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Surgical Technique
andDicult Situations
fromJuergen Weitz
(Conventional)
ChristophReißfelder andJuergenWeitz
48.1 Unilateral M.Gluteus MaximusFlap – 375
48.2 Bilateral M.Gluteus MaximusFlap – 375
48.3 VRAM (Vertical Rectus Abdominis
Muscle) Flap – 375
371
48
© Springer-Verlag Berlin Heidelberg 2017
M. Korenkov et al. (eds.), Gastrointestinal Operations and Technical Variations,
DOI10.1007/978-3-662-49878-1_48
372
C. Reißfelder and J. Weitz
48
e local recurrence rate aer rectal cancer operations could be drastically reduced since the
introduction of the total mesorectal excision
(TME) by R.Heald. Nevertheless, the recurrence
rate of low rectal carcinomas needing an abdominoperineal rectum extirpation (APE) of the rectum remained high in the literature. One of the
reasons is the dicult preparation in the region of
the M. levator ani. e specimen has always a
waist (“coning”) by performing a complete
TME.is waist has to be avoided for oncologic
reasons in an APE, because the tumor is mainly
situated in this region. In recent years, T. Holm
developed an operation technic – the elevated
APE – that takes care of the special anatomic
demands in the region of the low rectum.
e operation is divided into two parts, the
abdominal and the perineal part. e abdominal
part can be performed in the conventional open
style or laparoscopically.
e preoperative preparation and placement
of the patients are always important. Male patients
should always receive a urethral catheter for the
safe identication of the urethra during the perineal part of the operation. e abdominal part of
the operation will be performed in lithotomy
position.
Aer correct placement of the patient, preoperative administration of antibiotics, disinfection,
and “team time-out,” the open/conventional operation starts with the median laparotomy down to
the symphysis. is is important to have the best
access and view into the operation eld of the low
pelvis.
Aer exploration of the abdomen, the inferior
mesenteric artery (IMA) will be ligated 1–2 cm
aer leaving the aorta. is distance is important
to not injure the plexus hypogastricus superior
with its bers that are located pre-aortal (sympathetic innervation of the urinary bladder and the
sexual organs). As an alternative, lymphadenectomy can be performed along the IMA with its
resection distal the outow of the A le colic
artery. Subsequently, the mobilization of the colon
descendens and sigmoideum along Gerota’s fascia
will be performed. e le ureter doesn’t need to
be leashed routinely, because it is situated one
layer more dorsal than Gerota’s fascia. e mobilization of the le colon exure in an APE is not
necessary, because the remaining colon descendens is usually long enough for the colostomy. e
arterial blood ow through Riolan anastomosis
and the needed lengths for the colostomy determine the oral resection border. e transection of
the inferior mesenteric vein (IMV) on the level of
the pancreatic tail– like routinely performed in an
anterior resection of the rectum– is not necessary
in an APE.
e following steps of the preparation are
equal to a low anterior rectum resection with a
TME. e key structure for the further aboral
preparation is the dissected IMA with the mesenteric lymph nodes, the so-called pedicle package
by R.Heald. Starting from right underneath the
IMA, you will nd the access to the “holy plane,”
the connective tissue outside of the mesorectal
fascia. At the beginning, the caudal preparation
will be conducted strictly dorsal – in own
approach by diathermy. e basic principle of the
TME is “traction and countertraction.” With this
move, you get the optimal exposition in the small
pelvis. en the lateral preparation starts, coming
from dorsal. e lateral preparation is the most
dicult part of the resection because of the parasympathetic Nn. splanchnici pelvici and the
plexus hypogastricus inferior which have to stay
intact. e ventral preparation will start ventral of
Denonvillier’s fascia with a U-shaped incision to
protect the neurovascular bundle that is situated
anterolateral to the rectum.
e main dierence of an elevated APE to a
TME is not to perform the abdominal preparation
too far into the pelvis to prevent a coning of the
specimen. e aim is to retain the M. levator ani
on the specimen. e dorsal preparation should
stop above the tip of the os coccygeum, lateral
aer the identication of the erigent pillars
(. Fig. 48.1) and ventral at the prostate or in
women the proximal third of the vagina.
This is the end of the abdominal part of the
operation. At the end, a swab will be placed
dorsal at the deepest point in the pelvis. This
helps to find the right layer after resection of
the os coccygeum in the perineal part of the
operation.
An omentum ap into the pelvis reduces the
made defect and decreases the risk of an intraabdominal infection. Finally, the descendostomy
will be placed and the abdominal wall closed.
e sphincter ani and the M. levator ani will
be extirpated in the following perineal part of the
operation. e preparation layer can be extended,
according to the indication of the APE and the
size of the tumor.
Surgical Technique andDicult Situations fromJuergen Weitz (Conventional)
373
48
. Fig. 48.1 View into the pelvis. The prostate and the Nn.
erigentes (arrow) are visible
Most of the time, the preferred preparation
layer is lateral to the fascia of the M. sphincter ani
externus and M. levator ani. Basically, it is possible to extend the resection of the ischiorectal fat,
depending on the size of the tumor, to get a
tumor-free resection margin. e legs of the
patient should be spread that the surgeon can sit
between them as soon as the patient is placed in
prone position.
In the rst step, the anus will be sutured and the
sutures le for traction during the preparation le
. Fig.48.2). e incision has an oval shape around
(
the anus and will be extended dorsally up to the os
sacrum that it looks like a teardrop. e preparation goes strictly outside of the fascia of the two key
structures, the M. sphincter ani externus and M.
levator ani (variation as described above) to the lateral pelvic wall. From there, you reach the muscle
insertion of the M. obturatorius internus and the os
coccygeum which will be disarticulated. e previously placed swab helps to nd the right intraabdominal layer. Aerward, the M. levator ani will
be dissected circumferentially on the pelvic wall.
e specimen can now be extracted (. Fig.48.3).
e last step is the ventral preparation along the
prostate/the vagina. e ventral dissection of the
M. levator ani has to be done carefully, since the
. Fig. 48.2 The anus is closed and an oval incision of the
skin is made. You can see the os coccygeum (whitish shimmer) and the bers of the M. levator ani
Nn. erigentes are right underneath it. e ventral
resection border is the M. transversus perinei
supercialis, where the centrum tendineum perinei will be dissected. is is very demanding
because there are no further landmarks. In male
patients, the urethra at the apex of the prostate has
to be preserved. e placed urethral catheter helps
for the orientation. e perineal situs at the end of
the APE is demonstrated in the (. Fig.48.4).
If the tumor is placed ventrally, a part of the
prostate/the back wall of the vagina can be
resected. is is a lot easier in prone position
because of the better view on the prostate compared to the lithotomy position. e surgeon
should examine the specimen as an own quality
control. As mentioned before, the specimen
should not have a waist.
e closure of the perineal cavity can be done
in various ways and depends on the size of the
48
374
C. Reißfelder and J. Weitz
. Fig. 48.5 Unilateral muscle ap (M. gluteus maxi mus).
You can see the A. glutealis inferior (forceps) which is
needed for the blood circulation of the ap
. Fig. 48.3 The specimen is only attached to the vagina.
The cylindrical shape of the specimen is well recognizable
. Fig. 48.4 View into the pelvis (prone position). The M.
levator ani was resected next to the pelvic wall
defect. In case of a small defect, a direct closure
can be done. An alternative is the use of muscle
aps like the uni- or bilateral M. gluteus maximus
. Fig. 48.6 Unilateral M. gluteus maximus ap
. Fig. 48.7 Defect cover of the pelvis with a Permacol©
mesh
(. Figs. 48.5 and 48.6) or a VRAM (vertical
rectus abdominis muscle) ap. Furthermore, a
mesh(. Fig.48.7) can be used to avoid a perineal
hernia.
Surgical Technique andDicult Situations fromJuergen Weitz (Conventional)
375
48
48.1 Unilateral M.Gluteus
MaximusFlap
For this muscle ap, the M. gluteus maximus with
its subcutaneous fatty tissue and the skin will be
used. e proportion is 1.5:1 (length medial to
lateral). e incision will be marked aer the
APE.It starts on the caudal end of the perineal
wound and goes like a J to lateral cranially. e
incision has to be made through the subcutaneous fatty tissue down to the fascia of the M. gluteus maximus. e muscle will be divided into
half aer the incision of the fascia. Now the M.
gluteus maximus has to be mobilized without
dividing the A. gluteus inferior and the nerve
(. Fig.48.5). Furthermore, you have to remember
that the N. ischiadicus is directly under the muscle and shouldn’t be injured. e dissection can be
ended at the moment the muscle is mobile enough
to reach the other side. e muscle ap will be
xated in four layers: muscular, Scarpa fascia,
subcutaneous, and the skin. Two drainages should
be placed, one on the muscle and the second subcutaneously (. Fig.48.6).
48.2 Bilateral M.Gluteus
MaximusFlap
e bilateral muscle ap will be done accordingly
to the unilateral muscle ap by using both sides.
48.3 VRAM (Vertical Rectus
Abdominis Muscle) Flap
e right M. rectus abdominis will be mobilized
out of its fascia and, cranially, on the costal arch
dissected. e blood supply comes caudally out of
the epigastric vessels. is muscle ap, if necessary with the skin, can now be rotated into the
defect of the pelvis.
Surgical Technique
andDicult Situations
fromSteven Wexner
(Laparoscopic)
StevenWexner andMarcOsborne
49.1 Dicult Situations inLaparoscopic
Colorectal Surgery: Laparoscopic Low
Anterior Resection forRectal Cancer – 378
References – 381
377
49
© Springer-Verlag Berlin Heidelberg 2017
M. Korenkov et al. (eds.), Gastrointestinal Operations and Technical Variations,
DOI10.1007/978-3-662-49878-1_49
378 S. Wexner and M. Osborne
49
49.1 Dicult Situations
inLaparoscopic Colorectal
Surgery: Laparoscopic Low
Anterior Resection forRectal
Cancer
We began applying laparoscopic techniques to
colon and rectal surgery at the Cleveland Clinic
Florida over 25 years ago. During those years, we
have rened our approach and for many years
have routinely employed minimally invasive techniques for proctectomy for rectal cancer. Our
operative planning begins with a thorough preoperative assessment which includes a rectal cancer
protocol synoptic report, pelvic MRI, and endoscopy to locally stage the tumor as well as a CT of
the chest, abdomen and pelvis to evaluate for distant metastasis. All patients meet with an enterostomal therapy nurse for counseling and stoma
marking as well as a colorectal nurse for preoperative education. All patients undergo a mechanical
cathartic and oral and parenteral bowel prep.
Anesthesia considerations are individualized
toward the patient’s needs including the use of
central venous catheters and arterial lines. e
stomach is decompressed with an orogastric tube
which is removed at the end of the case. According
to SCIP guidelines, patients receive a dose of
appropriate antibiotics just before the incision is
made and continue for 24h postoperatively. All
patients wear sequential compression devices and
receive chemical deep venous thrombosis prophylaxis with 5000 units of subcutaneous which is
continued every 8 h postoperatively until discharge.
Aer induction of anesthesia, patients are
positioned in a modied lithotomy position with
stirrups. A bean bag and chest taping are used to
secure the patient to the operating table. ese
steps are essential to help ensure patient safety
during steep re-positioning maneuvers necessary
to gain adequate exposure. Patients may undergo
cystoscopy and bilateral uretic catheterization
with stent placement to facilitate intraoperative
identication of the ureters. e distal rectum is
then irrigated with betadine prior to sterile prep
and drape.
Entrance to the abdomen is gained via the
Hasson technique just below the umbilicus. A
10mm 30° angled scope is used to survey the
abdomen. Two right-sided 12 mm ports are
then placed under direct vision. e lower port
is placed approximately 2 cm cephalad and
medial to the anterior superior iliac spine.
Transillumination of the abdominal wall facilitates avoiding the epigastric vessels. e upper
port is placed a few centimeters below the costal
margin. Atraumatic bowel graspers are used to
create gentle traction to facilitate dissection.
Fine dissection is done with an ultrasonic scalpel while the mesentery and omentum are transected with a 10 mm electrothermal vessel
sealing device. e surgeon and the camera
holder stand on the patient’s right side. e
camera holder will need to be able to move
above and below the surgeon as the dissection
progresses between the splenic exure and the
pelvis.
e procedure starts with lateral mobilization
of the le and sigmoid colon. Exposure is achieved
by placing the patient in steep Trendelenburg
position with the patient’s le side up. e peritoneum is incised along the line of Toldt distal to
the iliac vessels. is maneuver facilitates entry
into the avascular plane between the mesentery
and the retroperitoneum. Great care is taken to
identify the le ureter throughout the procedure.
e le colon and its mesentery are fully mobilized to the midline, a step facilitated by frequent
adjustments with the le hand to ensure proper
traction.
e splenic exure is mobilized by continuing the liberation of the proximal le colon. e
patient is placed in steep reverse Trendelenburg,
again with the le side up. Once the spleen is
reached, the lesser sac is entered by anteriorly
retracting the stomach and incising the gastrocolic omentum. e omentum is transected with
the electrothermal vessel sealing device and care
is taken to preserve the gastroepiploic vessels.
e transverse mesocolon is then mobilized
from the inferior border of the pancreas. e
dissection proceeds from proximal to distal
until the point of the distal dissection is reached,
aer which the remaining retroperitoneal
attachments are incised to fully mobilize the
exure.
With the splenic exure, le, and sigmoid
colon fully mobilized, attention is then turned to
the vasculature. With the patient placed back in
steep reverse Tredelenburg, the distal sigmoid
colon and its mesentery are retracted anteriorly
and the peritoneum is incised below the superior
hemorrhoidal artery. We dissect through the
Surgical Technique andDifficult Situations fromSteven Wexner (Laparoscopic)
mesentery until the ureter is identied. In obese
patients, gaining adequate traction for exposure
can be dicult, and it is oen facilitated by placing
an additional port in the le lower quadrant in a
mirror image position to the right lower quadrant
port. Additionally, this port can also be used to
facilitate subsequent pelvic dissection. Aer the
ureter is identied, it is kept posterior and the mesentery is divided cephalad to the inferior mesenteric artery and caudal to the inferior mesenteric
vein. is maneuver is achieved with the ultrasonic
scalpel. A window above and below the inferior
mesenteric artery (IMA) is created to isolate the
IMA, which is transected by rst applying three
partially overlapping side-by-side sealings of the
vessel with the electrothermal vessel sealing device
and then cutting between the high and low sealings. e inferior mesenteric vein is divided in a
similar way aer dissection of the mesentery cephalad to the vein with the ultrasonic scalpel to isolate the vein. e IMA is transected between the
aorta and the le colic artery. e IMV is transected between the edge of the duodenum and the
le colic vein. Using the bipolar energy device the
mesentery is transected from the level of high ligation to the sigmoid descending junction to an area
free of diverticular disease. Transection of the mesentery from the high ligation to the bowel wall will
facilitate specimen extraction through a small
abdominal wall incision and/or through the anus.
Attention is turned towards the pelvis in which
the peritoneum on the lateral sides of the rectum is
incised. e presacral space is entered and the areolar attachments to the mesorectum are incised
with the ultrasonic scalpel in the right hand and
retraction created with the le hand. Additionally,
exposure can be facilitated via retraction from the
le lower quadrant port. Total mesorectal excision
commences as in an open case, the dissection
begins posteriorly and then commences laterally
and then anteriorly. Care is taken to identify and
preserve the parasympathetic nerves, the posterior
wall of the vagina, and the seminal vesicles. e
dissection proceeds distally to the levator muscles
for any tumor in the distal two thirds of the rectum
in order to ensure a total excision of the rectum
and mesorectum. Manual pressure applied to the
perineum can help facilitate exposure. Digital
examination from below is also routinely undertaken to help assess if further dissection is needed.
Aer complete laparoscopic mobilization, an
endoscopic articulating linear cutting stapler is
used to transect the rectum distally. A signicant
body of evidence has conrmed that as the number of stapler rings increase so does the incidence
of anastomotic leakage. erefore, great eort
should be taken to try to minimize the number of
stapler rings. Whenever possible one or a maximum of two stapler rings should be employed. If
more than 2 stapler rings are required an even
higher vigilance towards proximal fecal diversion
should be employed. Great care is taken to ensure
that the stapler is distal to the tumor, yet above the
sphincter complex. Again, digital and/or endoscopic examination is critical to ensure proper
placement of the stapler. If the stapler cannot be
intracorporeally placed at a satisfactory level then
we prefer a transanal approach. is approach
might be either by eacing the anus and then commencing with a dissection at the dentate line or by
transanal total mesorectal excision. Employing
either of these modalities will allow safe completion of total mesorectal excision under direct
vision as well as safe performance of an anastomosis at the level of the dentate line. In these instances
we do not perform any abdominal incision but
extract the entire specimen through the anus and,
if technically feasible, preferentially perform a
transperineal colonic J-pouch. Whether the specimen extraction will be transabdominal or transanal, the mesentery is divided from the point of
high ligation to the sigmoid descending junction,
again using the bipolar energy device. Intracorporeal mesenteric transection from the point of
high ligation to the bowel wall facilitates specimen
extraction through a smaller wound or through
the anus.
A small incision is made to deliver the rectum.
is extraction site incision may be made as a small
pfannensteil, periumbilical, or ostomy site incision.
A wound protector can be used to facilitate retrieval
and delivery for the extracorporeal phase of the
procedure. Aer the rectum is extracorporeally
delivered, the proximal resection margin is chosen
based both on oncologic considerations as well as
length required to create a tension-free anastomosis. e mesentery is divided with the electrothermal vessel sealing device and the bowel transected
with a linear cutting stapler. A 5–8 cm colonic
J-pouch is fashioned whenever possible. e pouch
is constructed with a single ring of the stapler
through an apical enterotomy, aer which, a purse
string is fashioned around the enterotomy, the
anvil of the chosen circular stapler is placed within
379
49
380 S. Wexner and M. Osborne
49
the lumen, and the purse string secured. If the
lower edge of the tumor is within a few centimeters
of the dentate line and/or the patient has a very
narrow pelvis transanal completion of the dissection may be optimal. More than 10 years ago we
rst employed standard anal eacement with either
mucosal or intersphincteric dissection commencing at the dentate line. We and subsequently others
clearly demonstrated oncologic equivalence
although as Rullier has noted intersphincteric dissection can be associated with functional compromise. Nonetheless, oncologic acceptability has
been clearly demonstrated. More recently, Sylla,
Whiteford, Lacy, and others have championed
transanal total mesorectal excision. Again, we have
demonstrated that using pneumoperitoneum with
a high ow insuator and transanal operating
equipment a very elegant total mesorectal excision
and subsequent anastomosis can be performed.
Regardless of whether the transanal dissection is
accomplished with or without pneumoperitoneum
and with or without specialized equipment in these
instances the entire specimen is transanally delivered and if possible a colonic J-pouch is created
prior to transanal coloanal anastomotic construction. ese techniques completely avoid any
abdominal incision other than the stab wounds for
the port sites and the trephine for the stoma.
Whether the colon is delivered through the abdomen or the anus proximal margin selection is conrmed by the use of indocyanine green uorescence
perfusion assessment [1]. e proximal bowel is
then placed back within the abdomen and pneumoperitoneum is reestablished.
Aer pneumoperitoneum is re-established,
circular stapler is inserted into the anus and the
trocar delivered through the distal staple line. e
anvil is placed onto the trocar with the assistance
of a laparoscopic anvil grasper clamp. e anastomosis is created only aer verication to ensure
proper alignment of the bowel and its mesentery.
Aer the stapler is closed but prior to it being
red indocyanine green perfusion assessment is
again performed to verify serosal perfusion at the
intended anastomosis. Laparoscopic uorescence
imaging is repeated using ICG perfusion assessment to conrm perfusion in both the proximal
and distal segments to be anastomosed. Flexible
sigmoidoscopy is performed to inspect the anastomosis and the anastomosis is submerged in
water to perform a leak test. In addition, we have
routinely employed indocyanine green (ICG) uorescence imaging to verify mucosal perfusion
aer anastomotic creation. e patient is then
repositioned to identify the cecum and the small
bowel is inspected to identify a site for a loop
ileostomy, approximately 40–60cm proximal to
the ileocecal valve. An atraumatic clamp is le on
the bowel wall at this site to allow delivery of the
bowel through the ostomy trephine. Prior to
removing the ports, a closed suction drain is
placed posterior to the pouch and is brought out
in the le lower quadrant. With the loop of bowel
adequately delivered, all fascia and port sites are
closed aer which the loop ileostomy is matured.
e ureteral stents are removed prior to the
patient awakening from anesthesia.
Antibiotics are continued for 24h postoperatively according to SCIP guidelines. Patients
immediately begin a clear liquid diet. We encourage early ambulation, and the bladder catheter is
removed sometime between postoperative day
1–3, depending upon the surgical indication and
the diculty of the pelvic dissection.
Several key maneuvers are employed to deal
with dicult situations. Meticulous attention to
hemostasis allows for improved visualization and
routine use of energy devices helps provide hemostasis. We primarily use the ultrasonic scalpel for
ner dissection, mobilization of the le colon and
splenic exure, and for TME dissection. e 10
mm electrothermal vessel sealing device provides
excellent hemostasis during transaction of the
mesentery and omentum. Exposure is oen dicult in obese patients, those with a narrow pelvis,
and/or a large tumor. Adding a le lower quadrant port for an extra grasper that held by an assistant as well as second assistant to provide pressure
on the perineum helps provide the exposure necessary to perform a complete rectal mobilization.
e performance of laparoscopic low anterior
resection has evolved since we began utilizing this
methodology in 1991. Numerous studies have
proven the oncologic superiority of laparoscopic
as compared to open total mesorectal excision.
We have shown a 25 % improvement in lymph
node yield using the laparoscopic technique without any compromise to the circumferential or distal resection margins or the quality of the
mesorectum [1–4].
Surgical Technique andDifficult Situations fromSteven Wexner (Laparoscopic)
381
49
Several meta analyses and systematic reviews
have supported these points, although there are
some isolated studies which have suggested a
lack of superiority in fact even a lack of equivalence [5–7].
We also found that the use of energy devices
have allowed these operations to be performed more
quickly through smaller incisions with less blood
loss. Electrothermal bipolar vessel ligation improves
operative time during laparoscopic total proctocolectomy: a large single-center experience [8–10].
In summary, laparoscopic low anterior resection for rectal cancer is our preferred technique
for managing patients with rectal cancer.
References
1. Jafari MD, Wexner SD, Martz JE, et al. Perfusion
assessment in laparoscopic left-sided/anterior resec-
tion (PILLAR II): a multi-institutional study. Am Coll
Surg. 2015;220(1):82–92.e1. doi: 10.1016/j.jamcoll-
surg. 2014.09.015. Epub 2014 Sep 28.
2. Boutros M, Hippalgaonk ar N, Silva E, et al. Laparoscopic
resection of rectal cancer results in higher lymph node
yield and better short-term outcomes than open sur-
gery: a large single-center comparative study. Diseases
of the Colon & Rectum 2013;56(6):679–88.
3. van der Pas MH, Haglind E, Cuesta MA, etal. COlorectal
cancer Laparoscopic or Open Resection II (COLOR II)
Study Group. A randomized controlled trial showed
signicant oncologic superiority particular for distal
rectal tumors for both the surrogate short term histopathologic and long term tumor recurrence and survival outcomes. Lancet Oncol. 2013;14(3):210–8.
4. Bonjer HJ, Deijen CL, Abis GA, et al. COLOR II Study
Group. A randomized trial of laparoscopic versus open
surgery for rectal cancer. (COLOR II). N Engl J Med.
20152;372(14):1324–32.
5. Arezzo A, Passera R, Salvai A, et al. Laparoscopy for
rectal cancer is oncologically adequate: a systematic
review and meta-analysis of the literature. Surg
Endosc. 2015;29(2):334–48. doi: 10.1007/s00464-014-
3686-4. Epub 2014 Jul 10.
6. Stevenson AR, Solomon MJ, Lumley JW, etal. ALaCaRT
Investigators. Eect of Laparoscopic-Assisted Resection vs Open Resection on Pathological Outcomes in
Rectal Cancer: The ALaCaRT Randomized Clinical Trial.
JAMA. 20156;314(13):1356–63.
7. Fleshman J, Branda M, Sargent DJ, etal. Eect of Laparoscopic-Assisted Resection vs Open Resection of
Stage II or III Rectal Cancer on Pathologic Outcomes:
The ACOSOG Z6051 Randomized Clinical Trial. JAMA.
2015;314(13):1346–55.
8. Garnkle R, Boutros M, Hippalgaonkar N, et al. The
transanal approach has further facilitated our ability
to perform TME with anastomosis at the dentate line
without any oncologic compromise. Surg Endosc.
2016;30(7):2840–7.
9. Lacy AM, Tasende MM, Delgado S, et al. Transanal
Total Mesorectal Excision for Rectal Cancer: Outcomes after 140 Patients. J Am Coll Surg. 2015;221(2):
415–23.
10. Wexner SD, Berho M. Transanal total mesorectal excision of rectal carcinoma: evidence to learn and adopt
the technique. Ann Surg. 2015;261(2):234–6.