fecal matter. Giving full bowel preparation has also been described in the literature [11], however, is unnecessary in the authors’ opinion and may create a more difcult operative eld to control with the presence of liquid stool. However, for taTME, consideration should be given to full mechanical bowel preparation if diversion is planned, and ostomy evaluation and marking should be undertaken preoperatively if required. Appropriate prophylaxis includes single-dose sys­temic antibiotics administered 30minutes prior to incision (our preference is ertapenem 1gm IV).

of the rectum is a balance between the morbidity of classical radical surgery with the increased risk of recurrence with local excision.

Since the introduction of TAMIS in 2010, which utilized a single-incision laparoscopic sur­gery port, exible access devices specically FDA approved for transanal surgery have been designed and are commercially available. The commonest of these “TAMIS ports” used today is probably the GelPOINT path transanal access platform (Applied Medical, Rancho Santa Margarita, CA, USA). Widespread availability, shorter learning curve, and easy training and implementation have led to extensive adoption of TAMIS compared to other modalities in the last decade. TAMIS is a valuable technique for local excision of lesions in the rectum that can be per­formed using readily available equipment and a minimally invasive skillset.

ticularly regarding any benet to adjuvant chemoradiation therapy.

Patients with T3 tumors with a response to neoadjuvant therapy can, in select instances, be considered for local excision – however, the authors caution that complete pathologic response in the primary tumor does not imply complete nodal response. T3 tumors frequently have nodal metastasis (40–50%) and may have positive nodes despite a complete pathologic response in the pri­mary tumor [5, 12]. Therefore, we do not recom­mend local excision in these cases unless the patient cannot tolerate radical surgery. There are no specic contraindications for TAMIS local excision other than those outlined above.

Surgical site infection and thromboprophy­laxis are given within 30minutes of surgery in accordance with guidelines for colonic surgery. Foley catheterization is optional as urinary reten­tion is rare.

exhibit tumor shedding with even minor instru­ment manipulation; this can theoretically result in the implantation of live tumor cells within resection bed. Although controversial, some sur­geons advocate en bloc removal of mesorectal fat beneath the lesion to retrieve lymph nodes, especially when the lesion is located posteriorly in the rectum. No literature supporting the supe­riority of this technique exists, although theoreti­cally the sampling of positive or negative juxtaposed mesorectal lymph nodes potentially may signicantly alter treatment recommenda­tions when the node is found to be positive. This notion is supported by several small studies of sentinel lymph node biopsy in rectal cancer. The dye-containing nodes are typically near the pri­mary tumor. Care must be taken to avoid breach­ing the mesorectal fascial envelope to minimize disruption of the anatomic planes should proc­tectomy become necessary [14].

Anterior lesions are still best accessed in the lithotomy position, in contrast to conventional transanal excision or TEM where the prone jack­knife position is necessary. Careful attention must be given for anterior lesions, as there is a risk of prostate or vagina injury, and this dissec­tion can be quite challenging since the anterior mesorectum is much thinner than it is posteriorly. Anterior organ injury was described in the early literature of TEM in the 1980s; however, it has 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, occur­ring 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 rst closing the peritoneum and then the rectal wall. Transient loss of pneumorec­tum may occur but is re-established following peritoneal closure. Rarely, laparoscopic access is required to cleanse the pelvis, facilitate wall clo­sure, or perform a leak test. Informed consent in patients at risk of peritoneal entry should be obtained prior to surgery and the operating room prepared accordingly.