repair, while more fit, younger patient undergo
14 years previously with functional end ileos- an abdominal approach. Perineal
tomy [18]. For the procedure, authors introduced rectosigmoidectomy (or the Altemeier proce-

and seated a single-port device (TAMIS port) dure) is a historic repair previously relegated to
transanally, established pneumorectum, and per- those unfit for an abdominal repair for high
formed a full-thickness incision proximal to the recurrence rates [21]. More recent work has
dentate line. To work at this level, the TAMIS shown the Altemeier procedure for rectal pro-
port was manually pulled back and manipulated lapse provides excellent results across all age
146 D. S. Keller
groups with minimal morbidity and recurrence Parastomal Hernia

rates comparable to other procedures [21].
Althoff et al. advanced the Altemeier procedure Parastomal hernias are a common problem with a
using the TAMIS platform to perform a recto- significant impact on patient quality of life after
pexy with rectosigmoidectomy in a patient with stoma construction. Multiple approaches, using
procidentia [22]. The authors initially follow the open, laparoscopic, and robotic platforms, have
classic Altemeier procedure steps, with eversion been described, with recurrence rates still leaving
of the prolapse segment, full-thickness circum- room for a more ideal approach to management.
ferential division proximal to the dentate, dis- Furajii et al. described a combined, two-team
section into the peritoneal cavity, and division approach for a TAMIS completion proctectomy
of the mesentery. Instead of performing a and concomitant parastomal hernia repair with
sutured anastomosis at this point, they divided transperineal mesh fixation in a pilot series of
the sigmoid colon with a linear stapler. Next, a three patients [23, 24]. The intra-abdominal
TAMIS port (GelPOINT Path Transanal Access adhesions and upper rectal mobilization were
Platform, Applied Medical, Inc., Rancho Santa performed from the abdominal approach and
Margarita, CA, USA) was introduced and pneu- mobilization and removal of the low and mid-
morectum established. They then examined the rectum via the perineal TAMIS port (GelPOINT
abdominopelvic cavity, identified the sigmoid Path) after an intersphincteric dissection. The air-
colon segment serving as the neorectum and the tight transperineal access provided excellent
sacral promontory, and then used absorbable visualization of a parastomal hernia and facili-
tacks to fixate the bowel to the sacral promon- tated treatment of the synchronous pathology. A
tory. The TAMIS access facilitated the fixation glove port was placed into the peristomal incision
be providing an ideal angle. After the rectopexy, after mobilization of the end ileostomy, and mesh
the stapled end of the sigmoid is delivered trans- was introduced, orientated, and fixed via the
anally, removed, and the sutured anastomosis is transperineal access. The authors reported no
performed (Fig. 15.1). This approach may offer perioperative complications nor were there
a more durable repair with the lower morbidity (short-term) recurrences with this innovative
of a minimally invasive, transanal approach in technique.
all ages.
Retrorectal Masses
Primary tumors of the retrorectal (or presacral)

space are often rare presacral embryologic rem-
nants. While usually found incidentally and while
the majority is asymptomatic, they may present
with lower back or pelvic pain, defecatory dys-
function, and concern for malignancy, prompting
resection. There is a wide range of retrorectal
masses, with origins including congenital,
inflammatory, neurogenic, osseous, and miscel-
laneous. Most are benign, but management
should be undertaken by an experienced
specialist. Depending on the height and location
of the lesion, traditional options for resection
have been a posterior parasacrococcygeal
Fig. 15.1 Remove of the rectum with TAMIS prolapse approach, an abdominal approach, or a combined
repair abdominal and posterior approach.
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.
Anastomotic Stenosis and Strictures

Anastomotic Defects and Sinuses
Anastomotic stricture is a well-described compli-
cation after low anterior resection and more Low anastomotic defects or sinuses are a feared
likely to occur after radiation therapy, anasto- complication after a colorectal or ileal pouch-
motic leakage, ischemia, and inflammation anal anastomosis. Anastomotic sinuses can have
around a double-stapled anastomosis. Such fac- a major impact on patient outcomes, and improper
tors can narrow the lumen post-anastomosis and management can result in pelvic sepsis, often
sometimes result in the development of luminal leading to loss of the pouch, and life with a per-
stenosis and obstruction. Endoscopic dilation is manent ileostomy. Other noninvasive means to
the usual management, but in situations where manage an anastomotic breach, such as the use of
the proximal lumen is not patent, TAMIS can be an endo-sponge, is not feasible at the low level of
an alternative. Bong et al. describe the use of the an IPAA [32]. While a defunctioning loop ileos-
TAMIS technique to manage a patient with a tomy diminishes septic sequelae, it does not pre-
completely occluded lumen at a double-stapled vent leakage and anastomotic failure. When a
colorectal anastomosis [31]. The authors used a contained leak or sinus forms, a chronically
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
imposed by body habitus [18]. In the learning 2. Atallah S, Albert M, Larach S. Transanal minimally
curve for the procedure, TAMIS with stereotactic 2010;24:2200–5.
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.
visualization and the ability to detect extrinsic 9. de Buck van Overstraeten A, Wolthuis AM, D’Hoore
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.
pose beyond local excision of rectal neoplasia. 11. de Buck van Overstraeten A, Mark-Christensen A,
Wasmann KA, et al. Transanal versus transabdominal
The introduction of the TAMIS has revolution- minimally invasive (completion) proctectomy with
ized minimally invasive surgery, and the success ileal pouch-anal anastomosis in ulcerative colitis: a
in rectal excisions has opened the gateway to comparative study. Ann Surg. 2017;266:878–83.
performing more kinds of procedures through 12. Uematsu D, Akiyama G, Sugihara T, Magishi A,

Yamaguchi T, Sano T. Transanal total pelvic exentera-
this transanal platform. With the clinical and tion: pushing the limits of transanal total mesorectal
functional benefits of the TAMIS approach, the excision with transanal pelvic exenteration. Dis Colon
applications of TAMIS will likely continue to Rectum. 2017;60:647–8.
evolve. 13. Uematsu D, Akiyama G, Sugihara T, et al. Complete
transanal total mesorectal excision for lower rectal
cancer. Dis Colon Rectum. 2017;60:872–3.
14. Uematsu D, Akiyama G, Sugihara T, Magishi A,

Ono K, Yamaguchi T, Sano T. Transanal total pelvic
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The Evolution of Robotic TAMIS
16
Sam Atallah, Nicolas C. Buchs,
and Seon-Hahn Kim
Introduction Soon after its introduction at the turn of the

century, medical robotics became accessible to
The initial impetus behind robotics in surgery was surgeons who became attracted not to the telep-
telepresence and telesurgery [1, 2]. The idea was resence aspect, but rather to other key features of
to enable surgeons to operate on patients in remote the platform – including 3D, stereoscopic vision,
locales. In some fields of science remote, “teleop- tremor cancelation, video image magnification,
eration” is not only possible but also a proven and surgeon control of a camera lens that locks
standard, such as for manned and unmanned onto a specific field of view. Interestingly, the ini-
space craft which are managed at centralized sites tial target for the da Vinci Surgical System
including the Jet Propulsion Laboratory (Intuitive, Inc. Sunnyvale, CA) was not the
(Pasadena, CA) and the National Aeronautics and abdominopelvic cavity, but rather it was to
Space Administration (Houston, TX). In 2001, improve cardiac surgery [3–7]. However, in the
robotic telesurgery became a reality after early 2000s, it was realized that fixed abdomino-
J. Marescaux (L’Institut de Recherche contre les pelvic targets represented an excellent applica-
Cancers de l’Appareil Digestif, IRCAD – France) tion for the robot, initiating a fierce arch rivalry
performed the first transcontinental robotic chole- between laparoscopy and robotic that remains
cystectomy, heralding the dawn of a new era in strong to this day in the field of minimal access
medical robotics [2]. However, with the transition surgery.
of the robot from military and telesurgical centers In 2001, J. Binder and W. Kramer reported the
to civilian hospitals, practical applications for this first robotically assisted radical prostatectomy
technology were needed. [8], quickly followed by the reports from others
centers in the same year [9, 10]. In 2002, the first
S. Atallah (*) robotic colon resection was reported by P. Weber
AdventHealth Orlando, Oviedo Medical Center, et al. using the da Vinci Surgical System for right
and University of Central Florida College of and sigmoid colectomies for nonmalignant dis-
Medicine, Orlando, FL, USA
ease [11], giving rise to the era of robotics in
colorectal surgery [12]. Over the next 16 years,
N. C. Buchs
the focus of robotics in this field would center on
University Hospitals of Geneva, Department
of Surgery, Geneva, Switzerland one aspect more than any other: the pelvic dissec-
tion, specifically for total mesorectal excision
S.-H. Kim
Korea University Anam Hospital, Colorectal [13–15]. Soon, robotic surgeon proponents, con-
Division, Department of Surgery, Seoul, South Korea vinced this would allow for improved operative

154 S. Atallah et al.
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.
Initial Dry Laboratory Experiments
Advancements in TAMIS would give rise to a new

paradigm in transanal surgery which melded con-
cepts of single-port surgery, with laparoscopy and
transanal endoscopic microsurgery (TEM). The
natural step forward was to create an amalgam by
combining TAMIS with the surgical robot – with
the objective of refining precision and thus the Fig. 16.1 First-generation QuadPort+ (Olympus,
quality of surgery. Initially, the concept of docking Shinjuku, Tokyo, Japan) became available circa 2010 in
a multi-arm robotic cart through a narrow radius the USA. Although intended for abdominal (not trans-
single port was still novel and first described in the anal) access minimally invasive surgery, this port would
accommodate larger diameter instruments, making it a
literature by J Kaouk et al. in 2009 [24] (the same suitable interface for robotic TAMIS. The first dry labora-
year TAMIS was created) with other reports emerg- tory experiments with robotic TAMIS were conducted
ing 2 years later [25, 26]. Therefore, robotic TAMIS using this port
16 The Evolution of Robotic TAMIS 155
Robotic TAMIS in the Cadaveric

Model
In 2011, after a preliminary work in a dry labo-

ratory setting, the next step was validation in a
cadaveric model. This was conducted using the
da Vinci S model, which, at the time, was the
only system for cadaveric evaluation (Fig. 16.3).
With the introduction of the GelPOINT Path
Transanal Access Platform (Applied Medical,
Inc. Rancho Santa Margarita, CA), the first sin-
gle port specifically designed for transanal
access, the experiments were conducted utiliz-
ing this platform at the Global Robotics Institute
(Celebration, FL, USA), and it was demon-
strated that intricate, precise operative maneu-
verability was quite feasible [27]. Specifically,
local excision (full thickness) and suturing with
intraluminal knot tying was possible, and the
level of difficulty was subjectively determined
to be low by the operators [27]. Potential
advantages of robotic TAMIS over standard

Fig. 16.2 With vertical docking of the Si platform and TAMIS include image stabilization under
the QuadPort+, the first dry laboratory experiments were
conducted for robotic TAMIS in September, 2010. single-surgeon control, 3D stereoscopic video
Arrangement and working arm encroachment were among processing, tremor cancelation, and image
the parameters assessed in the first preclinical assessment magnification. In theory, this could lead to
of robotic TAMIS improved excision quality, which is believed to
be a factor as to why advanced transanal plat-
forms carry an advantage over conventional
tor arms and a 30° lens. With vertical docking, parks local excision [28–31]. While TEM had
the system’s working arms and camera lens were been the gold standard for advanced endolumi-
delivered through the faceplate of the first- nal rectal surgery for over a quarter century, the
generation Olympus QuadPort+, whereby birth of TAMIS seemed to give rise to other
manipulation in a cylinder (so as to replicate the options–since it was not only disposable, but
confined space of the rectum) was successfully also economical (as the material from which
performed (Fig. 16.2). It was learned that it was the platform is constructed are much less
possible to operate the system quite precisely in important in retaining the quality of excision,
this fashion. Vertical docking was performed and for single-use devices the durability is not
because of the simplicity of doing so in the dry relevant). Perhaps the most economical of all
lab model, and work was then performed to modern platforms is the simplest – the glove
determine the best orientation of docking of the port. Introduced first in 2012 by A. Carrara as a
Si system. In a series of dry lab experiments, it technique for TEM [32], the glove port was
was determined that robotic cart side docking subsequently applied by R. Hompes as an
relative to the operating table would allow for interface for robotic TAMIS with excellent
the best access to the anorectum as the working results later that year [33] and represented an
arms and camera lens could be delivered over effective, low-cost interface quite suitable for
either the right or left thigh; alternatively, the transanal access [34].
robotic cart could be docked over the patient’s Robotic TAMIS in a cadaveric model remains
shoulder. an important, ongoing modality for research. In
Fig. 16.3 In 2011, at the

Global Robotics Institute
(Celebration, FL, USA),
the first robotic TAMIS
was conducted in a
cadaveric model. In a
series of experiments,
maneuverability and
functionality of the da
Vinci S system utilizing
the GelPOINT Path
Transanal Access Platform
were assessed. Local
excision, suturing, and
intraluminal knot tying
were assessed
2017, the application of the next-generation da Clinical Experience

Vinci SP platform (not currently FDA approved with Robotic TAMIS
for colorectal surgery at the time of this writing)
was demonstrated to be feasible in preclinical In 2012, the first robotic TAMIS for local exci-
evaluation [35]. In a study by J Marks et al., 12 sion of a rectal neoplasm in a human was reported
lesions were successfully removed from all [36]. Here, a 3.0 cm tubulovillous adenoma with
three segments of the rectum without fragmen- focal intramucosal adenocarcinoma was removed
tation and with negative >1 cm margins from transanally (intact and with negative margins)
where the mock lesion perimeter had been utilizing a da Vinci Si robotic system with 8 mm
marked [35]. The operative technique utilized a Maryland grasper and hook cautery, using a stan-
TAMIS port (GelPOINT Path Transanal Access dard laparoscopic insufflator and GelPOINT Path
Platform) for an interface. Advantages of the SP Transanal Access Platform (TAMIS platform)
platform are that it allows for “wrist and elbow” (Fig. 16.4). Barbed absorbable suture (3–0 V-Loc)
motion of 6 mm effector arms, a “cobra” angu- was used to reapproximate the bowel wall after
lation of the camera lens, and the ability to excision, operative time was 102 min, and the
admit three (as opposed to two) working arms– authors sited increased cost as an important limi-
with a navigational aid provided at the console tation, with an approximated additional per-case
the surgeon’s knowledge about the instruments’ cost of $1500 USD.
positions. Perhaps most importantly, the robot Afterward, validation via other, mainly single-
cart is essentially reduced to a singular device surgeon series and case reports on robotic trans-
arm, which greatly simplifies transanal access anal surgery (under the moniker RTS or robotic
and docking – a part of the operation that is oth- TAMIS) emerged in the literature [37–46], and are
erwise difficult in some patients, especially summarized in Table 16.1. Essentially, this dem-
those with a challenging body habitus. The flex- onstrated that the technique was feasible for local
ible working instruments of the SP, together excision (Fig. 16.5). The platform has also been
with the compact robotic cart’s single-arm con- used to repair rectovaginal fistulae, rectourethral
figuration, make such a system ideal for endolu- fistulae, and more advanced procedures including
minal access and surgery. taTME [41, 52, 53]. Current data on robotic
Fig. 16.4 2012: The first

robotic transanal excision
of a neoplasm in a human.
The da Vinci Si platform
was used in conjunction
with the GelPOINT Path
Transanal Access
Platform, the lesions were
completely excised, and
the defect reapproximated
robotically using barbed
absorbable suture. Note
the patient’s modified
Lloyd-Davies position and
the docking of the cart
over the right shoulder
Table 16.1 Chronological publications on robotic TAMIS

Author Date Country Interface Model n Remarks
Atallah [27] September USA GelPOINT Cadaver 2 1st experiment with robotic
2011 TAMIS
Atallah [36] May 2012 USA GelPOINT Human 1 1st robotic TAMIS in a human
Hompes [33] May 2012 UK Glove Cadaver 2 1st report of glove as interface for
transanal robotic access
Bardakcioglu December USA GelPOINT Human 1 2nd robotic TAMIS in a human to
[37] 2012 be reported
Atallah [47] June 2013 USA GelPOINT Human 1 1st robotic taTME in a human
Valls [42] August Spain Glove Human 1
2013
Buchs [38] August Switzerland Glove Human 3 1st description of the lateral
2013 approach
Hompes [40] April 2014 UK Glove Human 16
Atallah [48] June 2014 USA GelPOINT Human 3 1st pilot series on robotic taTME
Gómez-Ruiz January Spain Custom Human 5 Totally robotic (above and below)
[49] 2015 taTME
Atallah [41] February USA GelPOINT Human 18 Includes local excision, fistula
2015 repair, taTME
Atallah [50] May 2015 USA GelPOINT Human 1 1st report of robotic taTME with
LoneStar robotic ISR
Kuo [51] October Taiwan GelPOINT Human 15 Single port + 1 combined with
2016 robotic taTME
Gómez-Ruiz December Spain Custom Human 9 da Vinci Si utilizing specialized
[46] 2017 hybrid port
Erenler [45] April 2017 Turkey GelPOINT Human 1 1st published case using Xi
platform
Marks [35] July 2017 USA GelPOINT Cadaver 12 1st preclinical series with da Vinci
SP
Atallah [50] October USA Flex robot Cadaver 2 1st preclinical report utilizing
2017 port flexible robotic system for TAMIS
and taTME
TAMIS remains limited, with mostly single-

surgeon retrospective series reported in the litera-
ture [39].
Docking and Configuration
Today, docking of the multi-arm da Vinci robotic

cart can be performed in various methods and is
often predicated by surgeon preference, as well
Fig. 16.5 Local excision via robotic TAMIS. 8 mm as the specific platform’s design and interface.
wristed, instrumented, and stereoscopic magnified optics For S and Si platforms, with the patient in dorsal
are among the perceived advantages of the robotic plat- lithotomy, cart docking can be parallel and flush
form. Here, rectal neoplasm boarders have been delin-
eated with cautery marks, and a full-thickness excision is
against the operating table (Fig. 16.6) or tangen-
in progress. A Maryland grasper and hook cautery are the tially with the robotic arms delivered over the
only instruments required to complete the excision shoulder. In general, the Xi® system with its long
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
Fig. 16.7 The Xi® system

has been docked
orthogonally to the
operating table, and the
patient’s steep
Trendelenburg, Lloyd-
Davies position is evident.
The low-profile arms and
large wingspan of the Xi®
system allow for improved
transanal access with less
collision. Compared to the
Si, however, 5 mm
effector arm instrumenta-
tion is not (currently)
available representing a
potential limitation since,
in general, it is advanta-
geous to have small
diameter instruments so as
not to restrict workspace
arm span and low-profile configuration, provides

more leeway in cart-to-patient arrangement.
Common approaches using the Xi® system
include perpendicular docking relative to the
side of the operating table (Fig. 16.7), but other
options are valid.
While TAMIS is almost always performed
with the patient in dorsal lithotomy, robotic
TAMIS may or may not require the patient to
be positioned in this fashion. Indeed, other
patient positioning may be desirable. For
example, anterior lesions are best approached
with the patient positioned prone jack-knife.
The advantage here is that the lower extremi-
ties do not collide with the working arms dur-
ing the process of dissection, leaving the
effector arms with less likelihood for collision
(Fig. 16.8).
In the spring of 2014, the da Vinci Xi® was
introduced, providing significant advantages for
the operator, especially regarding versatility
with docking. The first robotic TAMIS utilizing
Fig. 16.8 Common configuration for robotic TAMIS
the Xi® platform was believed to have been per- using the Xi® system is adapted with 5 mm AirSeal for
formed on July 28, 2015 by S. Atallah (Fig. 16.9). pneumatics. Here, an anterior distal rectal lesion is tar-
The first published report using the Xi® was geted for local excision. Two working arms and a 30°
8 mm lens are mated to the TAMIS port. Note that the
reported in a video vignette by Erenler et al. in
GelPOINT Path Transanal Access Platform (TAMIS port)
2017 [45]. The Xi® platform allows for various is suspended by the hooks of the Lone Star Retractor,
options in docking, and some experts prefer the which allows the access channel sleeve to be only partly
prone jack-knife position with orthogonal cart admitted into the anal canal. This allows for improved dis-
tal access for low-lying lesions
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
positioning for anterior rectal wall pathology. pplications of Robotics Beyond

A
Another option is the lateral approach, which Local Excision
when combined with a glove port results in
improved robotic arm excursion, as demon- In 2013, just 3 years after the first reported human
strated by N. Buchs in 2013 with the Si system case of taTME by P. Sylla and A. Lacy, robotic
[38]. Furthermore, Gómez-Ruiz et al. have taTME was successfully performed on a human
described the use of a specialized interface in for the first time [54]. The patient was an obese
which the platform is part rigid and bedrail female with familial adenomatous polyposis
mounted and part reusable. The rigid portion is (FAP) syndrome and synchronous hepatic flexure
similar to a 40 mm dia. TEM scope, but the face- and rectal cancers. The abdominal resection was
plate utilizes an 80 mm GelPOINT membrane performed laparoscopically, and the taTME was
that is twice the diameter of the standard TAMIS performed by docking the da Vinci Si transanally
port (Fig. 16.10). This likely allows for improved with GelPOINT Path Access Platform as an inter-
instrument maneuverability, decreased arm col- face. While there were limitations of reach, the
lisions, and a simplification of the port-to-robot robotic taTME was successfully completed in
rendezvous. 87 min; the mesorectal envelop contained one
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
2001: First Robotic 2009 : First 2012 : First Glove Port

Prostatectomy TAMIS for Robotics TAMIS
1984: TEM 2009 : First 2011 : First Robotic

2001: Transcontinental 2017 : First
Developed Abdominal Robotic TAMIS Cadaveric
Robotic Surgery Cadaveric Report
Single Port Surgery Experimentation using SP System
2015: First Xi®

2013: First
System for
Robotic taTME
robotic TAMIS
~1999: Sugical 2010: First
Robotics Introduced Robotic Transanal 2012: First
Surgery Dry Lab Robotic TAMIS 2017: First
Experiments in a human Robotic TAMIS
and taTME
2002: First (Cadaveric)
Robotic With Flexible
Colectomy Roboitc System
Fig. 16.12 Timeline delineating the milestones in robotics in colorectal surgery including transanal approaches
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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]

166 K. M. Izquierdo et al.
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
mastery of single-port laparoscopy. Robotic Despite the limitations of these multi-arm

TAMIS, or robotic transanal surgery (RTAS) is a robotic platforms, Atallah et al. have successfully
natural evolution of the approach and promises to performed taTME and repair of complex fistulae
address the technical challenges of reach, visual- via robotic TAMIS [20]. They reported on four
ization, retraction, and ergonomics that has lim- patients who underwent RTAS-TME for invasive
ited endoluminal surgery. adenocarcinoma of the distal rectum. All speci-
mens were found to be complete or near com-
plete mesorectal excisions with negative distal
Current Applications and Outcomes and circumferential margins. Similarly, in a pro-
spective pilot study by Gomez et al. using the da
Atallah et al. demonstrated the feasibility of robotic Vinci Si, RTAS-TME was performed in five
TAMIS using the da Vinci Si robotic platform in a patients, and all TME specimens showed com-
cadaveric model in 2011 and reported the first plete mesorectal excision with negative distal and
human case with resection of an early stage rectal circumferential margins [21]. Robotic TAMIS
cancer in 2012 [15, 16]. Subsequently several for these applications has only been reported in
authors have reported on the feasibility and safety small series, and long-term oncologic outcomes
of robotic TAMIS. The advantage of robotic sur- have yet to be studied.
gery comes with its magnified 3D view, wristed Transanal surgery is highly demanding due
movements, tremor elimination, and excellent ergo- to the confined anatomic space in the pelvis,
nomics, which allow for greater precision. Initially restricted exposure, and limited proximal
used for local excision of rectal neoplasms, robotic reach. The conventional multi-trocar robotic
TAMIS was soon adopted for more complex proce- platforms were originally designed for transab-
dures, with the first report of RTAS-TME (i.e., dominal access [22]. The effector arms of these
robotic taTME) in 2013 by Atallah et al. [17] systems are not flexible, limiting dexterity in
Robotic TAMIS using the da Vinci multi-arm the narrow pelvis, and the 8 mm instruments
robotic platforms works through a transanal dis- add bulk and subtract from field view in this
posable access channel, for example, the confined space [22]. Furthermore, the sacral
GelPOINT path transanal access platform [18]. angulation in the pelvis and instrument torque
Such access channels are required to create a seal prevents dissection beyond 7–8 cm from the
that maintains the insufflation within rectum anal verge. The current platforms have limita-
needed for adequate visualization. The da Vinci tions with control of operative field, endolumi-
Si robotic system, while demonstrated to be fea- nal suturing, and surgeon ergonomics – making
sible for local excision of distal rectal tumors, is it challenging even for those with extensive
limited by its multiple bulky arms and restricted experience [23]. Most importantly, while
field of view which prevent effective treatment of workable, the Si and Xi da Vinci platforms used
more proximal lesions. Hompes et al. in a series transanally represent a potential risk to the
of 16 patients, where both malignant and benign external sphincter complex and present ergo-
rectal lesions were locally excised, used a trans- nomic obstacles which cannot be overcome.
anal glove port which permitted wider movement Due to these factors, it is not likely that robotic
of instruments within the rectum and reduced transanal approach will be widely adopted
arm collision externally [19]. The next-generation without platform innovation.
Xi system addressed this partially with decreased
arm bulk, in turn, allowing easier transanal dock-
ing and more proximal operative reach. The New Platforms in Robotic TAMIS
major disadvantage with this platform is the lack
of 5-mm instrumentation, a significant issue in Despite the demonstrated benefits of minimally
the small working space of the anus and rectum invasive surgery (MIS), the field of colorectal
(currently, only 8 mm instrumentation is avail- surgery has been slow to adopt MIS techniques,
able with the Xi platform). especially for transanal procedures. The high
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 instruments 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.
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
TRAS Robot (Single-Access

S
Transluminal Robotic Assistant
for Surgeons)
The STRAS is an ergonomic master–slave sys-

tem, with an intuitive control interface allowing
the surgeon to comfortably operate the system.
Andras et al. reported the feasibility of this sys-
tem in colonic endoscopic submucosal dissection
in animal models in 2017 [26]. The slave unit
consists of a carrier cart and a detachable flexible
endoscope, which is a 50 cm flexible device with
two 4.2 mm working channels for instruments Fig. 17.2 STRAS operating tip. Comprised of a 50 cm
and one 2.8 mm working channel for conven- flexible device with two 4.2 mm channels through which
tional flexible endoscopic instruments (Fig. 17.2) instruments are passed. The black arrow indicates the
2.8 mm working channel for conventional endoscopic
[27]. The 50 cm endoscope should allow access tools, and the red arrow identifies the two arms on the
to lesions within the sigmoid colon. The motor- open side, which allow for the triangulation of robotic
ized endoscope is initially inserted under endo- instruments. (From Légner et al. [27])
scopic visual control, and once it reaches the

target, the endoluminal view is established as it is
re-attached to the slave cart. Like the Flex®
Robotic System, the STRAS robot requires sig-
nificant time to redefine the operative visual field.
The endoscope needs to be positioned into place
manually, and the STRAS master console pro-
vides limited control of the endoscope.
The robotic instruments consist of a proximal
motor and a flexible shaft with a bendable distal
Fig. 17.3 The da Vinci SP system’s single 25-mm can-
tip. The two opening arms at the tip of the endo- nula through which three 6 mm, multi-joined, wristed
scope allow for endoluminal triangulation for instruments and a 3D 0° HD camera extend
the instruments. The master console provides
continuous feedback regarding the actual posi-
tion of the tools. With only two robotically con-
trolled instruments, a notable limitation of this
system is the lack of effective retraction.
Additionally, this platform lacks suturing capa-
bilities, thus limiting its use beyond partial thick-
ness excisions.
As currently configured, both the Flex®
Robotic System and the STRAS robot are opti-
mized for partial thickness local excisions of the
rectum. However, the current generation’s limita-
tions hinder these platforms’ adoption to more
Fig. 17.4 At-large view of the da Vinci SP platform’s set
complex operations such as taTME, fistula repair, up intraoperatively
and pure NOTES proctocolectomy.
Notwithstanding, these platforms improve ergo-
nomics to a significant degree compared to stan- (Fig. 17.5) allows for manipulation of the opera-
dard, laparoscopic-based TAMIS. tive field so that all quadrants of the rectum can
be accessed without repositioning the patient. A
holographic monitor of instrument position
uture Directions: da Vinci SP
F assists the surgeon to better understand intralu-
Surgical System minal instrument collisions; effectively, it serves
as a navigational aid to keep track of instrument
The next-generation da Vinci robotic platform, position. This feature combines well with three-
which is pending FDA clearance for use in arm control that assists in creating optimal instru-
TAMIS procedures, is a single-arm, single-port mental retraction easily. The fully robotic wrist
system. The da Vinci SP system includes three with 6° of movement articulation allows for the
6 mm, multi-jointed, wristed instruments and the control that previous surgeons have become
first da Vinci jointed 3D 0° HD camera. accustomed to with the robot.
Collectively, the three instruments and the cam- RTAS approaches will expand the armamen-
era head are transmitted through a single 25-mm tarium of the transanal surgeon. Current limita-
cannula (Fig. 17.3). This advanced platform with tions include the absence of an RTAS suction
its unique “cobra camera” and flexible end effec- device, vessel sealer, and stapler. However, these
tor arms allow for more proximal reach transa- same challenges have been overcome with every
nally (Fig. 17.4). Significant benefits of this new new generation of robot, so it can be reasonably
technology are many. A rotating 360° platform predicted the same will take place here. This
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
Fig. 17.6 The da Vinci

SP Surgical System with
Applied GelPOINT Path
Transanal Access
Platform
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
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.
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
4. Buess G, Kipfmuller K, Hack D. Technique of

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TAMIS: Current Controversies
and Challenges 18
Introduction rectal cancer. This debate is not specific to

TAMIS, and much of the available evidence has
Transanal minimally invasive surgery (TAMIS) been extrapolated from experience with
is increasingly being used as an alternative to TEM. Relative to the large body of literature on
transanal endoscopic microsurgery (TEM) for TEM, or even to published data on the transanal
transanal excision of both rectal adenomas and endoscopic operation (TEO), few studies have
early rectal cancer. There are multiple ongoing reported specifically on TAMIS. Furthermore,
controversies about the benefits of and limita- there have been no prospective clinical trials
tions of TEM and TAMIS. Given the relatively comparing TEM and TAMIS and few studies
recent and limited experience with TAMIS as reporting long-term follow-up for oncologic out-
compared to TEM, published data on this plat- comes after TAMIS.
form is more limited, with no prospective series One review published by Martin-Perez et al.
that compare the two platforms (and their respec- reviewed 390 TAMIS procedures encompass-
tive techniques) directly. What is known about ing 33 published retrospective case series as
the current controversies regarding TAMIS will well as 3 abstracts [1]. Of these, over half of
be summarized in this chapter. TAMIS procedures were performed for rectal
adenocarcinoma, with adenoma representing
the second most common indication. Margins
ocal Recurrence and the Use
L were positive in 4.4% of cases overall, speci-
of TAMIS for Early Rectal Cancer men fragmentation occurred in 4.1%, and over-
all morbidity was 7.4%. Larger TAMIS series
Arguably the most significant ongoing contro- have generally found similar short-term onco-
versy about both TEM and TAMIS is the appro- logic results, supporting the conclusion that
priateness of their use in local excision of early TAMIS is likely a safe alternative to TEM for
carefully selected, T1 rectal cancer [1–9]. A
matched analysis comparing 419 patients who
H. Carmichael
Department of Surgery, University of Colorado, underwent TEM and 228 patients who under-
Aurora, CO, USA went TAMIS for both benign and malignant
e-mail: [email protected] disease found no differences in the rates of pos-
P. Sylla (*) itive margins or lesion fragmentation, again
Division of Colon and Rectal Surgery, Icahn School suggesting similar results for the two operative
of Medicine at Mount Sinai, New York, NY, USA platforms [10].

176 H. Carmichael and P. 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
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].
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].
Partial- Versus Full-Thickness theoretical benefit to full-thickness resection of

Resections and Risk of Stenosis large adenomas over partial-thickness resection
given higher rates of occult malignancy in these
Overall, the risk of rectal stenosis with either lesions, it is unclear if this benefit is outweighed
TEM or TAMIS appears low, but it is much more by the risk of stenosis.
common in patients undergoing TEM for circum-
ferential lesions, with rates as high as 78%
reported in the literature [50]. Some have argued Economics
that TAMIS should not be used for circumferen-
tial adenomas because of this high risk of rectal There are no formal cost analyses comparing
stenosis [18]. Management of rectal stenosis after TAMIS to TEM, although it is broadly accepted
TAMIS or TEM is similar to stenosis seen after that TAMIS is less expensive. The upfront cost of
low anterior resection. Most cases described in the TEM platform is approximately $80,000,
the literature have been treated endoscopically while the cost per disposable transanal port is
with balloon dilatation or stenting, or as a proce- approximately $500 to $800 [11]. Other authors
dure under general anesthesia using Hegar dila- have noted that the cost of the insufflation tubing
tors. The stenosis usually improves with one to to TEM is equivalent to the cost per disposable
two treatment sessions [50]. port [20]. A matched analysis comparing TEM
It is unclear if partial-thickness resection in and TAMIS found that TAMIS had significantly
cases of larger, circumferential lesions is associ- lower median operative time (70 min versus
ated with lower rates of stenosis when compared 108 min, p < 0.001) as well as lower median hos-
to full-thickness resection. Given concerns for pital length of stay (0 days versus 1 day,
higher rates of upstaging in such large adenomas, p < 0.001) [10]. So while it appears that TAMIS
full-thickness resection may be preferable. For is likely cost-effective relative to TEM, there are
esophageal and gastric lesions involving more no published studies showing this.
than three-quarters of the luminal circumference,
endoscopic submucosal dissection (ESD) is asso-
ciated with higher rates of stenosis as compared Unusual Applications
to endoscopic mucosal resection (EMR).
However, these findings may not be true for Typical indications for transanal endoscopic sur-
colorectal lesions, perhaps because the presence gery have been for removal of rectal adenomas
of stool in the rectum provides a dilating pressure not amenable to standard endoscopic resection,
as the scar heals. Ohara et al. found that only treatment of early rectal cancer, and scar excision
about 20% of ESD resections for these circum- following neoadjuvant therapy [55]. However,
ferential colorectal lesions developed stenosis at TEM has been used for a variety of rectal lesions
1 month [51]. However, others have found that including neuroendocrine tumors, gastrointesti-
while asymptomatic stenosis may occur, symp- nal stromal tumors (GIST), presacral tumors,
tomatic stenosis requiring intervention was rare, benign stricture, rectourethral fistula, endorectal
and the role of prophylactic endoscopic dilatation condylomas, rectal prolapse, pelvic abscess, and
is unclear [52]. It is also unclear what role endo- management of traumatic or iatrogenic rectal
luminal injection of steroids might play in pre- perforation [55]. TEM has also been used in the
venting stenosis for colorectal lesions, although management of even more rare rectal lesions
this has been used after ESD for esophageal and such as isolated rectal ulceration, rectal endome-
gastric lesions to prevent stenosis [53, 54]. triosis, ganglioneuroma, and melanoma [56].
Currently, there is no published evidence com- Considering TAMIS specifically, published
paring stenosis rates after full-thickness resection applications have been more limited, but the use
using TAMIS to those seen after partial-thickness of TAMIS has been reported in the management
resection using ESD or EMR. Although there is a of neuroendocrine tumors [8, 11, 57] as well as
GIST excision and pelvic abscess drainage [57]. invasive surgery for benign and malignant rectal neo-
plasia. Am J Surg. 2014;208:372–81.
TAMIS has also been used to correct stenosis 12. Schiphorst AHW, Langenhoff BS, Maring J, Pronk
occurring after low anterior resection as well as A, Zimmerman DDE. Transanal minimally invasive
pouch-related issues after proctocolectomy for surgery: initial experience and short-term functional
inflammatory bowel disease [58]. Finally, tech- results. Dis Colon Rectum. 2014;57:927–32.
13.
Caycedo-Marulanda A, Jiang HY, Kohtakangas
nology developed for use in TAMIS has now EL. Transanal minimally invasive surgery for
been used for transanal total mesorectal excision benign large rectal polyps and early malignant rec-
(taTME), which will be the topic of the remain- tal cancers: experience and outcomes from the first
der of this book. Canadian Centre to adopt the technique. Can J Surg.
2017;60:416–23.

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Part II
Transanal Total Mesorectal
Excision (taTME)
Indications for Malignant
Neoplasia of the Rectum 19
Reagan L. Robertson and Carl J. Brown
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

188 R. L. Robertson and C. J. Brown
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
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).
Fig. 19.2 Summary of

preferred patient
indications for taTME in
malignant disease. (Data
source from Motson
et al. [4])
Male
Obesity
• Visceral
• BMI > 30 Narrow pelvis
Lower or bulky Distortion of tissue

tumor planes
• Height < 10–12 cm • Neoadjuvant therapy
• Diameter > 4 cm • Scarring (eg. previous TEM
or TAMIS excision)
Tumor-Related Factors ranted. Many taTME studies have only included

patients with low and mid-rectal tumors (gener-
Local Stage ally defined as <5 cm and <10 cm from the anal
In theory, taTME can be utilized as a surgical verge, respectively) [12]. Other series, including
technique for any T or N stage in patients with the initial consecutive patient cohort reported by
adenocarcinoma of the mid and lower rectum. Lacy et al., include all rectal tumors up to a height
However, caution should be exercised when of 15 cm [3]. The second taTME consensus state-
selecting this technique for locally advanced ment suggests the technique may be of maximal
lesions. Many series have excluded T4 tumors, benefit to patients with tumor height <12 cm [4].
and the results of taTME for these lesions are not The COLOR III trial plans to recruit only those
well known. Given the novel view of the “bot- with mid to low tumors (<10 cm), and the
tom-up” approach, with many practitioners still GRECCAR II trial will exclusively look at taTME
in the early phases of their learning curve, risks for low tumors requiring hand-sewn anastomosis
of injury to surrounding structures and a positive [24, 25]. The current evidence supports the use of
resection margin must be carefully considered. taTME for low to mid tumors. For higher tumors,
The current taTME consensus statement lists T4 the benefit of taTME is less certain, but can be
tumors as a relative contraindication to the tech- considered in selected cases depending on other
nique [4]. Other sources suggest tumors initially patient factors that may limit abdominal visual-
staged as T4 may be treated with taTME if there ization and dissection in the pelvis.
is downstaging to a lower T stage after neoadju-
vant therapy [3, 24]. The taTME database regis-
try showed inclusion of all tumor stages including Patient-Related Factors
T1–T2 (33.1%), T3 (61.4%), and T4 (5.5%) [19].
At our institution, taTME is considered for T1– Obesity
T3 tumors and downstaged tumors on a case-by- High BMI and visceral obesity are factors repeat-
case basis. The authors advise extreme caution edly associated with difficult TME dissection.
and careful patient selection when considering Obesity was a reason for conversion in 10% of
taTME for T4 tumors, tumors with threatened converted patients in the COLOR II study and
CRM, or multi-visceral resection. 26% of patients in the CLASICC trial [9, 11]. A
Of note, there are uncommon rectal cancers large volume of visceral fat makes retraction
(e.g., neuroendocrine tumors, gastrointestinal from above difficult and contributes to a bulky
stromal tumors, etc.) where total mesorectal exci- mesorectum that fills the pelvis and impairs visu-
sion is indicated for curative intent. While there is alization. A thick abdominal wall can further hin-
limited experience with these cancers, similar der the surgeon during laparoscopy due to
principles regarding taTME and potential for R0 increased torque and decreased range of motion.
resection apply. Higher BMI has been shown to negatively affect
local recurrence rates for low rectal tumors.
Tumor Height Recurrence rates of 2.5–6.1% were reported for
taTME is best suited for low and mid-rectal underweight and normal weight patients as
tumors where “complete” TME, to the pelvic opposed to 9.2–13.8% in overweight and obese
floor with low pelvic dissection, is required. patients [26]. During transanal dissection, the
Multiple studies have shown that during lapTME, low pelvic tissue planes are accessed without
low tumors are at higher risk for conversion and encountering the abdominal wall and
poor histopathologic outcomes [9, 11]. intra-abdominal adipose tissue. Both BMI >30
Conversely, lapTME is very successful for and visceral obesity are listed by the consensus
patients with upper rectal cancers, so the cost and group as patient factors that may benefit when the
additional time required for taTME are unwar- taTME approach is employed [4].
Narrow Pelvis imaging, including an assessment of the pelvic

The narrow pelvis, particularly in male patients, anatomy, is beneficial when deciding on the use
leads to worse visualization and access for dis- of taTME.
section when performing TME. A narrow pelvis
increases the difficulty of surgery and has been
associated with poorer-quality TME [27–29]. Procedure-Related Factors
Indeed, narrow pelvis was the most common rea-
son for conversion in the COLOR II trial (22%) ollowing Local Excision with Transanal
F
[9]. Although the narrow pelvis is often associ- Endoscopic Surgery (TES)
ated with male gender, gender itself has not been Transanal endoscopic surgery (TES) is indicated
a significant multivariate factor in all studies. in patients with T1 cancers with favorable histo-
Several authors have sought to better define pel- pathologic features [31]. However, poor specific-
vic anatomy and determine specific pelvic vol- ity of preoperative imaging modalities leads to
ume measurements that predict difficult unexpectedly advanced lesions (e.g., high-risk
TME. Certain pelvic measurements indicative of histopathologic features, ≥T2 cancer) identified
a narrow pelvis are associated with longer opera- after TES. Timely TME is recommended to miti-
tive times and higher rates of conversion in gate a high risk of local recurrence and is per-
lapTME [27, 30]. Ferko et al. assessed 14 pel- formed in up to 23% of these patients.
vimetry measurements using CT and MRI and Unfortunately, completion TME following
found the angle between the upper and lower TES of a rectal malignancy is associated with
pubic symphysis borders and the sacral prom- high rates of APR and significant patient morbid-
ontory to be a significant predictor of Grade 3 ity [32–35]. Scarring from the previous excision
mesorectal dissection (Fig. 19.3). No other pel- can distort tissue planes and makes completion or
vic measurements were found to be significant salvage TME technically challenging. In two
predictors of poor-quality TME [28]. Presently, small studies, completion taTME after TES
there are no formalized measurements to guide appears to be oncologically safe [35, 36]. Koedam
surgeons on patient selection for et al. showed advantages in the taTME approach
taTME. Regardless, careful review of patient in the pathologic specimen, with significantly
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]
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.
Intersphincteric Dissection Abdominoperineal Resection

Increasingly, there is a shift toward the use of To a lesser extent, taTME has been described and
sphincter-preserving operations in patients with utilized for patients undergoing APR for low rec-
low rectal cancer, many of whom would have tal cancer. Only 9% (65/720) of patients from the
conventionally been managed with APR. Rullier international registry have undergone taTME for
et al. first classified low rectal cancer into four APR. No individual outcomes for patients under-
types (Table 19.3). Type I–III lesions are candi- going APR vs. LAR with the use of taTME have
dates for sphincter preservation via partial or been reported. taTME may provide advantages
total intersphincteric techniques. Intersphincteric for some patients undergoing APR where margin
dissection has comparable 5-year local recur- status or quality of TME may be threatened, but
rence rates (5–9% vs. 6%) and disease-free sur- this area requires further study to provide further
vival (70–73% vs. 68%) to patients undergoing recommendations.
APR and should be considered in appropriate
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
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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Indications for Benign Disease
of the Rectum 20
Willem A. Bemelman
Introduction regarding the risk of port site metastasis).

Likewise, the common bile duct injuries that
The transanal approach pioneered for rectal can- occurred during the introduction of laparoscopic
cer brought to light all of the learning curve issues cholecystectomy in the early 1990s must be
that could be imagined. As the era of taTME remembered, as this represents a similar para-
launched, a déjà vu reminiscent of the implemen- digm to urethral injury observed with institution
tation of laparoscopic cholecystectomy and lapa- of the taTME approach. Appreciating and dealing
roscopic colorectal surgery and their known early with these learning-related challenges ensured
challenges existed. However, the learning curve that these once novel techniques finally had
issues have been clearly appreciated thanks to the become safely standardized and broadly imple-
taTME registry [1]. Apart from a new set of short- mented; today, they are the standard of care.
term complications (such as injury to the male TaTME will likely follow the same pathway of
urethra) that have been realized, the long-term implementation and will be the standard approach
oncologic safety of the transanal approach still for distal rectal cancer in the future.
has to be established. The quality of resection In transanal surgery for benign indications,
with taTME, such as the risk of margin positivity there are no oncologic factors to be examined and
with this technique, is still being established. compared to other operative methods. Since there
Furthermore, taTME is unique in that the rectum is no need to perform a radical excision in trans-
is intentionally divided or “perforated,” and we anal surgery for benign disease, one can choose
are still uncertain about the risk of such specimen for a safer mode of dissection staying close to the
perforations as the potential exposure of the dis- bowel avoiding vital structures – such as ureters,
section area with tumor cells might negatively the urethra, hypogastric nerves, and nervi erigen-
influence long-term outcomes [2]. tes. For this reason, the application of the trans-
As a point of reference, however, laparoscopic anal approach (which applies the techniques of
colorectal surgery was also met with challenges TAMIS and taTME) to pelvic pathology is an
when first implemented for colorectal cancer – excellent alternative for top-down surgery, espe-
with valid concerns about the oncologic adequacy cially for the complicated and challenging
of the approach raised in the beginning (e.g., pelvis.
The objective of the transanal approach is not
W. A. Bemelman (*) at all to complete the entire operation in the bot-
Department of Surgery, Amsterdam University tom- up direction. However, the most difficult
Medical Center, Amsterdam, The Netherlands part – i.e., along the deep pelvis – is best

198 W. 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
then positioned. Using blunt retractors the

dentate line is exposed. The level of transec-
tion is marked +/–3 cm proximal to the den-
tate line to guarantee a remaining rectal cuff of
+/–1 cm after the double purse-string stapled
ileoanal anastomosis. The TAMIS platform
GelPOINT® Path Transanal Access Platform,
Applied Medical, Rancho Santa Margarita,
CA, USA, is inserted with two 10 mm cannu-
las in the gel cap, as well as a valveless 8 mm
trocar to allow for operation of the AirSeal®
Insufflation System (ConMed, Inc., Utica,
NY, USA). Insufflation pressures are set on
15 mm Hg. In case of combined laparoscopy
and TAMIS, the pressure settings must be
increased to 20 mmHg because of the com-
petitive abdominal pressure. Using the elec-
trocautery hook, the bowel wall is
circumferentially transected, with care to
assure that the transection of the bowel wall is
full-thickness and circular (Fig. 20.2).
Unlike the approach to taTME for cancer,
the rectal lumen is not closed, because in this
setting the rectum is blind-ending and because
it is thoroughly cleansed with iodine solution.
Next, dissection is carried out in close proxim-
ity to the rectum using electrocautery or ultra-
sonic dissection. Care should be taken to
maintain a plane near to the rectal muscular
Fig. 20.1 Transabdominal and transanal single-port plat- tube and to avoid an outward extension of this
forms in place
fascial level, releasing incisions are often

made to increase exposure to the abdominal
cavity. After establishing pneumoperitoneum,
adhesions and the length of the rectal stump is
assessed. The proctectomy is started bottom-
up, in order to prevent an early rendezvous
with the top-down dissection, because rendez-
vous between TAMIS and laparoscopy means
less exposure working via the TAMIS, bot-
tom-up approach.
Step II. A perianal block is injected at 3 and 9
o’clock positions using 10 ml of an amide
local anesthetic (such as bupivacaine), with
5 ml on either site to make the external sphinc-
ter muscle relax. The Lone Star Retractor
(Cooper Surgical, Inc., Trumbull, CT, USA) is Fig. 20.2 Transection rectal wall full thickness
Fig. 20.4 Transabdominal view on the rendezvous with

the bottom-up dissection
Fig. 20.3 Close rectal dissection
plane, with entry into the mesorectal fat plane

(Fig. 20.3). The dissection next proceeds as
far as possible avoiding prematurely opening
the pouch of Douglas, because the moment
the connection is established with the abdomi-
nal cavity, the exposure of the bottom-up dis-
section diminishes. If connection is made, the
top-down dissection is started. Fig. 20.5 Exteriorized terminal ileum taking the connect-
Step III. With the single-port platform inserted at ing vessels to the inner arcade to increase length
the stoma site, pneumoperitoneum and visual-
ization of the abdominal cavity is established Step V. Pouch creation. The terminal ileum is
laparoscopically. The procedure is simplified exteriorized via the Alexis ring of the single-
when an additional 5 mm trocar is inserted in port platform. If there is still not enough reach,
the left lower quadrant, which can be used at the connecting vessels to the arcade of the ter-
the end of the operation to insert a pelvic minal ileum can be ligated (Fig. 20.5). Using
drain. The rectal stump is identified, and using linear staplers a pouch of 10–15 cm can be
the ultrasonic vessel sealing device, the “top- constructed. The redundant efferent loop is
down” close rectal proctectomy is initiated. removed with a linear stapler and oversewn
Often, the rendezvous can be made with the with a running suture to completely incorpo-
bottom-up dissection quite rapidly (Fig. 20.4). rate the blind loop into the pouch to avoid
The specimen can be extracted either transa- future blind loop syndrome. An anvil is placed
nally or via the stoma site. in the base of the pouch and fixed with a purse
Step IV. The mesentery of the small bowel is fully string. The size of the circular stapler depends
mobilized over the pancreatic head and duo- on the diameter of the anus and the relative
denum to obtain maximal length. Transverse length of the remaining rectal cuff. If the cuff
incisions are made over the anterior and poste- is relatively long, a larger diameter stapling
rior mesentery in order to increase pouch device can be chosen.
reach. This can be done best with the electro- Step VI. Purse-string creation of the rectal cuff.
cautery hook. Using a monofilament 0-Prolene or equiva-
202 W. A. Bemelman
lent, the purse string is made taking care to

create symmetric bites and to not have either
too much or too little bowel wall in the purse
string. The muscular layer must be
incorporated.
Step VII. Under laparoscopic control the pouch is
positioned in the pelvis without rotation and
without herniation of small bowel beneath the
mesentery. Transanally, a long clamp is
advanced to grab the tip of the anvil and pull
the tip of the anvil through the anal purse
string. With graspers the peritoneum and the
mesorectal fat is positioned alongside the
pouch to facilitate a smooth advancement of the
pouch in the pelvis. The anvil is mated to the
arm portion of the circular stapler. The stapler
is closed and fired. Typically, the rectal donut is
quite thick as a result of the double purse-string
single-stapling technique. Having pneumoperi-
toneum the anastomosis is checked for leaks
(reverse air leak test). It might be useful to rein-
force the anastomosis with interrupted or run-
Fig. 20.6 Final result of double single-port TAMIS proc-
ning suture. A pouch drain (Chap. 32) is tectomy and pouch
inserted in the pouch for decompression. In our
unit, it is a common practice not to defunction
the ileoanal anastomosis, accepting a leak rate ileostomy fashioned; an Endo-SPONGE is
of ~10–15%. inserted transanally via the anastomotic dehis-
Step VIII. Via the single-port access platform, a cence in the septic cavity [11]. Typically, one or
pelvic drain is positioned after removal of the two Endo-SPONGE exchanges are necessary to
additional 5 mm trocar. The position of the have a clean cavity over a time period of a week
mesentery and small bowel is checked. The in order to resuture the anastomotic defect in the
single-port platform is removed and the stoma following week. Using this protocol, we have
site is closed in layers. The skin is closed with been able to close all ileoanal pouch leaks within
a monofilament purse string (Fig. 20.6). 3 weeks after diagnosis [12].
If the pouch has been defunctioned primarily
The nasogastric tube is removed upon case for any reason, one should monitor the plasma
completion. The pelvic drain is removed after CRPlevel, which can help elucidate a silent leak.
48 h. The suprapubic catheter is clamped in the In addition, the anastomosis is routinely checked
following days after surgery, and if there is no endoscopically within 2–4 weeks after surgery. If
retention after voiding, the catheter is removed. there is a silent leak, Endo-SPONGE-assisted
Patients are allowed to have a liquid diet until the early closure of the anastomosis is still feasible.
pouch drain is removed at day 6. C-reactive pro-
tein is measured at day 4 and day 7. If there is any
indication of anastomotic leakage being clinical Preliminary Results
symptoms or elevation of CRP at day 7, a CT
scan with oral and transanal contrast is per- De Buck et al. [13] compared a cohort of nearly
formed. If a leak is identified radiographically, 100 Ta pouches to conventional laparoscopic
the patient must be taken back to theater and an pouches in a three tertiary referral center study.
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.
Surgical Causes of Pouch Dysfunction

(a) Dysfunction related to the rectal cuff length:
A rectal cuff that is of an improper length
may be resultant from the double-stapling
technique for performing the ileoanal anasto-
mosis. The cuff should not be larger than 2
centimeters; otherwise this will result in a
retained rectum. It is believed that having
such a cuff has a role in the fine continence
discriminating passage of air versus fluid.
The problem with having a long cuff (retained
rectum), however, is the occurrence of
cuffitis in ulcerative colitis and recurrent pol-
yps in familial polyposis. If these conditions
cannot be treated medically or by endoscopic
removal, respectively, the cuff requires surgi-
cal excision.
(b) Retained rectum: A retained rectum is

defined if the remaining rectum is >2 cm.
Proctitis of the retained rectum can cause
urge and increased bowel movements, thus
negatively impacting anorectal function. If
symptomatic, this should be corrected by Fig. 20.7 Specimen of pouch on retained rectum
204 W. A. Bemelman
Fig. 20.8 Efferent loop

of S-pouch (arrow)
Fig. 20.9 Overdistended S-pouch before remodeling
and long J-pouches). If symptoms of prob-

lematic evacuation warrant a redo pouch, and
if the patients prefer not to have an ileostomy,
the pouch needs to be dissected and remod-
eled, or an altogether new pouch should be
fashioned (Fig. 20.10).
(e) Chronic sinus: A chronic sinus is defined as
an anastomotic leak that persists for longer Fig. 20.10 Remodeled pouch
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
(a) Transanal excision of cuff, retained rectum

or efferent loop, and sleeve advancement of
the pouch with or without transabdominal
mobilization of the pouch Fig. 20.12 Crohn’s disease in pouch
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
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)
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
in combination with full TME surgery, the leak Surgical Technique

will not heal and will result in a chronic presa-
cral sinus. This accounted for almost 10% of all (a) Redo Anastomosis
anterior resections with anastomoses [23].
These chronic sinuses, even if they are still The procedure can be done utilizing either a
defunctioned, can cause severe septic compli- one- or two-team approach. The patient is posi-
cations, for example, septic coxarthrosis, nec- tioned in the Lloyd Davis position (stirrups) on a
rotizing fasciitis, fistulae to the buttocks, ureter short beanbag. Perianal block is performed, and a
strictures, etc. [24]. Lone Star Retractor is positioned transanally. In
For this reason, source control with resection this setting, most patients still had their defunc-
of the leaking anastomosis and debridement of tioning ileostomy. Intraoperatively, the ileostomy
the septic cavity is warranted. is managed with a Foley catheter and draped with
In a shared decision-making process, it must a sterile gauze and adhesive bandage. Depending
be decided either to fashion a permanent colos- on the level of the leaking anastomosis, the
tomy (with omental flap of the pelvic cavity) or to remaining rectum is transected immediately
perform a pull-through of the colon and redo below the leaking anastomosis. Often, this can be
coloanal anastomosis. Redo coloanal anastomo- done using the TAMIS port, particularly in male
sis is often a reasonable option for the fit and patients, whereby the anal canal is long and the
motivated patients who want to invest time and anastomosis is difficult to expose using conven-
effort to restore continuity. tional specula.
Notwithstanding, even for fit and motivated With the TAMIS technique, diathermy monop-
patients, such intervention can be quite arduous, olar hook electrocautery is used to transect the rec-
for a few reasons. First, the pull-through of the tum directly below the coloanal/colorectal
afferent colon must be possible. The pelvic organs anastomosis. It is important to find the plane of
(e.g., vagina and prostate) can be displaced poste- dissection along the neorectum (Fig. 20.18). When
riorly in such a way that the pull-through is not in doubt, one can stay close to the neorectum
technically possible. Second, there is no guaran- avoiding damage to the autonomic nerves, venous
tee that the newly created anastomosis will heal, plexus, urethra, and ureters. Obviously, this can be
as obviously a recurrent leak can recur. Finally, if done without any oncologic compromise. The dis-
the stoma can be closed, provided the anastomo- section proceeds cephalad as far as possible. If the
sis is healed, the function of the neorectum is bottom-up dissection has reached the peritoneal
unpredictable, and there is a high chance of hav- cavity anteriorly, then the most difficult part, com-
ing a low anterior resection syndrome [25]. ing from the top, has already been completed.
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].
Miscellaneous Procedures
In all procedures where there is difficulty to enter

the pelvic cavity due to (inflammatory) adhe-
sions, collapsed pelvis after prior rectal resection,
radiation therapy, endometriosis, and other con-
founding factors, the TAMIS platform is very
suitable to start the dissection along virgin opera-
tive planes, bottom-up, as this can help to facili-
tate the top-down dissection.
(a) Hartmann’s closure. Mostly, the rectal stump

is of sufficient length to localize its apex.
This is often the case if the Hartmann’s pouch
had been constructed secondary to compli-
cated diverticulitis. Hartmann’s closure of
dismantled low anterior anastomosis because
of leakage is much more difficult, however. Fig. 20.19 Posteriorly displaced prostate and bladder
after breakdown leaking low anastomosis. Top-down dis-
The rectal stump is often short (usually section toward the anus is very difficult
<10 cm), and sometimes the apex of the rec-
tal cuff is not healed and is in continuity with
a chronic septic cavity. Under both circum- as opposed to the top-down dissection where
stances, the rectal stump can be plastered antecedent surgery and/or radiation therapy
with densely adherent small bowel, the blad- might have occluded the pelvis, causing the
der, or even the posterior vaginal wall. If the anatomic approach to be hazardous
stump is really short (<7 cm), then the pros- (Figs. 20.20 and 20.21). Another possibility
tate of vagina can be displaced posteriorly. is to insert the TAMIS port in the vagina, to
Finding the correct plane toward the rectal perform a very precise excision of the fis-
stump from above can, in this setting, be tula – a technique termed VAMIS [27].
extremely difficult, and TAMIS-based tech- (b) Perforation of the Rectum
niques can be very helpful in finding the TAMIS is very useful modality to close fresh
proper planes (Fig. 20.19). perforations of the rectum up to 15 cm from
Even if a safe rendezvous is reached by the anal verge, regardless of the etiology. In
simultaneously operating bottom-up and top- case of old perforations (>2 weeks), the cav-
down, the passage toward the anus behind ity might need to be cleaned first (typically
the prostate or vagina can be very narrow with the aid of an Endo-SPONGE) after
making even passage of the colon loop to the diversion with a loop ileostomy before
anus very difficult. Lateral lysis of the poste- embarking on TAMIS-assisted closure.
riorly displaced prostate or vagina can be
done more safely via TAMIS; and this is
detailed on the chapter entitled taTME as a Final Remarks
Technique for Hartmann’s Reversal.
Colovaginal Fistula The TAMIS approach for benign pelvic pathol-
TAMIS can be very helpful in the takedown ogy might become even more important than the
of a colovaginal fistula, whereby a bottom-up application of TAMIS for rectal cancer (taTME).
dissection is performed in an untouched, There are no competing techniques for this (such
uninflamed area where it is much safer and as robotics). Except in rare circumstances, there
easier to define the proper dissection planes, are no oncologic concerns with the TAMIS
214 W. A. Bemelman
Fig. 20.20 (Left) Anastomotic defect with connection to the vagina. (Right) Endoscopically, the portion is visualized
via the anastomotic defect
total mesorectal excision: international registry results

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Operating Theater Setup
and Two-Team Coordination 21
Aimee E. Gough, Phillip R. Fleshner,
and Karen N. Zaghiyan
Introduction hinder uptake of a two-team approach, this

remains our preference for a successful taTME. In
Transanal total mesorectal excision (taTME) has this chapter, we will outline our operative room
emerged as a safe and feasible minimally inva- setup and two-team coordination for taTME as it
sive approach to overcome some of the pitfalls of is applied to malignant and benign disease.
traditional transabdominal TME [1–3]. Potential
advantages of taTME include improved access to
the mid and distal rectum, improved precision of Operating Theater Setup
the distal rectal transection, omission of multiple
staple firings of the distal rectum, and opportu- Since the operating theater setup for taTME
nity for transanal specimen extraction [4]. While requires two instrument sets as well as two sets of
taTME was initially described for cancer, the laparoscopic cameras with monitors and insuffla-
procedure has also been extended to benign dis- tion setup, we recommend performing taTME in
ease. The most common indication for proctec- a large operating room to facilitate the circulation
tomy in benign disease is ulcerative colitis of personnel and accommodate the setup of nec-
requiring total proctocolectomy and ileal pouch- essary equipment (Table 21.1).
anal anastomosis (IPAA). The taTME technique The operating table is positioned for modified
has been carried over to IPAA surgery [5, 6] with lithotomy with anesthesia setup at the patient’s
early reports of transanal IPAA (taIPAA) sug- head. Convoluted foam is used to provide pad-
gesting feasibility and safety [7] with potentially ding and prevent patient movement during posi-
lower morbidity compared with transabdominal tioning in extreme Trendelenburg and table tilt
minimally invasive IPAA [8]. position (Fig. 21.1). The back table for the
Both single-team [9] and two-team taTME abdominal dissection is positioned just lateral
[10, 11] have been described with similar safety and beyond the patient’s right leg (Fig. 21.2). The
profiles [3]. However, advantages of a two-team abdominal team generally stands on the patient’s
approach include reduced operative times and right side during laparoscopic portions of the
reduced conversion to open surgery [11]. While case with their video and insufflation tower
difficulties with dual surgeon availability may directly across from them near the patient’s left
hip (Figs. 21.2 and 21.3).
The transanal back table is placed beyond the
A. E. Gough · P. R. Fleshner · K. N. Zaghiyan (*) patient’s left leg (Fig. 21.2). The transanal team is
Cedars-Sinai Medical Center, Division of Colon & seated between the patient’s legs (Fig. 21.3) and
Rectal Surgery, Los Angeles, CA, USA

218 A. E. Gough et al.
Table 21.1 Equipment suggested for two-team taTME approach

Equipment Abdominal dissection Transanal dissection
Instrument tray Standard laparoscopic 1. Minor instrument tray
2. Single laparoscopic grasper
3. Lone Star® disposable retractor ring
(14.1 cm × 14.1 cm) and eight 5 mm sharp stay hooksa
Laparoscope Standard 30 degree 10 mm scopeb 3D 10 mm scope with articulating tipc
Monitor Standard 3D compatible
Insufflation Standard insufflation Continuous insufflation platformd
Trocars Option 1: two 10 mm and two Soft disposable transanal access platformg and 12 mm
5 mm trocarse AirSeal® trocar
Option 2: single-incision platformf
Energy device Advanced energy deviceh Energy device with combination suction and hook cauteryi
Rectal None Option 1 (stapled anastomosis)
anastomosis 29 mm EEA staplerj
0-Prolene suture x 2
Option 2 (hand-sewn)
seven 2–0 chromic sutures on SH needle
Endoscope Adult flexible sigmoidoscope
a
Lone Star® Retractor System, CooperSurgical, Inc. Trumbull, CT, USA
b
ENDOEYE II 10 mm, 30°, rigid video laparoscope, Olympus, Center Valley, PA, USA
c
ENDOEYE FLEX 10 mm articulating tip video laparoscope, Olympus, Center Valley, PA, USA
d
AirSeal®, Conmed Inc., Utica, NY, USA
e
Laparoscopic trocars rounded tip with balloon, Applied Medical Inc., Rancho Santa Margarita, CA, USA
f
GelPOINT® Mini Advanced Access Platform, Applied Medical Inc., Rancho Santa Margarita, CA, USA
g
GelPOINT® Path Transanal Access Platform (4 × 5.5 cm), Applied Medical Inc., Rancho Santa Margarita, CA, USA
h
LigaSure™, Medtronic Inc., Minneapolis, MN, USA
i
Endopath® Probe Plus II, Ethicon Inc. Somerville, NJ, USA
j
CDH29A 29 mm circular stapler; Ethicon Inc., Somerville, NJ, USA
Video
2
A1
Video
S1 1
Ba
ck
Ta
bl
e
A2 S2
Back Table
S Surgeon
A Assistant
Fig. 21.2 Operating theater schematic demonstrating

surgeon positioning, video tower, and back table setup for
abdominal and transanal teams
Fig. 21.1 Operating table setup with foam padding to

prevent patient falls in taTME surgery
21 Operating Theater Setup and Two-Team Coordination 219
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.
wo-Team Coordination: Low

T
Patient Preparation and Positioning Anterior Resection
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
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-
ransanal Team: Rectal Transection

T
and Mobilization
The beginning portions of the transanal dissec-

tion are performed simultaneously with the
abdominal team mobilization of the sigmoid and
descending colon (Fig. 21.7). Digital rectal
examination and, if needed, flexible sigmoidos-
copy are performed to confirm the location of the
tumor and distance from the anal verge. Prior to
colonic insufflation, the abdominal team is asked
to occlude the sigmoid colon with an atraumatic
bowel grasper to prevent insufflation of the entire
Fig. 21.5 AirSeal® iFS insufflation management system
placed lateral to the patient’s left leg between the transanal colon and the position of the tumor is verified
back table and the abdominal team’s laparoscopic tower. endoscopically. If the distal purse string is to be
The cords for the transanal setup passed over the patient’s placed endoscopically (for tumors in the upper
left leg rectum), the colon must remain occluded from
above until the purse string is secured. First, a
Lone Star® Retractor (CooperSurgical, Inc.,
Trumbull, CT, USA) is placed, and the
GelPOINT® Path Transanal Access Platform
(4 × 5.5 cm) (Applied Medical Inc., Rancho
Santa Margarita, CA, USA) is inserted and insuf-
flated using AirSeal® (Conmed Inc., Utica, NY,
USA). Alternatively, for low-mid-rectal tumors,
the purse string may be placed directly through
the GelPOINT® (aka TAMIS port) with the gel
cap removed or an intersphincteric dissection can
be performed, as predicated by tumor level. In
this case, the abdominal team can un-occlude the
colon and continue their dissection. Once the
purse string is performed, the GelPOINT® path
transanal access platform is capped and pneu-
morectum achieved at 12 mmHg using AirSeal®
(Conmed Inc., Utica, NY, USA). At this point, it
is important to ask the abdominal surgeons to
also turn insufflation to ≤12 mmHg to prevent
competing pressures.
The rectum is transected full thickness at a 90°
angle with the bowel wall circumferentially using
Fig. 21.6 GelPOINT® Mini placed at future ileostomy
site as single-site access for abdominal dissection electrocautery; at our center, the Endopath® Probe
Plus hook (Ethicon Inc., Somerville, NJ, USA) is
nally, the transanal team is also beginning their utilized. Next, the dissection is advanced cephalad
work (Fig. 21.7). However, when the splenic flex- toward the peritoneal cavity. When the abdominal
ure mobilization is begun, the transanal dissec- dissection has reached the point of splenic flexure
tion must halt temporarily, due to limitations mobilization, the transanal dissection must be
imposed by table positioning during this portion temporarily interrupted due to positioning of the
of the operation. patient in reverse Trendelenburg position.
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)
bdominal Team: Splenic Flexure

A retract the rectum upward as the transanal team
and Upper Rectal Mobilization continues to progress in their dissection toward
the rendezvous (Fig. 21.8).
After splenic flexure mobilization, during which
time only the abdominal team can work, the table
position is again changed to Trendelenburg and Both Teams: The Rendezvous
the abdominal team begins the upper TME dis-
section. The amount of dissection performed The anterior plane is typically an easier point to
from above is dependent on many factors enter into the peritoneal cavity from below; how-
including surgeon preference and difficulty of the ever sometimes if the posterior dissection is fur-
abdominal and transanal dissections. The lateral ther ahead or if the anterior dissection is
stalks can be divided and anterior peritoneal challenging, then posterior rendezvous is possi-
reflection opened to assist in meeting of the two ble and can be helpful as well. Once the rendez-
planes. At this time, the abdominal team can also vous has occurred, the abdominal team can help
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.
ransanal Team: Specimen Extraction

T Two-Team Coordination: Total
and Anastomosis Proctocolectomy with Ileal Pouch-
Anal Anastomosis
In the case of transanal extraction, the access
channel is removed and the entire rectum and sig- Abdominal Team: Laparoscopic
moid colon is eviscerated through the anus. If Colectomy and Assessment
available, fluorescence imaging can help guide of Pouch Reach
the proximal transection point. Otherwise, the
proximal transection is made using electrocau- Transanal Ileal pouch-anal anastomosis also uses
tery proximal to the IMA pedicle. an abdominal team and a transanal team, each
The anastomosis is then performed entirely with a surgeon and an assistant. The operating
transanally. Either a stapled, double purse- room setup is unchanged from the description
string anastomosis can be chosen, or the colon above. The abdominal colectomy is first per-
can be hand-sewn to the rectal cuff. In a double formed by the abdominal team through a
purse-string anastomosis, when the transanal single-
port access system (GelPOINT® Mini
team is placing the distal purse string, the Advanced Access Platform, Applied Medical Inc.,
abdominal operator can place the camera into Rancho Santa Margarita, CA, USA) prepared
the pelvis to visualize the suturing of the distal with three 10 mm cannulas widely spaced in a tri-
rectum to assure full-thickness bites are taken angle through the gel cap. An additional 5 mm
and extra-rectal tissue is not incorporated into port is placed at the suprapubic position to assist
the purse-string suture. Prior to closure of the in the dissection and tissue triangulation. After
distal purse string, the abdominal operator con- complete colonic mobilization and mesenteric
firms that the colon and mesentery lay straight division with preservation of the ileocolic pedicle,
across the retroperitoneum and that no small the small bowel and its mesentery are assessed for
bowel loops are caught under the colonic mes- length to ascertain pouch reach. If there appears to
entery. The two ends of the EEA are mated and be adequate length, the terminal ileum is tran-
the distal purse string is secured before closing sected laparoscopically with a stapling device
and firing the EEA stapler. The abdominal (Echelon Flex™ Powered Plus 60, Ethicon Inc.,
operator can maintain pneumoperitoneum at Somerville, NJ, USA), and the terminal ileal
this point to assess for a “reverse” air leak by attachments to the level of the duodenal sweep are
having the taTME surgeon (bottom team) check mobilized. During this dissection, the patient
for air escaping into the lumen through defects position is continuously changing as is the posi-
in the staple line. If present, this can be over- tion of the surgeons across the operating table pre-
sewn transanally. If a hand-sewn anastomosis is cluding any transanal work. Once the terminal
preferred, it can be performed directly to the ileum is mobilized, it is exteriorized through the
cut edge of the rectal cuff using interrupted 2–0 GelPOINT® Mini and ileal pouch created. At this
chromic sutures. A 0.25 inch Penrose drain is point the transanal team may also commence
placed transanally. proctectomy.
While the transanal team begins the proctec-
tomy, the abdominal team may create the ileal
bdominal Team: TAP Block
A pouch per standard fashion through the ileostomy
and Ileostomy Creation site. The pouch apex is secured by placing a
betadine-soaked gauze into the pouch and secur-
While the transanal team is performing the anas- ing it with 2–0 Prolene purse-string suture to pre-
tomosis, the abdominal team performs a laparo- vent spillage of bowel contents. This suture also
scopic transversus abdominis plane (TAP) block acts as a handle for pouch manipulation. The
[12], places a pelvic drain through a 5 mm port pouch is then reinserted into the abdomen and
site, and creates the diverting loop ileostomy. laparoscopy commenced.
ransanal Team: Transanal

T transanally followed by transanal specimen
Proctectomy removal. A laparotomy pad is placed in the anus
to allow abdominal insufflation with the trans-
Once adequate pouch reach is assured, the transanal access channel removed. The abdominal
anal team begins as in the previous section. The team then orients the pouch, places it at the pelvic
patient is positioned in Trendelenburg position. brim, and retracts the pelvic organs to allow the
The Lone Star® Retractor and GelPOINT® path pouch to be grasped and delivered down to the
access channel are placed. Working directly anus by the transanal team.
through the access channel, the purse string is The transanal surgeon delivers a ring forcep
placed above the edge of the access channel. The alongside the laparotomy pad and, using the lapa-
GelPOINT® is capped and AirSeal® insufflation roscopic monitor as a guide, grasps the pouch
begun at 12 mmHg. At this time, if the abdominal and gently delivers it toward the anus. The level
team is also working laparoscopically, they are of the anastomosis and residual mucosa retained
asked to also turn their abdominal insufflation can now be tailored to pouch reach. A hand-sewn
pressure ≤12 mmHg to avoid pressure mismatch. or double purse-string anastomosis can be cho-
However, if the abdominal team is still working sen. While the transanal team is working on the
open through the GelPOINT® Mini to create the anastomosis, the abdominal team places a drain
pouch, transanal insufflation can create a vacuum (optional), performs a laparoscopic TAP block,
effect in the de-insufflated abdomen. Thus, lower and creates a diverting loop ileostomy.
transanal AirSeal® pressures (8 mmHg or lower)
may be necessary to maintain visibility and avoid
suctioning of the rectum upward into the abdo- Perfecting the Two-Team Approach
men. The rectal wall is scored and transected
1 cm distal to the purse-string closure, and the One of the largest challenges but also most
taTME dissection proceeds. Dissection is carried advantageous aspects of two-team taTME is the
cephalad toward the abdominal operator. transanal-abdominal rendezvous. As the dissec-
tions continue toward each other, coordination
between teams so that the same quadrant is being
bdominal Team: Upper Rectal
A worked on can be helpful. Furthermore, as more
Mobilization of the rectum is mobilized, it can occlude the
transanal view. During this critical time, it is
After creation of the pouch and re-insufflation of often advantageous to have the abdominal team
the peritoneal cavity, the upper rectum is mobilized pull up on the rectum to allow it to straighten out,
by dividing the superior hemorrhoidal artery near providing more working room for the transanal
the rectal wall to avoid hypogastric nerve injury. team. Attempting to maintain a circumferential
The presacral space is entered and dissection car- transanal dissection so as to allow only a thin ring
ried out along the TME plane. A 5 mm suprapubic of tissue to remain prior to rendezvous is most
port is helpful during this portion of the procedure ideal. When the transanal team proceeds too far
for anterior retraction of the pelvic organs. posteriorly, peritoneal entry can occur before the
anterior and other key portions of the taTME dis-
section have been completed. This can result in
ransanal Team/Abdominal Team:
T spillage of air and fluid from the abdominal dis-
Bringing Down the Pouch, section obscuring the transanal view.
Anastomosis, and Final Steps However, when the rendezvous is reached, the
two teams must work together to completely dis-
At the point of top and bottom rendezvous, the mount the rectum. The abdominal team can ini-
paired teams can work together to dismount the tially pull up on the rectum and provide anterior
rectum. The pelvis is irrigated and fluid drained retraction using a fan retractor through the 5 mm
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
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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.
11. Koedam TWA, et al. Transanal total mesorectal exci- colorectal surgery. Dis Colon Rectum. 2019;62(2):
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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
Introduction seen the introduction of local excision endoscop-

ically and transanally [4]. Selection of the opti-
The management of rectal cancer has evolved mal surgical approach for rectal cancer depends
rapidly over the last four decades. Clearly, the on intricate considerations including tumor and
contribution with the highest impact in the evolu- patient characteristics, skills and expertise of the
tion of the surgical therapy of rectal cancer was surgical team, and resources available to the
the description of the mesorectal plane by institution.
Professor RJ Heald in the early 1980s [1]. In many instances the introduction of new
Multiple advances have been made focusing on technology/procedures lacks robust evidence to
enhancing outcomes while trying to minimize the support their implementation; therefore it should
invasiveness of surgical therapy. There is a broad follow a careful and monitored process in order
range of approaches in rectal cancer – from the to prevent unnecessary harm to patients; this is
traditional open surgical excision of the rectum relevant for any innovative surgery, but it is cer-
and mesorectum extending to the novel “watch tainly of paramount importance in the single-
and wait” non-operative management pioneered surgeon TaTME setting [5].
by Angelita Habr-Gama [2]. Transanal total mesorectal excision (taTME)
In recent decades, there have been significant has recently been introduced to the surgical com-
improvements to surgical techniques with the munity as a surgical approach which enables the
introduction of a minimally invasive or laparo- surgeon to excise the mesorectum in a minimally
scopic approach. Minimal invasion has been fur- invasive approach while providing excellent
ther modified with the introduction of visualization of pelvic structures and the meso-
robotic-assisted surgery [3]. The past decade has rectal fascia [6]. Some of the benefits touted by
taTME advocates are enhanced visualization,
perpendicular division of the rectum, and poten-
A. Caycedo-Marulanda (*) · G. W. Ma tial for increased preservation of distal rectum.
Health Sciences North, Department of Surgery, The literature on this approach is rapidly
Sudbury, ON, Canada
emerging with most experience focused on the
Colorectal Surgery North, Sudbury, ON, Canada two-team, or Cecil, approach [7, 8]. There have
been several select centers which have published
S. Ashamalla their experience with a single-team (or single sur-
Odette Cancer Centre, Toronto, ON, Canada
geon) approach [9, 10]. The description and early
Sunnybrook Health Sciences Centre, Department results of the single team demonstrate that such
of General Surgery, Toronto, ON, Canada

230 A. Caycedo-Marulanda et al.
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
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
Excellent training courses exist to introduce a sur-

Patient Consent geon to the taTME technique. The major benefit
of these programs is the opportunity to learn the
Patient consent should be transparent and inten- fundamentals of this complex operation and gain
tional [23]. The explanation of the taTME should cadaveric-based, hands-on experience. Recent
be clear and concise, and it is of great importance publications have focused on the inadequacy of a
to clarify that it is a novel approach to an existing single, 1- or 2-day training course in providing
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
Fig. 22.1 Assistant
on top
Fig. 22.2 Nurse setting up
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).
Fig. 22.3 Nurse holding camera Fig. 22.4 Extreme position
Equipment novice assistant. This is because gravity alone

keeps the otherwise view- obstructing loops of
The type of equipment used in a single-surgeon small bowel free from the pelvis during abdomi-
setting is not different than what is used during nal and transanal dissection.
dual-team approach. There is a need to have two In our experience a regular insufflator at the
laparoscopic towers, one for the top and one for top is sufficient. We have implemented the
the bottom. The generalities regarding the equip- Synergy® LEXION insufflation ports, which
ment for taTME have been previously discussed eliminate the issues that were initially encoun-
in this textbook; therefore we will limit our dis- tered with smoke during deep dissection in the
cussion to a few specifics that are essential for the pelvis. For the transanal dissection, it is crucial to
single-surgeon approach. prevent billowing which is common with the use
It is important to have a system device that of regular insufflators; we have found it useful to
keeps the patient secured to the operating table incorporate the AirSeal® IFS which can dramati-
preventing him/her from sliding down or falling cally improve the operative clarity of the trans-
off the table during the procedure while on anal approach by delivering a stable surgical
extreme positions, such as steep Trendelenburg space and allowing continuous visualization of
and/or lateral tilt (Fig. 22.4). There is no fixed rec- the field.
ommendation regarding what specific system
should be used. At our institution, we use the Pink
Pad (Pigazzi Patient Positioning System™) for its Equipment Setup for a Single Team
safety, versatility, and ease of use. For a single
surgeon, this device allows steep Trendelenburg As discussed previously, the setup of equipment
position facilitating pelvic dissection, even with a for a taTME is a complex process that requires
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.
Fig. 22.5 Room setup
The instrument table and scrub nurse should be The Procedure

positioned on the patient’s left side. With this
initial setup, the transabdominal component of Where to Start
the operation can begin.
The transanal component setup consists the It is recommended to start the operation from the
second laparoscopic tower setup above the abdomen. Valid rationale for this includes the
patient’s right shoulder and in front of the energy ability to survey the abdominopelvic cavity so as
source of the abdominal component. The monitor to exclude carcinomatosis or other unforeseen
for this tower is positioned directly in the midline findings which would otherwise preclude radical
over the patient’s head. The light and camera resection. Another reason this “top-first”
cords to this tower should be placed along the approach is preferred by experts especially for
patient’s right side going down to the transanal single-team taTME is to familiarize the first
field. The cautery and energy source for the trans- assistant with the anatomy and countertraction to
anal component should be positioned by the enable transanal dissection when the single sur-
patient’s left leg. If there is an additional free- geon goes to the bottom to complete the taTME
standing insufflator, it too should be positioned dissection.
by the patient’s left leg. The instrument tray and
scrub nurse for the transanal component should
be positioned on the patient’s left side adjacent to Transabdominal Approach
the left leg.
As a single surgeon, it is imperative that the The operation is initiated laparoscopically with
nursing team understands the setup such that the the surgeon on the patient’s right side and the
setup for the second component of the operation assistant on the patient’s left side. Once access is
can occur while the first component is obtained via a Hasson entry at the umbilicus, 3
underway. additional 5 mm ports are inserted (Fig. 22.6).
Fig. 22.6 Port Port placement

placement
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:
• Placement of the transanal platform including ystematic Approach to Single-

S
air insufflation setup Surgeon taTME
• Placement of purse string to close the rectum
below the lesion The operation is conducted sequentially using a
• Washout of the distal rectal stump regular laparoscopic technique; the steps have
• Rectotomy circumferentially into the TME been previously reported [35] and are summa-
plane rized below:
• Transanal TME until circumferential commu-
nication with abdominal component 1. Positioning (proper padding and security
• Continued dissection of TME until it is either strap for steep Trendelenburg to facilitate
complete or it becomes excessively challeng- pelvic dissection without the help of a sec-
ing in which case convert back to transabdom- ond surgeon)
inal component to complete final TME 2. Adjunctive monitoring (Foley catheter, arte-
attachments rial line, bilateral IV access) and ERAS
protocol
A bilateral pudendal nerve block using local 3. Single-surgeon abdominal component
anesthetic is performed. This helps relax the anal (transabdominal laparoscopic dissection to
sphincter for effacement of the anus, facilitating level of peritoneal reflection)
introduction of the TAMIS access channel. The 4. Recognition of transition point (below peri-
Lone Star® Retractor (Cooper Surgical) can be toneal reflection, prior to acute angulation of
used in combination with the TAMIS platform. rectum)
Alternatively, particularly with obese patients, 5. Single-surgeon perineal component (peri-
the anal canal can be effaced by placing tempo- neal retractor to efface anus, insertion of
rary interrupted 2-0 sutures in the four quadrants platform, identification, and purse string of
which encompass the top of the anal sphincter, distal margin)
the anal verge, and the perineal skin. These steps 6. Sterilization of perineal field (generous
facilitate the introduction of the transanal washout with antibacterial agent)
platform. 7. Recognition of full-thickness proctotomy
Once the platform is introduced, it can be 8. Constant reassessment for the identification
secured with silk stitches or in some cases with of “safe” anterior and posterior planes
the stays of the Lone Star Retractor. Once it is 9. Recognition and preservation of critical neu-
secured, the subsequent step is to place the purse rovascular structures
string, and this is then followed by cleansing with 10. Rendezvous transition point (abdominal

povidone and washing abundantly with sterile retraction by surgical assistant) to facilitate
water. circumferential dissection
Circumferential incision of the rectum is per- 11. Meticulous hemostasis and extraction plan
formed, until full division is achieved. (transanal vs transabdominal)
In the single-surgeon setting, it is important to 12. Reconstruction
be prepared to revert to the transabdominal
approach in order to complete the circumferential
detachment. Eventually, the surgeon will then When to Transition to the Bottom
return to the transanal component in order to
complete the anastomosis and may need to sub- As opposed to the two-team approach, in which
sequently go back to the transabdominal compo- the team can be conducting the transabdominal
nent to confirm colonic orientation and create a TME dissection simultaneous with the team con-
diverting loop ileostomy if indicated. ducting the taTME, the single-team approach can
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.
Rendezvous: Meeting of the Planes

Top-to-Bottom Transfers
The rendezvous time and the circumferential dis-
section are slightly different for the single- A caveat for the single-team approach is the need
surgeon approach. In a two-team setting, both to alternate between top and bottom at least once
surgeons are dissecting in synchrony, providing and more typically twice during the operation;
retraction and exposure to one another. In the this means having to change gowns and gloves at
single-surgeon scenario, it is possible to replicate those times, but this can still be done efficiently
these retraction and exposure components; how- by a team that has planned accordingly.
As the transanal approach is begun, it is bottom position changes to maximize operative

important to ensure the space for the surgeon and efficiency. In order to do this, all of the steps that
assistant at the patient’s left and right side for the can be performed at that given time should be
transabdominal approach is maintained and not performed. It is also valuable to select the seg-
filled in with equipment. The surgeon should ment of bowel that would be used for the creation
have no reservation about transferring back and of the loop ileostomy, when planned diversion is
forth to complete the taTME dissection. part of the operative plan. The selected loop is
After the purse string and rectotomy are com- marked with electrocautery in order to identify
plete and the TME is begun from the bottom afferent and efferent limbs and should be held
upward, dissection is carried cephalad. In most with a locking grasper for future exteriorization.
cases this will be continued until the communica- When ready for the anastomosis, the surgeon
tion is made between the two fields and the rec- must go back to the bottom and recover the bowel
tum is liberated. If extreme difficulty arises through the anal canal in a pull-through fashion
during taTME, reverting to the top should be an for reconstruction. During this section, the input
easy decision. The team likely will find the of the assistant from the top is very important,
remainder of the TME quite straightforward as emphasizing that the assistant must be able to
the distal margin and the very distal TME has function at the same level of a surgical resident
been completed. for key portions of single-team taTME (such as
anastomotic construction). In the single-surgeon
setting, recommendations for reconstruction
Managing Difficult Dissection (hand sewn or stapled) are not different than the
usual considerations for rectal cancer surgery,
In the single-team taTME setting, the surgeon and the decision algorithm includes tumor
must utilize both surgical fields as needed. The location in relation to the sphincter, patient’s age,
two-team approach naturally lends itself to the preference, and predicted functional outcome.
easier dissection with synchronous and thus
faster TME dissection times until the fields meet.
However, when only one surgeon is switching Auditing Your Results
between the fields, she/he must use their discre-
tion to ensure they are always pursuing the most Regardless of which approach one is using, either
straightforward dissection (up to down versus single or double team, it is imperative to keep a
down to up). record of all the procedures and the short- and
long-term outcomes. To ensure quality, auditing
results is a must for innovative and disruptive tech-
xtracting the Specimen
E nologies such as taTME; currently there exist two
and Creating the Anastomosis main international registries in which surgeons can
enroll their patients. They are the Pelican Cancer
Once the rectal dissection is completed, a Foundation (Europe) and Ostrich Consortium
Pfannenstiel incision can be used for extraction (United States and Canada); the direct website
in individuals with narrow pelvises or bulky links to patient enrollment are as follows:
specimens. Using a wound protector in this set-
ting is invaluable. If the anal canal is patulous and https://tatme.medicaldata.eu/
the mesenteric envelope is relatively narrow, https://tatme.ostrichconsortium.org
transanal extraction can be considered.
With single-team taTME, the surgeon rescrubs As with many surgical interventions, keeping
and returns to the top for the creation of the a logbook of surgical and oncological outcomes
Pfannenstiel incision, extraction, deployment of is recommended. The aforementioned is crucial
the anvil, and closure of the incision. It is benefi- to ensure any taTME program runs safely and
cial to decrease the number of surgeon top-to- successfully and also permits both surgeon and
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
Introduction plane [14]. A magnified view and pneumatic dis-

section exposes the embryonic fusion planes of
In the last 20 years, drawing inspiration from dissection with preservation of the lateral and
transanal endoscopic microsurgery (TEM) [1], posterior sacral autonomic nerve plexi. The spec-
natural orifice transluminal endoscopic surgery imen can then be removed transanally, avoiding
(NOTES) [2, 3], and natural orifice site extrac- enlarging the abdominal trocar scar or perform-
tion (NOSE) [4], attention from surgeon innova- ing a supplementary abdominal incision, with
tors as well as research and development has consequent reduces abdominal wall access
been refocused on the refinement of transanal trauma and thus the risk of postoperative inci-
endoscopic techniques [5–7]. This led to the sional hernia formation. However, the technique
development of transanal minimally invasive sur- is challenging, and a relatively steep learning
gery (TAMIS) by Atallah et al. in 2009 [8]. curve is required to gain proficiency [15–17].
TAMIS represents an innovative modification of Additional applications of TAMIS include the
conventional laparoscopy, one which adapts the resection of endoluminal benign rectal lesions or
instrumentation and optical scopes of abdominal early-stage rectal adenocarcinoma [18, 19] and
laparoscopy for procedures performed via natural treatment of colorectal anastomotic complica-
orifice access [7]. tions such as leak and fistula [20, 21], bleeding
TAMIS was initially developed for the local [22], and stenosis [23]. TAMIS and taTME can
excision of benign and well-selected neoplasia of be performed adopting various transanal plat-
the rectum, but as progress in advanced transanal forms and instruments. In this chapter, the differ-
surgery continued, it became apparent that the ent characteristics of these platforms are
versatility of the TAMIS platform was well suited discussed.
for transanal total mesorectal excision (taTME)
[9–13]. taTME has multiple theoretical advan-
tages, including the ability to precisely define the Platform Options
distal margin, thereby initiating the dissection
inferior to this point, to reveal the so-called holy Different transanal platforms are nowadays avail-
able for advanced transanal surgery, most of
G. Dapri (*) which have only emerged over the past decade.
Saint-Pierre University Hospital, European School There are multiple nuances of these platforms
of Laparoscopic Surgery, Department of and important differences and similarities as
Gastrointestinal Surgery, Brussels, Belgium well. For simplicity, they can be classified into

246 G. 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
diameter of the flexible system (its working

head) is 28 mm. This hybrid system is part
flexible and part rigid. The access channel is
similar in design to a rigid TEM scope, with
inner diameter measuring 40 mm. This reus-
able, rigid access channel is also bedrail
mounted. The flexible working head that is
navigated through a robotic-assisted console
by the surgeon is disposable and designed
for single use.
ransanal Rigid and Semirigid

T
Platforms (TEM Based)
Transanal endoscopic microsurgery (TEM) was

developed by Gerhard Buess in 1983 [1]. Until the Fig. 23.5 Transanal endoscopic operation (TEO) system
(Karl Storz Endoskope, Tuttlingen, Germany)
advent of TAMIS [7], TEM was the gold-standard
in advanced transanal surgery. Currently, there are
a variety of rigid, reusable platforms available, all and design to the TEM scope. It is formed
of which are predicated upon the original design by three parts: the access channel with its
by Buess. Some surgeons prefer to perform local holding arm, the obturator, and the metal
excision and taTME utilizing these platforms, cap or faceplate used as a point of access
rather than using the TAMIS platforms. Based on for surgical instrumentation and for gen-
available data, the quality of excision achieved eral access to the operative field. The hold-
with advanced transanal platforms appears to be ing (Martin) arm contains a connector for
equivalent [28]. Of note, for local excision of vapor evacuation. The access channel is
lesions, it is typically recommended that the available in three lengths: 7.5 cm, 15 cm,
patient be positioned such that the lesion is depen- and 20 cm. The cap is formed by four port
dent. For example, for a mid-anterior lesion of the orifices, where one is filled up by the scope,
rectum, the patient should be positioned prone with its lavage. Different operative instru-
jackknife. In contrast to this, for local excision ments from 3 mm to 14 mm can be
with the TAMIS technique, the patient is most introduced.
often positioned dorsal lithotomy and not based (B) The reusable Wolf TEM system (Richard
on lesion locale. Notwithstanding, for taTME, Wolf GmbH, Knittlingen, Germany)
both rigid and flexible systems are used with the (Fig. 23.6) was the original system designed
patient in modified lithotomy. In addition, the and develop by Gerhard Buess in the early
two-team approach is a valid option regardless of 1980s. It is a fixed arm platform with the
platform type. option to work by the telescope plus camera
as well as by a binocular, stereoscopic view
alone. The optics can be cleaned by an
Rigid Platforms accessory tube for the lavage. Out of the
optical view orifices, three other port orifices
(A) The transanal endoscopic operation (TEO) are in the cap to allow the introduction of the
system (Karl Storz Endoskope, Tuttlingen, 5 mm working instruments. The access
Germany) (Fig. 23.5) was developed in the channel is available in three lengths: 12 cm,
mid-2000s and is quite similar in principle 13.7 cm, and 20 cm.
Semirigid Platforms angulation of general laparoscopy – which is

(TEM/TAMIS Hybrid) to maintain the optical system in the center as
the bisector of the working triangulation

(A) The DAPRI Port or D-Port (Karl Storz formed by two ancillary tools [13] – with an
Endoskope, Tuttlingen, Germany) advanced transanal access platform. It is
(Fig. 23.7a–b) is a semirigid platform that was formed by three parts: a rigid tube, an obtura-
designed for advanced transanal surgery, tor, and a flexible cap. The tube is 30 mm
including for the application of taTME. This diameter and 7.5 cm length, facilitating its
platform has been developed based primarily introduction through the anal verge, and anal
on TAMIS. Unique to the D-Port design is that dilation prior to insertion is typically not
it merges the main principle of optics and tri- required. It allows the use of a center axis
positioned 10 mm scope and two 5 mm instru-
ments. An advantage of this port’s design is
that instrument tip clashing during the dissec-
tion is limited, and, when required, the process
of intraluminal suturing is facilitated.
Supported by two lock connectors, it per-
mits conventional insufflation of CO2 through
one connection and evacuation of the smoke
created by electrosurgery during dissection
through the second lock- connector outlet.
The D-Port is supported by four oval holes,
which allow the port to rotate, when neces-
sary, and to optimize transanal access. Finally,
four cardinal points are marked inside the
tube to orientate the surgeon during the differ-
ent steps of the procedure and to help the sur-
geon maintain a frame of reference.
The obturator is used for the introduction
of the shaft of the access channel through the
Fig. 23.6 Wolf TEM system (Richard Wolf GmbH, anal verge, and it is removed before the silicon
Knittlingen, Germany)
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
The instruments implemented through the trans-

anal platforms can be conventional straight-shaft
instruments used for general laparoscopy,
Fig. 23.8 Silicon cap-modified TEO system (Karl Storz Fig. 23.9 BUESS instruments (Richard Wolf GmbH,
Endoskope, Tuttlingen, Germany) Knittlingen, Germany)
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)
Fig. 23.10 (a–b) TEO a

instruments (Karl Storz
Endoskope, Tuttlingen,
Germany): coagulating
hook (a) and needle b
holder (b)
252 G. Dapri
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)
Fig. 23.13 (a–h) Flex a e

Robotic instruments
(Medrobotics, Raynham,
Massachusetts, USA):
handle and shaft (a),
laser holder tip (b),
fenestrated grasper tip
(c), Maryland dissector b f
tip (d), scissors (e),
needle driver (f), spatula
(g), needle knife (h)
c g
d h
operative length is 24 cm. They’re inserted References

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Intraoperative Decision-Making:
Converting to taTME, When 24
and for Whom?
Isacco Montroni and Antonino Spinelli
Introduction nullified, or reduced to a minimum, allowing sur-

geons to complete their task in a minimally inva-
Converting from one approach to another always sive fashion promoting better outcomes for
comes as a tough pill to swallow. It is so for the complex patients. In sum, it is one of the few
surgeon, whose plans have to change while exceptions in which conversion is not to a more
accepting that the initially preferred strategy has invasive approach, but rather to an approach
failed. It also poses challenges for the operating which conserves minimally invasive principles.
room (OR) staff who must rapidly modify the Because of the extreme paucity of published
work setting in order to create the best possible material on this matter, the following chapter,
environment to complete the case. There are probably a first in itself, will be based on authors’
challenges for the hospital administration as well, personal experiences and from the limited avail-
since there is evidence that conversion increases able current scientific literature.
the intraoperative and postoperative costs of the
surgical process [1]. Most importantly, for the
patient, as in the vast majority of cases, convert- Anatomy of a Conversion
ing from a minimally invasive approach to open
surgery leads to worst short- and long-term out- By the Cambridge English Dictionary, “conver-
comes [2]. sion” means “the process of converting some-
With the introduction and adoption of trans- thing from one thing to another.” [3]. The word
anal total mesorectal excision (taTME), we may comes from Latin, conversiō/convertō, and it
assist, for the first time, at a situation when the was originally used to describe a change of
majority of those downsides can be potentially direction while turning toward something or
someone else. The concept was then adopted in
the religious field to signify a change in some-
I. Montroni one’s beliefs, while most American football lov-
Colorectal Surgery, AUSL- Romagna, Ospedale per ers became familiar with it as it’s used when an
gli Infermi- Faenza, Faenza, Italy extra point (or two) is scored by kicking a field
e-mail: [email protected] goal or carrying the ball into the end zone after
A. Spinelli (*) scoring a touchdown! Instead of a “touchdown,”
Division of Colon and Rectal Surgery, Humanitas in the medical field, conversion is equitable to
Clinical and Research Center, Milan, Italy
“failure” of one’s original approach and pursu-
Department of Biomedical Sciences, Humanitas ing something different, which is usually less
University, Milan, Italy

256 I. Montroni and A. 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
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-
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
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
• The ability to create a purse string while Conclusion

directly identifying the level of the lesion/gap.
• The possibility to perform a high-quality Modern rectal cancer care cannot be an extempo-
cancer operation since a “virgin” mesorectal rary attempt but needs to be planned and prepared
plane is entered from below without interfer- in advance. Nevertheless, finding unpredicted
ence by the gap at the level of the lesion. situations when a conversion is needed might
• The opportunity to perform a minimally occur to any colorectal surgeon. Above all, if
invasive restorative procedure while also considering conversion to taTME, this should be
exploiting the transanal equipment already performed preemptively rather than reactively,
in place. especially because specialized equipment is
• The lesion in the case turned out to be a necessary.
T3 N0 (0/23 lymph nodes, negative circum- The sense of conversion is to switch from one
ferential resection margins, extramural vas- approach to another in which the surgeon consid-
cular invasion negative), and despite the ers her/himself more proficient or familiar. Thus,
obvious higher risk of perforation, resection converting to taTME requires proficient taTME
was carried out in the same operation without surgeons.
delay, in an oncologically radical fashion via Converting from a laparoscopy/robotic
taTME. approach to a transanal one could potentially not
be a rare event given the recently published 10% 6. Jayne D, Pigazzi A, Marshall H, Croft J, Corrigan N,
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,
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
Introduction Under such pretext, transanal total mesorectal

excision (taTME) has emerged as a treatment
Modern gastrointestinal surgery has changed modality for rectal cancer [5, 6]. While TME sur-
notably with respect to surgical modality since gery is conventionally performed from the abdo-
the advent of endoscopic surgery. The introduc- men, taTME is performed in the reverse direction
tion of endoscopic surgery in rectal cancer treat- from the anus – i.e., the bottom-up approach.
ment has enabled “better visualization of Although the pelvic floor is the region most distal
structures that could not be seen with conven- from the abdomen and for which visibility and
tional techniques,” especially in the deep areas of dissection manipulations are difficult, the taTME
the narrow pelvic cavity. Good surgical operation approach has enabled a direct and close-up view
under magnified vision that was not possible with of this area – which is the technique’s major
laparotomy became possible. As a result, laparo- advantage.
scopic total mesorectal excision (TME) has now In clinical practice, this surgery has several
been standardized as a procedure for the treat- advantages that account for its potential useful-
ment of rectal cancer. Several randomized com- ness. In particular, the deep dissection layers
parative studies from around the world have close to the tumor can be selected, and autonomic
recently been published that have shown that nerves that should be left intact can be visualized.
compared to laparotomy, laparoscopic surgery Thus, an increased efficacy in curability and
for rectal cancer is associated with certain con- function preservation could be realized. Rectal
cerns regarding the technique’s application cancer surgery, originally established amidst var-
toward curative-intent rectal resection [1–4]. This ious constraints, is considered “a surgical proce-
shows that laparoscopic surgery is a complex sur- dure that is performed in the most distal area.”
gical procedure requiring good surgical skills. However, when approached from the opposite
Even when a magnified view is obtained under direction (as is the case with taTME), what was
laparoscopic assistance, one cannot deny that the distal most region becomes the most proxi-
restrictions remain in the manipulation of forceps mal. Thus, taTME is a surgical procedure with
and dissectors in the deep pelvic areas. vast possibilities. This chapter reviews the impor-
tant points on abdominal dissection while per-
forming taTME.
M. Ito (*)
National Cancer Center Hospital East, Department
of Colorectal Surgery, Kashiwa, Japan

264 M. Ito
ositioning of taTME in Abdominal

P Table 25.1 Above first or below first?
Maneuvers Above first Below first
Surgical field of Familiar Takes time to get
taTME is a surgical procedure whereby the criti- view used to
Difficulty of Difficult Comparatively
cal portions of dissection, particularly the distal
dissection in the easy
and mid-mesorectal excision, are performed from pelvis
the anal side. Abdominal detachment maneuvers Forceps Some Less restrictions
are usually performed from the abdominal side. operation in the restrictions
taTME can be performed by two methods, either pelvis
Understanding of Comparatively Occasionally
a two-team surgery whereby the abdominal
surgical anatomy easy difficult
maneuvers and perineal maneuvers are per- Evaluation of Possible Impossible
formed simultaneously, or as a single-team oper- intraperitoneal
ation, in which the abdominal maneuvers and tumor
perineal maneuvers are performed sequentially. progression
No touch Possible Difficult
In the two-team arrangement, abdominal maneu-
isolation
vers are performed simultaneously with the peri- Risk of the Rare Certain risk in
neal maneuvers; therefore, the perineal team urethral injury the lower rectum
performs the majority of the TME dissection. For Autonomic nerve Possible Better visibility
that reason, the tasks that the abdominal maneu- preservation of NVB and
PSN
vers team must handle are primarily vascular
Selection of As usual Possible
management and mobilization maneuvers from dissection plane selection depend
the sigmoid colon through to the splenic flexure. on tumor depth
On the other hand, in the single-team surgery,
the detachment maneuvers that must be per-
formed from the abdominal side are often slightly level of technical familiarity with dissection pro-
different depending on whether the intraperito- cedures from below. When there is no familiarity
neal maneuvers or perineal maneuvers take pre- with taTME procedures from the anal side, we
cedence. The advantages and disadvantages of would recommend collaborative surgical proce-
the intraperitoneal maneuvers taking precedence dures by a single-team or dual-team approach
and those when the perineal maneuvers take pre- whereby the abdominal portion of the operation
cedence in the single-team surgery are summa- takes precedence.
rized in Table 25.1.
Laparoscopic TME is a commonly performed
surgical procedure, and there are no notable ey Aspects for Performing TME
K
problems associated with the anatomical under- from the Abdominal Side
standing regarding the dissection procedures
from the abdominal side. However, the anatomi- nderstanding the Perirectal Fascia
U
cal understanding for dissection procedures from Structure
the perineal side is difficult, and such procedures
are not easy; therefore a certain amount of expe- A clear understanding of the perirectal fascia
rience and familiarity are essential for adeptly structure is necessary for performing procedures
performing taTME. When taTME is to be per- from the perineal side and even while performing
formed, each institution must decide whether to TME procedures from the abdominal side to
use the two-team or single-team approach and if avoid pitfalls. The mesorectal envelope, the thin
it is the single-team surgery, whether the abdomi- fascial layer that covers the rectum and surround-
nal procedures or perineal procedures would take ing fat, is the most important landmark while per-
precedence. Such choices must be decided based forming TME. The mesorectum is surrounded by
on the experience of the surgical team and the a layer of pre-hypogastric nerve fascia. Preserving
25 Key Aspects of the Abdominal Dissection 265
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
Sacrum NVB;Neuro-vascular bundle

PSN;Pelvic splancnic nerve
266 M. Ito
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
Seminal vesicle is directly

resection is possible in the conventional TME exposed by resecting the
Denonvilliers’ fascia
dissection plane. For T3 and T4 rectal cancer
lesions, selection of a more inclusive dissection
layer is sometimes necessary to ensure adequate
circumferential resection margin (CRM). In
these cases, the dissection layer intentionally
includes the pre-hypogastric nerve fascia which
is located more externally than the mesorectum. Mesorectum
The pre-hypogastric nerve fascia is a series of

membrane structures that include the hypogas-
tric nerve and pelvic plexus on the lateral side Fig. 25.5 External dissection plane in anterior side of the
rectum
and Denonvilliers’ fascia on the anterior side.
With the regular TME dissection layer,
Denonvilliers’ fascia is recognized as the fascia gastric nerve fascia that becomes the dissection
that covers the seminal vesicle (Fig. 25.4). layer to be selected for the resection. If the
Meanwhile, if the selected dissection plane is Denonvilliers’ fascia is resected together with
one layer deeper than the regular TME dissec- the rectum, for males, the layer that exposes the
tion layer, then Denonvilliers’ fascia becomes seminal vesicles is where the dissection will take
the dissection layer in the anterior wall, while on place (Fig. 25.5). However, for females, the
the lateral side of the rectum, it is the pre-hypo- same fascia is usually thin and may not be accu-
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.
Fig. 25.6 Dissection between mesorectum and the pelvic

plexus in lateral side of the rectum 1 Mesorectum
2 Pre-hypogastric nerve fascia
3 Endo-pelvic fascia
1 2 3
RECTUM
NVB
Traction of the rectum
Intersphincteric plane Anal

canal
Sacrum
Recto-sacral fascia
Fig. 25.7 Identification of the intersphincteric space

behind the neurovascular bundle Fig. 25.8 Fascias in posterior side of the rectum
268 M. Ito
aution During the Dissection

C
in the Neurovascular Bundle (NVB)
Dissection plane from above
In TME procedures approached from the perito-
neal side, the dissection procedures of the antero-
Pelvic plexus
lateral region of the rectum are particularly Rectum
challenging. The anterolateral region of the rectum
is in close proximity to the NVB, where bleeding
NVB
can be readily triggered. Moreover, if the surgeon-
selected dissection plane is slightly exterior, auto- Prostate
nomic nerve injury may occur. We have often
experienced cases of voiding dysfunction and sex-
ual dysfunction occurring because of this injury.
In males with a narrow, android pelvis, dissec- Dissection plane from below
tion procedures in the vicinity of NVB may be
difficult as forceps maneuvers are restricted. In
cases where the tumor mass is located anterolat-
erally and where the depth of tumor invasion is
Fig. 25.10 Difference of dissection point between from
≥T3, a dissection plane where a part of the NVB
above and from below
is also resected has to be chosen. However, even
when the rectal cancer is T1 or T2, dissection
manipulations in this region are not always easy under good NVB visibility. As shown in
due to restriction of the bony pelvis. One of the Fig. 25.10, when the TME is performed from the
important and recently recognized advantages of abdominal side, there exists a potential to injure
the taTME procedure is good visibility of NVB the nerves located toward the central side of the
from the perineal side. In taTME, NVB is known NVB. In taTME, dissection in the periphery (i.e.,
as a bundle structure of a certain length. in a plane too lateral) is quite possible. Therefore,
Therefore, a dissection at the superior aspect of even from the viewpoint of nerve preservation, it
the NVB will not result in nerve injury (Fig. 25.9). is preferable to obtain a certain level of familiar-
Even in our experience, the incidence of voiding ity before performing dissection procedures in
dysfunction has been less in patients in whom TME. Thus, when one senses that dissection in
nerve preservation was done during the region of the NVB by the abdominal approach
taTME. Therefore, when taTME is performed to TME would be difficult, it is better to select a
from the perineal rather the abdominal side, dissection layer in this area that would work
selective dissection procedures can be performed cooperatively with the perineal (taTME) tech-
nique, so as to optimize correct-plane surgery
NVB and subsequent patient outcomes.
Pubis
㽢 ey Aspects for Adequate Blood

K
Prostate
Flow Preservation in the Colon
䚽 Rectum
While performing taTME, regardless of it being
Levator ani muscle
executed in single-team or dual-team fashion –
Coccyx Endo-pelvic fascia the team performing the abdominal dissection is
responsible for blood vessel management in the
vicinity of inferior mesenteric artery (IMA) and
Fig. 25.9 Neurovascular bundle from below the mobilization of the colon. The important
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-
References ral orifice transluminal endoscopic surgery (NOTES)
rectal resection: “down-to-up” total mesorectal exci-
1. Bonjer HJ, Deijen CL, Haglind E, COLOR II Study sion (TME)–short-term outcomes in the first 20 cases.
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
Introduction ity” through his own dynamic personal quest for

quality and value. It is this same pursuit of excel-
Just like a storybook, every surgical procedure lence that is required of surgeons to create the
has a beginning, middle and an end. Each part of perfect purse-string in an efficient and reproduc-
the operation requires careful attention, but per- ible manner. Taking the time to slow down, reflect
haps the most important part of transanal total and allow yourself to become totally absorbed in
mesorectal excision (taTME) surgery is the the task – a state of flow – a highly focused men-
beginning – the purse-string. The creation of a tal state as described by eminent psychologist
sound and perfect purse-string sets the founda- Mihaly Csikszentmihalyi.
tion for successful surgery to follow. This chapter The perfect purse-string is the beginning and
is largely based on personal experience with also the end of many taTME operations. This
observations made by myself and colleagues chapter will provide the surgeon with the knowl-
conducting workshops from around the globe. edge and helpful tips in their own personal quest
This is often found to be a time-intensive exercise for quality and the perfect taTME.
for novice surgeons, who typically require mul-
tiple attempts to achieve the goal of a water- and
airtight purse-string. The Setup
It has been through these various workshops
that I was reminded of the cult book from the There is basically two ways that a purse-string
1970s, Zen and the Art of Motorcycle Maintenance can be created. This will largely depend on the
by Robert M. Pirsig. This has become a classic height of the tumour from the anal verge or ano-
book on modern philosophy in which the author rectal junction. The purse-string can be placed
explores both the meaning and concept of “qual- either by using retractors and placed transanally
under direct vision or placed endoscopically via
the chosen transanal endoscopic platform.
Most surgeons will be more familiar with
transanal placement of purse-string with skills
A. R. L. Stevenson (*)
that may have been developed when performing
University of Queensland, Brisbane, QLD, Australia stapled hemorrhoidectomy or similar procedures.
Colorectal Surgery, Royal Brisbane Hospital,
As with all steps of any operation, the key is ade-
Herston, QLD, Australia quate retraction, exposure and illumination.

272 A. 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
Fig. 26.1 The perfect

purse-string (low)
to start the purse-string distal to the visible

tumour to ensure correct height of the suture.
Common Pitfalls
1. The “spiral” – It is not uncommon for novice

surgeons to place the suture at different lev-
els from the anal verge. This is typically too
far proximal in the anterior aspect and often
going too distal in the posterior aspect. This
then creates a spiral or eccentrically placed
purse-string which will make for a difficult
rectotomy and the potential for uneven
length of remaining rectal tube. The surgeon
needs to be mindful of placing each suture at
an equal distance from the anal verge or ano-
Fig. 26.2 The “rose petal” seen here in the upper left cor-
rectal junction to avoid this common ner of the photograph
mistake.
2. The “rose petal” (Fig. 26.2) – This is one of
the most feared pitfalls when performing the 4. The “stuck on you” (Fig. 26.3) – The ideal
purse-string. This is created by having the depth of each suture for the purse-string
suture needle taking too much of the rectal should be through mucosa and at least the cir-
wall circumference, i.e. taking too much tis- cular muscle layer of the rectal wall. However,
sue in one pass of the needle or simply stated, some surgeons may become frustrated with
“taking too big of a bite”. The resultant their initial attempts to achieve a secure purse-
appearance when a suture is tightened and string that they then take very deep bites
secured is to have an obvious segment which through the rectal wall. These deep sutures
lacks symmetrical radial folds. This will risk including adjacent tissue such as the pel-
become more evident once pneumorectum vic floor muscles, vagina or prostate. Whilst
has been initiated. Indeed, if the pneumorec- the purse-string may have appeared to be
tum is allowed to continue, there is a high secure, this will cause problems once the dis-
probability that a gap in the mucosa and rec- section has commenced and often leading the
tal wall will become apparent which may surgeon to proceed in the incorrect plane or
then lead to failure of the purse-string and the causing injury to the adjacent structures.
potentially catastrophic egress of bowel con- 5. The “locked” (Fig. 26.4) – You’ve placed the
tent or mucous in the operative field. sutures perfectly! The sutures are at the appro-
Furthermore, gas can distend the entire colon priate and equal height from the anal verge or
making the laparoscopic portion of the opera- anorectal junction, equal bites, perfectly
tion arduous. spaced. But, the job of achieving the purse-
3. The “overzealous” – The converse of the rose string is not yet over. All too commonly
petal is the surgeon who passes the suture observed through the workshops, the enthusi-
needle in and out so many times in going astic surgeon, eager to commence taTME dis-
around the circumference of the rectum that it section, will quickly throw a few knots and
makes it very difficult to bring the tissue edges often locking the second knot without prop-
together. This may create difficulties when erly bringing together the edges of the rectum.
tying the suture and again result in a central It is important for the surgeon to pay careful
gap in the purse-string. attention to this part of the procedure, not to
26 Zen and the Art of the Purse-String 275
Fig. 26.3 The “stuck on you”

suture inadvertently including
deeper tissues, becomes evident
after dissection has begun,
leading into deeper incorrect
planes
placement of the suture as the height from

the anal verge will be limited by retraction
and exposure. This may lead to an unneces-
sarily low anastomosis, possibly requiring a
handsewn coloanal anastomosis, leading to
potentially worse bowel function. If access
to place the purse-string is limited using
direct vision and a proctoscope, it is recom-
mended to place the purse-string under
endoscopic guidance with pneumorectum
(such as with the TAMIS platform) to hope-
fully reduce the risk of an unnecessarily low
rectotomy and anastomosis.
Fig. 26.4 The “locked” suture, leading to inadequate seal

Special Considerations
have their hands unnecessarily holding needle
holders or forceps. If a single throw is used to Whilst most purse-strings will be placed in the
tie the suture, the second throw should also be “sweet spot” at about 5–6 cms proximal to the
in the same direction so as to allow the sur- anal verge, there may be other times when it will
geon to “snug down” the knot and pulling need to be very low or much higher. With very
together the purse-string. It is often the second low tumours requiring an intersphincteric dissec-
throw that causes the problem if this is done in tion, it may not be possible to perform a purse-
the opposite direction to the first throw. When string until the dissection has been initiated. In
it comes time to tying a perfectly placed this situation, the Lone Star retractor can be uti-
purse-string, it is time for returning to your lized to gain exposure and the dissection com-
highly focused mental state (flow), finding mence in the mid-anal canal extending into the
your Zen. intersphincteric space. Once this has released the
6. The “limbo” – How low can you go?
tension on rectal tube, it may then be possible to
Sometimes this is unnecessarily low, partic- perform a purse-string. If a purse-string has been
ularly in larger patients or those with a long placed prior to beginning the dissection, for these
anal canal. This is more commonly a prob- very low tumours, it may be helpful to place a
lem when using a proctoscope for the further purse-string or at least figure of eight on
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
Preoperative Preparation tal distension and pneumoperitoneum. A urinary

catheter must be placed. The rectum is irrigated
Preoperative evaluation by an enterostomal ther- thoroughly with both saline and cytocidal solu-
apist, a trained nurse or a surgeon is highly rec- tions such as povidone-iodine to remove any fae-
ommended for demarcation of a potential stoma cal residue that may disturb the transanal vision
site to avoid postoperative ostomy-related com- or which may lead to postoperative infection.
plications. Mechanical bowel preparation plus For the transanal team, a regular laparoscopic
oral antibiotics should be administered the day instrumental set and a laparoscopic unit are
before surgery; intravenous antibiotic prophy- required. If available, the authors recommend the
laxis against aerobic and anaerobic bacteria use of a 3D scope with a flexible tip and a con-
should be administered 1 h prior to skin incision, tinuous insufflator with smoke evacuation as
as clinical evidence supports its use to reduce sur- better depth perception, proper hand-eye coordi-
gical site infections [1]. nation and a steady pneumorectum field are
To avoid deep venous thrombosis and pulmo- achieved. For the abdominal team, another regu-
nary thromboembolism, sequential compression lar laparoscopic instrumental set and a complete
socks are recommended from the induction of laparoscopy unit are needed.
general anaesthesia and in the postoperative
period until patient mobilization is fully achieved.
During the anaesthetic period, a deep pharmaco- One Versus Two Teams
logic muscle paralysis is induced to facilitate rec-
TaTME can be performed consecutively (one-
team approach) or simultaneously (two-team
Supported by: No sources of funding to disclose. approach). The latter is recommended for the fol-
F. B. de Lacy · A. M. Lacy (*) lowing reasons: possibility to perform traction and
Gastrointestinal Surgery Department, Hospital Clinic, countertraction, visualization of the surgical plane
University of Barcelona, Barcelona, Spain from two points of view and shorter operative
e-mail: [email protected]; time. The collaboration between the two teams is a
[email protected]; https://www.aischannel.com
valuable feature of this technique. If only one team
M. C. Arroyave is available, it is advisable to start in the abdominal
Department of Surgical Oncology, Clinica Somer,
Rionegro, Colombia field and stop the dissection just before opening
https://www.aischannel.com the peritoneal reflection and then proceed with the

278 F. B. de Lacy et al.
transanal dissection. This sequence avoids the

appearance of retropneumoperitoneum, which
makes the abdominal dissection harder due to dis-
tortion of the retroperitoneal space. Single-team
taTME is described in further detail in a chapter
dedicated to this topic.
Only case reports and small series have been
published about pure natural orifice transluminal
endoscopic surgery (NOTES) taTME, and in the
meanwhile, it should only be performed as part
of an investigation protocol in highly specialized
centres [2–4].
Positioning the Patient
The patient is placed in the modified lithotomy

(Lloyd-Davies) position with adjustable boot stir- Fig. 27.2 Abdominal and transanal teams working
together
rups that allow easy mobilization of the legs with-
out compromising the sterile field. The surgical
table must allow steep Trendelenburg inclination Abdominal Approach
when required during the procedure (Fig. 27.1).
Placement of the team for the transanal phase The abdominal approach will be described sepa-
is with the principal surgeon and assistant rately in a chapter dedicated to this topic. Briefly,
between the patient’s legs and scrub nurse in the the transabdominal phase is initiated with
left lower side of the patient. For the abdominal 12–15 mmHg pneumoperitoneum and insertion
phase, the team is placed with the principal sur- of a 10 mm trocar above the umbilicus for the
geon, second assistant and scrub nurse in the optical instrument. Under direct vision, a 12 mm
right upper side and first assistant in the left upper trocar is inserted in the right iliac fossa, and two
side of the patient (Fig. 27.2). 5 mm ports are placed in the right and left flanks.
The distal sigmoid is cross-clamped to allow con-
struction of transanal purse-string suture without
colon distension. Once the purse string is made
and confirmed to be airtight, both teams work
synchronically.
A medial to lateral approach is advised for
cancer resections. The inferior mesenteric artery
is divided 1 cm away from its origin at the aorta,
following the oncological principles of mesen-
teric resection with lymph nodes alongside the
vascular arcade (Fig. 27.3). After exposure of the
retroperitoneal plane and identification of the left
ureter, artery ligation is performed with a vessel-
sealing device, a vascular stapler or using regular
clips. The inferior mesenteric vein is visualized
more caudally and laterally at the level of the
Fig. 27.1 Patient positioned in Lloyd-Davies and steep inferior border of the pancreas and is ligated in
Trendelenburg the same fashion. Descending colon dissection is
27 An Overview of Operative Steps and Surgical Technique 279
standard laparoscopic instruments. As stated pre-

viously, occlusion of the distal sigmoid by the
abdominal team is essential to minimize colonic
distention.
With taTME, locating the distal edge of the
tumour is relatively easy as it is done under direct
vision. Distally, a purse-string suture with a
26 mm needle and a size 0 polydioxanone suture
(with small equal bites at the same rectal level) is
made, to close the rectal lumen (Fig. 27.4).
Performing a tight purse-string suture prevents
Fig. 27.3 Division of the inferior mesenteric artery at its
origin translocation of liquid stool and tumour cells,
reducing the risk of pelvic abscesses and locore-
gional recurrences.
continued by releasing the fusion plane along After washing out the closed rectal stump with
Toldt’s fascia and mobilizing the splenic flexure povidone-iodine solution, the rectotomy is started
when needed. just distal to the purse string. It is performed with
Following the posterior avascular plane, rectal monopolar cautery in a circumferential fashion
and mesorectal dissection is started. Circumferential (Fig. 27.5). The insufflation pressure should be
dissection preserving Denonvilliers’ fascia in set to ≤15 mmHg.
males is continued until rendezvous with the trans- By preference, the rectotomy commences
anal team. along the anterior surface of the rectum, at the 12
o’clock position, and is then extended in counter-
clockwise fashion. A full-thickness dissection is
Transanal Approach carried out until reaching the avascular “angel’s
hair” plane, sharply following the TME plane
Restorative Total Mesorectal described by Heald [5]. TaTME is not an easy
Excision operation, and finding the correct plane may be
challenging. However, once correctly identified,
id and Low Tumours to 2 cm Above
M
the Dentate Line
After digital rectal examination and proper irri-
gation, an anal retractor (Lonestar, Cooper
Surgical, Trumbull, CT, USA) is placed to efface
the anus and thereby visualize the dentate line,
followed by the introduction of the endoscopic
platform, which is fixed to the perineal skin. At
our centre, a TAMIS Port (GelPOINT Path
Transanal Access Platform, Applied Medical,
Rancho Santa Margarita, CA, USA) is used.
Three cannulas are inserted into the TAMIS
Port’s gel cap, forming an inverted triangle, with
the camera lens positioned at 6 o’clock. In case of
a challenging posterior mesorectal dissection, the
camera can be switched to one of the TAMIS
Port’s lateral cannulas. The abdominal team then
clamps the distal sigmoid, the pneumorectum is
initiated, and the transanal phase is started with Fig. 27.4 Purse-string suture to close the rectal lumen
Fig. 27.5 Circumferential rectotomy
Fig. 27.7 “Rendezvous”, meaning that both planes are

connected and both teams work together
may be increased. The improved visualization by

laparoscopic instruments may help the surgeon in
identifying the correct lateral planes and avoiding
dissecting laterally to the endopelvic fascia, in
false planes that become exposed due to pneu-
matic dissection during taTME.
Fig. 27.6 Down-to-up transanal dissection following the Once at the level of the peritoneal reflection,
“holy plane” the anterior surface is divided, and the peritoneal
cavity is entered. This is made lastly to maintain
this technique is characterized by a more natural a stable pneumopelvis. This rendezvous point in
dissection inside Denonvilliers’ and Waldeyer’s dissection allows both teams to work synchro-
fascias due to pneumatic dissection and direct line nously until the rectosigmoid is released from its
of site visualization of, in particular, the anterior attachment in toto (Fig. 27.7).
plane in males. This leads to a potential decrease
of intraoperative complications, such as haemor- ow Tumours, Distally to 2–3 cm Above
L
rhage, and autonomic nerve injury – while main- the Dentate Line
taining the integrity of the mesorectal envelope. The length of the TAMIS Port’s access channel
The cephalad dissection is performed with measures approximately 4.5 cm. When the
electrocautery and bipolar forceps (Fig. 27.6). A tumour is so low that its insertion is limited, an
circumferential dissection is preferred by the intersphincteric dissection with conventional
authors, with a focus on maintaining the enve- open instruments may be necessary (Fig. 27.8).
lope’s symmetry – since this medium (i.e. insuf- Rullier et al. [6] suggested that a partial inter-
flation using the TAMIS apparatus) enables sphincteric resection might be necessary for
pneumatic-assisted dissection to help localize the juxta-anal tumours (<1 cm from the anal ring)
mesorectum’s innermost correct plane. The TME and a total intersphincteric resection in intra-anal
plane is always easier to find at the anterior and tumours which do not encroach on the external
posterior aspects; that is why connecting them anal sphincter. One must remember that a partial
might help if any doubt arises while dissecting or a total intersphincteric resection is technically
the lateral boundaries. Compared to abdominal feasible, but with an increased risk of postopera-
TME, the risk of damaging the pelvic sidewall tive poor bowel function.
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).
Partial Mesorectal Excision
The surgical community has embraced taTME

mostly based on its benefits when dissecting mid
and low rectal tumours. However, at our centre,
taTME is also performed for higher lesions
because with appropriate experience, these
patients may benefit from shorter operative times
and lower conversion rates. In those higher
tumours in the upper rectum, it has been proven
Fig. 27.8 Intersphincteric dissection with conventional that, although total mesorectal excision is not
open instruments necessary, mesorectal residual cancer cells can
Fig. 27.9 Transanal field during abdominoperineal excision

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
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
Although there is a need for standardization of

the procedure, the anatomy of every patient is
heterogeneous. For this reason, the surgeon
should be familiar with the different anastomotic
techniques, including end-to-end, side-to-end or
Fig. 27.11 Handsewn colorectal anastomosis
colonic J pouch and stapled versus handsewn.
When a stapled anastomosis is attempted, we
favour the single-stapled double-purse-string
one. The anvil is inserted into the proximal colon,
either to perform a side-to-end or an end-to-end
anastomosis. A second purse string, usually with
a monofilament size 0 polypropylene suture, is
placed in the opened distal cuff, through the
access channel of the endoscopic platform. This
purse string may be performed by hand after the
removal of the endoscopic platform in mid and
low rectal tumours. Suturing by hand can be
extremely challenging in cases of higher tumours
(i.e. longer rectal cuffs), so performance with the
transanal platform and laparoscopic instruments
is highly recommended. This rectal cuff purse
string is then tied to the anvil, and the stapler is
connected. This can be performed with a variety
of staplers, including an endoluminal circular sta-
pler or, alternatively, a hemorrhoidal stapler. The
latter has a longer spike (measuring 13.5 cm)
making it easier to mate with the arm of the sta-
pler for ultralow taTME anastomoses. Such sta-
plers tend to provide wider doughnuts and robust
staple lines. However, its larger diameter (33 mm)
may sometimes represent a handicap, depending Fig. 27.12 Presacral dissection, venous plexus vessel
on patient anatomy. In either case, with low anas- can be seen
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LA, Fazio VW. Total mesorectal excision is not
necessary for cancers of the upper rectum. Surgery.
1. Kumar AS, Kelleher DC, Sigle GW. Bowel prepara-
1998;124:612–7. discussion 617–8.
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8. Atallah S, Albert M, Monson JR. Critical concepts
2013;26(3):146–52.
and important anatomic landmarks encountered dur-
2. Chouillard E, Regnier A, Vitte RL, Bonnet BV,
ing transanal total mesorectal excision (taTME):
Greco V, Chahine E, Daher R, Biagini J. Transanal
toward the mastery of a new operation for rectal can-
NOTES total mesorectal excision (TME) in patients
cer surgery. Tech Coloproctol. 2016;20(7):483–94.
with rectal cancer: is anatomy better preserved? Tech
https://doi.org/10.1007/s10151-016-1475-x. Epub
Coloproctol. 2016;20:537–44.
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3. Marks JH, Lopez-Acevedo N, Krishnan B, Johnson
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MN, Montenegro GA, Marks GJ. True NOTES TME
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Strategies for Ultralow-Lying
Rectal Cancer 28
Sam Atallah and Eric Rullier
Introduction surgical option, with the singular exception being

those lesions which invade the external sphincter
While taTME has in general been a useful modal- mechanism. It is possible to combine perineal
ity for managing rectal cancer, its greatest appeal techniques with taTME, but this requires subtle
remains toward the management of ultra-distal yet important modifications. In this chapter, the
rectal tumors that are extremely difficult to clear strategies for radical resection for ultralow-lying
from the abdominal approach without adjunctive, rectal tumors using the taTME technique are
perineal techniques. Such techniques include outlined.
those that preserve at least a portion of the sphinc-
ter complex, as well as those that sacrifice the
anorectal complex altogether. Due to the techni- he Development of ISR
T
cal complexity of sphincter preservation for for Rectal Cancer and a Farewell
ultralow-lying tumors, the vast majority of such to the 2 cm Rule
clinical cases were historically managed with
abdominoperineal resection, subjecting patients Prior to the introduction of sphincter preservation
to significant morbidity and to life with a perma- techniques, the only oncologic surgical option for
nent stoma. ultralow-lying, advanced-stage rectal cancer was
As technical expertise advanced, paradigms the Miles’ Operation (aka, abdominoperineal
shift, and surgeons explored options to permit resection, APR); developed in 1908 and named
sphincter preservation for low-lying rectal cancer after William Ernest Miles (1869–1947) [1]. The
with the intent for cure. It was the refinement of operation could be complete with one or even two
the technique for intersphincteric resection cou- teams [2] as is the case for the current approach to
pled with neoadjuvant therapy that made sphinc- taTME. For most of the twentieth century, it was
ter preservation for low rectal cancers an eligible not that the technical ability to perform ultralow,
sphincter-preserving surgery did not exist but
S. Atallah (*) rather that such techniques were not applied to
AdventHealth Orlando, Oviedo Medical Center, surgical management of cancer. Interestingly, the
and University of Central Florida College
techniques were developed as early as 1888 by
of Medicine, Orlando, FL, USA
e-mail: [email protected] Hochenegg [3, 4], and the so-called pull-through
was quite commonly employed during the 1950s
E. Rullier
Department of Colorectal Surgery, Haut-Levèque, and 1960s, but this was performed principally in
Pessac, France the pediatric population [5].

286 S. Atallah and E. Rullier
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
Fig. 28.1 A standardized

classification system for
low rectal cancers. AR,
Anorectal Ring; DL,
Dentate Line; AV, Anal
Verge
AR
DL
AV
Type I : Supra-anal Type II : Juxta-anal
Type III : Intra-anal Type IV : Transanal
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
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
The operative approach to taTME commences

with the standardized approach with either
single-team or two-team (Cecil) approach. When
the transanal portion of the operation begins, the
operator must be prepared to modify the initial
steps, albeit only slightly for Type I tumors.
The first step is to perform a digital examina-
tion to localize the position of the primary tumor,
and, in males, it is strongly recommended to digi-
Fig. 28.2 A posterior ulcerated 3 cm rectal cancer is vis- tally inspect the prostate gland [58]. An intraop-
ible with direct exposure using a handheld anal retractor. erative review of MRI to assess pelvic geometry,
The tumor’s relationship to the dentate line is clearly vis-
ible. As the lesion is positioned within 1 cm of the anorec-
the rectum, and the tumor in relation to the ano-
tal junction, this is classified as a Type II rectal cancer and rectal junction is particularly important as it pro-
requires at least partial ISR for tumor clearance vides a road map for the taTME surgeon [59].
Next, the rectal irrigation is conducted, and a

self-retaining retractor (such as the Lone Star
Retractor or equivalent) is positioned which acts
to efface the anal canal, and this ultimately facili-
tates access to the ultralow rectum. Such retrac-
tors are typically left in place throughout the
taTME operation; it serves as a useful adjunct to
facilitate construction of the anastomosis upon
completion of the resection. This applies to anas-
tomoses that are either handsewn or stapled; Fig. 28.4 Upon completion of the purse string, usually
however, Rullier Type I–III anastomoses, when utilizing 2–0 monofilament suture on an SH needle, the
performed post-resection, are typically purse string is tightened and the lumen closed by knot-
tying manually. Note the distal extent of the purse string.
handsewn.
This is far too distal to apply and seat the TAMIS port’s
With a self-retaining retractor in place, and the access channel, and so the dissection must proceed ini-
patient positioned in modified lithotomy, for tially under direct vision until adequate operating space
Type I rectal cancers, it is best to close the rectal has been created
lumen with the aid of a handheld anorectal retrac-
tor prior to the introduction of the access channel
(Fig. 28.3). The reason for this is because, if the
access channel is placed first, the inner portion of
the sleeve will prevent visualization of the lesion,
preventing lumen closure distal to the tumor.
Thus, the placement of the purse string below the
level of the tumor – prior to access channel
placement – is an important first step for manage-
ment of Type I lesions (Fig. 28.4).
After application of the purse string, the ano-
Fig. 28.5 Bactericidal and tumoricidal agents can be
rectum is irrigated once more in preparation for used to irrigate the rectal lumen before, after, and even
during purse-string placement. Here, the lumen is being
irrigated just prior to securing (cinching down) the purse
string. The retractor is in place to help expose the lumen
and to perform an effective rinse. The next step will be to
remove the handheld anal retractor and hand tie the purse
string with multiple knots, assuring it is airtight and
watertight prior to commencing dissection
transanal dissection (Fig. 28.5). This commences

with dissection under direct vision, with full-
thickness rectotomy. Here, care is given to create
a circumferential incision that opens all quad-
rants, in a plane and level that is equidistant from
the dentate line, so as to facilitate further steps of
Fig. 28.3 For Type I rectal cancers, a self-retaining
(Lone Star) retractor can be positioned to efface the anal
the anatomical taTME dissection. The transanal
verge and improve exposure. Next, under direct vision, a dissection then proceeds in a sequential manner
handheld anorectal retractor (in this case, a small-size cephalad, allowing enough distance to admit and
Hill-Ferguson) is used to access the anal canal so that a position the TAMIS port’s access channel. At this
purse-string suture can be applied just distal to the lesion,
which should be in direct view of the surgeon. This step is
point, the access channel can be suspended with
an important departure from standard taTME and is nec- the aid of a self-retaining retractor (Fig. 28.6).
essary to address low-lying, Type I tumors Next, the gel cap is secured to the “suspended”
anal canal. The dissection then proceeds so as to

include the entire IAS within the scope of dissec-
tion or just a portion of the IAS depending on
tumor level and the ability to obtain a negative
distal margin. Sometimes the initiation of the ISR
dissection can take place under direct vision,
using a handheld anorectal retractor (Fig. 28.7).
Classically, however, the dissection proceeds
after placement of a self-retaining retractor, and
the ISR technique for this utilizes sharp dissec-
tion (Fig. 28.8a, b). Recently, this component of
Fig. 28.6 An important adaption to access is illustrated. the operation has been described with the robotic
Ordinarily, the TAMIS access channel is delivered transa- taTME approach [51], whereby the da Vinci
nally where the inner lip is designed to seat above the ano- Surgical System is “dry-docked” (without a
rectal ring. Since this would not allow for exposure of the
ultra-distal rectum, a modification is performed whereby TAMIS platform) to perform this dissection
the hooks of the Lone Star retractor are used to anchor the meticulously (Fig. 28.9a, b).
channel (arrows). In such a setting, the channel is only Upon completion of the ISR (partial or com-
partly inserted and is instead “suspended” by the Lone plete) (Fig. 28.10), the dissection proceeds ceph-
Star Retractor pegs. This significantly improves distal rec-
tal access and allows taTME to be performed at a lower alad under direct vision, until there is enough
than normal distal starting point mobility of the distal anorectum to form an air-
tight purse string. This can then be completed
manually or with the aid of a robotic surgical sys-
access channel, and the dissection proceeds along tem (Fig. 28.11). Next, the access channel can be
a plane (that does not require ISR) using the secured by suspending it onto the self-retraining
established techniques for taTME. The analog for
this level of resection is the ultralow anterior
resection. As the dissection advances, the access
channel is further introduced until it is seated just
above the anorectal ring, and the outer rim is then
sutured to the dermis to prevent torque rotation
during dissection. When the operation is com-
pleted, a handsewn anastomosis is commonly
performed, although stapled anastomosis is pos-
sible, depending on the length of the rectal cuff.
t aTME for Rullier Type II and III

Tumors
As for Type I tumors, the operative approach to

taTME for Type II/III tumors commences with Fig. 28.7 The distal-most extent of dissection has been
initiated under direct vision. The white muscle fibers of
the standardized approach with either single- the internal sphincter muscle can be seen, and the internal
team or two-team approach. However, modifica- anal sphincter itself has been defined at its distal-most
tions for taTME for Type II lesions (which require extent. In this case, a total ISR is being performed for a
a partial ISR) and Type III tumors (requiring a Type III rectal cancer. Whether for partial or total ISR, this
portion of the operation is completed prior to purse-string
total ISR) are necessary. To perform this, a self- application, thus underscoring an important technical dif-
retraining retractor is positioned, thereby effac- ference in operative management between Type I and
ing the anorectum and providing exposure to the Type II/III rectal cancers
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
retractor as described previously. Finally, the

Fig. 28.9 (a) ISR can be completed by “dry-docking” a
TAMIS port’s gel cap can be secured, pneumatic da Vinci Surgical System with only a Lone Star or similar
inflow is established, and taTME then proceeds retractor to maintain exposure (Photograph (a) courtesy
along embryonic fusion planes until the point of of J. Kuo). Both Xi and Si da Vinci systems have been used
rendezvous at the anterior peritoneal reflection and (b) demonstrate the use of 5 mm instruments and the
Si platform to perform a total ISR. Note that a gauze has
(Fig. 28.12). been placed within the rectal lumen and the distal tumor is
visible posteriorly
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
with taTME has not been well studied to date,

and this remains an area of ongoing investigation.
Urogenital function can also be altered but is
attributable to the autonomic nerve-sparing dis-
section, TME quality, and local factors (espe-
cially radiation) [64–67] – and not directly related
to the ISR dissection. However, it should be noted
that the TME is more technically challenging in
this setting.
Fig. 28.10 ISR dissection has been completed. It is after
ISR dissection that the purse string is applied to the distal
rectum. The next step will be suspension of the TAMIS Oncologic Outcomes
access channel using the Lone Star Retractor and then ini-
tiation of the formal taTME dissection
Although the outcomes specifically for taTME
using TAMIS and ISR for Type II and III rectal
cancers have not been examined, inferences can
be determined from series and systematic reviews
which examine ISR for such lesions, with or
without the use of advanced transanal platforms.
These data appear quite encouraging and support
the technique of ISR for ultralow rectal cancer
[68–79]. In a 2017 study by Denost et al., n = 100
patients were randomized to either a transanal
approach with ISR or standard laparoscopic ante-
rior resection. With mean 60.2-month follow-up,
Fig. 28.11 For Type II and Type III tumors which require the local recurrence rate was 3% for those under-
ISR, purse-string application is not the first step but is
rather placed after initiation of the dissection. Most typi-
going ISR, while 5-year, disease-free survival
cally this is performed under direct vision, but recently was 72%. The study reported no statistically sig-
some centers have demonstrated feasibility utilizing the nificant difference in either the rate of local
da Vinci Surgical System. Here shown is the robotic Si da recurrence or 5-year disease-free survival for
Vinci Surgical System which is being used to create the
purse string after ISR
the two groups. In a study by J Marks et al.,
n = 106 patients underwent TATA utilizing
TEM. Outcomes were retrospectively comparted
to those undergoing anterior resection versus
local excision via TEM for case-matched cohorts.
For patients undergoing TATA for ultralow rectal
cancer, the rate of local recurrence was 3%, and
the overall survival measured 95% with mean
follow-up of 37.9 months [16].
Fig. 28.12 A partial ISR has been completed, the purse

Future Directions
string applied under direct vision, and then the access
channel suspended onto the Lone Star Retractor. The The ability to address ultralow-lying tumors
TAMIS apparatus is then connected to pneumatic inflow defines the most useful advantage of taTME.
(in this case, using AirSeal®) after placement of the gel
cap, and the dissection then proceeds cephalad to the level
Thus, advanced training and curricula should
of the peritoneal reflection using standard taTME tech- focus on this important application. Next steps
niques, as shown toward the mastery of this complex technique
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 experiment 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.
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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
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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.
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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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expertise on taTME, great care and careful under- dose preoperative radiation therapy as the key to
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16. Marks J, Mizrahi B, Dalane S, Nweze I, Marks

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MC, Bravo R, Cuatrecasas M, Lacy AM. Transanal
Critical Anatomical Landmarks
in Transanal Total Mesorectal 29
Excision (taTME)
Stephen W. Bell
Introduction 1 . The anorectal junction and the pelvic floor.

2. Luminal anatomy of the rectum in relation to
The advancement of transanal endoscopic tech- the purse string.
niques to the surgical management of rectal neo- 3. Rectal wall layers in relation to the

plasia (particularly for taTME) has led to an rectotomy.
improvement in surgical technique but also the 4.
The extrafascial, subserosal, and sub-
development of different potential complications. endopelvic fascia planes.
The cornerstone to all surgical dissection is a 5. Variations in pelvic floor anatomy.
clear understanding of and identification of ana- 6. Maintaining the correct plane and signs of
tomical landmarks and the correct and incorrect changing planes.
anatomical planes. The anatomy of the extraperi- 7. (a) Too deep posteriorly: presacral veins and
toneal rectum is familiar to most practicing the sacrum, (b) Too deep laterally: major ves-
colorectal surgeons; however this familiarity is sels, the ureter, and the “pelvic tonsils”. (c) Too
predominantly from an abdominal approach, deep anteriorly: vagina, prostate, and urethra
entering the pelvis from above. The anatomy 8. Entering the peritoneal cavity.
when viewed from below (transanally) is the
same; however the view is quite different, and
this necessitates a relearning of the anatomy as it he Anorectal Junction
T
is seen from this direction. This chapter will and the Pelvic Floor
focus on the applied surgical anatomy required
for a transanal total mesorectal excision (taTME). The three-dimensional anatomy at and around the
It will not detail all anatomic structures of the anorectal junction can be complex and variable.
anorectum, pelvis, and pelvic floor as this is There are multiple tissue planes, which vary
assumed knowledge. depending on the height within the bowel and also
The description of the anatomy will follow the radial position. The tissue planes are different
steps of the operation: anteriorly from posteriorly, and there are varia-
tions between women and men. The position of
the tumor will determine the position of the purse
string and subsequently the position of the rectot-
S. W. Bell (*) omy. It is important to have a clear idea of where
Cabrini Monash University Department of Surgery,
Malvern, VIC, Australia the rectotomy will be and how this relates to the
anal sphincters and pelvic floor. The circular
Alfred Hospital, Melbourne, Australia

300 S. 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).
ectal Wall Layers in Relation

R
to the Rectotomy
The rectal wall is composed of the mucosa, sub-

mucosa, and circular and longitudinal muscle
layers, before encountering the mesorectum and
Fig. 29.1 MRI scan of the anorectal junction demon-

strating the change in angle between the anal canal and the
lower rectum. The colored lines indicate potential sites of
a rectotomy. The yellow line sits within the anal canal,
when a partial intersphincteric dissection is undertaken.
The green line sits at the anorectal junction, with the pos- Fig. 29.2 Diagram representing the effect of a purse-
terior aspect being at the level of the puborectalis muscle. string suture on the rectal wall. The indrawing of the mus-
The purple line is in the lower rectum above the pelvic cle layers changes the angle of dissection through the
floor rectal wall when performing a rectotomy
29 Critical Anatomical Landmarks in Transanal Total Mesorectal Excision (taTME) 301
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-
Fig. 29.4 Lateral view Mesorectum

drawing of Fascia propria
extraperitoneal pelvis.
The red arrow indicates Presacral fascia Incised peritoneum
the common point of the
rectotomy. At this point
there is little or no
mesorectum, meaning
there is little tissue
Incised Fascia
differentiation between Incised rectosacral
of Denonvilliers
the subserosal and fascia
extrafascial planes
302 S. W. Bell
rectum or along the subserosal plane. Familiarity

with the specific patient’s MRI scan is important
to plan this dissection and have an understanding
of the expected changes in angles of dissection to
stay in the correct plane.
Variations in Pelvic Floor Anatomy
The direction of dissection is primarily deter-

mined by the visual cues encountered during the
dissection; however there is a lot of additional
Fig. 29.5 Dissection deep to the endopelvic fascia with information that is available on the patient’s
exposed puborectalis muscle. The red line indicates an preoperative imaging (particularly MRI scan)
inviting loose areolar plane, being too deep. The green that can offer a “road map” of what will be
line indicates the correct line of dissection, allowing the
endopelvic fascia to fall back onto the pelvic floor expected during the dissection. There is signifi-
cant variability between patients as to the verti-
cality of the pelvic floor and the angles between
gin. As has also been noted, once the rectotomy the anus, lower third of the rectum, and the mid-
has been completed circumferentially, the rectal sacrum. When the surgeon is forewarned of
wall tends to be pushed cranially by the pneumo- such angles and can be prepared for changes in
pelvis. At this point it is important to assess the the direction of dissection, this will assist in
planes and not be drawn to the loose areolar tis- avoiding drifting into a deeper plane and caus-
sue underlying the muscle layer. It is usually best ing injury to structures such as the presacral
to try to define the endopelvic fascia as the deep veins and the pelvic autonomic nerves. Figs. 6a
landmark and then proceed to dissect cranial to and 6b highlight this point, with the patient in
this. If the endopelvic fascia is lifted and dissec- Fig. 29.6a having a very vertical pelvic floor and
tion continues in a plane too deep, this will lead very little angle between the direction of the
the dissection into vital anatomic structures (to anal canal and the lower and the mid-rectum,
be described below) (see Fig. 29.5). Exposing the with the pelvic floor running in a similar direc-
pink skeletal muscle which will contract when tion to the rectal wall. The patient in Fig. 29.6b,
contacted by diathermy is an important visual however, demonstrates a significant change in
clue – along with recognition of the white fibrous direction of ~90 degrees between the anal canal
tissue being retracted centrally, with a visible cut and the lower rectum/pelvic floor. There is
edge distally. another significant change in direction of almost
The anterior plane is usually almost horizon- 90 degrees anterior to the lower sacrum. If the
tal in a direct line with the view from the access first angle is not appreciated, it could be possi-
channel, and it is most common that the dissect- ble to dissect into the subserosal plane, thus put-
ing instrument is horizontal when dissecting this ting the tumor margin at risk. If the second angle
plane. If this instrument is angling upward, this is not appreciated, it would be possible to dis-
may indicate dissection is too anterior. In com- sect into the presacral plane and cause signifi-
parison, the posterior plane is varying degrees cant bleeding. Albeit that one must pay particular
toward the vertical, at times being up to 90 attention to the visual cues during the surgery to
degrees from the angle of the access channel. keep the dissection in the correct plane, having
When beginning the dissection along the pelvic an awareness of the patient’s particular anatomy
floor posteriorly, the surgeon must be aware of is also important to assist guidance of the
this angle so as to avoid dissecting into the meso- dissection.
a section, and it is possible to dissect quickly over

a moderate distance in this plane before realizing
the error.
The pneumopelvis provides a very important
clue when the dissection changes planes. When
a fascial plane is incised, even only minimally,
the gas dissects into the new plane and creates
an “O” or “halo” (see Fig. 29.7). This is a very
important sign to recognize and should cause
the surgeon to assess the local anatomy and
decide on the correct plane of dissection, either
continuing in the original plane or dissecting
into the deeper plane if this is believed to be
appropriate. Most commonly when the dissec-
tion is proceeding in the correct plane, the
appearance of an “O” or “halo” signals the sur-
b geon to avoid the deeper plane and recorrect to
the original plane.
Along with the “O” sign, triangles of tissue
are often seen as a response to tissue retraction.
When the rectum and mesorectum are retracted
away from an area being dissected, the underly-
ing tissues of the deeper plane are tented up. The
apex of this tented tissue is the point of maximal
Fig. 29.6 (a, b) Vertical pelvic floor (a) and horizontal

pelvic floor (b) demonstrating significant variation
between individual patients’ lower pelvic anatomy
aintaining the Correct Plane

M
and Signs of Changing Planes
The point during an operation when the extrafas-

cial plane has been clearly defined circumferen-
tially is often accompanied by some acceleration
in dissection, particularly anteriorly. It remains
important to stay in the correct plane, and some
of the visual cues can confuse the surgeon lead- Fig. 29.7 Incising a fascial layer under the pressure of
ing to inappropriate dissection in a plane that is the pneumopelvis creates an often sudden circular open-
too deep. The correct plane is an areolar plane, ing (an “O sign” or “halo sign”). This indicates the dissec-
but it must be recognized that this requires active tion has changed planes into a deeper plane. If the
dissection was already in the correct plane, then the
dissection, as opposed to gentle pushing and deeper, often more inviting plane should be avoided (red
“pneumodissection.” The plane too deep is a very circle). Dissection should be returned to the top of the
inviting loose areolar tissue that needs little dis- green triangle to maintain the original plane of dissection
304 S. W. Bell
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”
When dissecting laterally it is important to main-

tain the correct plane, and the tendency can be to
dissect too deeply, particularly in the mid and
upper pelvis. There is a fear of dissecting too
medially, into the mesorectum and to breach the
oncologic principles of a TME. This, along with
the often inviting loose areolar plane deep to the
extrafascial plane, can lead the surgeon to dissect
more widely. There are numerous important ana-
tomical structures in this space, with some loose
supporting fatty tissue. The internal iliac artery
and its branches, along with the accompanying
veins, lie in this space, including the middle rec-
Fig. 29.9 Dissection has been in a plane too deep, at the tal artery. When the mesorectum and specimen
base of the triangle (red line), thus lifting the endopelvic
are retracted medially, this draws up the underly-
fascia and exposing the puborectalis muscle. The correct
position for dissection is at the apex of the green ing tissues, again creating a triangle. In this lat-
triangle eral position, this is not just fibro-fatty tissue
underlying but may also include the terminal

branches of the internal iliac artery including the
superior vesical artery and the obturator artery.
These vessels normally run parallel to the plane
of dissection but appear to be crossing the plane
if they are retracted medially (see Fig. 29.10a, b).
If dissection continues lateral to this fatty tissue,
it will “hang down” and become shifted slightly
medially to give the appearance of a tonsil (see
Fig. 29.11). This has been coined the “pelvic ton-
sil” by Dr. Matthew Albert. The appearance of a
tonsil should alert the surgeon to the fact that the
dissection is too deep and the appropriate correc-
tion be made to the more medial plane. If this is Fig. 29.11 Operative photo of dissection on the right
pelvic side wall with the specimen on the right of the
not recognized, and the dissection is continued in
photo. Dissection too far laterally exposes the fatty tissue,
coined the “pelvic tonsil” (shown in yellow). Dissection
deep to the tonsil (red line) will result in significant bleed-
a ing, whereas the green line indicates the appropriate cor-
rection into a more medial plane
Fig. 29.12 Pelvic MRI scans demonstrating the incorrect

(red) and correct (green) planes of dissection on the lateral
pelvic side wall. If dissection is too lateral, the pelvic ton-
sil (yellow) may appear, and dissection further in this
plane could result in major vascular injury and significant
bleeding
this deep plane, significant vessels will be

encountered and possibly injured, leading to
major bleeding and a loss if the surgical view and
clear appreciation of the tissue planes. It is impor-
tant to note that this tonsil does not appear when
Fig. 29.10 (a) Lateral pelvic side wall without traction, performing an abdominal dissection of the pelvis
with a vessel lying flat. (b) Lateral pelvic side wall with as the dissection passes directly over these tissues
traction on the rectum, tenting the side wall vessel into the
and they are not lifted. As such, this appreciation
apparent plane of dissection (red line). The green line
indicates the correction that needs to be made to avoid of the pelvic side wall anatomy is unique to the
injury to the vessel taTME operation (see Fig. 29.12).
306 S. W. Bell
Proximal to the pelvic tonsils in the antero-

lateral quadrant are the ureters. These are usually
defined more proximally when performing an
abdominal dissection and are then followed cau-
dally into the pelvis. This maneuver is not pos-
sible when dissecting from below; however if
there are concerns during taTME dissection,
then identifying the ureters abdominally should
be completed. The ureters are often not seen dur-
ing a taTME dissection but are only one plane
deeper than the dissection. It should be recog-
nized that the direction of dissection in the upper
half of the pelvis is from a lateral position head-
Fig. 29.13 The position of the right ureter (yellow) at the
ing centrally and medially, as the specimen nar- point of breaching into the peritoneal cavity as seen from
rows toward the upper rectum. It is most common below. The red line indicates dissection too laterally put-
to breach the peritoneum and join the peritoneal ting the ureter at risk, whereas the more medial dissection
cavity close to or in the midline anteriorly. along the green line is the correct plane
Having defined the correct position, the division
of the peritoneum can be taken further laterally. and should avoid the dissection drifting too far
This will keep the dissection medial to the ureter laterally (Fig. 29.13).
oo Deep Anteriorly: Vagina,

T
Prostate, and Urethra
The anterior dissection is distinctly different in

a male and female patient. In the female the rec-
tovaginal septum is often very clear, and the
more anterior structures including the urethra
are not in danger. This plane can be affected by
tumor, radiotherapy, and previous surgery such
as gynecological prolapse procedures. In the
normal state, however, this plane is clear and
often the easiest to define. The direction of dis-
section is quite “horizontal,” with the operating
instruments passing horizontally and the sur-
geon’s hands at the same level as the access
channel.
Anterior dissection in a male must be under-
taken with some caution. One of the more pub-
licized and feared complications of taTME is
male urethral injury, and this can be prevented
with a clear understanding of the anatomy and
careful dissection and recognition of the ana-
tomical landmarks. When the urethra has been
exposed and at risk, the problem has usually
occurred earlier in the dissection. Having placed
a purse-string suture and performed a rectot-
omy, the rectum becomes mobile. Retraction
posteriorly on this mobile rectum transmits pos-
terior traction on the prostate while it is still
attached. It is usually necessary to mobilize the
prostate laterally to expose the urethra, and this
occurs when dissection has been in a plane too
deep around the distal rectum posteriorly and
laterally and continued anteriorly and cranially.
Fig. 29.14 MRI scans of the pelvis demonstrating the
Figure 29.14 demonstrates the correct and correct (green) plane of dissection around the mesorec-
incorrect planes that lead to lateral mobilization tum and the incorrect (red) deeper plane of dissection
of the prostate. With posterior retraction and the that leads to mobilization of the prostate along with the
weight of the rectum and prostate assisting, the rectum. This deeper dissection drops the prostate poste-
riorly, exposing the urethra and placing it at risk of
urethra comes into view (Fig. 29.15). The dumb- injury
bell appearance of the rectum and attached pros-
tate may be able to be seen. The urethra may
also be visible as a longitudinal cord centrally. 1. The dumbbell appearance of the rectum and
There is no plane to dissect here, and efforts to prostate fused together, both being posterior
try to dissect this tissue will lead to urethral to the plane of dissection.
injury. 2. Visible muscle fibers on the anterolateral pel-
The clues that the prostate has been mobilized vic wall (there should be no muscle fibers
include: anteriorly in a man).
308 S. W. Bell
Fig. 29.16 taTME view of Denonvilliers’ fascia being

reflected posteriorly, with dissection passing between this
Fig. 29.15 Operative images during taTME demonstrat- and the prostatic capsule. The lower most extent of
ing inadvertent mobilization of the prostate, exposing the Denonvilliers’ fascia is not a clear structure. As such,
urethra as a midline cord when it is identified, it may be necessary to actively incise
to pass into the plane anteriorly
3. The longitudinal midline cord without a tissue
plane. the dissection can be guided safely, and vital
4. The operating surgeon’s hand being placed structures, including intraperitoneal organs such
low with the instruments angling upward, as the small bowel, can be easily avoided. When
indicating the dissection is too anterior. operating with a single team, there are a number
5. Bleeding at the 10 and 2 o’clock position from of cues that the peritoneal reflection is being
the neurovascular bundle of Walsh, when this approached. When dissecting anteriorly, in both
is distracted downward into the plane of females and males, there is slightly more extra-
dissection. peritoneal fat in the region of the peritoneal
reflection compared to more distally. The tissues
Denonvilliers’ fascia can be clearly identified here are also more loosely attached. The pressure
from below, and the dissection can pass anterior differential between the pneumopelvis and the
or posterior to this at the surgeon’s discretion. pneumoperitoneum can lead to a “fluttering” of
The caudal end of Denonvilliers’ fascia is not a the tissues, both just before and just after incising
distinct structure and so can be difficult to define the peritoneum. As the defect in the peritoneum
at its distal most extent where it inserts onto the enlarges, this fluttering diminishes and disap-
urogenital diaphragm. Once dissection has pears as the two cavities merge and the pressures
passed a short distance, the fascial tissue becomes equalize. There may also be the impression of
clearer. At this point a decision can be made to small bowel or other intraperitoneal organs mov-
dissect anteriorly with the capsule of the prostate ing subtly, seen through the thin peritoneum
gland on view, or posteriorly, lifting Denonvilliers’ before division. This is an important sign to rec-
fascia and leaving it attached to the prostate (see ognize so as to avoid inadvertent injury when
Fig. 29.16). incising the peritoneum. Laterally it is important
to be aware of the position of the ureters and
avoid dissecting too laterally, as described previ-
Entering the Peritoneal Cavity ously and shown in Fig. 29.13. It is often safer to
breach the peritoneal reflection anteriorly and
Identifying the peritoneal reflection is most clear then continue division of the peritoneum toward
when operating synchronously with both a trans- the lateral structures to be certain that these are
anal and an abdominal surgeon. With both views protected.
section, achieving a high-quality total mesorectal

excision and avoiding complications.
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
Introduction sary to avoid urethral injury as use of taTME

becomes more widespread.
Transanal total mesorectal excision (taTME)
allows for improved exposure and visualization
of the distal rectum, improving the quality of Incidence of Urethral Injury
resection. However, there is a unique risk for iat-
rogenic injury to the male urethra due to the fact There is significant variability in the rates of ure-
that the prostate can be inadvertently mobilized thral injury reported in current case series, and
from below, but not from above, thus exposing not all series reporting on the initial results of
the prostatic urethra [1]. This risk is particularly taTME have documented complications includ-
important given that, thus far, taTME has been a ing the incidence of urethral injury. To date, rates
preferred approach in men, given its benefits in of urethral injury have varied from 0% in several
approaching a narrow or deep pelvis [2], as dem- large case series to 6.7% in a study of n = 30 male
onstrated by data from the international taTME patients by Rouanet et al. [5]. A number of large
registry (LOREC) showing that 1080 of 1594 case series have reported no incidences of ure-
cases (67.8%) were performed in male patients thral injury including a study of n = 140 patients
[3]. Moreover, urethral injury has not been docu- by de Lacy et al. [6], a study of n = 80 patients by
mented in other sphincter-preserving methods of Veltcamp Helbach et al. [7], and a study of n = 50
rectal resection (i.e., low anterior resection) and patients by Chen et al. [8]. Three other series
is only a rare complication in abdominoperineal have reported single cases of urethral injury, with
resection, with reported incidence ranging a rate of 2% in a study of n = 50 patients by Burke
between 1.5% and 3.0% [4]. Specific training to et al. [9], a rate of 5% in a study of n = 20 patients
understand anatomic landmarks and risk factors by Kang et al. [10], and a rate of 1% in a study of
and prevent wrong-plane surgery will be neces- n = 100 patients by Perdawood et al. [11]. Results
from the voluntary international taTME registry
noted that of n = 1594 patients undergoing
H. Carmichael
Department of Surgery, University of Colorado, taTME, 12 patients were documented to have a
Aurora, CO, USA urethral injury (0.8%), similar results to those
e-mail: [email protected] found in the initial publication including n = 720
P. Sylla (*) patients [3, 12]. Of note, most series report rates
Division of Colon and Rectal Surgery, Icahn School that are not broken down by patient sex and
of Medicine at Mount Sinai, New York, NY, USA therefore do not report the incidence in males

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
that this risk can be mitigated by training spe- nderstanding the Anatomic

U
cific to urethral injury – the same group found Landmarks
that the rate of prostate mobilization could be
decreased with additional training about land- Understanding the critical anatomic landmarks is
marks and how urethral injuries occur, decreas- crucial to avoid wrong-plane surgery in taTME
ing substantially from 20% to 3.3% after specific and therefore prevent urethral injury [1, 9, 16,
training on urethral injury and anatomic land- 17]. Atallah et al. have highlighted the impor-
marks was provided [14]. tance of three key anatomic aspects that should
Urethral injuries, when they do occur, can be recognized by the taTME surgeon [16]. The
have exceedingly debilitating effects on urinary first is the paired neurovascular bundles of Walsh
and even sexual function. Of the 34 injuries doc- which are located laterally between the rectum
umented by Sylla et al., 32 (94.1%) were identi- and the prostate (at the 10 and 2 o’clock positions
fied intraoperatively [15]. Of these, 12 were during taTME dissection) and each include two
converted to a transabdominal approach or 3–4 mm paired arterial vessels [18]. The dissec-
unplanned APR or Hartmann’s procedure tion in taTME should always be posterior (super-
(37.5%). Of 34 injuries, 9 patients (26.4%) went ficial) to these structures as well as the
on to develop complications from the repair rectoprostatic (Denonvilliers’) fascia [16, 19].
including stricture (n = 4), rectourethral fistula Secondly, the surgeon should recognize the
(n = 3), urethral dehiscence (n = 1), or urethra- smooth, spherical, and symmetric shape of the
perineal fistula (n = 1). These patients with com- inferior lobe of the prostate, which is normally a
plications experienced a 30% rate of failed pale yellow in color [1, 16]. Unfortunately, recto-
urethral repair requiring permanent cystostomy. prostatic plane identification can be severely
Sexual function was assessed in 22 patients, with complicated by dense postradiation fibrosis,
13 (59%) noting erectile dysfunction. prostate enlargement, or plane distortion from
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
understanding of the slope of the sacral curvature

and length of the horizontal rectum [13]. Such
review also allows the surgeon to evaluate the
dissection plane between the prostate and the
anterior rectum, including factors that might
affect the positioning of this plane including a
tight or narrow pelvis, which may push the pros-
tate more cephalad and bring the prostatic urethra
in closer proximity to the anterior rectum, or a
hypertrophied prostate, which may alter the nor-
mally inline or horizontal orientation of the rec-
toprostatic fascia and anterior dissection plane in
taTME [23].
Recognizing Patients at Risk

Fig. 30.2 Partial urethral transection during
taTME. Anterior taTME dissection proceeds along the
incorrect plane, too far superiorly and erroneously head- In addition to understanding critical anatomic
ing toward the apex of the prostate. The posterior aspect of landmarks, it is also important to understand
the prostatic urethral is transected; the injury is recog- patient-specific risk factors that may put certain
nized by visualization of the Foley catheter (white arrow). individuals at higher risk for urethral injury with
The dissection is redirected inferiorly and closer to the
anterior rectal wall (blue arrow). The correct plane of dis- taTME. As mentioned previously, normal ana-
section between the rectum and prostate is finally identi- tomic relationships may be distorted in the set-
fied and dissected, after which the urethral injury is ting of benign prostatic hypertrophy, a large
primarily repaired with sutures anterior tumor with threatened circumferential
radial margin (CRM), a narrow pelvis, or bulky
In the series of 34 urethral injuries collected pelvic musculature [13, 23]. Of the 34 cases of
by Sylla et al., the most common technical error urethral injury analyzed by Sylla et al., 33% of
leading to urethral injury was a failure to identify patients had a baseline prostatic abnormality,
the correct anterior TME plane or landmarks as most commonly benign prostatic hypertrophy
noted above, usually because of distortion of tis- [15]. Other risk factors include history of prior
sue planes (Sylla et al., manuscript submitted for pelvic radiation, transrectal prostate biopsy, radi-
publication) [15]. Many surgeons noted continu- cal prostatectomy, brachytherapy, or other pelvic
ing the dissection in the posterior and lateral surgery. Patients with these risk factors are likely
planes in the face of a difficult anterior dissection to have fibrosis, scarring, and fusion of the recto-
can lead to a “drooping” of the prostate into the prostatic fascia, leading to unclear dissection
rectum and actually increases the risk of carrying planes and increased chance of wrong-plane sur-
the dissection along the inferior lobe of the pros- gery [1]. Finally, tumor characteristics can also
tate, placing the posterior membranous urethra at increase the risk of urethral injury, with low and
risk (Figs. 30.1 and 30.2). anterior tumors posing the highest risk for injury,
In addition to recognizing anatomic land- especially when taTME is completed with partial
marks, understanding the particular anatomy of a or complete intersphincteric resection (ISR) [1].
patient undergoing taTME with review of the rec-
tal protocol magnetic resonance imaging (MRI)
prior to the case is critical [13, 16]. This allows Intraoperative Prevention
the surgeon to review the location of the tumor, Strategies
height from the anal verge, and circumferential
resection margin (CRM). However, as pointed Several intraoperative techniques have been
out by Atallah et al., preoperative review of the described to help better locate or visualize the
MRI in midline sagittal section allows for a better correct planes of dissection during taTME. The
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
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.
may be helpful in identifying the urethra and pre- 2018;32(5):2312–21.
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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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EL. Transanal minimally invasive surgery for
How to Avoid Urethral Injury
in Males 31
Sam Atallah and Itzel Vela
Introduction The true incidence of urethral injury is diffi-

cult to ascertain, and reports vary in the frequency
With early experience in taTME, it became evi- of this complication, including a recent series on
dent that a new type of procedure-specific, taTME for mid and low rectal cancer in which no
gender-specific morbidity had emerged, as injuries were observed in the study group of 186
described by one of the original clinical series on patients [3]. Funded by the Pelican Foundation,
this new operation by P. Rouanet [1]. Namely, the Low Rectal Cancer Development (LOREC)
this was iatrogenic injury to the male urethra dur- database has been used to collect and register
ing the transanal dissection. In this 2013 series by clinical and pathologic details on taTME opera-
Rouanet, taTME (then using the moniker trans- tions, as self-reported by surgeons. While subject
anal endoscopic proctectomy (TAEP)) was per- to reporting bias, this data was analyzed by
formed utilizing the transanal endoscopic M. Penna et al. on behalf of the taTME registry
operating (TEO) platform. Of the 30 male collaborative [4]. It revealed that, of the 720
patients who underwent taTME, two (6.7%) had taTME operations performed for benign and
iatrogenic injury to the urethra. Subsequently, malignant disease, 489 (67.9) were male. There
Burke et al. reported initial outcomes of taTME were five urethral injuries (presumably all male
with 50 consecutive patients (male and female) patients), and thus the observed incidence of this
using the transanal minimally invasive surgery morbidity in the registry data was 5/489 (1%).
(TAMIS) platform whereby a single urethral While generally it appears that the risk of ure-
injury occurred [2]. Importantly, urethral injury thral injury is ≤5%, this may not accurately
during taTME is specific to males. There were 30 reflect the true incidence of this morbidity as
male patients in this series by Burke et al., and there are several anecdotal cases of urethral
thus the gender-adjusted incidence of urethral injury that are currently unpublished.
injury was 1/30 (3.3%). Furthermore, other data are available to suggest
that the risk of urethral injury may indeed be sig-
nificantly higher. Much of this is based on data
S. Atallah (*)
AdventHealth Orlando, Oviedo Medical Center, gathered from training courses and analysis of
and University of Central Florida College of Medicine, the uptake of taTME in clinical practice. To date,
Orlando, FL, USA in the largest training center in North America,
e-mail: [email protected] over 220 surgeons have received specialized
I. Vela cadaveric-based training, and during wet lab ses-
Instituto Nacional de Cancerología, Mexico City, sions, it was observed that 1 in 5 delegate trainee
Mexico

322 S. Atallah and I. Vela
teams would inadvertently mobilized the prostate

during taTME [5]. In the same study, it was also
found that, upon course completion, 25% of sur-
vey respondents reported having had a urethral
injury after implementing a taTME program at
their respective institutions [5]. Even inadvertent
exenteration by delegate surgeons was observed
at these cadaveric training sessions, highlighting
the gravity and scope of potential iatrogenic
injury to the urinary system [6]. Based on this,
the importance of this potentially catastrophic Fig. 31.1 The anatomic relationship of the prostate gland
complication must be very carefully understood. and urethra in relation to the rectum during distal taTME
Although urethral injury has been described dissection can place the pre-membranous portion of the
with the abdominoperineal resection (APR), it is urethra at risk for iatrogenic injury. Note the “vertical”
presentation of the urethra which is typical when the pros-
uncommon, and urethral injury with sphincter- tate gland is dorsally distracted
preserving rectal extirpation appears to only be a
risk with taTME [6]. Even when compared to the
transanal abdominal transanal (TATA) operation ssessment of Patient Risk
A
(often considered the prequel to the modern-day for Injury
taTME), the incidence of urethral injury distinctly
The first step is to assess the patient’s indepen-
differs [6–9], and this can be attributed to the con-
stant tactile feedback surgeons utilize during dent risk of urethral injury during taTME [6].
TATA to confirm the position of the prostate gland, This is important for surgeons to understand
a subtle yet crucial distinction between taTME and beforehand and is considered a vital step in case
TATA. Notwithstanding, male urethral injury preparedness. The objective is to risk-stratify
appears to be contingent upon a perineal approach patients for the potential for this injury, since not
to organ extirpation. Here, the factors related to all patients pose the same risk for urethral injury
urethral injury during taTME are analyzed and [6, 10]. As detailed in Table 31.1, urethral injury
discussed. Avoiding male urethral injury during risk stratification is dependent upon these six fac-
taTME represents one of the most paramount tors: (a) prior local therapy, (b) previous local
modules in training and is absolutely essential to operations, (c) congenital malformations of the
the maturation of the taTME surgeon. genitourinary system, or a history of male pelvic
penetrating or blunt trauma, (d) pre-existing his-
tory of benign prostatic hypertrophy or pathology
Specific Point of Urethral Injury intrinsic to the male urethra, (e) history of prior,
especially chronic or recurrent inflammatory dis-
Male urethral injury occurs during distal anterior ease of the anus, rectum, or prostate, and (f)
dissection, when the anterior taTME rectotomy tumor-specific factors – such as is the case for
lies within ≤3 cm from the anorectal ring [10]. radiated, low-lying anterior and fixed lesions
With distal dissection, the prostate can be dis- which exhibit desmoplastic changes. Such locally
tracted dorsally, and, in the process, the pre- advanced cancers pose a challenge for surgical
membranous urethra can become exposed leading clearance and, with taTME, may dorsally distract
to iatrogenic injury to its posterior aspect the prostate-urethral complex in the process,
(Fig. 31.1). Immediate recognition of the urinary which could place the organ structures at risk for
catheter has prevented complete urethra disrup- injury.
tion, and to date, in vivo urethral injury has not Patients who possess significant risk of ure-
involved complete transection through the ven- thral injury based on preoperative assessment,
tral wall of the urethra. including the six categories mentioned, should be
31 How to Avoid Urethral Injury in Males? 323
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
important nuances of taTME related to urethral

injury prevention are detailed in the following
sections.
he Rectourethralis Muscle
T
and the Pre-rectal Muscle
Fibers of Luschka
The first step in the transanal portion of taTME is

the application of the purse string [12, 13]. Care
must be taken to have symmetric suture bites
which do not extend beyond the outer, longitudi-
nal muscle of the rectum as this can inadvertently
incorporate tissue that is beyond the scope of dis-
section, such as the periprostatic fascia and extra-
rectal muscle fibers intrinsic to the pelvic floor.
However, even with correct purse-string place- Fig. 31.2 An anatomic plate delineates the muscles of
ment, entry into the proper TME plane – espe- the pelvic floor in relation to the prostate gland, urethra,
cially anteriorly – can sometimes be challenging and taTME apparatus. The first step after purse-string
because an often dense structure is encountered, application is to divide the rectal wall, which is often
thickened anteriorly as it is fused with the fibers of
and this can create a barrier to holy plane entry. Luschka and the rectourethralis muscle. The surgeon must
This specifically applies to taTME dissections transect these attachments when operating distally to enter
carried out ≤3 cm of the anorectal ring. Extra- the holy plane. The contiguous muscle fibers appear
rectal bands of muscle extend from the rectum homogenous from the taTME perspective, and this makes
proper division challenging. Note the puborectalis muscle
are properly inserted onto the endopelvic fascia flanking the prostate gland. This is the skeletal muscle that
and the preprostatic fascia [14–18]. This is the becomes visible anteriorly when the prostate gland is
most pronounced anterior to the rectum and inadvertently mobilized
likely represents a composite of the pre-rectal
muscle fibers of Luschka and the rectourethralis male urethral injury. Thus, taTME surgeons, spe-
muscle, both of which lie medial to the puborec- cifically when performing the distal anterior rec-
talis and the levator ani muscle complex tal dissection, must remain vigilant of these
(Fig. 31.2). They also contain muscle fibers from factors and must have a remastered comprehen-
the conjoined longitudinal muscle of the anal sion of the relevant extra-rectal muscle anatomy.
canal. Anteriorly, the rectourethralis and pre-
rectal muscle appear fused, becoming quite
defined. During the taTME dissection, they orphology of the Prostate
M
appear as broad “vertical” bands of muscle Gland and Urethra
extending from the pre-membranous urethra and
posterior lobe of the prostate gland to the anterior Should the prostate gland become mobilized dur-
rectal wall which makes distinction between the ing taTME, the posterior lobe will be distinctly
two organs difficult to discern (Fig. 31.3). A com- recognizable as a pale-yellow spherical and sym-
mon error is to assume that these bands of muscle metric gland that is characteristically smooth [19].
“belong to the rectum” and novice taTME sur- Surgeons may sometimes confuse this “mass”
geons will tend to include the rectourethralis anteriorly for that of an anterior positioned rectal
muscle and fibers of Luschka in the specimen by tumor. However, the smooth contour of the mobi-
purposely dissecting too far anteriorly. This is lized gland is not a characteristic of invasive rectal
one of the most important factors predisposing to cancer. Furthermore, the cylindrical urethra can
Fig. 31.3 The anterior, distal taTME dissection presents

the surgeon with an obscure sheet of muscle that directly
communicates with the rectal wall and is contiguous with
the rectourethralis and muscle of fibers of Luschka. The
challenge for the operator is to transect this muscle bundle
at a point that precisely separates the prostate gland from
the anterior rectal wall without injury to either structure
also be seen at the 12 o’clock position (Fig. 31.4).

Finally, the mobilized prostate appears as a sepa-
rate structure ventral to the anterior, mobilized rec-
tum, and the two structures together form the Fig. 31.4 Video still frames of iatrogenic uretrhal injury
shape of a figure “8” [20], and surgeons should be during taTME in males
trained to quickly discern this. To do so, taTME
surgeons are encourage to maintain a global view
during dissection – such that the purse string and Denonvilliers’ Fascia
rectum remain in view as this provides an impor-
tant frame of reference for the operator. Denonvilliers’ fascia is unique to males. This
dual-layered envelope establishes the plane
between the anterior rectal wall and the posterior
Anterior Exposure aspect of the prostate gland (Fig. 31.5). Extending
of the Puborectalis Muscle from its point of insertion at the urogenital dia-
phragm to the peritoneal reflection, this fascia
The striated skeletal muscle of the pelvic floor is helps separate the two structures. With the taTME
a conical extension of the anal canal. Through the approach and with perineal insufflation, the ante-
taTME vantage point, depending on prostate rior plane often is established easily, resolving
size, this skeletal muscle should not be visible to what is otherwise one of the greatest challenges
within approximately ±20° from the 0° anterior of conventional radical rectal resection, namely,
midline. Exposure of this muscle at this level the anterior dissection along the horizontal por-
typically implies mobilization of the prostate tion of the rectum. However, this fascial plane
gland and should warrant immediate reassess- and the associated neurovascular bundles of
ment of the plane of dissection (Fig. 31.2). Walsh which flank Denonvilliers’ fascia can be
Fig. 31.5 The anatomic arrangement of Denonvilliers’

fascia relative to the neurovascular bundle of Walsh
(NVBW) and the anterior rectal wall is crucial to the mas-
tery of the taTME approach. The NVBW flanks the bilay-
ered fascia and can be distracted dorsally during taTME
dissection. Surgeons must be cognizant of these structures
Fig. 31.6 The paired arteries are visible components of
as early recognition helps surgeons maintain the correct
the NVBW and can be identified along the lateral borders
anterior TME plane
of Denonvilliers’ fascia at the 10 and 2 o’clock position.
These landmark vessels should always be identified dur-
ing the taTME dissection and reflected ventrally. This is a
dorsally distracted, moving the pre-membranous
critical step in the distal anterior dissection that prevents
urethra into the operative field where it becomes posterior distraction of the prostate and preprostatic
prone to insult. urethra
The Neurovascular Bundle of Walsh apparent, and this serves as an opportunity to

readjust the plane of dissection before injury to
In general, colorectal surgery training has hereto- the midline urethra occurs. Occasionally, the
fore not included formal study of the prostate NVBW is not recognized and is instead tran-
gland and its neurovascular complex. Essentially sected. However, this often results in arterial
exclusive to the taTME vantage point, the neuro- bleeding that is readily recognized and often not
vascular bundle of Walsh (NVBW) [21] can not controlled with monopolar cautery alone due to
only be visualized, but it can often serve as an vessel diameter. After gaining control of hemor-
important landmark, which, when recognized, rhage, it is important to reassess the plane of dis-
can help the operator remain on the correct plane section, reflecting the NVBW ventrally so as to
thereby avoiding injury [10, 19, 22]. The NVBW maintain the correct anterior taTME plane.
contains paired nerves, veins, and arteries. Of A reproducible and safe approach to the ante-
these, it is the arteries that are most recognizable rior dissection is to begin along the dorsal rectum
during taTME (Fig. 31.6). Along the anterior and then gradually extend the dissection laterally.
hemisphere, at the two and ten O’clock positions This leads to identification of the nerve branches
and flanking Denonvieller’s fascia, course the derived from the S4 and S5 arcade as they inner-
arteries of the neurovascular bundle. These ~ vate the rectum to become part of the distal rectal
4 mm arteries are known as prostatic capsular plexus. These are often visible laterally creating
arteries and derive from the inferior vesicle arter- “triangles” that extend to the mesenteric enve-
ies. When the prostate gland is inadvertently lope [23] and can be reflected laterally at what is
deflected downward, and when the taTME sur- often a triangular entry point to the mesorectal
geon enters a plane of dissection which is too envelope. As the dissection then proceeds ven-
anterior, the visible vessels of the NVBW become trally in a stepwise manner from the 3 (or) 9
Fig. 31.8 The Kanizsa triangle is the archetypal example

of perceptual (visual) completion, whereby the mind “fills
in” a picture that is not true reality. Here, our mind envi-
sions an equilateral triangle, although there is no such tri-
angle in actuality. Filling in what is not real can result in
misperception that results in iatrogenic injury. This is
more likely to occur when the frame of reference is lost
Fig. 31.7 This critical view allows surgeons to maintain and when anatomic structures are misidentified
a safe frame of reference and identify the correct division
point anteriorly. In a stepwise approach, the lateral nerve
branches, including those that derive from the S4 and S5
nerve roots, are reflected away from the mesorectal enve- field of view with laparoscopy is broad, thereby
lope. Anterolaterally, the NVBW is then identified, which constantly enabling the surgeon to define and
defines the ventral most extent of the taTME plane. Once redefine the visual frame of reference during the
this structure is identified, the fusion of anterior rectal
wall together with fibers of Luschka and fibers of the rec- process of dissection. While the optics achieved
tourethralis muscle can be safely transected through laparoscopic high-definition systems
delivers superb video quality, with taTME, there
is a potential hazard of tunnel vision as close
o’clock position toward to the midline 12 o’clock proximity positioning of the camera’s lens in
position, the visible artery of the NVBW can be relationship to the point of dissection may lead to
identified as it is seen coursing along the lateral disorientation. While telescoping the lens toward
aspect of the prostate gland. Once identified, the the vicinity of dissection provides the operator
surgeon is provided with the perspective needed with enhanced anatomic detail, the frame of ref-
to then safely divide the rectourethralis muscle erence within the visual field can be lost. This can
and fibers of Luschka in the proper plane result in misperception that leads to the phenom-
(Fig. 31.7). enon of visual completion.
Visual or perceptual completion occurs when
the human mind “fills in” a visual defect to com-
urgeon Misperception and Visual
S plete a picture that is only an illusion [25]. The
Completion archetypal example of this is the Kanizsa triangle
[26, 27], whereby one’s mind “completes” the
Surgeons operate though comprehension of ana- image of a triangle that in reality does not exist
tomic planes in a specific context and with cogni- (Fig. 31.8). Thus, visual completion can result in
tion derived from having a frame of reference a specific kind of disorientation in which the sur-
[24]. With camera-based minimally invasive surgeon is not aware that the visual cues being pro-
gery, the visual scope and the frame of reference cessed are incorrect.
it provides are derived by the anatomic landmarks One can consider common bile duct (CBD)
contained within the visual field. Typically, the injury during cholecystectomy as a paradigm to
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
Fig. 31.10 A near-infrared luminescent stent has been

placed in the male urethra during taTME. It is visible dur-
Fig. 31.9 A urinary catheter is also a urethral stent. This ing the dissection, providing augmented information
concept is important and can be used by the taTME sur- about the position of the urethra during dissection
geon to localize the male urethra when there is uncertainty
about its position. Here, a vibratory stimulus is transmit-
ted using an ordinary electric skin clipper which when Table 31.3 Emerging and theoretical techniques to
applied to the catheter can be registered as a vibratory sig- localize the urethra during taTME
nal along its entirety, including the preprostatic portion of Currently applied techniques
the urethra. The surgeon can then register this vibration
Direct tactile feedback
either electronically via Doppler wave form or audible
signal (shown) or more simply by tactile feedback Application of traction release on urinary catheter to
detect movement
Transmission of vibratory stimuli along urinary catheter
Ultrasound detection of urethra ± retrograde irrigation
feedback) include applied vibratory stimuli that Doppler detection of urinary catheter with vibratory
stimuli transmission
can be transmitted and palpated by the operating
Use of infrared luminescent urethral stent
surgeon (Fig. 31.9), laparoscopic ultrasonogra-
Augmented reality with stereotactic navigation/
phy with or without retrograde catheter irriga- cybernetic surgery (select centers only)
tion, and the use of lighted near-infrared ureteral Future directions
stents [6, 40]. Use of organic dyes and near-infrared imaging
Newer techniques focus on the use of bio- Accelerometers and laser Doppler vibrometry
fluorescence and organic dyes [6, 41, 42]. This Passive millimeter-wave imaging
includes indocyanine green (ICG) – the best stud- Magnetic or radioisotope impregnated urinary catheter
ied of the organic dyes for surgical applications Piezoelectric sensors coating of urinary catheter
Intraoperative X-ray fluoroscopy
(Fig. 31.10). Since it is cleared hepatically, ICG
is not excreted in the urinary system, and thus
systemic administration will not produce fluores- Future developments may include urinary
cence of the urethra. However, it can be directly catheters which are impregnated with materials
instilled into the urinary system, whereby it that exhibit luminescence in the near-infrared
avidly binds to urothelium and fluorescence can spectra [6]. This may include photostable quan-
be observed [41]. ICG, like most organic dyes, tum dots and single-walled carbon nanotubes that
has an important translucency property that represent hexagonal lattices of graphene [6, 43–
allows deep soft tissues to become visible. This 46]. Finally, although currently experimental for
enhanced visibility “beyond the visible light pelvic visceral surgery, stereotactic intraopera-
spectrum” [6] allows surgeons to see what they tive imaging and navigation holds promise to
otherwise cannot. Newer organic dyes may sig- localize pelvic viscera which include the prostate
nificantly improve detection of deeper structures gland and urethra [47–54]. Table 31.3 summa-
allowing surgeons to appreciate vital structures, rizes current and evolving methods to localize the
including the urethra, before injury occurs [42]. male urethra during taTME.
Urethral Injury Management elated Injuries to the Urinary

R
System
While iatrogenic urethral disruption represents a
major complication not encountered during The tri-compartment structure of the male pelvis
abdominal approaches to mesorectal excision, is composed of the rectum posteriorly and the
there is ample experience with urethral injury bladder anteriorly. The structures are normally
management which is derived primarily from the separated by the mid-compartment – occupied by
trauma literature. In particular, males subjected to the prostate gland. However, this “textbook”
blunt force trauma and subsequent pelvic rami arrangement is not always exact as a patulous,
fractures are prone to urethral transection. A ure- atonic bladder can be displaced into the middle
thral disruption proximal to the urogenital dia- pelvic compartment in males – and in post-
phragm is considered a Type 2 injury based on the hysterectomy females as well.
Goldman classification [55]; this is the type of Bladder atony results in bladder volumes in
injury that occurs with taTME, albeit from sharp excess of normal (~400 ml) with volumes of
rather than blunt insult. In the setting of trauma, a 6000 ml being reported [56]. Implicit is an
Type 2 injury is managed by suprapubic catheter increased surface area that, even with adequate
drainage and delayed urethral repair. In this set- urinary catheter drainage, can result in risk of
ting, urinary catheter placement is contraindi- injury if this structure. Thus, it is possible during
cated, even when urethral disruption is only the anterior, sub-peritoneal taTME dissection to
suspected as placement can lead to creation of a injure the bladder without displacing the prostate
false passage. However, intraoperatively, with iat- gland or urethra as this injury tends to occur
rogenic injury to the urethra during taTME, the more proximally (Fig. 31.12a, b).
urinary catheter should be left in place and not Fortunately, bladder injury with taTME is
removed as it serves as a stent so that the defect uncommon. When the bladder is forcibly dis-
can be allowed to heal after primary repair. Most tracted ventrally – as is often the case with the
taTME experts recommend primary sutured two team taTME approach – injury to the bladder
repair of the urethral disruption with absorbable becomes less likely. Thus, synchronicity of the
suture and delayed catheter removal (Fig. 31.11). abdominal and perineal surgeons during taTME
is important in reducing the risk of iatrogenic
bladder injury as the dissection approaches the
peritoneal reflection from below.
If injury to the bladder is recognized at the
time of taTME, then it is recommended the
patient undergo urologic evaluation to exclude
injury to the trigone and to assess the extent of
the bladder injury. This can be performed via
cystoscopy. Furthermore, the camera lens used
for taTME can be advanced into the bladder to
evaluate the organ and to insure the ureterovesi-
Fig. 31.11 The transected urethra during taTME is here cal junctions are uninjured. A layered repair with
being repaired using a laparoscopic needle driver and absorbable suture utilizing the transanal plat-
absorbable suture via the transanal access platform. Most form is recommended, with prolonged catheter
experts recommend repair of a urethral disruption and
continued catheter drainage. Note the vertical bands of drainage postoperatively. Interval cystoscopy or
muscle which likely represent a composite of the recto- contrast imaging is also advised to assess
urethralis muscle and fibers of Luschka healing.
Dis. 2016;18(6):570–7. https://doi.org/10.1111/

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A Roadmap to the Pelvic
Autonomic Nerves During 32
Transanal Dissection
Werner Kneist
Introduction As this book makes very clear, the video

endoscopic- assisted, bottom-up (taTME)
In addition to the principle of oncologic radical- approach is promising, but it requires special
ity, a total mesorectal excision (TME) should knowledge of surgical anatomy, excellent techni-
take into account the principle of functional pres- cal skills, training, and experience driven by high
ervation, by maintaining pelvic autonomic nerves volumes. These requirements are particularly
[1]. From the start, the taTME approach has important for achieving nerve preservation.
brought hope of better preservation of autonomic
nerve fibers [2–4]. However, it can be difficult to
identify subperitoneal nerve structures in the Transanal Nerve-Sparing
minor pelvis intraoperatively, due to the complex Mesorectal Dissection
neuroanatomical topography and various patient-,
tumor-, and surgery-related factors. The diffi- In its reflection of the different steps involved in
culty in achieving intraoperative pelvic auto- the taTME procedure, a macroscopic description
nomic nerve preservation (PANP) appears to of the topographical location of nerves should
parallel the difficulty in achieving a qualitatively give the surgeon at least an idea of where caution
adequate TME specimen. Therefore, it is not sur- is warranted for preserving the urogenital and
prising that more challenging cases, with an internal anal sphincter nerve supply. Table 32.1
implicit high degree of operative difficulty, por- documents the findings and experiences reported
tend an increased risk of nerve injury. The diffi- previously by individual authors that performed
culty in PANP increases with severe obesity, a taTME. Didactically, this chapter is arranged
narrow male pelvis with a voluminous mesorec- according to the topography of extrinsic auto-
tum, neoadjuvant chemoradiation therapy, a local nomic pelvic innervation.
advanced tumor in the mid-rectal third, or a very
low cancer [5, 6]. Since all of these factors are
improved by the taTME technique, it stands to erminal Branches of the Internal
T
reason that taTME can result in PANP. Anal Sphincter Nerves
W. Kneist (*) A complete intersphincteric resection removes the

University Medicine of the Johannes Gutenberg- entire internal anal sphincter (IAS), and thus, it ren-
University Mainz, Department of General, Visceral ders the innervation inconsequential. Nevertheless,
and Transplant Surgery, Mainz, Germany it is desirable to preserve some relevant nerves

336 W. 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
2 Levator ani muscle IASN (Postero-) lateral at

the 4 and 8 o’clock
lithotomy positions
3 Pelvic sidewall above Posterior-inferior edge of Lateral at the 3 and 9

the level of the levator the IRP o’clock lithotomy
ani muscle positions
4 Sacral nerve routes S4 PSN Posterolateral

and S3
5 Prostate/vagina IHP with its anterior parts Anterolateral at the

and NVB 2–3 and 10–11
o’clock lithotomy
positions
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
Internal Anal Sphincter Nerves
In the 1950s, Otto Goetze described tuft-shaped,

branched, fine fibers that projected from the low-
est section of the pelvic ganglion in a specimen
after abdominoperineal excision. He reasoned
that extrinsic IAS innervation could be spared
with a transanal, bottom-up approach, and he
stated that the lower the resection and the less
IAS nerve preservation, the worse the continence
outcome [18].
When an incision is performed above the den-
Fig. 32.1 Inferior rectal plexus (IRP) on the right pelvic
tate line or the IAS level, the transanal video side in a male patient with taTME for rectal cancer
endoscope-assisted approach is suitable for veri-
fying the internal anal sphincter nerves (IASNs)
[10]. The extrinsic IAS innervation approaches the 2–3 and 10–11 o’clock positions, at the level
the anorectal junction with a varying number of the distal rectum, have been reported to be
(two to six) of nerve fascicles bilaterally, from nerve-rich zones [10, 13, 15, 20, 21].
the 5 and 8 o’clock location (with patients posi-
tioned dorsal lithotomy), at the level of the leva-
tor ani muscle. This nerve location might vary Neurovascular Bundles
somewhat, due to changes in the perspective,
according to different lengths of anal canal, the During the anterolateral dissection, one must rec-
angle of the anorectum (90–100°), and the posi- ognize the combined structure of cavernous
tion of the platform shaft (and the nerve displace- nerves and blood vessels – the neurovascular
ment this may cause). Nevertheless, the initial bundles (NVB) of Walsh. A very low, strictly
posterior dissection appears to be safe with anterior dissection of the perineal body does not
respect to this innervation. During the subsequent cause injury to these cavernous nerves. At the
bottom-up mesorectal dissection, the IASN can beginning, the NVB should first be identified by
be traced in the caudal to cephalic direction, and locating paired pulsatile arteries anterolaterally.
it curves from a lateral to an anterolateral posi- To avoid injuries to the nerves, blood vessels,
tion [8–10, 15, 20]. vagina, prostate, or urethra, it is necessary to find
an adequate plane of dissection. This plane is
behind the NVB of Walsh and anterior to the uro-
Inferior Rectal Plexus genital septum (Denonvilliers’ fascia in males).
With a caudal to cephalic approach, the nerves
During the lateral dissection, tracing the IASN diverge from the lateral aspects of the perineal
within the triangle that lies between the anterolat- body and follow the anterolateral surface of the
eral aspect of the rectum and the posterolateral mesorectum. They pass along the inferior border
border of either the prostate or the vagina leads to of the prostate – or along the lateral surface of the
the inferior rectal plexus (IRP). The sub-plexus vagina, at the level of the junction of the lower
of the inferior hypogastric plexus (IHP) is located and middle thirds of the vagina. Then, the nerves
anterolaterally, along the pelvic sidewall, starting can be traced to the lower anterior part of the IHP,
at the 3 and 9 o’clock locations (lithotomy posi- at the 2–3 and 10–11 o’clock locations (patient
tion), above the inferior medial level of the leva- positioned dorsal lithotomy) [8–10, 12–17]
tor ani muscle (Fig. 32.1). The areas revealed at (Fig. 32.1).
Pelvic Splanchnic Nerves efferent branches [24, 25]. In addition to efferent

nerves, the IHP also contains afferent fibers.
A cephalad posterolateral dissection enables Topographically, the dorso-cranial angle of
the identification of the pelvic splanchnic the IHP forms at the confluence of the internal
nerves (PSNs). However, parts of these nerve iliac vein. The ventro-caudal angle forms at the
fiber diameters are less than 150 μm; thus, iden- lateral aspect of the prostate gland, or at the entry
tification and preservation might be relatively point of the ureter into the uterine ligament, at the
difficult. The sacral spinal nerves (mainly from base of the parametrium. During a down-to-up
S3 and S4) course across the piriformis muscle. TME dissection, the dorso-caudal angle of the
A thin parietal fascial sheath covers these IHP could project to the fourth sacral region. As
routes. Approximately at the height of the tran- described above, the PSN must be identified, and
sition from the lower third to the middle third of during a lateral dissection, care must be taken to
the rectum, the PSN connects with the IHP in a avoid opening the parietal fascia (violations to
“bow”-shaped manner, particularly evident the fascia result in the so-called halo sign), due to
from the taTME vantage point. With careful the risk of entering a false plane with subsequent
preparation and pneumodissection, the PSNs inadvertent total denervation of the hemi pelvis
can be reflected dorsolaterally, and then, they autonomics. According to an international con-
can be traced to the anterior aspect. By follow- sensus statement, the lateral dissection should be
ing the autonomic nerves to the anterior aspect performed last, after dissecting the dorsal and
and recognizing the S4 and the NVB, the pros- ventral parts, to minimize the risk of damaging
tate gland can be identified, and a central dis- neurovascular structures (alternative approaches
section of the perineal body can be performed may also be valid). The extra-mesorectal, avascu-
[10, 14–16]. lar fat (“adipose pillars”), at 3 and 9 o’clock posi-
tions, at the level of the mid-rectum, represents
an important landmark, and these pillars, often
Inferior Hypogastric Plexus visible during taTME, must remain in the lateral
region as they are prone to medial displacement
Described as a triangle, the IHP is located [10, 14, 26, 27].
between the leaves of the parietal fascia, and it
spreads over the lateral walls of the pelvis minor.
It contains nerves from different sources, includ- Hypogastric Nerve
ing hypogastric nerves, pelvic splanchnic nerves,
sacral splanchnic nerves, the sympathetic chain, After dividing the lateral rectal ligaments, a dis-
and the mesenteric plexus. section along the “holy plane” (the plane between
A vertical organization of the IHP has been the presacral fascia and the mesorectal fascia)
described according to the pelvic organs and ana- proceeds in a caudal to cephalic course, up to the
tomical structures. The bladder lies at the superior peritoneal reflection, until reaching the level of
extent, the genital organs are in the medial region, the sacral promontory. Originating in the IHP
and the rectum is positioned at the inferiormost within the parietal pelvic fascia, the hypogastric
extent. The length, width, and depth of the IHP are nerves (HN) run medially from the ureter, inter-
approximately 40 mm × 10 mm × 3 mm [22, 23]. nal iliac artery, and veins and could be identified
The ganglion cell clusters are located lateral to the shining through in caudal-lateral to a cranio-
urinary bladder, seminal vesicles, paracervix, and medial direction. The left HN is described as sig-
middle rectum. Starting from the vesical plexus, nificantly shorter (53.0 ± 1.0 mm) and narrower
there are up to eight efferent branches, and from (1.7 ± 0.2 mm) than the right HN (73.8 ± 19.4 mm
the prostatic and rectal plexuses, there are up to six and 1.9 ± 0.0 mm, respectively).
340 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].
uture Aspects of Nerve-Sparing

F
taTME
Currently, cadaveric dissection is a recommended

key module in taTME training. Subperitoneal
autonomic nerve preservation can be studied in
detail in prepared didactics and other resources,
including this one, which help surgeons to under-
stand the intricate nerve anatomy, as well as the
relevant evidence and pitfalls. Furthermore, ana-
tomic specimens prepared for training and course-
work should be used to demonstrate autonomic
nerve tissues, followed by a hands-on module
with formalin-fixed pelvises. TaTME performed
in a cadaveric model should be used for teaching
visual identification and preservation of the differ-
ent nerve segments [15] (Fig. 32.2).
Intraoperative electrophysiological assess-
ments (i.e., neuro-mapping) might provide new
insights into the complex issue of how to incor-
porate PANP into minimally invasive TME
approaches (laparoscopic, transanal, robotic,
hybrid, etc.). Indeed, during taTME, identifying
the IRP and its posterior branches (IASN) with
an electrophysiological assessment (80% accu-
racy) was more meaningful than with visual
Fig. 32.3 Robotic-guided and transanal neuromapping.
assessment (45% accuracy), for both sides of the Documentation of the innervation with EMG of the internal
pelvis. Fully robot-guided pelvic neuro-mapping anal sphincter and manometry of the urinary bladder [17]
Fig. 32.4 Mixed reality

in taTME opens up
further possibilities [31]
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.
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Operative Vectors, Anatomic
Distortion, and the Inherent 33
Effects of Insufflation
Sam Atallah, Albert M. Wolthuis,
and André D’Hoore
Introduction dioxide insufflation separates fusion planes dur-

ing taTME pneumatically, thus insufflation itself
Prerequisite to taTME is a fundamental surgeon is a crucial aspect of this complex operation. In
skillset. This typically includes advanced this chapter, focus is given to understanding
colorectal MIS experience as well as experience aspects germane to operation within the subperi-
with an advanced transanal platform – such as toneal pelvis, to examining the important aspects
for TAMIS or TEM – especially as applied related to insufflation, and to the peculiar effects
toward local excision of rectal neoplasia. of gas flow observed during the transanal portion
However, there are important aspects of taTME of the taTME operation.
that must be understood as this operation is not
simply a hybrid combination of minimally inva-
sive laparoscopy and TAMIS. One reason for Operation in the Subperitoneal
this relates to how the workspace during taTME Space
is created and how this potential space is actual-
ized by the pneumatic forces of insufflation. To Commencing with the rectotomy (created after
some extent, the creation of this space and oper- purse-string application) until the point of perito-
ation in this modality are more similar to the neal entry during the taTME operation, the dis-
techniques and viewpoint achieved during totally section is created in an actualized, potential space
extraperitoneal endoscopic surgery, such as is along the fascial fusion planes which surround
the case for inguinal hernia repairs. Thus, taTME the mesorectal envelope circumferentially. This
radically differs from how workspace and opera- is perhaps one of the most fundamental differ-
tive field exposure occurs during laparoscopy, ences between the so-called up-to-down and
whereby transabdominal insufflation almost down-to-up approaches to TME. Hence, unlike
instantly creates a sustained workspace. Carbon with laparoscopy where the operative field and
workspace are defined immediately upon insuf-
flation of the peritoneal cavity, with taTME (dur-
S. Atallah
AdventHealth Orlando, Oviedo Medical Center, ing the down-to-up portion of dissection), the
and University of Central Florida College of Medicine, space created is a potential space. This space is
Orlando, FL, USA gradually developed along embryonic fusion
A. M. Wolthuis · A. D’Hoore (*) planes by the combination of sharp and gas dis-
University Hospitals, Abdominal Surgery, section as the field is actualized. The dissection
Leuven, Belgium may or may not proceed along the correct plane,

Change in taTME workspace volume as a function of time
taTMEWork space volume dv
Rectotomy Extra-peritoneal taTME dissection After peritoneal entry
taTME dissection time dt
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 relation 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
Abdominal CO2 insufflation vectors
Pelvic cavity
Ta TME CO2 insufflation vector
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
CO2 gas flow physics as applied to taTME
P1 Velocity flow rate 2 P2
Ca
nnu
la
CO2 flow velocity gradient CO2 outflow

CO2 inflow A1 Insufflation trocar to surgical field
Velocity flow rate 1
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
not subject to collapse as this can dramatically

limit the ability to continue with safe dissection.
Traditional insufflators were designed to dis-
tend the relatively large volume of the peritoneal
cavity. Such insufflation technology was actually
based on a quite rudimentary mechanical model.
In simple terms, the system delivers CO2 gas in a
pulsed fashion via a singular disposable insuffla-
tion tubing. The laparoscopic insufflator then
senses the pressure via sampling and delivers or
Fig. 33.4 The faceplate of the TAMIS port commonly
ceases to deliver gas in response to an arbitrary used for taTME is shown. One of the cannulas has been
set pressure. Thus, when the pressure in the insuf- replaced by an 8 mm valveless trocar (AirSEAL®), which
flated cavity falls to below the set level, gas is maintains a pressure barrier seal pneumatically rather than
with the trapdoor design that typically smudges the lens
actively pumped into the cavity until the desig-
during camera lens entry. As can be seen, the trocar is
nated pressure set point is reestablished. Minor completely transparent along its long access
fluctuations in pressure do not exhibit an appre-
ciable effect on larger spaces such as the abdomi-
nal cavity and insufflation through this modality ing a valveless trocar system that would create an
is quite reliable. However, minor fluctuations in invisible pressure barrier [20] so as to prevent
pressure in a small operative field can result in smudging of the camera’s lens with repeated tro-
collapse of the workspace – before the insuffla- car withdraws and reinsertions – a known prob-
tion system can respond to the change, thereby lem with trapdoor style trocars (Fig. 33.4). The
resulting in noticeable loss of the operative field system also was designed to maintain stable
of view (since this field is essentially created by pneumatics and to address the problem of smoke
pneumatic distension which must remain stable). accumulation. Specifically, by adapting a special-
Furthermore, the restricted view is also limited as ized, no-valve trocar to triple lumen insufflation
plumes of smoke often accumulate as there is tubing, (a) smoke evacuation, (b) pressure moni-
poor smoke dissipation, since the smoke is not toring, and (c) CO2 delivery could be separately
able to be distributed over the larger volume of managed. While these were considered important
the peritoneal cavity. advantages for advanced robotic and laparo-
Most insufflators for laparoscopy have not scopic abdominal surgery [21, 22], it should be
evolved since their inception, and have essen- underscored that the AirSEAL® system was not
tially remained unchanged in their technology designed for transanal surgery per se, nor was the
over the decades. Existing systems had worked system designed to rectify the problem of cyclic
quite well for laparoscopy and given there had billowing with TAMIS. Instead, like TAMIS
not been any incentive to alter this technology it itself, the advantage of AirSEAL® iFS for trans-
remained perfectly well suited for most rudimen- anal access in resolving the issue of pelvic breath-
tary laparoscopic procedures. However, the ing and smoke accumulation was realized
increasing use of complex laparoscopy and espe- completely by accident [23, 24].
cially robotics in MIS leads to refinements that Today, AirSEAL® iFS is the commonest insuf-
would serendipitously benefit transanal platforms flation system preferred by experts for use in con-
and especially TAMIS-based procedures. junction with the TAMIS platform for both local
Insufflation system that had been developed to excision and taTME to resolve the issue of cyclic
improve clarity with abdominal (and especially billowing, which is otherwise considered to be one
robotic) minimally invasive surgery emerged. In of the most significant intraoperative limitations
particular, one system (AirSEAL® iFS) was based on European Registry data [25]. However,
developed (originally by SurgiQuest and cur- AirSEAL® iFS may or not be available, and thus
rently, ConMed, Inc.) with the objective of utiliz- other substitutes can be considered, including a
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
Fig. 33.5 Gas flow for

taTME is delivered via
transanal access. This
insufflation vector
matures planes naturally
and is considered a
fundamental component
of the operation, greatly
assisting with sharp
dissection and with
actualizing the
subperitoneal
workspace. However, as
the planes develop,
especially posteriorly,
the rectum and
mesentery exhibit a
characteristic gross
anatomic distortion, as
illustrated
Fig. 33.6 (a) The

posterior plane of
a
dissection during taTME
is shown with separation
between the angel hair
(cheveux d’ange) and Anatomic distortion
the mesenteric envelope

correctly established.
Clearly shown is a
concavity of the dorsal
mesentery which
represents gross
anatomic distortion that
Cheveux d’ange
occurs due to the
insufflation vector
required during
taTME. On occasion,
such anatomic distortion
can challenge the
surgeon’s understanding b
of the operative
anatomy, and this may
lead to wrong-plane
surgery. (b) An artist’s
rendition of anatomic
distortion illustrating the
classic concavity of the
mesorectal envelope
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).
Mesorectum with mesorectal fascia
Halo effect or “O” Sign

Tethering
point
creates
‘Triangle’
Mesorectum with mesorectal fascia

Insufflation vector
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-
False Planes the mesentery itself, in some instances, to take on

an areolar appearance that can be confused for a
The insufflation vector of taTME affects the ante- plane of dissection. However, this often leads to
rior dissection differently than it does to the pos- one of the most common errors in taTME surgery,
terior dissection, and this is one of the most namely, intramesorectal dissection and violation
fundamental principles to understand that is quite of the mesenteric envelope with consequent onco-
unique to this operative approach. For the ante- logic compromise (when the operation is per-
rior dissection, there is no appreciable difference
in the opening of fascial planes, and operative
progress is similar to the standard, up-to-down
approach. This is because there is no directional
layering of fascia anteriorly. In contradistinction,
during the posterior and lateral dissections, there
is a specific orientation to the extra-mesorectal
fascia, which layers in such a way that when the
dissection is carried out from below, fascial
planes are pneumatically opened, as they tend to
“stand up” during the taTME dissection
(Fig. 33.8). Thus, during the posterior and to
some degree the lateral dissection, the planes
beyond the mesenteric envelope are exposed as
dissection proceeds “against the grain” of fascial Fig. 33.8 The transanal approach to taTME with the
applied insufflation vector from the perineum tends to
layering. The most pronounced effect of this is “stand up” fascial planes that may lead a surgeon to enter
observed along (a) Waldeyer’s fascia, (b) the lat- a plane that is too deep. Here shown is the standing up of
eral fat pillars (Fig. 33.9), and (c) the inferior Waldeyer’s fascia. The correct plane is to proceed ven-
hypogastric roots of S2 and S3 autonomic nerve trally along the mesorectal envelop, but a more dorsal
plane deep to the endopelvic fascia is often incorrectly
plexi (Fig. 33.10). selected. The standing up of planes is not typical of the
Importantly, the tapered distal mesenteric abdominal approach to TME and is a characteristic spe-
envelope can be dissected by airflow jets causing cific to taTME
Lateral fat pad
CO2 dissection lateral to correct plane
Correct TME plane
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
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
Exposed rectal wall
‘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
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
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
Introduction the mesentery becomes attached to the posterior

abdominal wall. This is mediated by the perito-
The hindgut refers to the intestine distal to the neal reflection at the periphery of the digestive
junction between the second and third part of the system, by Toldt’s fascia between mesentery and
transverse colon. Hindgut mobilization refers to posterior abdominal wall and by vascular points
detachment of the hindgut from its surrounding of connectivity such as the inferior mesenteric
attachments. This alone is not enough to enable artery [6, 7].
its resection. To enable resection, the mesentery Hindgut mobilization requires that the mecha-
that is contiguous with the hindgut must be also nisms by which the mesentery and intestine are
detached, and any analysis of good-quality held in position are disrupted. The peritoneum
colorectal resections will show that most opera- must be incised and the plane between the mes-
tive time is spent in mobilizing the mesentery entery and fascia disrupted by separating both
[1–5]. In contrast, division and reconstitution of [8–11].
the intestine can be rapidly achieved, once the This chapter contains an explanation of the
mesentery has been adequately released. anatomical and surgical foundation underpinning
The importance of the mesentery in hindgut total hindgut mobilization during taTME.
mobilization stems from the embryological Fortunately, the anatomical basis is the same for
development of both mesentery and intestine. this as it is for visceral surgery everywhere from
During development, the mesentery arises first, the esophagogastric to the anorectal junction, and
and the intestinal tube gradually takes shape at so the same anatomical principles apply through-
the mesenteric periphery, receiving cellular and out. This means the technical requirements are
connective tissue inputs from the mesentery. the same at all levels from transverse mesocolon,
Once the mesentery and intestine have assumed through splenic flexure, left mesocolon, mesosig-
their final position within the abdominal cavity, moid and mesorectum.
The following will commence with a brief
overview of the development of the technique by
J. C. Coffey (*)
University Hospital Limerick and University of which the hindgut is mobilized for taTME. It is
Limerick, Department of Surgery and Graduate followed by a detailed description of the anatom-
Entry Medical School, Limerick, Ireland ical basis of the technique. Some references will
e-mail: [email protected] be made to the embryological development of the
R. Sehgal hindgut, but a detailed description of that aspect
University Hospital Limerick, Department of Surgery, is beyond the scope of this chapter. The chapter
Limerick, Ireland

358 J. C. Coffey and R. 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
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.
Definitions and Terminology to expose this plane, the peritoneal reflection

must first be divided.
• Hindgut: intestine and mesentery from distal
transverse colon (mesocolon) to anorectal • Attachment: Mechanism of anchorage of
level. regions of the mesentery to the posterior
• Mesentery: the organ that maintains all abdominal wall.
abdominal digestive organs in position and in • Detachment: Separation of the mesentery
continuity with systems of the body. from the posterior abdominal wall.
• Peritoneal reflection: The bridge of perito- • Disconnection: Complete separation of the
neum that occurs between abdominal wall mesentery from the body.
peritoneum and organ, wherever an organ
comes into close proximity with the abdomi-
nal wall. Anatomy
• Plane: A plane is the conceptual zone between
two contiguous (i.e. touching) and continuous The mesentery is continuous; this means the
surfaces. mesentery of transverse colon continues as that
• Mesofascial plane: conceptual zone between of the left colon (i.e. the left mesocolon)
mesentery and underlying fascia. (Fig. 34.4). The left mesocolon then continues
distally as the mesosigmoid and the continuation
Comment This is arguably the most important of the mesosigmoid is the mesorectum [1, 5, 12,
plane in colorectal surgery. It occurs throughout 15, 34, 35].
and is of considerable technical importance. The term hindgut traditionally referred to the
intestine only, as the mesentery was previously
• Toldt’s fascia: The areolar connective tissue regarded as absent in certain regions (including at
that occurs between an organ and the posterior the left mesocolon). In the following the “hind-
abdominal wall, whenever an organ comes gut” is taken to refer to both intestine and mesen-
into close contact with the abdominal wall. tery from the splenic flexure distally (Fig. 34.5).
• Mesofascial separation: Separation of compo- The mesorectum terminates at an apex just above
nents that make up the mesofascial plane. the pelvic floor. This is the distal anatomical ter-
mination of the mesentery. The proximal termi-
Comment The components that generate the nation of the abdominal mesentery is at the
mesofascial plane are the mesentery and underly- esophagogastric junction [1, 5, 12, 15, 34, 35].
ing fascia. Mesofascial separation refers to sepa- The left mesocolon is attached to the posterior
ration of the mesentery from the underlying abdominal wall and Toldt’s fascia occurs between
fascia. It is a critical activity required to achieve it and the abdominal wall [1, 5, 12, 15, 34, 35,
mesenteric (and hence intestinal) detachment. 56]. The same applies for the medial aspect of the
Detachment is required before mesenteric dis- mesosigmoid. The lateral aspect of the mesosig-
connection can be achieved. moid is not attached and is mobile. As a result, if
one were to follow the mesosigmoid from medial
• Peritonotomy: Division of the peritoneal to lateral, one would observe that the medial
reflection. region is attached while the lateral region is
detached (Fig. 34.6) [1, 5, 12, 15, 34, 35, 56].
Comment This is a crucial activity in so far as The medial and lateral regions of the meso-
when one first inspects the abdominal cavity one sigmoid then converge at the rectosigmoid func-
cannot visualize the mesofascial plane. In order tion to continue as the mesorectum. This is
a b c
Fig. 34.4 The mesentery (current model). (a) Anterior, (b) anterolateral and (c) posterior view
Right mesocolon Transverse mesocolon Left mesocolon
Fig. 34.5 The left mesocolon. (Taken from Chap. 2, “Mesenteric and peritoneal anatomy”. In Mesenteric Principles of
Gastrointestinal Surgery: Basic and Applied Principles)
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].
Left mesosigmoidal peritoneal reflection

Sigmoid colon
White line
of Toldt
Pelvic side wall

connective tissue
Mesorectum
Left iliac
fossa
Fig. 34.7 Axial view of the mesorectum viewed from

Fig. 34.6 The lateral aspect of the mesosigmoid. (Taken above down. (Taken from Chap. 2, “Mesenteric and perito-
from Chap. 2, “Mesenteric and peritoneal anatomy”. In neal anatomy”. In Mesenteric Principles of Gastrointestinal
Mesenteric Principles of Gastrointestinal Surgery: Basic Surgery: Basic and Applied Principles)
and Applied Principles)
Fig. 34.8 Sagittal view

of the mesorectum.
(Taken from Chap. 2,
“Mesenteric and
Mesorectum
peritoneal anatomy”. In
Mesenteric Principles of
Gastrointestinal Surgery: Toldt’s
Basic and Applied fascia
“Mid” mesorectum
Principles)
Waldeyer’s
Anterior collar of mesorectum
fascia
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)
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
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
esentery and posterior abdominal wall. The

m sigmoid. It is advisable to spend time ensuring
reflection is somewhat more complex to visual- these anatomical impediments have been
ize. It is best if one starts by considering the left adequately mobilized away from the left mesoco-
peritoneal reflection and tracking this proximally lon and mesosigmoid before ever commencing
towards the splenic flexure. At the splenic flex- mobilization [54].
ure, it is obscured from direct visualization
because the omentum adheres to the reflection to
varying degrees. This anatomical relationship ateral to Medial Detachment
L
obscures the anatomical relationship of other and Disconnection of the
components of the splenic flexure from view, Mesosigmoid: Peritonotomy
unlike at the hepatic flexure, where their position
in relation to each other is directly visualized [1, Assuming one has obtained unimpeded mesen-
5, 10, 12]. teric access, the next step is to identify the reflec-
tion at the left side of the mesosigmoid
(Fig. 34.12). This is achieved by lifting the meso-
Mobilization Techniques, Including sigmoid away from the posterior abdominal wall
for taTME which places the mesosigmoid and underlying
fascia on stretch. The reflection comes under
btain Unimpeded Mesenteric
O stretch (i.e. is placed on tension), and one fre-
Access quently observes the indentation formed where
the peritoneum separates from the posterior
In the case of laparoscopic or robotic hindgut abdominal wall to join the mesothelium of the
mobilization during taTME, the tendency is to mesosigmoid [9, 54, 58, 59].
adopt a medial to lateral approach. In open proce- This indentation marks the starting region of
dures, a lateral to medial approach is favoured. In the peritonotomy. The division is of the perito-
either case, it is crucial to first obtain unimpeded neum alone, and not the underlying adipose tis-
mesenteric access. This means that the surgeon sue. If one is in the correct position, then during
can directly access the mesentery and conduct laparoscopy CO2 gas will diffusely inflate through
the procedure. Impediments include the greater the areolar tissue of the fascia thereby making it
omentum and adhesions between the small intes- more clearly visible to the surgeon. Classical sur-
tinal mesentery and the left mesocolon and meso- gical texts describe the importance of identifying
a b
Left peritoneal reflection Descending
colon
Descending Divided left Left

colon peritoneal peritoneal
reflection reflection
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-
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,
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
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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The Role for Perfusion
Angiography 35
António S. Soares and Manish Chand
Fluorescence-Guided Surgery Fluorophore Characteristics
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]

374 A. S. Soares and M. Chand
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
to 91.6% of rectal cancers operated through this

approach as demonstrated by the data submitted
to the taTME registry [16]. The registry has cap-
tured data on 1594 patients submitted to surgery
through the transanal platform with a docu-
mented leak rate of 15.7% [16]. Previous work
has shown that a blood flow reduction in the rec-
tal and colonic stumps was associated with an
increase in AL [17]. Perfusion angiography using
ICG offers a method of reducing this complica-
tion and is currently the most studied application
of fluorescence in colorectal surgery. By assess-
ing the proximal colonic transection point and
the anastomosis itself in a more objective man-
ner, perfusion can be optimized. Most data pub-
lished to date has been on the effect of using PA
for left-sided bowel resections, although data on
right-sided resections has been accruing recently.
Perfusion angiography can be used at the point
of bowel transection to identify where the bowel
remains ischaemic. ICG is given intravenously
and acts rapidly (often within a minute) allowing
the surgeon to make an assessment of the bowel
using the NIR equipment. A clear demarcation Fig. 35.1 Demonstration of injury to the marginal artery
between perfused and non-perfused tissue is gen- during natural orifice specimen extraction in transanal
surgery. (Illustration courtesy of Sam Atallah and Paulo
erally evident and used as a guide for the proximal Gonzalez)
transection [11, 18, 19]. For left-sided resections,
the proximal colon needs to be mobilized to
achieve the adequate position for a tension-free imposed by transanal extraction during
anastomosis, and the conduit relies purely on per- taTME. This is especially true with the high
fusion from the marginal artery [20]. It is plausi- degree of proximal mobilization required. When
ble that the need for more proximal bowel the marginal artery is disrupted proximally, the
mobilization entails an increased risk of vascular end result is loss of terminal bowel perfusion,
insufficiency that could lead to AL based on a vas- conduit ischemia and anastomotic failure. PA
cular cause. This is a fundamental consideration assessment of the proximal colon provides an
when using a NOSE (natural orifice specimen objective assessment of perfusion also in this con-
extraction) technique for colonic surgery – the text and therefore is a very helpful adjunct.
favoured method of specimen extraction in Mechanical patency tests are used after anas-
taTME. A review has shown that transrectal spec- tomosing the colon in left-sided resections and
imen extraction when compared with open extrac- have shown to be associated with a smaller rate
tion results in less pain, comparable operative of complications [22]. However, this does not
time and length of hospital stay [21]. The degree provide information on the vascular status of the
of mobility required from the proximal colon is anastomosis. Standard tests performed in this set-
higher in this setting because it is necessary to ting to assess vascular integrity are limited to
consider enough extension to be able to transect visual assessment for discolouration either
the specimen extracorporeally through the anus. extraluminally or endoluminally through endos-
As demonstrated in Figs. 35.1 and 35.2, the mar- copy in the cases of left-sided resection. The use
ginal artery may be torn due to shear stress of PA can assess the vascular status of the tissue
of change in surgical decision) was 3.3%, while

patients included in the control arms had an anas-
tomotic leak rate of 7.58% with a statistically sig-
nificant difference (p < 0.01). Importantly, the
definition of anastomotic leak differed among
studies including clinical diagnosis, radiological
diagnosis or no mention as to diagnosis method –
entailing a high risk of bias.
A more recent systematic review and meta-
analysis from Blanco-Colino et al. [18] were per-
formed in 2017. It included 1302 patients from 5
non-randomized studies that took place between
2003 and 2015. The risk of bias in assessing the
outcomes was considered low to moderate in the
studies included. The definition of AL was also
variable in the papers included. When the results
were pooled for all patients included in this
review, ICG has not shown a significantly lower
odds ratio for AL (OR 0.51, confidence interval
0.23–1.13). When the results for patients under-
going surgery for colorectal cancer were pooled
(956 patients), a significantly lower AL rate was
observed (OR 0.34, CI 0.16–0.74). The same
Fig. 35.2 Perfusion of affected areas after marginal result was found for rectal cancer patients, when
artery injury during transanal specimen extraction (green, these data were pooled (OR 0.19, 95% CI 0.05–
well perfused; black, non-perfused). (Illustration courtesy
0.75). Changes in surgical decision on the point
of Sam Atallah and Paulo Gonzalez)
of transection occurred in 7.4% of cases overall
(range 2.5–10.6%).
included in the anastomosis. This technique has A series of 504 patients was recently pub-
been described both to assess the serosa (extralu- lished after the systematic reviews mentioned
minally) and the mucosa (endoluminally) [23]. above [11] that included patients submitted to
colorectal surgery for both benign and malignant
indications. In this group, 143 (28.4%) patients
linical Outcomes in Colorectal
C underwent right-sided resections. The AL rates
Surgery for right-sided resections were similar between
patients in this study and historical controls
The clinical outcomes of using ICG in the assess- (2.8% vs 2.6%, respectively, p-value 0.928). For
ment of colorectal anastomoses have been well left-sided surgery, rates were 2.6% for the study
documented with no significant concerns over group versus 6.9% in the historic controls
technique or safety. Assessment was performed (P = 0.005). This represents an unselected larger
successfully in a significant majority of cases (97– number of patients than previously described in
100%) [24]. The additional time required for using single studies.
ICG during surgery has been shown to be between
30 seconds and 6.8 minutes per patient [24].
A systematic review from 2016 [19] included Changes in Management Decisions
1388 patients with colorectal anastomosis in 13
studies. The anastomotic leak rate among patients Utilization of PA with a minimally invasive
who underwent FA intraoperatively (irrespective (laparoscopic or robotic) approach can result in a
change in intraoperative management, mostly sis, sometimes lengthening techniques must be

leading to a more proximal transection of the employed [34]. These involve specific mobiliza-
colon (i.e. conduit) [11, 12, 25–29]. When con- tion of the mesentery but may also involve vascu-
sidering only studies with more than 100 patients, lar ligation of the ileocolic, right colic and
there was a change in intraoperative management superior mesenteric artery at its distal third, tak-
in 3.7–19% of cases [24]. The perfusion of the ing advantage of the perfusion through the right
proximal colon is a key determinant in the suc- branch of the middle colic and the marginal
cess of the anastomosis and commonly reliant on artery. Due to the need to ligate several important
the integrity of the marginal artery. A clearly vessels, perfusion angiography could be a useful
ischaemic section of colon is apparent to all sur- adjunct during surgery. The use of fluorescence
geons, but often it can be difficult to assess the in this context has been described previously [11,
last few millimetres of bowel. The use of a fluo- 35, 36], and this is an area of active research.
rophore to highlight perfusion to the edge of the
transection margin is helpful to make a more con-
fident assessment of the bowel viability. A clear Limitations
cut-off is demonstrated which allows the anasto-
moses to be constructed with a healthy, perfused While the data on the use of PA is rapidly accu-
section of bowel. mulating, there is still a need to identify its exact
indications and in which patients there is most
benefit. This would require higher level evidence
ecision on the Use of Diverting
D on the clinical outcomes after PA, a better under-
Ileostomy standing of the aetiology of AL, the quantifica-
tion of the fluorescent signal and the development
PA can also be used as an adjuvant to inform the of targeted fluorophores.
decision of not creating a diverting ileostomy in
the context of low anterior resections [30]. A
decision not to proceed with diversion was made urrent State of Data on PA to Reduce
C
in 6% of 90 low anterior resections in the VOIR Anastomotic Leaks
network study [11], none of which had an anasto-
motic leak. It is stated that the results of the per- So far, no randomized evidence exists on the use
fusion angiography provided enough assurance of PA and its effect on AL rates. The current stage
not to proceed with the ileostomy. Further study of this application of fluorescence is an IDEAL
is warranted to explore this finding, but this has phase 2b [37]. Despite having opened for recruit-
financial and quality of life (QoL) implications. ment, the PILLAR III randomized trial was
Diverting stoma is often kept for a period of closed in June 2017 [38]. The IntAct (intra-
months and associated with morbidity. In addi- operative fluorescence angiography to prevent
tion, there is a financial burden which must be anastomotic leak in rectal cancer surgery) trial is
borne out by healthcare systems. currently open for recruitment [39]. The trial will
include both patients undergoing laparoscopic
TME and taTME. This is an international multi-
Ileo-Anal Pouch Assessment centre randomized trial that will allocate patients
to surgery with or without FA. The primary out-
The TAMIS platform and general taTME tech- come is clinical anastomotic leak within 90 days
niques have been used for restorative procto- of surgery. The recruitment target is 880 patients
colectomy with ileo-anal pouch. The current data over 36 months. The impact of PA in the decision
seems promising [31–33], and this surgical to proceed with diverting ileostomy after colorec-
approach has been used more frequently. For the tal anastomosis and after pouch surgery also mer-
pouch to reach the distal site prior to anastomo- its further study given the potential benefits.
Multifactorial Aetiology of AL Targeted Fluorophores
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
Preoperative Assessment a routine screening examination. Other patients

may present with rectal bleeding, incontinence,
History and Physical Examination rectal pain, weight loss, anemia “change in bowel
habits,” diarrhea, constipation, or abdominal pain
The preoperative assessment for transanal total [1]. Patients should be asked about their bowel
mesorectal excision (TaTME) should begin with habits including the quality of their stool – “pen-
a thorough history and physical examination, cil thin” stools may be a sign of impending
which is the most important part of the patient’s obstruction. Patients may also complain of bloat-
evaluation. Typically, patients will present for ing, abdominal cramping, nausea, or vomiting. It
their first visit to a surgeon already carrying a is important to assess for these types of symp-
diagnosis, and it is the surgeon’s task to assess if toms as they may be indicative of partial obstruc-
surgery is indicated and formulate the optimal tion and may alter the initial operative strategy
surgical plan. It is important to elicit a thorough with diversion prior to the initiation of neoadju-
description of the patient’s current symptoms, vant therapy, if indicated.
which may indicate either benign or malignant Baseline urinary and sexual function should be
pathology, and to get a sense of the patient’s documented for all male patients. The rates of uri-
understanding of his or her condition. In the set- nary dysfunction following surgery for rectal can-
ting of malignancy, the patient could be asymp- cer have been reported to be between 30% and 70%
tomatic as the lesion may have been identified on [2–5]. Similarly, the rates of sexual dysfunction in
men following rectal cancer surgery is reportedly
A. R. Bhama 30–64% [6–8]. Therefore, it is important to docu-
Rush University, Chicago, IL, USA ment function preoperatively to assess for any post-
A. R. Althans operative changes from baseline. Importantly, it is
Department of Colorectal Surgery, Digestive Disease critical that the prostate gland is adequately
and Surgery Institute, Cleveland Clinic Foundation, assessed by history and physical examination. By
Cleveland, OH, USA
DRE, the gland’s shape and size should be estab-
Case Western Reserve University School lished at baseline. Furthermore, a history of prior
of Medicine, Cleveland, OH, USA
prostatic surgery, such as prior radical prostatec-
S. R. Steele (*) tomy, or a history of prior urethral reconstructive
Department of Colorectal Surgery, Digestive Disease
and Surgery Institute, Cleveland Clinic Foundation,
surgery is germane to the planning of the TaTME
Cleveland, OH, USA operation. This can help alert the transanal surgeon
e-mail: [email protected] of the potential difficulty with the anterior plane.

382 A. R. Bhama et al.
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
used, it is important to document baseline func- Preoperative

tion for planning and comparative purposes.
Anorectal manometry, which can be performed Patient evaluation and optimization
Patient education
without sedation, can provide information regard- Mechanical and antibiotic bowel preparation
ing the anatomy and function of the sphincter Preoperative analgesia (NSAIDs, gabapentin)
muscle. First, the length of anal canal can be Fasting prior to surgery
measured; men typically have a longer sphincter
complex than women. Functional metrics that
Intraoperative
may be assessed include rectoanal reflexes, rectal
sensation, rectal compliance, and intraluminal Minimally invasive approaches when indicated
pressure changes when bearing down. Resting Intraoperative fluid restriction
Intraoperative analgesia (TAP block)
and squeeze pressures are provided. The volume Venous thromboembolism prophylaxis
to first sensation, volume to first urge to defecate,
and maximum tolerate volume are also measured.
Balloon expulsion testing is typically performed.
Postoperative
Patients who are unable to expel the balloon
within 1 min are suspected to have defecatory Early feeding and advancement of diet
Venous thromboembolism prophylaxis
disorders [19, 20]. Patients with abnormal Postoperative analgesia (multimodal,avoiding
manometry may require defecography or endo- opioids when possible)
anal ultrasound as well. Endoanal ultrasound, Postoperative fluid restriction
especially in women, will provide information
regarding the anatomy of the sphincter muscles Fig. 36.1 Enhanced recovery after surgery
and whether or not there are any defects in the
muscles from prior obstetric injuries. Patients feeding and advancement of diet, venous throm-
with abnormal studies should be thoughtfully boembolism prophylaxis, specific analgesia regi-
evaluated if proctectomy with sphincter preserva- mens, fluid restriction, and discharge planning.
tion is appropriate, and patients should be While each institution typically has its own spe-
selected on an individualized basis. cific regimen for ERAS, generalized guidelines
exist.
nhanced Recovery After Surgery

E
(ERAS) Preoperative
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
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].
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.
Conclusion transanal total mesorectal excision results from

the international TaTME registry. Ann Surg. 2018;
Epub ahead.
Proper patient selection and perioperative man- 10. Suwanabol P, Maykel J. Transanal total mesorectal
agement are the first steps to good postoperative excision: a novel approach to rectal surgery. Clin
outcomes in TaTME surgery. This procedure, Colon Rectal Surg. 2017;30:120–9.
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Intraoperative Morbidity of taTME
37
T. W. A. Koedam, Jurriaan Benjamin Tuynman,
Sam Atallah, and C. Sietses
Introduction the new technique. Even though the embryologi-

cally derived planes are the same as during stan-
Intraoperative complications during laparoscopic dard laparoscopic rectal cancer surgery, changing
rectal surgery are fortunately an infrequent event the approach to a transanal one makes the recog-
for experienced surgeons. Most articles evaluat- nition of these planes more difficult [4].
ing morbidity include all adverse events within With this down-to-up technique, the anatomy
30 days after the procedure [1]. Some authors that may appear distorted and unfamiliar, and this may
specify intraoperative complication rates report result in serious procedure-related complications.
percentages of approximately 12–13% [2, 3]. The international taTME registry reported in 1594
Transanal total mesorectal excision (taTME) patients an overall morbidity of 30.4% and re-
gives new options for the treatment of distal and intervention needed in 8.0% of the patients.
mid rectal cancer patients. Specifically, the obese Intraoperative complications were reported in
male patient with a narrow pelvis might benefit 30.6% of the patients who underwent taTME,
the most from the access and vantage point pro- which was mainly caused by technical problems
vided by taTME. By approaching the rectum during the transanal phase (18.0%). Visceral inju-
both from above and below might improve resec- ries during the transanal phase were reported in
tion margins both distally and circumferentially. 1.8%, including urethral, rectal, vaginal, bladder,
However, there are also possible risks related to and hypogastric nerve injuries [5]. Perdawood
et al. reported a 13% rate of intraoperative com-
T. W. A. Koedam plications after taTME, which was comparable to
Amsterdam UMC, Department of Surgery, laparoscopic and open approach [6].
Amsterdam, Noord-Holland, The Netherlands Koedam et al. reported on the learning curve of
J. B. Tuynman taTME. Even though no learning curve effect is
Department of Surgery, Amsterdam University described for intraoperative complications, major
Medical Center, location VUmc, Cancer Center morbidity was increased during the first 40 patients.
Amsterdam, Amsterdam, The Netherlands
The same learning curve was observed for anasto-
S. Atallah motic complications and abscess formation [7].
AdventHealth Orlando, Oviedo Medical Center,
and University of Central Florida College of Medicine, Most intraoperative complications can be pre-
Orlando, FL, USA vented by standardizing the sequence of the proce-
C. Sietses (*) dure, this will be discussed in detail in other chapters
Gelderse Vallei Hospital, Department of Surgery, of this book. Most serious c omplications occur due
Ede, Gelderland, The Netherlands to misjudgment of the accurate dissection plane,

392 T. W. A. Koedam et al.
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
Posterior and Anterior Plane
After the circumferential full-thickness rectot-

omy, most taTME surgeons start dissecting the
TME plane at the safe dorsal side. The posterior
midline is avoided because the rectal sacral liga-
ment can make the localization of the proper
plane difficult. It is easy to be pushed behind the
rectal sacral fascia with possible bleeding from
presacral venous plexus.
Fig. 37.3 In an unprepped colon, in the event that the After localization of the TME plane on the
purse-string failure occurs during taTME dissection,
extensive spillage of stool can sometimes occur, as shown, dorsal side, the posterior dissection plane
underscoring the importance of an adequate seal should be extended laterally, but not beyond 4
and 8 o’clock positions. The dissection next
ficient tissue tension could therefore result in an proceeds from the posterior to the anterior
inadvertent violation of the rectal wall proper. plane, and this can be done continuously
Such iatrogenic perforation not only make the next through the lateral aspects. Here, there is the
step of the taTME more difficult; it also may con- potential for morbidity which results from
taminate the surgical field and may compromise extending the dissection lateral to the envelope
the oncologic integrity of the operation as well. proper. In effect, due to pneumatic dissection of
The anterior dissection through the rectal wall in false, lateral planes, the surgeon may extend the
males is particularly challenging, because crossing dissection into an extra-mesorectal plane with
fibers that extend to the prostate and urethra (the possible injury to pelvic autonomic nerve plexi
rectourethralis muscle and fibers of Luschka) cre- with a resultant compromise and impairment of
ate a smooth sheet of muscle that appears to be postoperative functional results (Fig. 37.4).
part of the rectal wall, but is not, and which must This lateral dissection may result in sacral
be properly divided to assure entry into the correct venous injury that may be challenging to con-
anterior plane and to assure that the prostate is not trol, with hemorrhage from pelvic side wall
distracted posteriorly where injury to the posterior veins or even iliac vessels (Fig. 37.5). Pelvic
aspect of the pre-prostatic urethral is possible. bleeding of more than 100 mL has been
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
anterolateral side (Fig. 37.6), it should warn the

surgeons that wrong plane is followed; specifi-
cally, in male patients, it indicates that the pros-
tatic complex including the urethra is being
mobilized inadvertently.
This can result in one of the most important,
procedure-specific complications of taTME,
transection of the urethra, which is detailed fur-
ther in a separate chapter. Briefly, however, in
male patients, the angle of the anal canal and the
TAMIS platform are directed toward the prostate
Fig. 37.5 Posterior sacral venous bleeding occurs when
the plane becomes too deep, especially posteriorly but gland, which could easily result in the taTME
also laterally. It is important that surgeons follow the natu- surgeon entering a plane that is too anterior,
ral curvature of the sacrum and not continue straight with- thereby leading to mobilization of the prostate,
out anticipating this curvature. Failure “turn upward” will
which is in very close juxtaposition to the ante-
result in violation of the often elaborate venous plexus
that is not only difficult to control but also renders the rior rectal wall (Fig. 37.7). The posterior lobe of
fusion planes much more difficult to visualize the prostate gland will rotate downward leaving
the urethra as a structure vulnerable to injury.
With prerequisite training and experience, mobi-
described in 4.2% of the patients undergoing lization of the prostate is recognizable by the
taTME [5]. experienced taTME surgeons prompting immedi-
The conical skeletal muscles of the pelvic ate plane correction. The taTME registry noted
floor surround the rectum and mesoretum. that a urethra injury occurred in 0.8% of the
Normally, the muscle is surrounded by investing patients; however, true male urethral injury rates
fascia. However, this fascial layer can be violated may be significantly higher as such cases may sim-
during the process of taTME dissection. When ply not self-reported in the registry data available.
this muscle is exposed and clearly visible on the In female patients, vaginal injury of the posterior
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
Given the fact that taTME always starts with a

dissection of the rectal wall, the technique
always leaves an open rectal stump to be purse-
string closed in preparation for anastomosis.
Depending on the length of the rectal cuff, either
a stapled or hand sewn anastomosis is performed.
In case of a stapled anastomosis, a purse string
should be placed at the rectal cuff, and this
should be done with meticulous care, of compa-
rable quality as the first one, so as to assure
proper tissue union upon endoluminal stapling.
Fig. 37.6 The exposed skeletal muscle of the pelvic floor is
An insufficient purse string might result in an
clearly visible during the posterolateral dissection. This mus-
cle is typically covered by investing fascia, and exposure of anastomotic failure (leak) due to technical error.
bare muscle signifies dissection in a plane that is too deep Fortunately, this can often be localized and
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))
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
corrected through the transanal port or under

direct vision since the anastomosis is typically
quite low (Fig. 37.9).
Other Complications
Although rare, carbon dioxide (CO2) embolism

can be a severe, life-threatening complication
that occurs during taTME of which both the sur-
geon and the anesthesiologist should be keenly
aware of this risk and prepared to initiate treat-
ment if necessary. Due to the pneumopelvis
Fig. 37.9 A stapled anastomosis after taTME is shown.
with CO2, insufflation gas can be introduced The ultralow position allows for direct, inline operative
into the relatively low-pressure venous system access. Thus, if a small defect in the anastomotic line is
during dissection when inadvertent bleeding is identified, it can easily be oversewn
encountered. In the current literature, only one
case report has been described, although this is with one team and the procedure is started transa-
an area of ongoing investigation. It reports a nally. The insufflated CO2 accumulates in the ret-
classic CO2 embolism with a decrease of satura- roperitoneum making subsequent transabdominal
tion and blood pressure, which were restored surgery more difficult. Furthermore, an incom-
after the cessation of insufflation [14]. The plete purse-string closure may result in significant
absolute risk during taTME is still under inves- dilation of the bowel itself, making exposure of
tigation, but anecdotes in the taTME community the operative field from above more challenging.
suggest that it might occur more often than cur- Pneumatic dissection along tissue planes can also
rently reported. lead to crepitus to the level of the neck. In males,
A complication not seen during standard lapa- the scrotum is particularly at risk for pneumatic
roscopy is pneumatosis of the retroperitoneum. dissection during taTME (Fig. 37.10). However,
The pneumatosis of the retroperitoneum can these effects are transient and resolve without fur-
develop when the transanal approach is performed ther sequelae.
5. Penna M, et al. Transanal total mesorectal excision:

international registry results of the first 720 cases.
Ann Surg. 2017;266(1):111–7.
6. Perdawood SK, et al. Effect of transanal total meso-
rectal excision for rectal cancer: comparison of short-
term outcomes with laparoscopic and open surgeries.
Surg Endosc. 2018;32(5):2312–21.
7. Koedam TWA, et al. Transanal total mesorectal exci-
sion for rectal cancer: evaluation of the learning curve.
Tech Coloproctol. 2018;22(4):279–87.
8. Bondeven P, et al. Extent and completeness of meso-
rectal excision evaluated by postoperative magnetic
resonance imaging. Br J Surg. 2013;100:1357–67.
9. Bülow S, et al. Intra-operative perforation is an
important predictor of local recurrence and impaired
Fig. 37.10 Pneumo-dissection is possible in several kinds survival after abdominoperineal resection for rectal
of minimally invasive procedures and especially with cancer. Color Dis. 2011;13(11):1256–64.
taTME. Here, severe pneumo-scrotum is evident. Pneumatic 10. Barnes TG, et al. Improved urethral fluorescence dur-
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12. Atallah S, Martin-Perez B, Drake J, Stotland P,

tumor implantation after taTME has been Ashamalla S, Albert M. The use of a lighted stent
reported [15]. Therefore, care should be given to as a method for identifying the urethra in male
assure that proper irrigation with tumoricidal patients undergoing transanal total mesorectal exci-
agents (such as sterile H2O) is employed prior to sion: a video demonstration. Tech Coloproctol.
2015;19(6):375. https://doi.org/10.1007/s10151-015-
and after purse-string application [16]. Finally, 1297-2. Epub 2015 Mar 28.
transanal extraction can lead to conduit isch- 13. Mabardy A, Lee L, Valpato AP, Atallah S. Transanal
emia due to shear stress on the marginal artery. total mesorectal excision with intersphincteric resec-
This will be detailed in a separately in another tion and use of fluorescent angiography and a lighted
urethral stent for distal rectal cancer. Tech Coloproctol.
chapter. 2017;21(7):581–2. https://doi.org/10.1007/s10151-017-
1629-5. Epub 2017 May 22.
14. Ratcliffe F, Hogan AM, Hompes R. CO2 embolus:
an important complication of TaTME surgery. Tech
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2005;365:1718–26. TN, Bonjer HJ, Sietses C. Intra-abdominal bacterial
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Functional Outcomes to Transanal
Minimally Invasive Surgery 38
(TAMIS) and Transanal Total
Mesorectal Excision (taTME)
Elisabeth C. McLemore and Patricia Sylla
Anorectal Function and Assessment evaluates the coordination of the pelvic floor

muscles, rectum, and sphincter muscle relaxation
Transanal minimally invasive surgery (TAMIS) during evacuation [3].
and transanal total mesorectal excision (taTME) Assessing the severity of fecal incontinence (FI)
may impact defecatory, sexual, and urinary can be measured using a variety of instruments
function. There are a number of ongoing clinical ranging from healthcare-directed question to
trials assessing the impact of these procedures response grading scoring system such as the CCII
on functional outcomes; however, the current [1]. The CCII assesses the frequency and severity
data available for review is limited. This chapter of accidental loss of gas, liquid stool, and solid
will address what is currently known regarding stool [1]. There are a variety of validated question-
changes in bowel function following TAMIS naires assessing patient’s perception of the severity
and taTME. of their bowel, bladder, and sexual function and
Anorectal physiology and bowel continence impact on their quality of life. These are particu-
are the result of a complex and dynamic interplay larly helpful to assess preoperative and monitor
between pelvic floor musculature and timely con- postoperative functional outcomes [1, 4–7].
traction and relaxation of the sphincter muscle The Colorectal Functional Outcome
complex [1]. Formal and functional assessment Questionnaire (COREFO) is a validated instru-
of anorectal function includes anal manometry, ment that focuses on assessing bowel function
dynamic defecography, cross-sectional imaging, after colorectal surgery [4]. Low anterior resec-
and continence scoring systems such as the tion syndrome (LARS) is a well-established syn-
Cleveland Clinic Incontinence Index (CCII, drome characterized by alteration in bowel habits
Table 38.1) [1, 2]. Anal manometry measures following low anterior resection. Patients with
rectal compliance and capacitance as well as anal LARS typically have increased fecal urgency,
resting and squeeze pressures. Defecography frequency, and clustering of bowel movements. A
validated scoring system known as the LARS
E. C. McLemore (*) Score [8] is another instrument available to assess
Colon and Rectal Surgery, Los Angeles Medical the impact on function after rectal surgery.
Center, Kaiser Permanente, Department of Surgery,
Los Angeles, CA, USA
TAMIS and taTME are relatively modern evolu-
e-mail: [email protected] tions of transanal microscopic surgery (TEM)
P. Sylla
and low anterior resection (LAR), respectively.
Division of Colon and Rectal Surgery, Icahn School As such, the functional outcome data available
of Medicine at Mount Sinai, New York, NY, USA for review is limited at this time. The bowel

400 E. C. McLemore and P. 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 proof 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,
an international multicenter randomized clinical References
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Scintu F, et al. Risk of complications and long-term 34.
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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].

406 S. K. Perdawood
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
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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.
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TaTME for Radical Exenteration
40
Sami A. Chadi and Dana Sands
Introduction techniques rely on the individual surgical teams

having a strong familiarity of embryologic planes,
The transanal total mesorectal excision (taTME) the vascular anatomy of the pelvis and supply of
was pioneered with the objective of optimizing other pelvic organs, the distribution of the nerves
the oncologic outcomes of the distal rectal dissec- in the sidewall and sacral foramina, and, finally,
tion. Surgeons have noted an improved visualiza- the need at the time for reconstructive techniques
tion and dissection of the TME plane with hopes based on the structures resected and local factors,
of improving the oncologic outcomes given the such as prior radiation exposure.
ease of access via a perineal approach. The “head- Few cases of exenterative techniques in
on” view of the bottom-up approach, pioneered taTME have been reported in the literature, often
by Sylla and Lacy [1], has been reported to be referred to as transanal total pelvic exenteration
associated with excellent R0 resection rates and (taTPE). Moreover, they tend to mostly be per-
low incidences of CRM positivity. However, in formed at a few specialty and high-volume insti-
some situations, despite the best efforts of the tutions only [3, 4]. The rational for taTPE may
multidisciplinary team to downsize the tumor be, in part, related to the remarkable ease of
with neoadjuvant adjuncts to improve both the mobilizing the prostate gland and the urethra
amenability to resection and the likelihood of a noted during taTME. Ironically, the Achilles’ heel
negative CRM, the malignancy involves adjacent of taTME (i.e., inadvertent urethral injury) has
structures that, if resected, can still afford the likely been a contributing factor in why the taTPE
patient a disease-free state post- resection. approach has been pioneered, as the urethra is
Excellent results – with a high rate of R0 resec- now intentionally divided as part of the planned
tions – have been observed in high-volume spe- operation. Thus, the vantage point of taTPE
cialty centers, when coordinated between the together with the known, high-quality excisions
appropriate specialties [2]. These exenterative achieved with taTME in expert hands has
intrigued surgeons to explore this technique as a
S. A. Chadi (*) valid approach to curative-intent resection.
University Health Network and Princess Margaret It should be highlighted that a “total” exen-
Hospital, University of Toronto, Toronto, ON, Canada
teration is not necessarily always the objective;
selective anterior or posterior exenterations are
D. Sands
also possible, based on the oncologic require-
Department of Colorectal Surgery, Cleveland Clinic
Florida, Weston, FL, USA ments of the resection. The main individual cases
e-mail: [email protected] that have been presented have included those in

412 S. A. Chadi and D. Sands
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.
Patient Indications Anatomical Planning
Indications of treatment can be categorized in Prior to embarking on the procedure, it is impor-

baseline performance characteristics as well as tant for surgeons to plan all aspects with subspe-
the oncologic resectability of the primary tumor. cialty collaborators. This is even more important
It is crucial to ensure the patient is well informed with a taTPE where many other subspecialists
of both the physical demands imposed by exen- may not be aware of the details and requirements
teration and the extended recovery and changes of the technique. Sequencing the procedure
in quality of life – even in instances whereby through a rehearsal process is crucial to address
reconstruction via low colorectal/coloanal anas- all potential impediments of surgery from patient
tomosis is possible [5]. Patients have been shown positioning, repositioning when necessary, intra-
to perform best when they demonstrate high lev- operative difficulties in dissection, and staging
els of baseline quality of life metrics and should specialty-specific involvement in the procedure as
be advised that improvements in quality of life well as staging reconstruction (gastrointestinal,
can take between 2 and 12 months to manifest [5, urologic, or plastic myogenous/myocutaneous).
6]. Minimally invasive approaches to an exenter- Imaging is crucial in these procedures. CT
ation may facilitate both the recovery process and imaging can be helpful in demonstrating sys-
the resumption of an active lifestyle but can only temic disease as well as local tumor extent. The
be performed in select cases [7]; however, the details of the locoregional extent of disease can
extent of the resection remains a significant be optimized with MRI. This can help clarify
source of morbidity, and the procedure is only details including fascial involvement, extent of
possible in highly selective patients. The major- other pelvic organ involvement, and adherence to
ity, if not all patients, will have been treated with or invasion of pelvic vasculature. Furthermore,
neoadjuvant therapy to both decrease the burden MRI has been shown to improve assessments of
and improve the likelihood of an R0 resection [2, both tumor viability and regression following the
40 TaTME for Radical Exenteration 413
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
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,
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.
Female Patients and taTPE when a minimally invasive approach to this radi-

cal operation is utilized [7, 11]. Urethral catheters
As of yet, there are no publications or video should be managed by the urologic team as
reports of an anterior exenteration in a female should the ureteric stents in cases of ileal urinary
patient via the taTPE. The approach has been dis- conduit creation. Additionally, standard anasto-
cussed and theorized among authors. Many ante- motic assessments should be performed prior to
rior exenterations in female patients mandate en reversing diverting stomas for coloanal anasto-
bloc posterior vaginectomy. Theoretically, the moses, assuming an anastomosis has been
main technical impediment with the taTPE constructed.
approach is the difficulty in maintaining pneumo-
pelvis when the posterior vaginal wall has been
excised, because the transanal TAMIS port cannot References
close the entire perineal defect. As such, the peri- 1. Sylla P, Bordeianou LG, Berger D, Han KS, Lauwers
neal approach, with or without sphincter preser- GY, Sahani DV, et al. A pilot study of natural ori-
vation, can be potentially performed posteriorly fice transanal endoscopic total mesorectal excision
and laterally, leaving the tumor and specimen with laparoscopic assistance for rectal cancer. Surg
Endosc. 2013;27(9):3396–405.
pedicled on the anterior attachments to the poste- 2. PelvEx Collaborative. Surgical and Survival Outcomes
rior wall of the vagina. Additionally, care should Following Pelvic Exenteration for Locally Advanced
be taken to ensure preservation of the autonomic Primary Rectal Cancer: Results From an International
nerves that coarse along the lateral vagina, if Collaboration. Ann Surg. 2019;269(2):315–21.
3. Uematsu D, Akiyama G, Sugihara T, Magishi A,
oncologically permissible. Once the perineal dis- Yamaguchi T, Sano T. Transanal total pelvic exentera-
section is communicated posteriorly and laterally tion. Dis Colon Rectum. 2017;60(6):647–8.
to the abdominal dissection, the abdominal team 4. Uematsu D, Akiyama G, Sugihara T, Magishi A, Ono
can also continue the abdominal dissection to the K, Yamaguchi T, et al. Transanal total pelvic exen-
teration with sphincter-preserving surgery. Dis Colon
level of the cephalad limit of the intended vagi- Rectum. 2018;61(5):641.
nectomy. The vaginectomy can then be performed 5. Rausa E, Kelly ME, Bonavina L, O'Connell PR,
transvaginally and transperineally into the vaginal Winter DC. A systematic review examining qual-
vault and circumferentially around the area of the ity of life following pelvic exenteration for locally
advanced and recurrent rectal cancer. Color Dis.
vagina involved. If the anus is preserved, the pos- 2017;19(5):430–6.
terior wall of the vagina can be closed with or 6. Quyn AJ, Austin KKS, Young JM, Badgery-Parker
without added reconstruction. If the anus is not T, Masya LM, Roberts R, et al. Outcomes of pelvic
preserved, a myocutaneous flap can often be per- exenteration for locally advanced primary rectal can-
cer: overall survival and quality of life. Eur J Surg
formed to reconstruct the posterior wall of the Oncol. 2016;42(6):823–8.
vagina and the perineum. If an en bloc hysterec- 7. PelvEx Collaborative. Minimally invasive sur-
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tomy can be performed with the anterior dissection tematic and meta-analysis review. Surg Endosc.
2018;34(2):2177.
continued along and through Morrison’s pouch to 8. Vermaas M, Ferenschild FTJ, Verhoef C, Nuyttens
communicate with the vaginal vault. Care must be JJME, Marinelli AWKS, Wiggers T, et al. Total pel-
taken to avoid injury to the bladder and urethra vic exenteration for primary locally advanced and
anteriorly during this dissection. locally recurrent rectal cancer. Eur J Surg Oncol.
2007;33(4):452–8.
9. Battersby NJ, How P, Moran B, Stelzner S, West NP,
Branagan G, et al. Prospective Validation of a Low
Postoperative Considerations Rectal Cancer Magnetic Resonance Imaging Staging
System and Development of a Local Recurrence Risk
Stratification Model: The MERCURY II Study. Ann
The postoperative course of patients does not dif- Surg. 2016;263(4):751–60.
fer from patients managed with a standard exen- 10. Zhao R-S, Wang H, Zhou Z-Y, Zhou Q, Mulholland
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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-
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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
Introduction namely, transanal total mesorectal excision

(TaTME), has several benefits over laparoscopic
Abdominoperineal excision (APE) is an impor- surgery. This approach can also be utilized in APE
tant operative procedure for patients with low- procedures and is also known as transperineal
lying rectal cancer who are not eligible for APE (TpAPE). There are several benefits of
sphincter-preserving surgery. APE is performed TpAPE over the conventional method, such as bet-
as a combination of abdominal and perineal ter exposure of the surgical field despite the small
stages; the perineal stage is usually performed skin incision used to gain perineal access. This
under direct vision. APE has been reported to be chapter presents the surgical procedure of TpAPE.
associated with poor outcomes, such as higher
local recurrence rates or poor overall survival,
probably due to the higher rate of positive cir- Anatomical Considerations
cumferential margins, especially at the anterior
aspect [1, 2]. A wide skin incision in the lithot- There are several important anatomical land-
omy or prone position has been utilized to marks specific for APE. In this procedure, it is
improve surgical exposure [3], especially on the important to have a thorough knowledge of the
anterior aspect, even when the skin is spared anatomy of the striated and smooth muscle com-
from tumor invasion. Although recent reports plex surrounding the anal canal. The schema of
have described division of the levator ani muscle the anatomy around the anal canal from below is
and the ischioanal fossa even from a laparoscopic shown in Fig. 41.1. The external anal sphincter
approach [4], exposure of the anterior aspect is (EAS) is located at the lower part of the anal
still difficult even with this procedure. canal and is sometimes divided into two or three
The recent development of the endoscopic bot- parts (subcutaneous, superficial, and deep). It is
tom-to-top approach in rectal cancer surgery, fusiform-shaped and partly extends anteriorly
and posteriorly to connect with the bulbospon-
S. Hasegawa (*) · D. Kojima · A. Komono giosus muscle and the coccyx, respectively. The
R. Sakamoto · N. Aisu · Y. Yoshida transverse perineal (TP) muscles sometimes
Department of Gastroenterological Surgery, Fukuoka
partly intermingle with muscle fibers of the ante-
University Hospital, Fukuoka, Japan
e-mail: [email protected] rior part of the EAS, forming the boundary
between the anterior urogenital and rectal
T. Okada · Y. Sakai
Department of Surgery, Graduate School of compartments. During APE, this muscle is a

Medicine, Kyoto University Hospital, Kyoto, Japan good landmark for anterior dissection.

420 S. Hasegawa et al.
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
The puborectalis muscle is located behind the Energy devices T-anal

Laparo
TP and is U-shaped with two major bilateral
slings, pulling the rectum anteriorly to form the
T-anal
anorectal angle. This is the major muscle that con-
tributes to rectal closure. The levator ani is a thin,
sheet-like muscle that is anatomically divided into T-anal
team
the ischiococcygeus, iliococcygeus, and puborec- Anaesthesiologist
talis, forming the major part of the pelvic floor. Laparo
There are also several important smooth mus- team
Laparo
cle structures that are significant in performing
APE. In male patients, the rectourethral muscle
Energy devices Ns
(or perineal body) is an anterior extension of lon-
gitudinal smooth muscle layer of the rectum
Fig. 41.2 Operative setup (two-team synchronous
extending toward the urethral sphincter just approach)
below the prostate. The hiatal ligament, however,
is the posterior extension of the longitudinal
smooth muscle extending toward the coccyx. toneum are very important for keeping the surgical
These structures must be divided during APE, field stable and clear. Thus, many surgeons prefer
and it is often difficult to find an appropriate dis- to use the AirSeal® insufflation system. We use a
section plane here. two-team synchronous approach, where the lapa-
roscopic and transperineal teams perform surgery
simultaneously. The major advantage of this two-
atient Position and Operative
P team approach is the easier exposure of the surgi-
Setup cal field with a shorter operative time. For these
reasons, this approach has recently become pre-
The patient is placed in the modified lithotomy ferred compared with the one-team approach. The
position. Because of the small operative field in operative setup for the two-team approach is
the transanal/perineal approach, continuous smoke shown in Fig. 41.2. The monitors are placed such
evacuation and maintaining a stable pneumoperi- that each surgeon can see both operative fields.
41 TaTME for Abdominoperineal Excision 421
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
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).
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)
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)
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.
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
issection Along the Rectovaginal

D anterior side, despite good visibility.
Septum • Extra cost and resources are required for the
transperineal procedure.
For female patients, at the anterior aspect, the
perineal body can be divided under direct vision
at the most inferior part of the vagina, where
there is no clear dissection plane, under the guid- References
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roscopic approach. oncologic outcomes. Surg Endosc. 2016;30:3001–6.
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Hartmann’s Reversal
by a Combined Transanal- 42
Transabdominal Approach
Jean-Sébastien Trépanier, F. Borja de Lacy,
and Antonio M. Lacy
Introduction for various reasons, and it could be improved

with a Hartmann’s reversal [4].
Henri Hartmann first described his eponymous Interest in minimally invasive surgery (MIS)
operation in 1921 at the 30th Congress of the has grown significantly in the last decades and is
French Surgical Association [1]. It was initially justified by diminished surgical trauma, resulting
proposed for the treatment of rectal cancer, in an in better outcomes for many patients who undergo
attempt to lower the morbidity associated with colorectal procedures. Thus, laparoscopic
the abdominoperineal resection, developed by approaches for reversal of Hartmann’s procedure
William Ernest Miles at the beginning of the using multiport or single-port configurations
twentieth century. Nowadays, the Hartmann’s have been attempted [5–9]. They were shown to
procedure is still commonly performed in various be safe in trained hands and are associated with
benign and malignant conditions and both in faster postoperative recovery and fewer compli-
elective and emergent settings. After this opera- cations based on recent publications [10–14]. In
tion, many patients will never undergo colostomy 2014, a robotic approach to HR was described as
closure (or Hartmann’s reversal – HR). In the lit- a case report [15].
erature, closure rates range between 28% and Even with these different MIS approaches,
60% [2, 3]. Restoring intestinal continuity is HR remains a challenging operation. The rates of
often a technically challenging operation and has laparoscopic HR remain low (17.6%) according
significant risks of mortality and morbidity, to a study of the ACS-NSQIP data [16]. When a
respectively, up to 10% and 50% [3]. Quality of laparoscopic approach is chosen, the conversion
life is often impaired in patients with a colostomy rates to an open procedure are as high as 50%
[17]. Conflicting data regarding the benefits of
laparoscopy for HR was demonstrated by a recent
J.-S. Trépanier (*)
retrospective study of 276 patients: it failed to
Maisonneuve-Rosemont Hospital, General Surgery
Department, Montréal, Québec, Canada demonstrate a difference regarding the length of
e-mail: [email protected] stay and complication rate [18]. Therefore, the
https://www.aischannel.com search for a different approach for HR remains
F. B. de Lacy · A. M. Lacy pertinent.
Gastrointestinal Surgery Department, Hospital Clinic, With the rapid development of advanced trans-
University of Barcelona, Barcelona, Spain
anal procedures, from transanal endoscopic
e-mail: [email protected];
[email protected] microsurgery (TEM) [19, 20] to transanal mini-
https://www.aischannel.com mally invasive surgery (TAMIS) [21], and more

430 J.-S. Trépanier et al.
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
colostomy site, and establishing pneumoperito- taHR: Transanal Aspects

neum. The mucocutaneous junction is resected,
and a purse-string suture is performed on the colon The transanal steps of taHR are similar to the
opening and tied around the anvil of an end-to-end ones of a taTME. The main differences are that
anastomosis stapler. The anvil is then delivered with taHR, less importance is given to obtaining
back into the abdominal cavity. The platform is a total mesorectal excision. In addition, the purse-
secured in place at the former stoma site, and string suture to occlude the lumen prior to the
pneumoperitoneum (set to 15 mmHg) is created. A rectotomy with taTME is a step that may be omit-
5 mm or ideally a 10 mm 30° laparoscopic camera ted during taHR.
is inserted through a trocar in the single-port plat- Thus, the first step for the transanal portion of
form, and the other trocars are then inserted under taHR is the positioning of the transanal platform.
direct vision as shown in Fig. 42.1. Usually, some We favor a flexible (TAMIS) platform (Gelpoint
degree of lysis of adhesions is necessary to allow Path Transanal Access Platform; Applied Medical
for safe placement of trocars. Often, the camera Inc., Rancho Santa Margarita, CA) over a rigid
trocar is placed more centrally and away from the TEM platform (Fig. 42.2). Then, we evaluate the
instruments trocars to avoid interference with their rectal stump under direct vision, looking for the
movements. Alternatively, three trocars (or cannu- best suitable place for the anastomosis. Often, it is
las) can be introduced through the flexible single-
port platform in the colostomy wound to perform
a laparoscopic single-port abdominal dissection.
To allow for the performance of a tension-free
anastomosis, a mobilization of the left colon is
generally necessary. To gain significant reach for
the proximal colon, a splenic flexure takedown is
achieved if not previously done during the
Hartmann’s procedure.
Then, attention is directed toward the pelvis.
The rectal stump is often identified by blue poly-
propylene tag sutures placed during the Hartmann’s
procedure. If the rectal stump is long and easily
identifiable, proceeding with a laparoscopic-only
HR is recommended. If the rectal stump is short or
there are many adhesions in the pelvis, the tech-
nique of taHR can be utilized.
Fig. 42.1 Proposed single-port platform and trocars Fig. 42.2 Transanal flexible platform with an anal
placement retractor
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)
Fig. 42.6 Another transanal view of the purse-string

suturing
Fig. 42.4 Rectotomy reaching the total mesorectal plane
(upper right corner) using a 0 or 2–0 polypropylene suture (Figs. 42.5
and 42.6). The proximal colon with the anvil in
decided to resect the proximal part of the rectum place is pulled down into the pelvic inlet. The rec-
beneath the previous Hartmann’s suture/staple tal stump purse string is tied around the anvil’s
line, to avoid creating the anastomosis in a fibrotic long central spike, as is the case of PPH stapler.
or narrowed rectal wall. If a longer segment of the Alternatively, a drain or a urinary catheter can be
rectum has to be resected, one can close the rectal used to guide the anvil if a standard EEA stapler is
lumen with a 0 polypropylene purse-string suture. employed. Then, a d ouble purse-string single-sta-
Subsequently, the rectotomy is performed, cutting pled anastomosis is created after connecting the
the rectal wall perpendicularly (Figs. 42.3 and anvil to the stapler (Figs. 42.7 and 42.8). An end-
42.4). Once the perirectal mesorectum fat is to-end or a side-to-end anastomosis can be per-
reached, dissection is directed cephalad toward the formed according to the surgeon’s preference and
desired point of rendezvous with the abdominal colon characteristics. Inspection of the anastomo-
team. Often, dissecting in the total mesorectal sis is achieved laparoscopically and transanally.
plane will help to connect the abdominal and An air leak test is also performed. If there exists
transanal fields and will avoid having parallel concern about the appropriate vascularization of
planes. In the process, the old staple line on the the colon or rectum before completing the anasto-
rectal stump is completely resected and extracted mosis, an intraoperative blood perfusion assess-
through the transanal platform. Next, a purse- ment is performed using indocyanine green (ICG)
string suture is placed on the open rectal stump fluorescence imaging. A temporary diverting loop
42 Hartmann’s Reversal by a Combined Transanal-Transabdominal Approach 433
Conclusion
A combined laparoscopic abdominal and taHR is

a novel approach to achieve intestinal continuity
reconstruction. Further studies are needed to
prove the safety of the procedure and to clarify its
indications. However, in centers with expertise in
transanal surgery, in particular with taTME, it
was found to be a valuable additional tool to
accomplish Hartmann’s reversal by a minimally
invasive approach.
Acknowledgments We would like to thank www.ais-

Fig. 42.7 Creation of an end-to-end single-stapled dou- channel.com for the media support.
ble purse-string anastomosis (EEA anvil still in the proxi-
Support No source of funding to disclose.
mal colon)
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Pure NOTES Transanal TME
43
Joel Leroy, Frédéric Bretagnol, Nguyen Ngoc Dan,
Hoa Nguyen Hoang, Truc Vu Trung,
and Chuc Phan Ngoc
Introduction In 1982, Heald et al. published the concept of the

total mesorectal excision (TME) for rectal cancer
At the beginning of the twentieth century, Miles treatment [2]. This procedure remains the gold
(1906) [1] was the first to propose an oncologic standard worldwide in the surgical treatment of
resection in rectal cancer reducing local recur- advanced rectal cancer (Fig. 43.1). Laparoscopic
rence rate from 90% to 30%. He defined the ben- resection has been shown to be oncologically
efit to remove “en bloc” all the rectum and the equivalent as compared to open resection in the
regional nodes with clear margin (R0 resection). hands of experts, but TME is a challenging tech-
nique particularly for low rectal adenocarcinoma
managed by open or laparoscopy even with
J. Leroy (*) robotic assistance, useful in obese patient [3].
Hanoi High Tech & Digestive Center, St Paul Transanal TME (taTME) is not a completely
Hospital, Digestive Colorectal Department
of Minimally Invasive Surgery, Hanoi, Vietnam new concept [4] but, rather, a mixture of surgical
techniques developed during the end of the twen-
F. Bretagnol
Digestive Surgery—University Louis Mourier tieth century [transanal endoscopy microsurgery
Hospital (APHP), Paris, France (TEM), transabdominal transanal (TATA), and
N. N. Dan transanal minimally invasive surgery (TAMIS)].
Hanoi High Tech & Digestive Center, St Paul Patricia Sylla and Antonio Lacy (2010) reported
Hospital, Hanoi, Vietnam their early experience, with transanal video assis-
H. N. Hoang tance, showing encouraging results in terms of
Hanoi High Tech & Digestive Center, St Paul safety and efficacy [5].
Hospital, Digestive Colorectal Department of
In the technique we describe below, oncologic
Minimally Invasive Surgery, Hanoi, Vietnam
TME is performed exclusively via the pathway
Thai Binh Medical University, Thai Binh, Vietnam
using perirectal and retroperitoneal endoscopic
T. V. Trung dissection. We described it in experimental and
Hanoi Medical University, Hanoi, Vietnam
clinical settings [6–9].
St Paul Hospital, Digestive Colorectal Department
of Minimally Invasive Surgery, Hanoi, Vietnam
C. P. Ngoc Rationale
Hanoi High Tech & Digestive Center, St Paul
Hospital, Digestive Colorectal Department
of Minimally Invasive Surgery, Hanoi, Vietnam In advanced rectal cancer, the surgical gold stan-
dard is TME performed either by (a) a minimally
Hanoi Medical University, Hanoi, Vietnam
invasive laparoscopic [without (90%) or with
436 J. Leroy et al.
Fig. 43.1 TME principles for rectal cancer. Meso and its
tail are removed respecting fascial envelop
robotic assistance (10%)] resection or, alterna-

tively, (b) by an open, abdominal procedure. To
perform a TME, Gerald Marks in the 1980s pro-
posed transanal route for low rectal tumors after
radiochemotherapy (RCT) and in fragile patients
or patients with a difficult pelvic access (obesity),
i.e., narrow space. In the 1990s, his son John Fig. 43.2 Gold standard of oncologic rectal resection for
Marks updated this approach by combining it cancer with lymphadenectomy
with laparoscopy [10]. All these techniques are
hybrid techniques that combine two approaches. transanal procedure removing the rectum and the
They called this technique the TATA (transanal- mesorectum, dividing the inferior mesenteric ves-
transabdominal) proctectomy [11]. sels with en bloc lymphadenectomy (Fig. 43.2),
The transanal route was used, by us and most and doing a transanal colorectal or coloanal anas-
authors, to finish “up-to-down” TME using inter- tomosis after removing the specimen transanally.
sphincteric resection (ISR) in ultra-low rectal Oncologic resection of the rectum must include
tumors and for performing full-thickness resec- rectal resection, mesorectal resection respecting
tions with TEM platform. Recently surgeons have propria fascia with free lateral and distal margin
proposed to begin transanally using video endo- (R0 resection), and en bloc vascular package
scopic platform to facilitate laparoscopic distal removal including inferior mesenteric vessels and
step of the TME using the concept proposed by nodes (Fig. 43.3). Most authors include the mobi-
Gerald and John Marks in the TATA. Zorron lization of splenic flexure, but it is only for the
(2014) named this approach down-to-up TME in purpose of constructing a tension-free anastomo-
opposition of the up-to-down TME [12], but sis, and not for any oncologic reason.
authors performed only a distal or subtotal perirec- In early rectal cancer, different techniques
tal dissection, and it is more appropriate to say dis- have been described. Local full-thickness
tal partial or total mesorectal dissection (TMD). resection was introduced using a specifically

Both techniques use combined methods (transanal designed operating apparatus (i.e., TEM) begin-
and laparoscopic). They are well described in ning in the early 1980s by Gerhard Buess with
other chapters of the book. success in selected cases [13]. The local recur-
Our area of investigation focused on exploring rence rate was low but not nil. In our opinion,
the possibility of performing a pure NOTES (nat- oncologic, curative- intent local excision must
ural orifice transluminal endoscopic surgery) include analysis of the nodes in the mesorectum
43 Pure NOTES Transanal TME 437
Fig. 43.3 Mid-pelvis sacrum Superior Rectal Vessels

cross-section view in
Sacral vessels
male. Anatomic
landmarks of fasciae plane of dissection
Superior
Hypogastric nerves
Parietal fascia
TOTAL
Sacral nerves
MESORECTAL
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
Patient selection is paramount when considering

a pure NOTES taTME approach. After a thor-
ough discussion concerning risks, benefits, and
alternative approaches, consenting patients are
included in our prospective trial for pure NOTES
taTME. We select patients with mid-to-low early
rectal cancers (T1, T2) (Fig. 43.6). Currently, we
exclude patients with locally advanced (T3, T4)
disease.
Surgical Technique
Armamentarium
Instrumentation is essential to the success of this

approach. We use the TEO® platform (Karl Storz,
Fig. 43.4 CT-scan showing a long compliant sigmoid Tuttlingen, Germany) which is a 4 cm diameter
loop (ideal case for pure NOTES taTME) operating rectoscope tube (Fig. 43.7). The plat-
form includes 4 cm diameter tubes at the oblique
distal extremity (the superior border is the lon-
gest) and at the proximal orifice, which allows the
connection of cups of different shapes and func-
tions allowing for the introduction and use instru-
ments of various diameters – including fiberscopes
up to 2 cm in diameter (each instrument can main-
tain a seal with the aid of device-specific caps).
For the TEO® apparatus, there are three access
channel tube lengths (the “short” one which is
7.5 cm long, the “medium” one is 15 cm long, and
the “long” one is 20 cm long). Once introduced
into the rectum (after dilating the sphincter with a
dilator), the tube is fixed by an articulating sup-
port to the operating table. The TEO® can be
Fig. 43.5 CT-scan of T2 lateral mid-rectal cancer (same

patient, ideal case) Fig. 43.6 Endoscopic view of the T2 mid-rectal cancer
Fig. 43.7 TEO® platform from Karl Storz
repositioned by adjusting the Martin arm which is

mounted to the operating table, and this allows
scope movement to more proximal portions of the
rectum, which is required during NOTES
taTME. This is important, as the working space is
a function of the size and length of the operating
tube and of the instruments size – since work is
done in the axis of the tube. The main advantage
of using the TEO® platform is in the concept of
circular retraction done by the shape of the tube. It
is exactly similar to the endoscopist when he per-
forms a mucosectomy inside a cup exposing the
field (Fig. 43.8). Thus, TEO® is used to expose Fig. 43.8 Endoscopic cap use for EMR at the extremity
the field doing circular retraction leading to a of a fiberscope
larger surgical field to dissect safely in the middle
and for making a tunnel in the dissection plane
without an additional retractor. This allows one to camera’s lens), and the last tap, located in the
perform the operation autonomously. TEO® scope’s handle, is used for evacuating
Insufflation is performed using CO2 gas set plumes of smoke created during the process of
with continuous high flow (typically in the range electrocautery dissection. It is very important to
of 12–15 mmHg). The platform includes three have a specialized gas insufflator, with continu-
taps, or access points – two of them are a part of ous high flow of CO2, to clear the operative field
the faceplate connected to the rectoscope (one for and evacuate the smoke (ENDOFLATOR® 40
the CO2 insufflation, the other for cleaning the SCB, Karl Storz, Tuttlingen, Germany). To limit
440 J. Leroy et al.
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
Fig. 43.13 Suction, irrigation, and monopolar distal

coagulator (useful for pelvic bleeding control)
Setup
All patients were administered a standard preop-

erative bowel preparation. Specifically, patients
received 3–8 days of a low residue diet, and,
upon admission 1 day prior to the operation,
cathartic enemas were administered. We have
since modified our protocol to include a full
mechanical bowel preparation combined with
oral antibiotics, based on evolving guidelines
supported by recent data [14].
The step-by-step procedure has been previ-
Fig. 43.11 Cap fixed to the TEO®. Cap with three work-
ously published and described in detail [28].
ing channels and one for the camera
Under general anesthesia, the patient is placed
supine in a lithotomy/Lloyd-Davies position with
urinary catheter placement and padding required
around the calves to protect the common pero-
neal nerve in the lower leg. The patient’s buttocks
should extend slightly beyond the inferior edge
of the table. Thromboprophylaxis is initiated and
includes graded compression stockings, intermit-
tent pneumatic compression devices, and venous
foot pumps. Operating table with remote control
changes in positioning is recommended.
The final control monitoring screen is placed
Fig. 43.12 Monopolar spatula with smoke evacuation above the pubis in the visual axis of the operator,
channel (Olympus™, Japan)
as described previously.
For safety reasons, the different control panel
other energy devices (e.g., THUNDERBEAT™ elements (carbon dioxide pressure, carbon dioxide
platform or LigaSure Advance™ (Covidien, New output, insufflated volume, power of used energies)
Haven, CT, USA) for the safe and durable sealing should be visually and rapidly accessible to the
of vessels. To control local bleeding, we use bipolar team. The laparoscopic equipment should be pre-
coagulation, monopolar coagulation with spatula, pared in the operating room in case of conversion
and, if necessary, the suction-irrigation-coagulation or should a hybrid technique be required. The
cannula from Olympus Company designed by patient is draped for both approaches, as well, if the
J. Okuda (Fig. 43.13). event transabdominal access becomes necessary.
442 J. Leroy et al.
Fig. 43.16 Purse string minimum 1 centimeter under the

tumor
Fig. 43.14 Team and patient installation for pure taTME
tep 2: Posterior Rectal Space Opening

S
The rectal mucosa is initially incised from a 10 to
a 2 o’clock position (Fig. 43.17), and then a full-
thickness posterior rectotomy is performed
(Fig. 43.18). The plane of dissection begins just
posteriorly to the rectal fascia and is developed
up to the promontory along a plane anterior to the
sacral fascia in the posterior midline. The
pneumo-dissection performed using insufflation
facilitates the identification of this space
Fig. 43.15 Perfect purse string closing the distal rectum (Fig. 43.19). In our experience and in the major-
ity of cases, the dissection was performed behind
the presacral fascia. Recently, we have success-
The surgeon works in a seated position between the fully dissected along a plane between the presa-
patient’s legs with one or two assistants who will cral fascia and the propria fascia. In so doing, this
manipulate the TEO® in order to change its posi- opens the plane just above their fusion point (i.e.,
tion during the surgical maneuver (Fig. 43.14). Waldeyer’s ligament) leading to entry in the
“holy plane” (Fig. 43.1), as described by RJ
Heald [2]. This embryonic plane not only pro-
Dissection vides oncologically precise but also allows for an
avascular and thus safe plane which does not
tep 1: Closing the Distal Stump
S encroach upon the pelvic autonomic nerves. As
of the Rectum Placing a Purse-String the dissection progresses cephalad beyond the
Suture sacral promontory, the retroperitoneal space
A purse-string suture is placed 1 cm distal to the becomes exposed just inferior to the aortic bifur-
inferior boarder of the tumor (Fig. 43.15), in order cation. In the pure NOTES taTME technique, the
to prevent fecal and cancer cell contamination and dissection can be continued from down-to-up by
to avoid colonic insufflation. The closure must be advancing the TEO® rectoscope forward and lat-
perfect to avoid insufflation of the proximal rec- erally reaching the level of the sacral promontory.
tum and colon (Fig. 43.16). The distal rectum is Anterior and medial retraction of the mesorectum
then irrigated copiously with a povidone-Iodine® is done via the transanal approach by using the
solution in an attempt to sterilize the distal TEO® platform’s access channel as a circular
anorectum. retractor that “stents open” the operative field.
a b
Fig. 43.17 Drawing of the incision under the purse string

(A posterior, B anterior)
Fig. 43.20 Left lateral dissection, sliding along the lat-

eral side wall fascia (white structure). Nerve branch cross-
ing the space
“holy plane,” it becomes more challenging as

progress is made more cranially and laterally.
As the lateral dissection progresses, the 15 cm
length TEO® rectoscope is advanced to a posi-
tion between the rectum and the side wall fascia.
This will slowly expose the middle rectal vessels
and the autonomic branches of the lateral plexus
Fig. 43.18 Full-thickness rectotomy from 2 to 10 (including the nervi erigentes) crossing the lat-
eral side wall pelvic fascia to reach the lateral
side of the rectum and mesorectum (Figs. 43.20
and 43.21). It is important to note that until this
point in the pure NOTES taTME dissection, the
abdominal cavity has not opened as the perito-
neal reflection has not been violated. In this tech-
nique of dissection, the pressure of the CO2 gas is
not the principle factor in creating the operative
exposure, but it is rather the retraction of the
TEO® rectoscope shaft. The CO2 is only used
with a low pressure (12–15 mmHg) – with the
purpose of clearing the field of view. Landmarks
for doing a safe lateral pelvic dissection is to fol-
Fig. 43.19 Retrorectal and presacral dissection with low the medial side of the side wall pelvic fascia,
monopolar spatula. TEO® is pushed slowly to open the
which appears white. In so doing, iatrogenic
space without another retractor
injury to anatomical structures including the lat-
eral aspects of the inferior hypogastric plexus can
tep 3: Cranial and Lateral Progression
S be avoided (Fig. 43.22).
of the Dissection
If the plane initially entered is not the “holy tep 4: Extending the Perirectal
S
plane” but the presacral space just posterior to the Dissection Anteriorly
presacral fascia, care must be taken to avoid dis- Once the posterior and lateral dissection of the
secting too posteriorly, which can result in injury mesorectum has been completed, the remainder
to the autonomic plexus and presacral veins. of the distal rectal transection is performed ante-
While entering the presacral space and not the riorly from a 2 o’clock to a 10 o’clock position
444 J. Leroy et al.
Fig. 43.21 Right lateral dissection. Visualization of Fig. 43.23 Full-thickness anterior rectotomy from 10 to 2
nerves plexus branches
Fig. 43.24 Female patient: Denonvilliers’ fascia (white).

Fig. 43.22 Right side wall fascia (white). Resistant Douglas pouch visible
structure which protect laterally the inferior hypogastric
plexus
(Figs. 43.17 and 43.23). The rectal wall must be

completely dissected to enter into the rectovagi-
nal plane in female patients (Fig. 43.24) and the
rectoprostatic plane in males (Fig. 43.25).
Dissection is developed until the level of the peri-
toneal reflection is reached.
tep 5: Dividing the Anterior Peritoneal

S
Reflection and Opening the Abdominal
Cavity
This maneuver reveals the rectouterine pouch
(Douglas’ pouch) in women (Fig. 43.26) and the
recto-vesicular pouch in men (Fig. 43.27). As in
transabdominal resections, this step is more dif-
ficult in men. In men with anterior lesions, the Fig. 43.25 Male patient: Denonvilliers’ fascia anterior,
dual-layered Denonvilliers’ fascia is kept on the rectum posterior, and Douglas pouch
Fig. 43.26 Female patient: opening the Douglas pouch Fig. 43.28 Proximal lateral division on left of the root of
the mesorectum
abdominal cavity through the peritoneal entry

point along the pouch of Douglas. It is at this
moment that the patient is positioned in steep
Trendelenburg to obtain retraction of the bowel
in the upper part of the abdominal cavity above
the pelvic brim, to better expose the upper
aspect of the pelvis. The pressure of the intra-
abdominal CO2 gas completes the retraction of
the small bowel maintaining it away from the
pelvis and operative field, as during classical
laparoscopy. Pushing the rectum anteriorly
results in tenting of the root of the mesorectum
(Fig. 43.29) at the level of the promontory
exposing the lateral peritoneal attachments of
the mesorectum we divide to open the retroperi-
toneal space.
Fig. 43.27 Male patient: opening of Douglas pouch
tep 7: Reaching the Root
S
mesorectum (to assure oncologic clearance), and of the Inferior Mesenteric Vessels
care is taken to prevent urogenital tract injuries The TEO® long rectoscope (20 cm length) is
(prostate, seminal vesicles, and urethra). For now utilized. The shaft is advanced behind the
these steps, the TEO® platform provides excel- rectum toward the promontory by dissecting
lent exposure by retracting the fasciae, and this planes posteriorly with a monopolar spatula elec-
facilitates precise and safe dissection. trode. Care is taken to prevent injury to presacral
veins posteriorly, to the mesorectal envelope
tep 6: Proceeding with the Dissection
S medially, and to pelvic nerves, ureters, and distal
Toward the Root of the Mesorectum branches of iliac vessels coursing laterally. With
and the Retroperitoneal Abdominal anterior retraction of the root of the mesorectum,
Space the retroperitoneal space anterior to the aorta is
Once the anterior peritoneal reflection has been entered, with care to preserve the preaortic fascia
opened, the rectum is gently distracted down- and hypogastric plexuses (Figs. 43.30 and 43.31).
ward to expose and divide the lateral attach- As stated previously, exposure of the space is
ments of the root of the mesorectum (Fig. 43.28). maintained by the circular TEO® retractor
Next, the rectum is pushed cephalad into the (Fig. 43.32), which allows for the dissection to be
446 J. Leroy et al.
Fig. 43.32 Vison of a 20 cm TEO® in intra-abdominal

position during a pure taTME (view through a right iliac
fossa trocar, before doing diverting stoma)
Fig. 43.29 Root of the mesorectum tented anteriorly

exposing the anterior aspect of the promontory
Fig. 43.33 Dissection origin IMA
extended toward the root of the sigmoid mesen-

tery, following the dorsal aspect of the vascular
sheet of the inferior mesenteric vessels. The ret-
roperitoneal dissection of the sigmoid mesentery
is continued to reveal the origin of the inferior
Fig. 43.30 Male patient: 20 cm TEO® pushed above the mesenteric artery (IMA) (Fig. 43.33). This step
promontory inside the retroperitoneal space, in front of may be facilitated by the division of the medial
the aorta
and lateral peritoneal attachment of the sigmoid
colon and the ventral lifting of the mesentery. For
this step, longer instruments (43 cm) are helpful
to achieve better operative angles and improved
operative ergonomics.
tep 8: Dividing the Inferior Mesenteric

S
Vessels and the Sigmoid Mesentery
For oncological purposes (as well as to improve
conduit reach), a high ligation of the IMA is the
standard approach (Fig. 43.34). Otherwise, for
early tumor and benign lesions, a distal division
of the superior rectal artery may be performed
Fig. 43.31 Female patient: 20 cm TEO® pushed above [15–17]. Distal or high divisions of the inferior
the promontory inside the retroperitoneal space, in front mesenteric vessels are performed after sealing
of the aorta
Fig. 43.34 Clipping IMA trunk before division
Fig. 43.36 Division of the mesosigmoid
Fig. 43.35 Dissection and division IMV with a sealing

device
[with THUNDERBEAT™ Type S (Olympus,

Tokyo, Japan) or with LigaSure™ (Covidien, New Fig. 43.37 Control of the vascularization with ICG®
Haven, CT, USA)] or after clipping. Division of the
IMV (Fig. 43.35) is done afterward, and the left When the division of the sigmoid mesentery
colic artery is also divided after high tie of the IMA. has been completed, the distal extremity of the
Division of the sigmoid mesentery (Fig. 43.35) rectum is grasped and pulled slowly through
is performed intra-abdominally after selecting the the TEO® rectoscope; a transanal extraction is
best segment (summit of sigmoid loop). One can then performed at the same time (Fig. 43.38).
divide the mesentery first or divide the sigmoid The specimen is gently exteriorized, with care
colon first with a linear stapler introduced into the to maintain the integrity (Fig. 43.39) and qual-
12 mm operative channel of the TEO® faceplate ity of the mesorectal envelope, the vascular
(stapler access can be obtain removing the sili- pedicle, and the mesenteric lymphadenectomy
cone obturator). Division of the mesentery is per- (Fig. 43.40); the proximal margin and distal
formed with a sealing device (Fig. 43.36). At the limit of the resection are determined as well
end of the division, we observe the quality of the (Fig. 43.41).
vascularization with visual comparison of the Next, the now transanally exteriorized sigmoid
color; alternatively indocyanine green (ICG) can colon is divided extracorporeally. To perform this, a
be used to assess bowel perfusion (Fig. 43.37). So suitable portion of sigmoid colon (demonstrating
as to more easily divide the mesentery, it is useful adequate vascularity) is prepared and then divided
to retract (by a pushing maneuver) all the rectum with a linear Endo-GIA stapler (Fig. 43.42). A
mesorectum laterally toward the right iliac fossa. suture is fixed on the bowel maintain its orientation.
448 J. Leroy et al.
Fig. 43.38 Transanal exteriorization of the specimen
Fig. 43.40 Control of the quality of oncologic resection

and vascular package
Fig. 43.39 Macroscopic view of rectal specimen
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.
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].
Why TEO® Platform? I s Mobilization of Splenic Flexure

The TEO® platform is not a mere “point-of- Necessary?
access” device equitable to a trocar. When Gerhard For most authors, mobilization of splenic flexure
Buess develop the revolutionary TEM apparatus, is a step of TME’s procedure. Increasingly, how-
he proposed an automatic gas distension to expose ever, there is a growing consensus not to perform
the rectal cavity [13]. Doing only full-thickness mobilization systematically and thus leading
excision of rectal neoplasia, he did not, at that most experts to recommend a case-by-case selec-
time, envision the advantage of using the device’s tion. It is one of the techniques available to obtain
rectoscope as “tunneling machine” to provide adequate length, especially for construction of an
retraction in a circular manner that would enable ultra-low anastomosis, but has little direct effect
more radical, en bloc resections. In our opinion, on blood supply, and splenic flexure mobilization
such rigid platforms (TEM or TEO®) provide the can increase operative and postoperative morbid-
advantage to expose the plan of dissection, and ity. If it is necessary for anatomic reasons (spe-
CO2 gas flow aids in clearing the operative field. cifically, to gain reach) or because it is otherwise
The TEO® scope can be navigated around the rec- deemed necessary, transanal flexure mobilization
tum and, subsequently, in the retroperitoneal is, in fact, feasible with the adaption of long
space, stenting the operative field open, in a simi- instruments – as John Marks has demonstrated to
lar fashion to how the cap is used to do so by inter- be successful [34]. An operative fiberscope can
ventional endoscopists during EMR (Fig. 43.8). be useful as an adjunct, as well [9], and in this
Currently at our center, we are exploring the manner, pure NOTES taTME including splenic
possibility to eventually connect the TEO® plat- flexure mobilization is possible.
form to a foot pedal or a voice-piloted robotic
arm to improve the ergonomic and functional Teaching and Training
arrangement, allowing a surgeon to operate more TME procedure for rectal cancer remains a techni-
autonomously, expeditiously, and without the cally demanding operation, whether completed in
need for a skilled assistant. Combined, these fac- the open, laparoscopic, robotic, and now via the
tors can reduce the cost of the procedure. transanal approach. Through experience, and since
the inception of laparoscopic digestive surgery, a
Why a Retroperitoneal Approach? standardized methodology of these procedures is
Decades of experience with conventional, up-to- essential to reproduce and to teach surgeons so that
down TME taught us that the dissection of the they may gain proficiency. Thus, a new procedure
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
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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.
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Totally Robotic taTME: Experiences
and Challenges to Date 44
Marcos Gómez Ruiz
Introduction cancer surgery. Laparoscopic rectal resection has

shown clear advantages in short-term clinical out-
For the last two decades, total mesorectal exci- comes [7, 8]. However, ALaCaRT and ACOSOG
sion (TME) has been transforming the outcomes Z6051 trials further questioned the oncologic
of rectal cancer surgery and is a technique which equivalence of the laparoscopic approach for rectal
holds great promise [1]. cancer. These trials failed to establish the oncologi-
As in any other oncological surgical tech- cal noninferiority of laparoscopy compared to open
nique, TME surgical quality has a direct impact rectal cancer surgery [9, 10].
on local control and survival [2, 3]. In the patho- Robotic-assisted surgery was introduced at the
logical assessment of rectal cancer specimens, dawn of the new millennium. This new technique
the circumferential radial margin (CRM) and the appeared to present clear advantages over lapa-
plane of surgery achieved are clear independent roscopy, with improved stereoscopic visualiza-
predictors of local recurrence [4]. At the same tion, endowristed instrumentation, and superior
time, not only oncological but also functional surgeon ergonomics that diminish fatigue, partic-
outcomes have a significant impact on patients’ ularly for long and complex operations. Robotic-
postoperative quality of life. These results are not assisted surgery has been shown (in single-center
always favorable with current surgical techniques series and some meta-analysis reports) to be asso-
for rectal cancer treatment. ciated with lower conversion rates, better TME
Open approach for rectal cancer treatment is the quality, lower positive CRM rates, and earlier
standard of care in most of the centers in the world. recovery of genitourinary functions [11]. Robotic
This approach is associated with poor postopera- surgery is generally easier to learn than laparo-
tive outcomes in terms of patient recovery, pain, scopic surgery, improving the probability of auto-
lengths of stay, and blood loss [5]. Laparoscopic nomic nerve preservation and genitourinary
colorectal surgery started 27 years ago [6] to function recovery [12, 13]. Furthermore, in very
improve the clinical, oncological, and functional complex rectal cancer, TME procedures such as
outcomes that open surgery can provide in rectal intersphincteric dissections and transabdominal
transections of the levator muscle, the robotic
M. G. Ruiz (*) approach is associated with increased perfor-
Hospital Universitario Marqués de Valdecilla, mance and safety compared to laparoscopic sur-
IDIVAL, Servicio de Cirugía General y Aparato
Digestivo, Unidad de Cirugía Colorrectal,
gery [14, 15]. Despite these encouraging data, the
Santander, Spain ROLARR trial failed to establish a clear benefit
e-mail: [email protected] of robotic-assisted approach when comparing

456 M. G. 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
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
division of the inferior mesenteric vein and artery

at their root. The descending and sigmoid colon
are then mobilized, finishing the dissection at the
sacral promontory once the ureter and iliac ves-
sels are identified. The robotic surgical system is
next undocked, and the patient is repositioned in
the Trendelenburg position with a slight right tilt
for the next phase of the operation.
Partial intersphincteric resection can be per-
formed for tumors located at ≤3 cm from the anal
verge. A Lone Star retractor (Lone Star Medical
Products Inc., Houston, TX) or a PPH anoscope
(Ethicon Endosurgery, Cincinnati, OH) is posi-
tioned, and the mucosa and internal sphincter Fig. 44.3 Transanal access port proctoscope. (Developia-
IDIVAL, Santander, Spain)
muscle are dissected circumferentially beginning
at least 1 cm below the distal margin of the tumor.
Intersphincteric dissection is extended cephalad patient. The fenestrated bipolar grasper is then
for 1–2 cm, and a purse-string suture is then placed in Arm 1 on the left, while monopolar
placed to occlude the rectum below the tumor scissors are placed in Arm 2 on the right, and a
(Fig. 44.2). 30° endoscope is placed through the 12-mm tro-
Following rectal occlusion, a “transanal access car. The assistant trocar is used primarily to assist
port” proctoscope (Fig. 44.3) is inserted transa- in tissue countertraction or to apply suction or
nally, and a 80-mm GelPOINT gel cap is adapted irrigation (Fig. 44.4). If available, an AirSEAL
to this custom-made platform. The robotic tro- System (Conmed, Utica, NY, USA) 5-mm or
cars are then directly introduced through the gel 8-mm valveless tocar can be used for the assis-
cap for robotic taTME. tant, thereby stabilizing the pneumatics, as dis-
A 12-mm or an 8.5-mm trocar can be used for cussed elsewhere.
the optical port. Two 8-mm trocar ports are When partial intersphincteric resection had
inserted with a distance of at least 4 cm between not previously been done (patients with tumors
robotic instruments, and an accessory 12-mm tro- located higher than 3 cm from anal verge), the
car is inserted for the assistant port. The da Vinci rectum is insufflated with CO2 to a pressure of 8
robotic cart is next docked over the left hip of the to 10 mmHg. The rectal mucosa is then scored
460 M. G. Ruiz
Table 44.1 Clavien-Dindo Complication Distribution

Clavien-Dindo Complications
Number Rate (%)
No complications 28 75.7
I 3 8.1
II 3 8.1
IIIb 2 5.4
IV 1 2.7
Total 37 100.0
the stoma site in 37.8%, Pfannenstiel incision

was used in 6% of the patients. Clavien distribu-
tion is shown in Table 44.1. Mean hospital stay
Fig. 44.4 Da Vinci Si System docked transanally using
PAT proctoscope was 7.54 +/−5.258 days (Table 44.2.). Three
patients presented anastomotic leak (8.1%), one
of them Grade C.
circumferentially with monopolar cautery begin- TNM and UICC distribution of the patients
ning distal to the purse-string and followed by is described in Tables 44.3 and 44.4. The
full-thickness rectal dissection. After rectal wall median harvested lymph nodes were 12.6. TME
division, the pelvic space around the remnant quality assessed by pathologist was complete in
anal canal is insufflated to facilitate pelvic dis- 94.6% and almost complete in two cases: 5.4%.
section and robotic taTME. Anteriorly, the rec- DRM and CRM were negative in all cases.
tum is dissected from the posterior vagina or Mean tumor height from anal verge was 5.33 cm
prostate following Denonvilliers fascia until the (2–9 cm). In the follow-up, no patient presented
peritoneal reflection is reached and divided. local recurrence.
Posterior and lateral mesorectal dissection is When analyzing our results and comparing
performed by using a transanal approach with them with the ones published in the International
laparoscopic assistance. taTME Registry [25], our lower rate of visceral
Following adequate colonic mobilization, the injuries and rectal perforations supports this
rectum can be grasped and exteriorized transa- potential benefit, even though our experience is
nally under laparoscopic visualization or through limited to 37 cases, which is still under the
the ileostomy site. An Alexis wound retractor learning curve for taTME [51]. The goal is to
(Applied Medical Inc., Rancho Santa Margarita, achieve the best quality of surgery to obtain the
CA) can be utilized. A handsewn end-to-end best clinical, oncological, and functional out-
coloanal anastomosis or mechanical end-to-end comes. To do this, the key points are to obtain an
colorectal anastomosis is performed, depending excellent vision and information of the surgical
on case specifics and tumor height. A diverting anatomy with the assistance of surgical
loop ileostomy is next created, and a pelvic drain instruments.
can be placed intra-abdominally. TaTME may provide better results because it
improves the vision of the surgical field. The
robotic systems facilitate the surgical perfor-
Clinical Outcomes mance with the endowristed instrumentation. In
addition, they can optimize vision and informa-
Thirty-seven consecutive totally taTME robotic tion of the surgical field with the 3D immersive
cases have been performed in our unit between view and with the potential use of augmented
2013 and 2017. Conversion was required in one reality. The use of stereotactic navigation in the
case (2.70%). Transanal specimen extraction was pelvic surgery can be another important step to
performed in 56.2% of the patients, and through facilitate the safety as well as oncological quality
Table 44.2 Mean hospital stay

Hospital stay
N Minimum Maximum Mean Std. deviation
Hospital stay 37 4 30 7.54 5258
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
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Next-Generation Robots for taTME
45
Jessie Osborne Paull, Abdullah I. Alalwan,
and Vincent Obias
Introduction 1982, Heald’s total mesorectal excision (TME)

technique [2] was developed, based on the con-
Although colorectal cancer incidence and death cept that the rectum and mesorectum are of the
rates have declined over the years, mainly due to same embryological origin and thus share lym-
advances in early detection and treatment, phatic and venous systems, allowing cancer to
colorectal cancer still remains one of the most spread between them. TME shifted the manage-
common cancers affecting humans. Further, ment of rectal cancers from Dr. Ernest Miles’
recent studies have shown an increase in the inci- abdominoperineal resection (1908), with the
dence rates in individuals of a younger age [1]. extraction of the mesorectum and rectum for
The goal of rectal cancer treatment remains com- completeness of oncologic resection. It later
plete cancer removal while preserving rectal and became the gold standard of treatment as study
sphincter function, and, throughout the years, this results showed improvement of disease-free sur-
has undergone various advancements with vival from 68% to 80% at 5 years and 66% to
improved morbidity and mortality rates. 78% at 10 years [3].
Many surgical techniques have been devel- As the laparoscopic era emerged and domi-
oped to approach rectal tumors, which are spe- nated the surgical spectrum in the 1990s, the intro-
cifically known for their anatomical restrictions duction of laparoscopy in the management of
and challenges. The nonlinear anatomy hinders rectal tumors had conflicting results when com-
visualization and instrumental maneuvering, pared to open rectal tumor resection. In random-
sometimes resulting in specimen fragmentation ized clinical trials, such as COLOR II, COREAN,
and making the attainment of surgically negative and CLASICC, it was shown that laparoscopic
margins technically more arduous to achieve. In TME had better short-term outcomes and compa-
rable long-term outcomes with open TME [4–6].
J. O. Paull However, in recent studies, such as AlaCaRT and
Walter Reed National Military Medical Center, ACOSOG Z6051, it failed to prove non-inferiority
Department of General Surgery, Bethesda, MD, USA
for pathologic outcomes when compared with
A. I. Alalwan open approaches [7, 8]. This failure was attributed
The University of Toledo, Department of General
to the rigidity and straightness of laparoscopic
Surgery, Toledo, OH, USA
instruments, resulting in poor maneuvering capa-
V. Obias (*)
bilities specifically with low-lying rectal tumors
George Washington University Hospital, Department
of Surgery, Washington, DC, USA confined within a nonlinear lumen and a narrow,
e-mail: [email protected] restrictive bony pelvis. The introduction of robotic-

466 J. O. Paull et al.
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
Fig. 45.1 The da Vinci

Si® Surgical System.
(Photo courtesy of Sam
Atallah, MD)
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
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
Fig. 45.2 The
Medrobotics Flex®
System. (Photo courtesy
of Sam Atallah, MD)
insufflation system (namely, AirSEAL®, Conmed,

Inc., Utica, NY, USA).
The Medrobotics Flex® System is an operator-
controlled computer-assisted flexible endoscope
with remote user manipulation. It utilizes a multi-
linked articulating scope with a high-definition
display, allowing for navigation through nonlin-
ear anatomy (with near 180-degree mobility) that
would otherwise impose significant challenges
for traditional laparoscopic and robotic linear
cameras and instruments (Fig. 45.3). Through the
use of insufflation, the surgeon is able to advance
and navigate the endoscope toward anatomic tar-
gets from the anus to distal sigmoid colon with Fig. 45.3 The Flex Robotic Platform is utilized to remove
ease and clear visualization. a pT1 adenocarcinoma 4 cm from the anal verge anteri-
orly in a female. (Photo courtesy of Sam Atallah, MD)
Flexible instruments that accommodate
85-degree articulation are passed through two
3 mm operating ports facilitating dissection and when compared to the da Vinci® Si and Xi
suturing (Fig. 45.4). Currently seven instruments Surgical System [27–29]. Given the novelty of
are available for use with the Flex® Robotic this technology, large-scale studies have yet to be
System, with optional bipolar and monopolar undertaken; however retrospective reviews are
electrosurgery capabilities. The system accom- underway and continue to demonstrate the bene-
modates both proprietary and third party fits of visualization and nonlinear access to
instruments. lesions from the anus to distal sigmoid colon
The Flex® CR Drive has been shown in both with therapeutic intervention potential through
cadaveric models and case series to be quite the use of articulating surgical instrumentation
effective given its ease of anatomic access, visu- with tactile feedback [30]. Preclinical cadaveric
alization, and decreased operating room footprint models have also been used to demonstrate the
Fig. 45.4 Flex® CR

Drive 3-dimensional,
high-definition scope
and instruments. (Photo
courtesy of Sam Atallah,
MD)
feasibility of the platform in performance of platform continues to undergo preclinical studies

transanal procedures and have documented a with FDA approval for clinical use currently
reach of 17 cm along a nonlinear path from the pending.
anal verge [31].
Da Vinci SP® Surgical System

SPORT™ Surgical System
An alternative robotic platform to the SPORT™
Surgical robotic innovation has continued to Surgical System is the da Vinci SP® Surgical
evolve with a natural combination of articulating System (Intuitive Surgical, Inc., Sunnyvale, CA,
instrumentation and single-port surgery. This has USA). This fourth-generation da Vinci robotic
recently been demonstrated through the develop- platform utilizes three multi-jointed wristed
ment of the SPORT™ Surgical System (Titan instruments and a 3-dimensional high-definition
Medical). The robotic system utilizes a single-port endoscope through a single 2.5 cm cannula that
site through which multi-articulating instruments can reach 24 cm [33]. The articulation of the
with single-use tips are used to address intraab- instruments allows for 360-degree rotation from
dominal pathology (Fig. 45.5) [32]. The remote a single cannula, and the instruments are triangu-
user console includes a work station, equipped lated as to avoid operative collision, which has
with a hand-controlled surgeon interface, opera- been an obstacle reported in several of the robotic
tional foot pedals, and a 3-dimensional high-defi- transanal case series mentioned previously. As
nition screen for improved visualization and with all other da Vinci robotic platforms, the sur-
ergonomics; a mobile single-arm patient cart is gical console remains the same, allowing for con-
applied at the bedside for a decreased operating tinuity of skills for those surgeons already
room footprint (Fig. 45.6). Currently six instru- familiar with the da Vinci platform. However, the
ments with cautery capability are compatible with da Vinci SP was designed with a navigational aid
the platform. Since its initial preclinical trial in that displays each of the working arm’s positions.
September 2017, the SPORT™ Surgical System This allows the operator to have constant aware-
has demonstrated safe and feasible applications in ness of the orientation of the instrument,
multiple surgical fields, including general, colorec- especially the portion that is not within direct
tal, urologic, and gynecologic surgery. The robotic view of the camera’s lens.
Fig. 45.5 The CMR

modular versus platform
allows surgeons to
operate in two fields
simultaneously to
perform two-team
taTME. (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
with the da Vinci SP for taTME, as well as other

colorectal applications.
Technological advancements in the robotic
approach to taTME continue to emerge at an
increasingly rapid pace. The ergonomic advan-
tage of articulating instruments through nonlin-
ear anatomy gives a clear advantage over previous
approaches, such as seen with TEM and TAMIS,
which utilize rigid, linear tools. Given the preva-
lence of colorectal cancer, and the increasing bur-
den on those of younger age, developing safe and
effective approaches to manage this disease pro-
cess remains an important challenge in colorectal
Fig. 45.6 The Senhance modular operation platform is a
blend of robotics and laparoscopy which could be utilized surgery.
for robotic taTME, although this remains experimental.
(Photo courtesy of Sam Atallah, MD)
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Video-Based Training Apps
and Deferred Live Surgery 46
Joep Knol
Introduction help guide safe dissection and appropriate pro-

gression through the case, and procedures can be
In the progression of surgical training, whether recorded to audit the case-specific anatomy, to cri-
for a novice surgeon learning, a new procedure, tique the chosen surgical planes, and to assess
or an established surgeon in practice advancing progression of technical skills for focused learn-
their technical skills with new techniques, many ing and improvement. As a result, the MIS revolu-
factors are critical to the process of becoming tion forced the surgical community to rethink the
proficient and technically skilled and to be able to ideal surgical training pathway and how to adapt
perform a safe and effective surgical procedure. to and incorporate new technologies safely into
The most essential factors are procedural knowl- practice. During the same time, cultural shifts in
edge, cognitive and psychomotor skills training, surgical education emerged, where international
and direct guidance from a mentor during all duty-hour restrictions limited the time trainees
steps of the procedure-specific training pathway have in the hospital setting to perform live proce-
(Fig. 46.1) [1]. dures and receive mentorship, and economic real-
The procedure-specific knowledge acquisition ities limited the ability for surgeons in practice to
phase should ideally be completed and tested to travel and learn new techniques to incorporate
validate proficiency before advancing along the more difficult procedures into their practice arma-
training pathway. Next, basic technical skills mentarium [3–5].
should be practiced in the dry and wet lab setting, This paradigm shift has driven the search for
before attempting a procedure on live patients and innovative training solutions, with a greater
ascending the procedure-specific learning curve emphasis on the role of cognitive skills training
[2]. The introduction of minimal invasive surgery to accelerate the trainee’s understanding of a pro-
(MIS) made this training model more achievable, cedure, formalize the steps being practiced, and
for both cognitive skills training and mentorship reduce the overall training time required to
by an experienced surgeon. In MIS, the conduct become technically competent [6].
of the operation is displayed on a screen in real Much focus in cognitive skills training is
time, the trainer and trainee have the same view to placed on deliberate practice and simulation.
Deliberate practice assumes that improvement
and expertise depend on deliberate efforts to
J. Knol (*) change particular aspects of performance [7]. In
Department of Abdominal Surgery, Jessa Hospital, many domains of professional life, expertise in
Hasselt, Belgium complex tasks has been described as only

476 J. 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
Fig. 46.1 The new pathway for surgical skills training
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
185, 110, and 43 minutes, respectively, for

Millennials (born 1980–2000), Generation X
(born 1960–1980), and Boomers (1940–1960)
(source: Statista.com, accessed 2018).
Also, among medical trainees and healthcare
professionals, the number of mobile Internet
users is very high, with an estimated >90% own-
ing a smartphone and having medical smartphone
apps installed on their devices [11, 12]. In fact,
practicing physicians and medical students are
the highest percentage of smartphone users
among any single community [13, 14]. An impor-
tant benefit of mobile resources over traditional
methods of accessing relevant medical informa-
tion lies within their easy, immediate access and
ability to update information; reportedly, online
resources are more up-to-date than medical text-
books [15, 16].
Because of the global accessibility of smart
devices and increased availability of apps, there
has been a shift in the retrieval method for the
online content from use of mobile websites to
mobile apps.
Prior surveys have reported that mobile users
spend 86% of their online time on mobile apps, Fig. 46.2 Benefits of mobile apps over mobile websites
with the rest on mobile websites (Flurry Analytics
2014). As they put it: “It’s an App world. The
Web Just Lives in it.” The reason for this clear ommendations or meaningful geographically
preference is multifaceted, but for users there are personalized information. In addition, websites
several obvious advantages to mobile apps over can’t be accessed when offline; however, most
mobile websites (Fig. 46.2): mobile apps offer a basic functionality to operate
with cellular data even if the Internet is not
1. Download speed connected.
2. Notifications Currently, the two largest global platforms for
3. Personalization app distribution are Apple’s “App Store,” which
4. Offline workability caters to iOS users, and Google Play, belonging
5. Engaged experience to the eponymous company, which caters to
Android OS users. The Apple App Store launched
Mobile apps download content faster than in July 2008, at which time it contained 800 apps.
websites and therefore are more convenient to Google originally launched the “Android mar-
users. ket” in October 2008; in December 2009 this was
Also, with mobile apps, updates and events rebranded as the “Google Play Store,” containing
can be announced with push notifications, or in- 6000 apps at that time (source: Statista.com).
app messages instead of repetitive emails, which Currently (2018), it’s estimated that there are 3.6
often are automatically filtered into “Junk Mail” million apps in Google Play and 2.2 million apps
and are thus never seen or read by the user. As in Apple’s App Store, but the exact number con-
mobile apps can track and observe user engage- tinues to grow daily with new offerings
ment, they can provide the user with custom rec- (Fig. 46.3). Apple’s App Store offers a variety of
478 J. Knol
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
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. 46.4 iLappSurgery logo Fig. 46.5 iLapp taTME logo

480 J. Knol
Fig. 46.6 Growth of

iLappSurgery taTME
App after launch
(Fig. 46.6). In many courses the app has become

part of the taTME training pathway and didactic
curriculum, as it provides a functional pre- and
per-course cognitive skills tool for surgeon dele-
gates (UK and Dutch training model as submitted
for publication). The library and chapter content
is updated on a regular base, and validation as a
training tool is pursued.
From the beginning the taTME App was setup
as a dynamic text and video book in which some
features were crucial:
• Administration interface: Easily add content,

news, and events and activate directly online
• Secured and compliant: General Data
Protection Regulation (GDPR) and Health
Insurance Portability and Accountability Act
Fig. 46.7 iLappLiver logo
(HIPAA) compliant
• Adaptive learning: Possibility to apply rules
in practical exercises and examinations to technical complexity of these procedures, fear of
allow the content delivery to be adapted to the compromising the oncological results, and the lack
knowledge level of the user of training opportunities, uptake of laparoscopic
• Personalized: Possibility to personalize con- liver surgery was initially slow [22]. With the help
tent for particular users of experts in the field, a training pathway is pre-
• Evaluations: Exercises, automated exams, sented with focus on cognitive skills training. iLap-
and supervised exams pLiver has the same format as the taTME App and
• Configurable push notifications: Notifications was launched in September 2018 (Fig. 46.7).
to inform the users about new content, events, As video teaching plays an important role,
and news both in cognitive skills training in general and in
• Analytics and reports: Insights in registration, the healthcare-related teaching apps, much focus
engagement, and completion rates is on improving the images and creating a situa-
• Copy-Paste structure and concept: Same for- tion like being in the OR, either by using a multi-
mat for any future app camera recording that can be made available in a
synchronized fashion (dLive) or by using virtual
As a next project, the iLapp Foundation developed reality (VR). These images will be added to the
an app for laparoscopic liver surgery. Due to the available apps in future updates.
Video-in-Picture fashion. The traditional teaching of new tech-

niques has involved observation of live surgical
For the iLappSurgery Foundation, there is a spe- procedures conducted by experts in the field with
cific program developed that can serve as an specific transferable skillsets.
extension in video teaching and further the inter- Unfortunately, live surgery has inherent limi-
active learning experience of apps. It is called tations – primarily centered around the idea that
Video-in-Picture (VIP). The VIP app (VIPicture) there is significant variability that cannot be pre-
has recently been described in a manuscript on dicted, including preoperative indications, physi-
Deferred Live surgery and is freely available in cian fitness, intraoperative complexity, and the
Apple and Google store [23]. patient’s overall physiologic fitness. Indications
One can download the app by searching the for surgery can often be “loosened” by Live
App Store for VIPicture or by using a QR code Surgery Course organizers for the purpose of
(Fig. 46.8). Images that are qualified for use with recruitment or may vary between the host institu-
the application are identified by the presence of tion and that of the surgeon’s home practice envi-
the “VIP” logo. After opening the VIPicture appli- ronment [24]. Furthermore, patients may be
cation on your smart device, allow your phone to required to wait longer than usual so as to accom-
access your camera. This will activate the camera modate the conference’s preset timetable [25];
within the application so as to recognize the image this can be of significant concern in oncologic
within the manuscript, thereby linking you to the cases.
appropriate video demonstration. In addition, language barriers can affect dis-
In the Deferred Live Surgery section below, the cussions of informed consent between the treat-
VIPicture App can also be used for this purpose. ing and hosting surgical teams. A number of
factors can also affect the intraoperative perfor-
mance of surgeons, including operating in an
Deferred Live Surgery unfamiliar environment with an often unfamiliar
team, jetlag (in many cases), operating room traf-
The technical nature of surgery necessitates an fic, potentially distractive intraoperative ques-
education for trainees that are based on careful tioning from the audience, and the availability of
observation of procedures, often in a repetitive familiar instrumentation and resources, among
others. Many reviews on the subject of live sur-
gery have concluded that it is often a number of
additive factors, and not one single factor, that
result in the potential for adverse events [26, 27].
The presence of these concerns and others led
to the development of an alternative method of
surgical presentation known as Deferred Live
surgery (dLive). In a review of the procedure, our
group and colleagues discussed the nature of this
technique for surgical education wherein multi-
ple 4K synchronized cameras are used to record
the multifaceted aspect of surgical procedures
[23]. The synchronized nature of the recording
and the dLive mainframe allows the presenter to
go through an otherwise unedited full-length sur-
gical procedure, with the ability to toggle between
various intraoperative camera views (Fig. 46.9).
This provides the audience with the experience of
Fig. 46.8 iLapp VIPicture QR code being exposed to all the advantages of the live
482 J. Knol
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-
Fig. 46.10 Video-in-Picture (VIP) image of capabilities of the dLive platform
vers, in addition to the method of communicating Conclusion

the planes of dissection and aiding each other in
completing the excision and gastrointestinal As novel tools for surgical training are develop-
reconstruction. The dLiveMed group has been ing quickly, they will allow us to increase the
able to also bookmark various procedural land- quality and accessibility of cognitive skills
marks, allowing the presenter to focus on these training. Video teaching will play an important
aspects, if asked by the audience, or to toggle role in advancing the teaching of MIS tech-
between different cases to demonstrate differ- niques. Furthermore, ease of access on mobile
ences in, for example, lateral or anterior perineal devices will further increase the availability to
dissection planes in thin and obese patients. learners. Additionally, using multi-camera syn-
Although there may be a persistent and impor- chronized deferred recording, educating large
tant role for live surgery sessions, we propose audiences about these surgical skills can be
that the dLive concept is an additional tool to made more easily available in a less controver-
demonstrate all aspects of a surgical procedure or sial fashion, known as Deferred Live surgery
intervention in optimal quality, with the main- (dLive). These new training pathways hold sig-
tained advantages of live surgical broadcasts — nificant value and serve as important adjuncts
but also avoiding some of the discussed ethical for the education of complex procedures such as
concerns that are being brought forth. It will form taTME.
a critical component of the cognitive training
pathway for trainees and practicing surgeons Acknowledgements We acknowledge Stephanie
Philippaerts and the iLappSurgery Foundation for the
alike, further improving the safety of introduc-
illustrations and VIP-technology used in this manuscript.
tion of new techniques such as taTME into Twitter: @iLappSurgery. Website: www.ilappsurgery.
practice. com
484 J. Knol
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
Introduction Functional and oncological outcome after

multimodal treatment for rectal cancer could be
Functional and oncological outcome after multi- improved. Long-term morbidity after multimodal
modal treatment for rectal cancer could be treatment for rectal cancer is reported in up to
improved. This can be achieved with a better rec- one third of patients, and it is suggested to mainly
ognition of anatomical dissection planes, of ana- originate from nerve injury-related disorders
tomical landmarks, and of the dissection margin such as urogenital and bowel dysfunctions [4–6].
to the tumor to optimize resection margins and to Additionally, a positive circumferential resection
minimize iatrogenic nerve damage. Recently, the margin (CRM) rate has been reported in a signifi-
performance of stereotactic navigation for mini- cant number of laparoscopic rectal resections –
mally invasive transanal rectal surgery has been up to 12% (range 3–12) – being even higher in
reported [1, 2]. Additionally, critical challenges case of low rectal cancers [7–11]. For this reason,
related to soft-tissue stereotactic pelvic naviga- the transanal approach was developed for TME
tion were assessed [3]. Surgical navigation sys- (taTME) [12]. Potential benefits of this approach
tems could improve the quality of surgery for include a better oncological outcome via a
rectal cancer as shown when used in other con- decrease in the positive CRM rate with a better
texts. It is likely to improve the accuracy and effi- specimen quality and better quality of life through
ciency of pelvic surgical procedures in which it is increased sphincter and nerve preservation. On
difficult or impossible to identify and dissect the other hand, taTME is associated with new
along anatomical planes. challenges related to this bottom-up approach to
the pelvic anatomy, especially when performing
dissection anteriorly. Urethral injuries have been
described since the inception of taTME [13, 14].
L. G. C. Romagnolo
IRCAD Latin America, Barretos, Brazil Additionally, air embolisms were described,
probably resulting from venous lesions anterolat-
Department of Surgery, Barretos Cancer Hospital,
Barretos, Brazil erally at the level of the neurovascular bundle of
Walsh [13].
A. R. Wijsmuller
Department of Surgery, University Medical Center The challenges associated with improved
Groningen, Groningen, The Netherlands oncological and functional outcomes have one
thing in common; namely, the importance of the
A. G. F. Melani (*)
IRCAD Latin America, Barretos, Brazil recognition of anatomical dissection planes, of
anatomical landmarks, and of the dissection
Americas Medical City, Rio de Janeiro, Brazil

486 L. G. C. Romagnolo et al.
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
argin to the tumor to optimize resection mar-

m where anatomical landmarks are obscured and
gins and to minimize iatrogenic damage. cannot be used for topographic orientation [16].
Consequently, surgical navigation could improve The first reports of the performance of stereo-
the quality of surgery for rectal cancer as shown tactic navigation for minimally invasive transanal
for stereotactic navigation, a type of surgical nav- rectal surgery were published by Atallah et al. in
igation, when used in other contexts. 2015 [1, 2]. The challenges associated with ste-
Stereotactic navigation was developed by neu- reotactic pelvic navigation were recently assessed
rosurgeons who integrated medical imaging and by a study investigating the potential differences
intraoperative stereotaxy [15]. Stereotactic navi- in patient anatomy between intraoperative lithot-
gation functions quite similarly to a navigation omy and preoperative supine position for imag-
system in a car. Both systems determine and track ing [3]. It seems that when several aspects related
the position of an instrument or a car in relation to patient setup are taken into account, pelvic ste-
to a patient or the earth, respectively. However, reotactic navigation can be performed with
the type of localization technology differs. A ste- accuracy.
reotactic navigation system does not localize via
triangulation similarly to a global positioning
system with the help of several satellites. It local- Equipment and Operative Setup
izes and tracks reflective marker spheres by
means of a stereoscopic infrared emitting cam- The navigation systems which have been used for
era. Subsequently, by means of a process that is stereotactic soft-tissue navigation during trans-
called registration, a point in patient space is anal rectal surgery rely on several major compo-
assigned to the corresponding anatomical point nents (Fig. 47.1):
in image space.
It is reported to increase safety and to mini-
mize the invasiveness of surgical procedures by
acting as a real-time guidance tool during the • A stereoscopic infrared emitting optical
operation using tracked surgical instruments in system – determines the position of an
conjunction with preoperative images. It helps instrument and the pelvis of the patient in
the surgeon to identify anatomical structures, the operation room (OR) by detecting
which should be targeted or avoided. These sys- infrared light which is reflected by
tems are currently mainly used in the brain, skull marker spheres affixed to a patient tracker
base, and vertebral surgery, and they have proven and an instrument tracker (Fig. 47.1).
to be an essential adjunct to surgical procedures
47 Navigation for Transanal Total Mesorectal Excision 487
In stereotactic navigation, it is essential to

• A patient tracker – is fixed to the patient obtain a perfect patient position registration in the
or operating table and has marker OR by means of the infrared optical system. To do
spheres fixed to it for continuous tracing so, several skin reference points overlying the
of the patient by means of the optical area of anatomical interest are marked by means
system (Fig. 47.2). of at least four radiopaque fiducials during preop-
• An instrument tracker – is fixed to an erative CT scanning, and these fiducials are left in
instrument and has marker spheres fixed place or changed for sterile fiducials intraopera-
to it for continuous tracing by means of tively. In the studies, published 12 to 18 fiducials
the optical system (Fig. 47.3). were placed on the skin anteriorly to the pelvic
• Skin fiducials – at least four fiducials are area to optimize the registration process [1–3].
fixed to the skin of the patient during CT Subsequently, after uploading these p reoperative
scan just before the operation. Initially in CT scan images to the navigation system, the
the OR, the position of the pelvis is deter- position of the patient in the operation room (OR)
mined by touching the center of these can be determined via recognition and registration
fiducials via a calibrated instrument with of the position of the fiducials by using a cali-
marker spheres attached to it (Fig. 47.2). brated instrument of which the position of the tip
• A computer platform – matches the is recognized by the infrared optical system
three-dimensional position of the patient (Fig. 47.2). This is the only registration option,
to the CT scan by recognition of the which has been described in the literature for ste-
fiducials. The position of the tip of the reotactic soft-tissue pelvic navigation [1–3]. After
instrument in the 3D image data set is this registration, the patient is tracked by means of
depicted on a separate screen. optical markers on a patient tracker, which is fixed
• Merging software – merges an MRI or to the operating table or the patient’s anterior
CT scan which was performed well in superior iliac spine by Kirschner wires or a screw
advance and which relevant anatomical (Fig. 47.2). Surgical instruments are tracked by
structures and tumor were segmented to means of an instrument tracker, which is fixed to
the most recent CT scan with fiducials the instrument allowing the position of the tip of
which was used to determine the posi- the instrument to be determined and visualized in
tion of the patient. the navigation scans (Figs. 47.3 and 47.4). A
computerized process is used to match the

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
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
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
[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.
uture Directions in Pelvic

F Acknowledgments The authors want to thank Bernard
Stereotactic Navigation Dallemagne for his guidance during the projects leading
up to this chapter. We also thank Guy Temporal and Chris
Burel for their editorial assistance.
Stereotactic navigation would be more effective
when the tumor, relevant anatomical structures,
and resection margins are highlighted. MRI is cur-
rently the most accurate tool for the depiction of a References
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it is expected that the combination of a surgical tal cancer based on cadaveric surgery: a study
navigation system with robotic-assisted surgery from the Cooperative Clinical Investigators of the
Dutch total mesorectal excision trial. J Clin Oncol.
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advancements are an important step forward gery for rectal cancer (COLOR II): short-term out-
toward the development of digital surgery [22]. comes of a randomised, phase 3 trial. Lancet Oncol.
2013;14(3):210–8.
8. Guillou PJ, et al. Short-term endpoints of conven-
tional versus laparoscopic-assisted surgery in patients
Conclusions with colorectal cancer (MRC CLASICC trial):
multicentre, randomised controlled trial. Lancet.
2005;365(9472):1718–26.
The application of stereotactic navigation during 9. Kang SB, et al. Open versus laparoscopic surgery for
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dissection margins to the tumor, these margins resection vs open resection of stage II or III rectal can-
can be optimized and iatrogenic injuries can be cer on pathologic outcomes: the ACOSOG Z6051 ran-
minimized. In the appropriate context, this may domized clinical trial. JAMA. 2015;314(13):1346–55.
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Current Controversies
and Challenges in Transanal 48
Total Mesorectal Excision (taTME)
Shlomo Yellinek and Steven D. Wexner
Introduction ment of any treatment [1]. The standards require

MDT attendance by at least one member of each
Total mesorectal excision (TME) is the requisite of the following disciplines: surgery, pathology,
method of surgical extirpation for optimizing radiology, medical oncology, and radiation
outcomes of rectal cancer surgery. Components oncology. This group might arrive at a consensus
of TME include a complete or near-complete opinion that preoperative neoadjuvant chemora-
rather than an incomplete mesorectal specimen, diotherapy is recommended to help mitigate
tumor-free circumferential resection margins some of these adverse prognosticators and help
(CRM), a tumor-free distal resection margin meet the surgical goals. However, there is a sec-
(DRM), and the assessment of ≥12 lymph nodes. ond set of less modifiable factors that may chal-
Tumor-related characteristics may decrease the lenge the surgeon to produce a complete or
potential of achieving these goals. Some adverse near-complete TME specimen with tumor-free
prognostic factors noted on pre-treatment thin CRMs and adequate DRM and lymph node extir-
slice rectal cancer protocol magnetic resonance pation. Such patient-related variables include
imaging (MRI) include a threatened CRM and gender, body mass index (BMI), and prior radia-
extramural vascular invasion (EMVI). Following tion. Male gender and high BMI associated with
the American College of Surgeons (ACS), overweight, obese, and morbidly obese patients
Commission on Cancer (CoC), National are risk factors for less optimal surgical results
Accreditation Program for Rectal Cancer which, in turn, pose compromise to clinical out-
(NAPRC) standards, all patients with newly diag- comes. While robotic surgery was theorized to
nosed rectal cancer presenting to an NAPRC cen- improve upon these odds for optimal surgery,
ter should be discussed in the multidisciplinary unfortunately the recently published Robotic ver-
tumor (MDT) conference prior to the commence- sus Laparoscopic Resection for Rectal Cancer
(ROLLAR trial) [2] showed that this postulate
failed. Thus open, laparoscopic, and robotic TME
S. Yellinek all seem to offer equivalent results as discussed
Department of Colorectal Surgery, Cleveland Clinic below.
S. D. Wexner (*)
Department of Colorectal Surgery, Cleveland Clinic
Digestive Disease Center, Weston, FL, USA

494 S. Yellinek and S. D. Wexner
omparison Between Open

C plete TME (in this study, “noncomplete” was
and Laparoscopic Approach defined as either nearly complete or incomplete)
was reported in 179 (13.2%) of 1354 patients
In the COLOR 2 randomized controlled trial, Van undergoing laparoscopic TME and 104 (10.4%)
der Pas et al. [3] randomized 1044 patients to of 998 patients undergoing open TME. The DRM
laparoscopic (n = 739) or open (n = 364) resec- involvement, the mean number of lymph nodes
tion of rectal cancer. There were no differences in retrieved, the mean distance to the distal margin,
positive CRM and DRM rates and no significant and the mean distance to radial margins were not
differences in postoperative morbidity and mor- significantly different. The authors concluded
tality. At 3 years, the locoregional recurrence rate that the risk for achieving a noncomplete TME is
was 5.0% in both groups. Disease-free survival significantly higher in patients undergoing lapa-
rates were 74.8% in the laparoscopic-surgery roscopic compared with open TME and thus
group and 70.8% in the open-surgery group. questioning the oncologic safety of laparoscopy
Overall survival rates were 86.7% in the for the treatment of rectal cancer.
laparoscopic- surgery group and 83.6% in the Unfortunately, the Martinez-Perez et al. study
open-surgery group. [7] is critically and fatally flawed in that they erro-
Bonjer et al. [4] reported on 1044 patients, neously grouped near-complete with incomplete
699 of whom were in the laparoscopic group and resections. The appropriate internationally
345 in the open group. At 3 years, the locore- accepted standard would have been to correctly
gional recurrence rate was 5.0% in the two group near-complete with complete TMEs and
groups. Disease-free survival rates were 74.8% in compared that group of oncologically satisfactory
the laparoscopic-surgery group and 70.8% in the specimens to the oncologically unsound group
open-surgery group. Overall survival rates were exclusively comprised of incomplete specimens.
86.7% in the laparoscopic-surgery group and Fleshman et al. [8] conducted the ACOSOG
83.6% in the open-surgery group. Z6051 randomized clinical trial to assess the
Boutros et al. [5] reviewed 234 patients under- pathologic results of laparoscopic versus open
went resections for rectal cancer, including 118 rectal resection. The primary outcome was to
laparoscopic and 116 open resections. The lapa- compare successful resection in laparoscopic
roscopic group had slightly higher lymph node versus open rectal resections. Successful resec-
yield in the TME specimen than the open group tion was defined as a composite of CRM greater
(26 vs 21, p = 0.02), with no differences in CRMs, than 1 mm, DRM without tumor, and complete-
DRMs, and completeness of TME specimen. ness of TME. A 6% non-inferiority margin was
In a Cochrane review from 2006 and update in chosen according to clinical relevance estima-
2014, Vennix et al. [6] evaluated the differences in tion. Successful resection occurred in 81.7% of
short- and long-term results of laparoscopic ver- laparoscopic resection cases and 86.9% of open
sus open TME. There was moderate-quality evi- resection cases and did not support non-inferiority
dence that laparoscopic and open TME had of laparoscopic rectal resection for stage II and
similar effects on local recurrence, 5-year disease- III rectal cancer. Moreover, there were no signifi-
free survival, and overall 5-year survival. There cant differences in three year local recurrence or
was moderate- to high-quality evidence that the survival between the laparoscopic and open
number of resected lymph nodes and surgical groups. Thus the problem with the well-inten-
margins were similar between the two groups. tioned ACOSOG Z6051 study was not a techni-
Martinez-Perez et al. [7] published in 2017 cal problem with laparoscopic technique, but
systematic review and meta-analysis of the rather a methodologic and statistical problem of
pathologic results of laparoscopic compared to using a never before used and un-validated com-
open rectal TME. Of 2989 patients, positive posite score. Unfortunately this score cannot be
CRM was found in 135 (7.9%) of 1697 patients recommended for use due to its complete lack of
undergoing laparoscopic TME and 79 (6.1%) of correlation with the actual desired oncologic end-
1292 patients undergoing open TME. A noncom- point of recurrence free survival [9].
48 Current Controversies and Challenges in Transanal Total Mesorectal Excision (taTME) 495
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):
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for rectal cancer -the ROLARR randomized clinical P, Jayne DG, Brown JM. Long-term follow-up of the
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48 Current Controversies and Challenges in Transanal Total Mesorectal Excision (taTME) 497
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laparoscopic total mesorectal excision for rectal can- J, Lacy AM. Transanal total mesorectal excision in
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series of 120 consecutive patients. Ann Surg Oncol. Hevia M, Jimenez M, De Lacy B, Castells A, Bravo
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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.)

500 R. A. Cahill
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
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
identification and preservation as well as shorten reduction in significant anastomotic complica-

learning curves overall. This can improve the vari- tions (most especially leak) postoperatively [19].
ability in surgical performance and outcome known A large international, multicentre randomized
to exist internationally and help elevate standards trial is under to prove its exact use and is expected
above simple competence [18]. to conclude in 2020 [20].
One example of how this is already happen- While it also has application in biliary surgery,
ing, and likely to markedly improve in the near- the use of ICG in this way as a perfusion indica-
term future, is in the use of near-infrared (NIR) tor is appealing as it discloses its information
laparoscopy and disclosing dyes. Conventional within moments of administration and so can be
endoscopes and laparoscopes have used white used easily by surgeons to check or inform
light alone for tissue illumination. Recently, how- decision-making irrespective of duration of pro-
ever, it has been appreciated that broadening the cedure or processes beforehand. Biliary mapping
spectral energy into the near-infrared range can needs pre-administration and interpretation is so
add significant information regarding the region time-dependent – i.e. meaning earlier then lanned
of interest under inspection. Within near-infrared enquiry can give misleading information, such as
wavelengths, energy can penetrate tissues to a when a signal is from the vasculature instead of
depth of several millimetres, and biological tissue the biliary tree. This can result in misinterpreta-
lacks back reflectance in this spectral zone. Specific tion if this information is not realised and taken
signalling agents placed into the tissue can indicate into account by the surgeon.
their presence and thus characterize the tissue, by ICG can also be used as a lymphatic mapping
means of fluorescence emission of detectable agent. For this, interstitial deposition allows the
energy back to the irradiating source at a different agent to be taken up by the lymphatic system and
wavelength that can be displayed optically. The the dye concentrated into draining lymph nodes
only such fluorophores approved for use are indo- as is normal physiological action. Thus nodal
cyanine green (ICG) (Fig. 49.1) and methylene identification is performed, but this is not any
blue (MB), the former being widely available for indicator of presence of pathology (specifically
circulatory mapping of the lymphatic and vascular cancer) within these lymph nodes and further
systems and the latter under specific circumstance processing, usually by histopathology, is needed
can be useful for urinary tract delineation. The for such analysis. MB is cleared renally after its
mechanisms of action of both dyes depend on nor- systemic administration and so its near-infrared
mal physiologically processing from which spe- illumination can display the ureters laparoscopi-
cific information can be inferred. cally [21] and this could also be potentially
ICG is highly protein-bound, so it remains in important for identification of the male urethra
the circulation after systemic intravenous admin- during taTME [22]. MB is not a perfect dye for
istration until its clearance without metabolism this use however, it is not approved for this indi-
by the liver. Therefore, depending on timing it cation and may act as generator of free radicals
can be used as an indication of perfusion suffi- on exposure to intense light energy.
ciency and of biliary channel mapping. Its use as Notwithstanding, it indicates well that the prin-
an indicator of intestinal perfusion adequacy is ciples related to NIR-ICG can be broadened with
already proving beneficial in guiding interpreta- additional dyes. Interestingly also some groups
tion of perfusion adequacy before and after anas- have used NIR energy alone as a means to indi-
tomotic construction, especially intracorporeally. cate site of peritoneal connection during taTME
Prospective studies are showing, quite consis- [23] and deployed its lymphatic channel marker
tently, a change in operative strategy based on the capability as a means to indicate posterior meso-
near-infrared visualized segments in approxi- rectal fascial margins [24, 25].
mately 6% of cases, and that such adjustment is This work shows the application of NIR along-
associated with a significant (indeed two thirds) side dye administration and shows it can fit within
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
Table 49.2 Ideal qualities of new disclosing dyes for

d
surgery and artificially intelligent visual processing and
feedback systems
Disclosing dyes Optical feedback systems
Rapid signalling Rapid processing
(within moments of and display
administration) (within moments)
High signal to background Applicable to all surgical
noise ratios camera systems, rigid
and flexible
Broad applicability Easy to understand
Easy to include within Widely available
surgical timescales and
work flows
Cheap Decision support rather
than instruction
Safe re toxicity and Machine learning
anaphylaxis rates applicable (and so will
improve with time)
Fig. 49.1 (continued) High sensitivity and Deployable outside of
specificity exclusive platforms
and add value to operative decision-making and

flow. Perhaps most importantly it provides a although do show concept and application capa-
method of resolving uncertainty in instances of bility of deep basic science. Agents capable of
doubt as well as a method for standardizing and rapid dissemination along with off-on signalling
enhancing intraoperative decision- making. New within the microenvironment of relevance
agents will allow increased specificity for pathol- whether ischemia, hypoxia or cancer cell pres-
ogy including cancer-specific targeting and nor- ence are of great interest and are in development.
mal anatomy identification including genitourinary Correct optical delineation of primary and local
nerves and, in combination, can provide a method mesorectal nodes can allow partial mesorectal
for determining broadening or narrowing radical- excision with accuracy from inside the rectum.
ity on a personalized basis. Further, in situ identifi-
cation of nodal disease along with peritoneal or
occult liver surface deposits may help improve Cognitive Assistance-Smart
surgical oncological outcomes and correctly allow Systems Versus Dumb Droids
fuller disease excision and so great R0 resections
and assign postoperative adjuvant and even sur- Surgery, as the exemplar real-time decision-
veillance strategies. making specialty, needs its practitioners to be
When considering novel agents, it is impor- able to comprehend and make sound judgements
tant that newer agents allow further stepwise on the operative landscape in sequence. Adding
implementation and stick to the fundamental non-informative extraneous information or data
principles of best use as shown by ICG as a per- that requires complex cerebral processing is not
fusion agent (see Table 49.2). The organic dyes helpful especially given recent work defining the
should exhibit a high safety profile, be low-cost cognitive burden of operating and its difficul-
to implement and widely available. Real-time ties – especially with non-expert practitioners or
imaging and assessment is also crucial. Weak sig- in cases when unexpected complexity or compli-
nallers needed to be administered long before cation is encountered. With increased complexity
application – in order to concentrate sufficiently of image presentation, perhaps with multispectral
within the region of interest and to wash out of imaging of multiple dyes at different wavelengths
other tissues – will have limited usefulness, simultaneously, there is a need for machine assis-
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”.
Autonomous Operations
With perfect image registration, potentially by

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Index
A AirSeal® insufflator system, 72, 73, 83, 84,

Abdominal dissection 91, 200, 221, 247, 420, 502
advantages, 263 Alternative neoadjuvant strategies, 33
colon, adequate blood flow preservation in, 268, 269 American College of Colon and Rectal Surgeons
dual-team taTME, 269 (ASCRS), 24
gastrointestinal surgery, 263 American Medical Systems score, 124
taTME, 278, 279 American Society of Colorectal Surgery (ASCRS), 501
positioning, 264 Ampicillin/sulbactam, 385
TME, 187, 188, 263 Anastomosis, 224, 241, 283, 374, 395, 396,
NVB, dissection in, 268 407, 432, 433
perirectal fascia structure, 264, 265, 267 Anastomotic defect, 214
Abdominal entry, 117 Anastomotic leak (AL), 198, 210, 374–378, 383
Abdominoperineal excision (APE), 281, 427 current state of data to reduce, 377
abdominal stages, 419 multifactorial aetiology of, 378
anatomical considerations, 419, 420 Anatomic landmarks, TaTME, 313–315
avoid urethral injury, 425 Anatomical distortion, 348, 350
operative procedure Anorectal function
anterior dissection, 421 anorectal continence, 123–124
bilateral mesorectal dissection, 425 assessment tools, 124, 399
GelPOINT-mini® device, 421 rectal compliance and capacity, 124
lateral extension of dissection plane, 424 rectoanal excitatory reflex, 124
left anterior-lateral dissection, 425 rectoanal inhibitory reflex, 124
levator ani muscle and puborectal muscle, Anorectal junction, 299, 300
exposure of, 423 Anorectal manometry, 384
perineal dissection planes, 422 Anterior approaches, 456
posterior dissection, 421 Anterior organ injury, 92
puborectal muscle sling, 425 APE, see Abdominoperineal excision
rectourethral muscle and right neurovascular Applied GelPOINT Path Transanal Access
bundle, dissection of, 426 Platform, 171
right anterior-lateral dissection, 424 Artial urethral transection, 315
subcutaneous and ischioanal fat, Autonomic nerves, 335, 337
division of, 421, 422
surgical field after specimen extraction, 426
patient positions and operative setup, 420 B
perineal stage, 419 Bactericidal and tumoricidal agents, 289
rectovaginal septum, dissection along, 427 Benign disease of rectum
Abdominoperineal resection (APR), 3, 193, 322, 328 Crohn’s disease, Ta completion
Accreditation Council of Graduate Medical proctectomy in, 209, 210
Education (ACGME), 478 indications, transanal surgery for, 197
Adenomatous polyps, 19 inflammatory bowel disease, 198
Adjuvant therapy, 450 pouch dysfunction, Ta redo surgery for, 203, 205
Advanced hemostatic devices, 84 pouch redo operations, 209
AirSeal® iFS insufflation management single-team procedure, 199–202
system, 221, 347, 348, 353 surgical approach, 205, 206, 208

Excision (taTME), https://doi.org/10.1007/978-3-030-11572-2
510 Index
Benign disease of rectum (cont.) peritoneal entry, 114

Ta proctectomy and ileoanal pouch rectal wall defect, 113, 115
surgery, 198, 199, 209 TEM or TAMIS, 113, 114
TAMIS revisional pouch surgery, 209 Cognitive assistance-smart systems vs. dumb
miscellaneous procedures, 213 droids, 506, 507
Hartmann’s closure, 213 Cognitive skills training, 475
perforation of rectum, 213 Colo-anal anastomosis, 466
rectal cancer, pelvic sepsis after low anterior Colonic perfusion, 374
resection, 210, 211 Colorectal anastomosis, 501
intersphincteric resection, end colostomy and Colorectal cancer, 465
omentoplasty, 212 Colorectal Functional Outcome Questionnaire
laparoscopic success, 212 (COREFO), 399, 400
redo anastomosis, 211, 212 Colorectal surgery, 370
TAMIS, 212 PA, 375
taTME registry, 197 AL, 374, 375
Bernoulli’s Law, 345 changes in management decisions, 376, 377
Billowing, 70, 71 clinical outcomes, 376
Bio-fluorescence organic dyes, 329 diverting ileostomy, use of, 377
Bipolar coagulation, 441 ileo-anal pouch assessment, 377
Bipolar diathermy, 64 mechanical patency tests, 375
Bipolar electrosurgery, 469 Colorectal/coloanal anastomosis, 412
Bladder injury, 330, 331, 395 Colostomy, 429–431, 449
Boomerang suture technique, 276 Colovaginal fistula, 213
Bottom-to-top approaches, 419 Common bile duct (CBD) injury, 327
Bottom-up approaches, 411, 430, 456, 466, 485 Complete clinical response (cCR), 32, 37, 38
Bowel function, 399 Confirmatory bias, 328
Boyle’s law, 65 Coping behavior, 129
BUESS instruments, 250 Crohn’s disease, 198, 205, 209, 210, 382
Cuff, 207
Cuff/efferent loop excision, 205
C Custom-made port, 160
Carbon dioxide (CO2) Cyclic billowing, 346–348
embolism, 353, 396 Cystoprostatectomy, 415
entrainment, 353
insufflation, 343
Cefazolin, 385 D
Cefoxitin, 385 da Vinci Si platform, 154
Ceftriaxone, 385 da Vinci Si robotic system, 167, 471
Cervix cancer, 214 da Vinci Si® Surgical System, 153, 291,
Chronic presacral sinus, 211 458–461, 466, 467, 471
Chronic sinus, 204 da Vinci single-port (SP) surgical system,
Cipro, 385 168, 170–173, 470, 472
Circumferential radial margin DAPRI instruments, 251, 252
(CRM), 315, 455–458, 460 DAPRI Port, 62, 249, 250
Circumferential rectotomy, 280 Deferred Live surgery (dLive), 287,
Circumferential resection margins 476, 478, 481–483
(CRM), 406, 407, 485, 493–495 Delayed salvage surgery, 45–47
CLASICC trial, 495 Denonvilliers’ fascia, 266, 279, 308, 325, 326, 364
Clavien-Dindo complication distribution, 460 Digital rectal examination (DRE), 101
Cleveland Clinic Incontinence Index, 399, 400 Distal purse-string, 276
Clindamycin, 385 Distal resection margin (DRM), 407, 456,
Close rectal dissection, 201 458, 460, 493–495
Closure vs. non closure Diverting ileostomy, 118, 377
abdominal cavity entry, 114 Double single-port TAMIS proctectomy, 202
after transanal excision, 113 Double-stapled technique, 466, 501
endoluminal suturing, 114 Down-to-up approaches, 280, 343, 391
endoscopic suturing, 113 D-Port, 249
extracorporeal single suturing, 114 Dry-docking, 291
intracorporeal running sutures, 114 Dual-team taTME, 269
neoplasms, 115 Durant’s maneuver, 353
Index 511
E Flex® Colorectal (CR) Drive, 461, 469, 470

Early-stage rectal cancer, 4 Flex® Robotic System, 168, 169, 247, 461, 469, 470
Efferent loop of S-pouch, 204 Flexible sigmoidoscopy, 58, 59
Electro Lube®, 85 Flexible-tip laparoscope, 85
En bloc perineal resection, 413, 414 Fluorescence imaging, 316
End colostomy, 212 Fluorescence-guided surgery, 378
ENDOLOOP® ligature, 276 fluorophore characteristics, 373, 374
Endoluminal locoregional resection (ELRR), 97, 99 indocyanine green (ICG), 374
anteriol lesions, 107 Full-dose NT (fdNT), 102
cranial and caudal margins, 108 Full-thickness anterior rectotomy, 444
cT1, 104 Full-thickness local excisions (FTLEs), 36–37
cT2, 104 Full-thickness rectotomy, 392, 393, 415, 443
cT3, 104 Functional outcomes
early dehiscence, 110 anorectal function
late dehiscence, 109, 110 anorectal continence, 123–124
lateral lesions, 106 assessment tools, 124
length discrepancy of two edges, 110 rectal compliance and capacity, 124
peritoneal entry, 107 rectoanal excitatory reflex, 124
posterior lesions, 105, 106 rectoanal inhibitory reflex, 124
rectal ampulla, 111 intraoperative factors
surgical procedure, 105, 106 chemoradiation, 128
suture closure of the defect, 108–110 incontinence scores, 128
Endopath® Probe Plus, 221 sphincter complex, 127, 128
Endopelvic fascia, 302 transanal endoscopic microsurgery, 127
Endorectal brachytherapy, 52 transanal excision, 127
Endoscopic submucosal dissection (ESD), 180 transanal minimally invasive surgery, 128–130
Endoscopic totally extraperitoneal hernia repair, 344 preoperative evaluation
EndoWrist® three-arm instrumentation, 472 anorectal manometry, 125
End-tidal CO2 (ET-CO2), 353 endoanal ultrasonography, 125
Enhanced recovery after surgery (ERAS) magnetic resonance imaging, 125
intraoperative phase, 384–386 physical examination, 125
postoperative phase, 384, 386 rectal barostat measurements, 125
preoperative phase, 384, 385
Enhanced recovery after surgery (ERAS) protocol, 449
EPIX, 73–75 G
Epix electrosurgical probe, 84 Gas flow mechanics, 345, 346
Ertapenem, 385 Gastrointestinal surgery, 263
European Association of Endoscopic Surgery (EAES), Gel cap, 81
24, 501 GelPOINT gel cap, 458
European Society of Coloproctology (ESCP), 24, 501 GelPOINT path, 81, 82, 247
External anal sphincter (EAS), 419 GelPOINT Path Platform, 232
External beam radiotherapy (EBRT), 52 GelPOINT path transanal access platform, 60, 62, 156,
External dissection plane, 266 167, 246, 288, 348
Extrafascial planes, 301, 302 GelPOINT TAMIS port, 467, 468
Extramural vascular invasion (EMVI), 493 GelPOINT®, 221, 225
Extraperitoneal pelvis, 301 GelPOINT® Mini Advanced Access
Platform, 219, 221
GelPOINT® Path Transanal Access Platform, 200
F GelPOINT-mini® device, 421
Failed pouch, 205 General Data Protection Regulation (GDPR), 480
Fascias, 267 Gentamycin, 385
Fecal incontinence (FI), 121, 178, 179, 399, 400 Goldman classification, 330
Fecal Incontinence Quality of Life (FIQL)
scale, 124, 400
Fecal incontinence severity index H
(FISI), 124, 178, 400, 401 Hagen-Poiseuille Law, 345
First-generation QuadPort+, 154 Handsewn colorectal anastomosis, 283
Flagyl, 385 Hartmann’s closure, 213
Flex Robotic instruments, 251, 252 Hartmann’s reversal (HR), see Transanal-laparoscopic
Flex Robotic Platform, 469 transabdominal Hartmann’s reversal
512 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
T2 rectal cancer, 22, 23 Mechanical patency tests, 375

T2 rectal cancers, 23 MedicalTek®, 440
technical and surgeon-related factors, 25 Mesenteric continuity, 359, 360
techniques, 17, 18 Mesofascial plane, 361
traditional indications, 18, 19 Mesofascial separation, 360, 361, 368
tumor budding, 20 Mesorectal excision, 330
excisional biopsy, 14 Mesorectum
full-thickness, 93 dissection, 267
functional outcomes (see Functional outcomes) identification of, 266
indications, 11–13 Mesosigmoidal reflection, 368
malignant pathology Minimally invasive surgery (MIS), 165, 167, 256
advanced tumors, 139–141 Modified frailty index (MFI), 384
disease-free survival, 138, 139 Modified Rullier criteria, 413
indications, 136 Monopolar cautery, 91
limitation, 137 Monopolar diathermy, 64
local recurrence, 136–139, 141 Monopolar electrocautery, 82, 84
transanal endoscopic microsurgery, 137 Monopolar electrosurgery, 440, 469
transanal excision technique, 137 Multidisciplinary tumor (MDT), 493
transanal minimally invasive surgery, 138 Myocutaneous flap, 416
monopolar cautery device, 92
oncologic outcomes, 135, 136
organ preservation strategies N
adjuvant therapy, 50, 51 Narrow pelvis, 192
clinical pathological features, 50 National Accreditation Program for Rectal Cancer
cohort and population-based studies, 50 (NAPRC), 493
funcional outcome, 50 National Comprehensive Cancer Network (NCCN), 24
low burden, 49 National Surgical Quality Improvement
neoadjuvant therapy, 51, 52 Project (NSQIP) database, 256
recurrence rates, 50 Natural orifice specimen extraction (NOSE)
patient characteristics, 14 techniques, 245, 375
patients with ypT2 or ypT3 disease, 14 Natural orifice transluminal endoscopic surgery
rectal cancer, 12 (NOTES), 6, 245
survival rate, 14 Near-infrared (NIR) laparoscopy, 373, 504, 507
T1 tumors, 12 Near-infrared luminescent stent, 329
T1N0 rectal cancers with adverse features, 14 Near-miss injury, 314
technique, 92 Neoadjuvant chemoradiation (nCRT)
Local recurrence, 455, 456 clinical assessment, 34
Lone Star® retractor, 60, 82, 206, 208, 239, 291, 449 dose escalation studies, 32
Lonestar® device, 413 full-thickness local excisions, 36–37
LoneStar™ retractor, 448 future aspects, 38
Long-term complications, 121 incomplete clinical response, 34, 35
Low anterior resection syndrome (LARS), 31, 399, 402 local disease control, 32
Low coloanal anastomosis, 449 local recurrences after transanal local excision, 37
Low colorectal anastomosis, 433, 449 negative endoscopic biopsies, 35
Low rectal adenocarcinoma, 435 oncological outcomes, 38
Low Rectal Cancer Development (LOREC) database, pathological complete response, 31
321 radiological studies, 35, 36
Low/ultra-low anterior resection, 193 time intervals, 33
Low-wattage monopolar cautery, 84 tumor response assessment, 33
Luschka, rectourethralis muscle and pre-rectal muscle Watch and Wait Strategy, 37–38
fibers, 324, 325 Neoadjuvant therapy (NT), 100, 383, 395, 413, 437
Lymph node metastasis (LNM), 20, 90 full-dose NT, 102
Lymphadenectomy, 436 less invasive (laparoscopic/robotic) techniques, 102
Lymphatic involvement, 20 morbidity, mortality, and functional sequelae, 102
with LE, 102, 103
postoperative urinary, sexual, and bowel
M dysfunctions, 102
Males urethral injury, see Urethral injury stoma, 103
Malignant neoplasia, rectum, see Transanal total Nerve-sparing taTME, 340, 341
mesorectal excision Neurovascular bundle of Walsh (NVBW), 326, 327
514 Index
Neurovascular bundles (NVB) radical surgery, 53

dissection in, 268 O sign, 303
transanal nerve-sparing mesorectal dissection, 338
Newtonian fluids, 345
Next-generation flexible robotic transanal systems, 8 P
Next-generation robots for taTME Palliative radiotherapy, 52, 53
da Vinci SP® Surgical System, 470, 472 Parks transanal excision (TAE), 3, 4
evolution of transanal surgery, 466 Pathological complete response (pCR), 31
Flex® Robotic System, 469, 470 Patient consent, 232
initial progress with transanal robotics, 466–468 Pediculized omentoplasty, 208
SPORTTM Surgical System, 470 Pelvic autonomic nerve preservation (PANP), 335
Nodal metastases, 19 Pelvic autonomic nerves, 336
Nonsteroidal anti-inflammatory drug, 382 transanal nerve-sparing mesorectal dissection, 335
NOTES colorectal surgery, 172 hypogastric nerve, 339, 340
Nucleotide-Guided Mesorectal Excision (NGME), 108 IHP, 339
Nurse holding camera, 235 internal anal sphincter nerves, 335, 337, 338
IRP, 338
NVB, 338
O PSNs, 339
Obesity, 191 Pelvic floor, 299, 300, 324
Obturator, 249 Pelvic plexus dissection, 267
Occult lymph node metastases, 20 Pelvic side wall
OCTO port, 62 with traction, 305
Olympus-OSF-2 flexible sigmoidoscope, 58 without traction, 305
Omentoplasty, 212 Pelvic splanchnic nerves (PSNs), 339
Oncologic outcomes, 456 Pelvic stereotactic navigation, 486, 490
circumferential resection margin, 406, 407 Pelvic surgery, 488, 489
distal resection margin, 407 Pelvic tonsils, 304–306
distant metastasis, 408 Perfusion angiography (PA)
grading of TME specimen, 405, 406 in colorectal surgery, 375
local cancer recurrence, 407, 408 AL, 374, 375
Open approach changes in management decisions, 376, 377
laparoscopic approach, 494, 495 clinical outcomes, 376
for rectal cancer treatment, 455 diverting ileostomy, use of, 377
Operating theater setup, 85 ileo-anal pouch assessment, 377
Operative vectors, 344, 345, 348 mechanical patency tests, 375
Organ preservation strategies definition of, 374
local excision fluorescence-guided surgery
adjuvant therapy, 50, 51 fluorophore characteristics, 373, 374
clinical pathological features, 50 indocyanine green, 374
low burden, 49, 50 limitations
low morbidity rates, 50 current state of data to reduce AL, 377
neoadjuvant therapy, 51, 52 multifactorial aetiology of AL, 378
recurrence rates, 50 quantifying fluorescence, 378
nCRT targeted fluorophore, 378
clinical assessment, 34 Perioperative considerations, 86
dose escalation studies, 32 Peritoneal cavity, 308
full-thickness local excisions, 36–37 Peritoneal reflection, 359–361, 364, 365
future aspects, 38 Peritonotomy, 360, 361, 367, 368
incomplete clinical response, 34, 35 Pescatori score, 124
local disease control, 32 Pneumatic dissection, 344, 396, 397
local recurrences after transanal local excision, 37 Pneumatic insufflation, 354
long-course CRT, 32 Pneumatosis of retroperitoneum, 396
negative endoscopic biopsies, 35 Pneumodissection, 303
oncological outcomes, 38 Pneumopelvis, 303, 412, 413, 416
pathological complete response, 31 Positive down-to-up pressure gradient, 348
radiological studies, 35, 36 Positive end-expiratory pressure (PEEP), 353
time intervals, 33 Postoperative care, 86
Watch and Wait Strategy, 37–38 Pouch drain, 202
palliative radiotherapy, 52, 53 Pouch dysfunction, 203
Index 515
Preemptive conversion (PC), 256 dissection, 98, 99

Pre-hypogastric nerve fascia, 265, 266 ELRR
Presacral sinuses, 208 anteriol lesions, 107
Presacral veins, 304 cranial and caudal margins, 108
Presacral venous plexus, 282, 283 cT1, 104
Procedure-specific training pathway, 475 cT2, 104
Proctectomy, 145, 210 cT3, 104
Proctocolectomy, 198 early dehiscence, 110
Proctoscopes, 272 late dehiscence, 109, 110
Prostate, 307, 308 lateral lesions, 106
Prostate gland, 322, 324, 325 length discrepancy of two edges, 110
Prostatic urethra, 314 posterior lesions, 105, 106
Proximal rectal neoplasia, 114 rectal ampulla, 111
Puborectalis muscle, 302, 325 surgical procedure, 105, 106
Pure natural orifice transluminal endoscopic suture closure of the defect, 108–110
surgery (NOTES) transanal total informed consent, 104
mesorectal excision neoadjuvant therapy
feasibility and safety, 450 full-dose NT, 102
patient selection, 438 less invasive (laparoscopic/robotic)
postoperative care, 449 techniques, 102
rationale, 435–437 morbidity, mortality, and functional
retroperitoneal approach, 450 sequelae, 102
splenic flexure, mobilization of, 450 postoperative urinary, sexual, and bowel
surgical technique dysfunctions, 102
abdominal cavity opening, 444, 445 stoma, 103
anterior peritoneal reflection, dividing, 444, 445 with LE, 102, 103
armamentarium, 438–441 patient selection, 101
cranial and lateral progression pre-NT
of dissection, 443, 444 anal sphincter manometry, 102
inferior mesenteric vessels and sigmoid digital rectal examination, 101
mesentery, division of, 446–448 endorectal ultrasound, 101
inferior mesenteric vessels, root of, 445, 446 flexible endoscopy and biopsy, 101
low colorectal/coloanal anastomosis, 449 macro-biopsies, 101
mesorectum and retroperitoneal abdominal space, MRI, 101
445, 446 PET-CT, 102
perirectal dissection anteriorly extend, 443, 444 quality of life forms, 102
posterior rectal space opening, 442–443 rigid rectoscopy, 101
purse-string suture, 442 tattooing, 101
setup, 441, 442 rationale, 99–100
teaching and training, 450, 451 total mesorectal excision, 98
TEO® platform, 450 total mesorectal resection, 98
Pure retroperitoneal lymphadenectomies, 450
Purse-string, 273, 300, 392, 395, 413, 460
application, 392, 397 Q
distal, 276 Quality of life (QOL), 102, 124
ends of, 276 Quirke grading system, completeness, 189
failure, 393
limbo, 275
locked suture, 274, 275 R
overzealous suture, 274 Radical exenteration, 411, 412
principles, 272, 274 anatomical planning, 412, 413
rectotomy, 276 operative approach
rose petal suture, 274 female paients and taTPE, 416
setup, 271, 272 platforms, 413
spiral, 274 prostate seminal vesicles and bladder, 414, 415
stuck on you suture, 274, 275 sphincter preservation, 413, 414
suture, 279, 300, 442, 449, 459 patient indications, 412
sweet spot, 275 postoperative considerations, 416
Pyramidal excision (PE) Radical prostatectomy, 381
anesthesia, 105 Radical surgery, 53
516 Index
Radiochemotherapy (RCT), 436 Remodeled pouch, 204

Reactive conversion (RC), 256 Rendezvous, 222, 223, 280
Rectal cancer, 405–408, 429, 435, 436, 450, 465, 485 single-team taTME, 240
management of, 229 Reoperative pelvic surgery, 430
miscellaneous procedures, 213 Restorative proctocolectomy, 198
Hartmann’s closure, 213 Retained rectum, 198, 203, 206
perforation of rectum, 213 Retroperitoneal approach, 450
pelvic sepsis after low anterior resection, 210, 211 Right pararectal reflection, 364
intersphincteric resection, end colostomy and Robot-guided pelvic neuro-mapping, 340
omentoplasty, 212 Robotic rectal surgery, 461
laparoscopic success, 212 Robotic TAMIS
redo anastomosis, 211, 212 applications, 160, 161
TAMIS, 212 cadaveric model, 155, 156
surgery, 405–407, 419, 457, 493 chronological publications, 157
Rectal neoplasia clinical experience, 156
functional outcomes (see Functional outcomes) docking, 158
local excision dry laboratory experiments, 154, 155
defects, 94 patient configuration, 158, 159
full-thickness, 93 (see Local excision) Robotic TAMIS, new platforms in, 167, 168
monopolar cautery device, 92 Robotic total mesorectal excision (Robotic TME), 503
vs. radical surgery, 89, 90 Robotic transanal total mesorectal excision
technique, 92 (Robotic taTME)
lymph node metastases, 90 advantage, 461
operative technique Clavien-Dindo complication distribution, 460
anterior lesions, 92 clinical outcomes, 460, 461
lesion assessment, 91 da Vinci Si Surgical System, 458
partial-thickness excision, 92 Flex® Colorectal Drive, 461
peritoneal entry, 92 Flex® Robotic System, 461
positioning, 90, 91 mean hospital stay, 461
preparation, 90 single-port and natural orifice surgery, 461
TAMIS equipment and setup, 91 SPORT ® Surgical System, 461
ultralow rectal lesion, 93 surgical technique, 458–460
SEER data, 90 TNM distribution, 461
T1 and T2 rectal tumors, 90 transanal access port proctoscope, 458
T3 tumors, 90 UICC distribution, 461
Rectal prolapse, 145, 146 Robotic versus Laparoscopic Resection for Rectal
Rectal surgery, 370, 488 Cancer (ROLLAR trial), 493, 495
Rectal wall defect, 113, 300, 301 Robotically assisted radical prostatectomy, 153
Rectoanal excitatory reflex (RAER), 124 Robotic-assisted rectal surgery, 455, 465–466
Rectoanal inhibitory reflex (RAIR), 124 Robotic-assisted transanal surgery for TME (RATS-
Rectotomy, 276, 301 TME), 467, 468
Rectourethral muscle (RUM), 314 RTAS transection of IMA, 173
Rectovaginal fistula, 118, 121, 214 Rullier classification system, 286
Rectovaginal septum, 427 Rullier type I tumors, 288–290
Rectum Rullier type II and III tumors, taTME for, 290–292
benign disease of
Crohn’s disease, Ta completion
proctectomy in, 209, 210, 212 S
indications, transanal surgery for, 197 Sacrum, 304
inflammatory bowel disease, 198–203, 205, 206, Salvage surgery
208, 209 delayed, 45–47
rectal cancer, pelvic sepsis after low anterior immediate, 44, 45
resection, 210 Senhance modular operation platform, 472
taTME registry, 197 Short Form 36 health survey (SF-36) questionnaire, 401
fascias, posterior side of, 267 Short-term complication
luminal anatomy of, 300 fecal incontinence, 121
malignant neoplasia of (see Transanal total infection, 120
mesorectal excision) postoperative bleeding, 119, 120
Redo anastomosis, 211, 212 subcutaneous emphysema, 120
Redundant efferent loop, 203 urinary retention, 120
Index 517
Silicon cap-modified TEO system, 250 Sudeck’s point, 269

SILS™ port, 82, 154, 246 Surgeon misperception, 327, 328
Simulated-based training, 476 Surgical navigation systems, taTME, 341
Single incision laparoscopic surgery clinical applications, 489, 490
(SILS), 60, 63, 166, 246 equipment and operative setup, 486–488
Single-access transluminal robotic assistant pelvic stereotactic navigation, 490
for surgeons (STRAS) robot, 169, 170 specific pelvic surgery-related challenges, 488, 489
Single-port access system, 224 stereotactic navigation, 486
Single-port incision surgery port system, 7 Surgical training, 475, 476
Single-port laparoscopic platform, 199 Deferred Live surgery, 481–483
Single-Site™ da Vinci® port, 467 development in surgery, 478–479
Single-team taTME iLappSurgery and taTME App, 479, 480
advocating for, 231 mobile apps, 476, 477
dedicated nursing team, 233, 234 advantages, mobile websites, 477
equipment setup for, 235–237 Apple App Store, 477, 478
feasibility and sustainability, 230 Google Play Store, 477
implementation of, 230 Junk Mail, 477
institution, 230, 231 video textbooks in a dynamic format, 478
patient consent, 232 VIP, 481
potential complications, 232
procedure
anastomosis, specimen and creating, 241 T
dedicated nurse and surgical assistant, Ta completion proctectomy in Crohn’s disease, 209, 210
roles and assignments of, 240 TAMIS beyond local excision
managing difficult dissection, 241 colorectal and pelvic procedures
rendezvous, 240 hyserectomy with VAMIS, 144, 145
starting approach, 237 parastomal hernias, 146
systematic approach, 239 pelvic exenteration, 144
top-to-bottom transfers, 240, 241 proctectomy, 145
transabdominal approach, 237, 238 rectal prolapse, 145, 146
transanal approach, 238, 239 retrorectal (or presacral) space, 146, 147
transition to the bottom, 239, 240 robotic TAMIS, 147
safe implementation, 233 TAMIS-ileal pouch-anal anastomosis, 143, 144
securing sustainable funding, 231, 232 managing complication
seeking institutional support, 230 anastomotic defects or sinuses, 148, 149
surgeon, 233 anastomotic stricture and stenosis, 148
surgical assistant, 233, 234 bleeding, 147, 148
training, 232, 233 foreign bodies retrieval, 150
Sinus, 205 foreign body retrieval, 150
Small bowel, 220 neuromapping, 151
Society of American Gastrointestinal stereotactic navigation, 150, 151
Endoscopic Surgeons (SAGES), 501 urethral, vaginal, and bladder fistula repairs, 150
Sphincter-preservation techniques, 3, 413, 414 TAMIS debridement cavity, 211
Splanchnic nerve, 394 TAMIS mobilized pouch, 206
Splenic flexure, 366, 369 TAMIS port—GelPOINTPath transanal platform, 144
lateral to medial approach, 370 TAMIS-ileal pouch-anal anastomosis
medial to lateral approach, 369, 370 (TaIPAA), 143, 144
mobilization of, 450 Ta proctectomy, 198, 199
SPORT ® Surgical System, 461 Transanal total mesorectal excision (taTME)
S-Portal® system, 440 abdominal dissection, positioning, 264
SPORTTM Surgical System, 470 advantage of, 292
S-pouch, 204 artial urethral transection during, 315
Standard laparoscopic insufflation, 82 initial outcomes of, 321
Stenosis, 214 mixed reality in, 341
Stereoscopic infrared emitting optical system, 486 operating theater setup for, 220
Stereotactic navigation, 485–490 prostatic urethra during, 314
Subcutaneous emphysema, 120 with rates of urethral injury, 312
Sub-endopelvic fascia planes, 301, 302 real-time stereotactic navigation for, 316
Subperitoneal space, operation in, 343, 344 for Rullier type I tumors, 288–290
Subserosal planes, 301, 302 for Rullier type II and III tumors, 290–292
518 Index
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
da Vinci SP surgical system, 170–172 operative procedure, 421–426

evolution of, 166, 167 patient positions and operative setup, 420
Flex® Robotic System, 168 perineal stage, 419
MIS, 165 rectovaginal septum, dissection along, 427
NOTES colorectal surgery, 172 autonomous operations, 507
robotic TAMIS, new platforms in, 167, 168 bottom-up approach of, 187
STRAS robot, 169, 170 challenges, 496
TATA, 165 changing planes, maintaining correct plane
TEM, 165 and signs of, 303, 304
Transanal single-port platforms, 200 CO2 aerosolization of bacteria and
Transanal surgery tumor cells, 353, 354
access platforms CO2 entrainment and embolization, 353
GelPOINT path transanal access platform, 60, 62 cognitive assistance-smart systems vs. dumb droids,
Lone Star retractor, 60 506, 507
OCTO port, 62 COLOR III and GRECCAR 11 trial, 457
operating sigmoidoscopes, 60 consensus statement indications and
rigid access channels with insufflation, 61 contraindications, 190
robotic-assisted TAMIS, 63 conversion
SILS port, 60, 62 anatomy of, 255
TEM device, 61 benefits of, 257
TEO device, 59–61 crucial importance, 257
transanal retractors, 60 from laparoscopy/robotic transabdominal
billowing, 70, 71 approach, 257
flexible sigmoidoscopy, 58, 59 from robotic procedure, 257
glove port, 60 from TAMIS, 258–260
insufflation laparoscopy/robotic to, 258
AirSeal® Insufflator System, 72, 73 minimally invasive approaches, 256
compliance, 66, 67, 69, 70 reactive/preemptive, 256
compliant space, 66 self-retaining, 256
control algorithm, 68, 69 CRM, 457
delivery and sensing cycle, 68, 70 cyclic billowing, 346–348
EPIX, 74, 75 distal margin, delineation of, 188
hazards, 75, 76 distal resection margin, 456
insufflated rectum, 67 educational advances, 501, 502
ISB, 73–75 emerging technologies, 316, 317
non-compliant space, 66 extrafascial, subserosal and sub-endopelvic fascia
normal laparoscopy, 66 planes, 301, 302
physical laws, 65 factors, 190
TEM, 71, 72 false planes, 351–353
volume of gas, 66, 67 feedback systems, 506
limiting factors, 57 functional outcomes, 401, 402
open access, 58 gas flow mechanics, 345, 346
ordinary laproscopic instruments Hartmann’s procedure, 501
automated suturing devices, 63 heterogeneity, 189
diathermy, 64 image-guided surgery, 503, 504, 506
energy devices, 64 in a cadaveric model, 456
modified instruments, 63 instrumentation advances, 502
TEM devices, 59, 60 instruments for, 250, 251, 253
TEO devices, 59 intraoperative complications, 391
Transanal total mesorectal excision (taTME), 166, 188, intraoperative morbidity
189, 217, 311, 399, 501 anastomosis, 395, 396
abdominal approach, 278, 279 anterior dissection plane, 393–395
anastomosis, 283 CO2 embolism, 396
anatomic landmarks, 313–315 conduit ischemia, 397
anatomical distortion, 348–350 full-thickness rectotomy, 392, 393
anorectal junction and the pelvic floor, 299, 300 lumen, preparation of, 392
APE, 427 pneumatic dissection, 396, 397
abdominal stages, 419 pneumatosis of retroperitoneum, 396
anatomical considerations, 419, 420 posterior dissection plane, 393–395
avoid urethral injury, 425 posterior sacral venous bleeding, 394
520 Index
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

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Transanal Minimally

Invasive Surgery (TAMIS)

ISBN 978-3-030-11571-5 ISBN 978-3-030-11572-2 (eBook)

© Springer Nature Switzerland AG 2019

Upon writing this, I finally understood the true meaning of the

Moreover, transcontinental registries have been established to assure respon-

Orlando, FL, USA Sam Atallah

Part I Transanal Minimally Invasive Surgery (TAMIS)

1 Historical Perspectives and Rationale for Development�������������� 3

11 Closure Versus Non-closure After Local Excision������������������������ 113

Part II Transanal Total Mesorectal Excision (taTME)

19 Indications for Malignant Neoplasia of the Rectum �������������������� 187

27 An Overview of Operative Steps and

42 Hartmann’s Reversal by a Combined

Naoya Aisu, MD, PhD Department of Gastroenterological Surgery,

Frédéric Bretagnol, MD, PhD Digestive Surgery—University Louis

Anne-Marie Dufresne, MD, FRCSC Royal Columbian Hospital,

Joep Knol, MD Department of Abdominal Surgery, Jessa Hospital, Hasselt,

George Melich, MD Royal Columbian Hospital, Department of Surgery,

Luis Gustavo Capochin Romagnolo, MD IRCAD Latin America, Barretos,

Patricia Sylla, MD, FACS, FASCRS Division of Colon and Rectal Surgery,

Introduction principles with conventional laparoscopic instru-

© Springer Nature Switzerland AG 2019 3

from the high morbidity of APR while maintain-

lesions and, even a more alarmingly, from 18% to

Surgical evolution has been largely influenced by

Since its first description, the use of TEM has

Fig. 1.4 Shown is a Single-Incision Laparoscopic (SILS)

Evolution and Milestones in Rectal Surgery

TEM TEO Transanal minimally

Transanal excision Microsurgery Operation Dr. Larach, Dr. Atallah

Fig. 1.6 Evolution and milestones in rectal surgery

4. Rosen L, Veidenheimer MC, Coller JA, Corman

43. Gomez Ruiz M, Cagigas Fernandez C, Alonso

Introduction sal equipment availability, the relatively faster set

© Springer Nature Switzerland AG 2019 11

Contraindications While the idea of transanal excision for rectal

Background function and low anterior resection syndrome [6].

© Springer Nature Switzerland AG 2019 17

Denotes disease-free survival

Besides tumor location and primary characteristics

* Radical resection may be considered based on surgeon/patient discussion

these high-risk features can be safely observed, Conclusions

Introduction through an endoscopically placed cecostomy as

© Springer Nature Switzerland AG 2019 31

Radiological studies are also essential for the

Fig. 4.2 Endoscopic findings consistent with incomplete

response) is rarely associated with no residual

tumor response to nCRT [49]. Performance of

Even though there are very few series looking at

immediate radical re-operation for poor responders: 64.

Introduction TME. Initially, local excision was performed via

© Springer Nature Switzerland AG 2019 43

Introduction risk tumors in the rectum is not without risks. The

© Springer Nature Switzerland AG 2019 49

Radical Surgery Local excision is associated with low morbidity

References microsurgery for rectal tumors: the St. Mary’s experi-

© Springer Nature Switzerland AG 2019 57

 istory of Transanal Access

Orlando, FL, USA Sam Atallah

Part I Transanal Minimally Invasive Surgery (TAMIS)

1 Historical Perspectives and Rationale for Development�� 3

11 Closure Versus Non-closure After Local Excision�� 113

Part II Transanal Total Mesorectal Excision (taTME)

19 Indications for Malignant Neoplasia of the Rectum �� 187

27 An Overview of Operative Steps and

42 Hartmann’s Reversal by a Combined

Introduction principles with conventional laparoscopic instru-

Introduction sal equipment availability, the relatively faster set

Contraindications While the idea of transanal excision for rectal

Background function and low anterior resection syndrome [6].

these high-risk features can be safely observed, Conclusions

Introduction through an endoscopically placed cecostomy as

Introduction TME. Initially, local excision was performed via

Introduction risk tumors in the rectum is not without risks. The

Radical Surgery Local excision is associated with low morbidity

istory of Transanal Access

igid Access Channels

Ordinary Laparoscopic Instruments

Insufflation and Billowing pressure within the abdomen would be directly

Insufflation Compliant phase of inflation

AirSeal® Insufflator System

Introduction descriptions of the recommended equipment that

Perioperative Considerations fecal matter. Giving full bowel preparation has

Introduction sexual and bladder dysfunction, and permanent

AMIS Equipment and Setup

anaging the Ultralow Rectal Lesion

anagement of Defects After

Patient Selection in our protocol, we consider it mandatory to

Neoadjuvant Therapy (NT) • Morbidity 20–30%