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220
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
A. E. Gough et al.
with three 10 mm ports triangulated placed
through the cap and placed through the future
ileostomy site, and pneumoperitoneum is
achieved. Often an additional 5 mm trocar is
placed in the suprapubic location to aid in triangulation during splenic exure mobilization and
used for a fan retractor which retracts the uterus
or bladder during the TME dissection. After conrming absence of peritoneal or liver metastases,
the two teams can begin working simultaneously.
The patient is positioned with the table tilted to
the right and in Trendelenburg position.
The small bowel is swept out of the pelvis.
The dissection of the sigmoid colon is begun in a
medial to lateral fashion. After identication of
the left ureter, the inferior mesenteric artery is
divided high on its pedicle near the aorta using a
vessel sealing device (e.g., LigaSure™,
Medtronic, Inc., Minneapolis, MN) and the retroperitoneal dissection carried to the white line of
Toldt and inferior border of the pancreas where
the inferior mesenteric vein can be divided. Next,
the white line of Toldt is divided and the colon
medialized. As this is being performed abdomi-
21 Operating Theater Setup andTwo-Team Coordination
Fig. 21.5 AirSeal® iFS insufation management system
placed lateral to the patient’s left leg between the transanal
back table and the abdominal team’s laparoscopic tower.
The cords for the transanal setup passed over the patient’s
left leg
Fig. 21.6 GelPOINT® Mini placed at future ileostomy
site as single-site access for abdominal dissection
nally, the transanal team is also beginning their
work (Fig.21.7). However, when the splenic exure mobilization is begun, the transanal dissection must halt temporarily, due to limitations
imposed by table positioning during this portion
of the operation.
221
Transanal Team: Rectal Transection
andMobilization
The beginning portions of the transanal dissection are performed simultaneously with the
abdominal team mobilization of the sigmoid and
descending colon (Fig. 21.7). Digital rectal
examination and, if needed, exible sigmoidoscopy are performed to conrm the location of the
tumor and distance from the anal verge. Prior to
colonic insufation, the abdominal team is asked
to occlude the sigmoid colon with an atraumatic
bowel grasper to prevent insufation of the entire
colon and the position of the tumor is veried
endoscopically. If the distal purse string is to be
placed endoscopically (for tumors in the upper
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 insufated 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 pneumorectum achieved at 12mmHg using AirSeal®
(Conmed Inc., Utica, NY, USA). At this point, it
is important to ask the abdominal surgeons to
also turn insufation to ≤12 mmHg to prevent
competing pressures.
The rectum is transected full thickness at a 90°
angle with the bowel wall circumferentially using
electrocautery; at our center, the Endopath® Probe
Plus hook (Ethicon Inc., Somerville, NJ, USA) is
utilized. Next, the dissection is advanced cephalad
toward the peritoneal cavity. When the abdominal
dissection has reached the point of splenic exure
mobilization, the transanal dissection must be
temporarily interrupted due to positioning of the
patient in reverse Trendelenburg position.
222
ab
A. E. Gough et al.
dc
Fig. 21.7 Transanal and abdominal teams work simultaneously during the beginning portions of the operation.
While the abdominal team performs the inferior mesen-
Abdominal Team: Splenic Flexure
andUpper Rectal Mobilization
teric artery ligation (a) and sigmoid colon mobilization
(c), the transanal team places the transanal purse string (b)
and begins the taTME dissection (d)
retract the rectum upward as the transanal team
continues to progress in their dissection toward
the rendezvous (Fig.21.8).
After splenic exure mobilization, during which
time only the abdominal team can work, the table
position is again changed to Trendelenburg and
Both Teams: TheRendezvous
the abdominal team begins the upper TME dissection. The amount of dissection performed
from above is dependent on many factors
including surgeon preference and difculty of the
abdominal and transanal dissections. The lateral
stalks can be divided and anterior peritoneal
reection opened to assist in meeting of the two
planes. At this time, the abdominal team can also
The anterior plane is typically an easier point to
enter into the peritoneal cavity from below; however sometimes if the posterior dissection is further ahead or if the anterior dissection is
challenging, then posterior rendezvous is possible and can be helpful as well. Once the rendezvous has occurred, the abdominal team can help
ab
ab
21 Operating Theater Setup andTwo-Team Coordination
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 eld
223
Fig. 21.9 When the rendezvous is achieved, the abdominal team can retract the peritoneal reection anteriorly (a),
place a grasper into the opening to provide retraction, or
pull the rectum upward into the abdomen and either assist
in the dissection or allow the transanal team to completely
dismount the rectum from below (b)
by retracting the anterior peritoneal reection
upward, placing a retractor through the opening
to facilitate the dissection, or continuing to
retract the rectum upward and into the abdominal cavity where the dissection can be completed
by the transanal or abdominal team (Fig.21.9).
When the entire rectum is dismounted, the transanal cap is removed, the table position is leveled,
and the pelvis is copiously irrigated from above
with warm saline or sterile water and allowed to
drain transanally. Next, the distal purse-string
suture is grasped and the specimen can often be
retrieved transanally. In the case of a bulky tumor
or mesentery precluding transanal extraction, a
Pfannenstiel incision can be used for specimen
extraction.
224
A. E. Gough et al.
Transanal Team: Specimen Extraction
andAnastomosis
In the case of transanal extraction, the access
channel is removed and the entire rectum and sigmoid colon is eviscerated through the anus. If
available, uorescence imaging can help guide
the proximal transection point. Otherwise, the
proximal transection is made using electrocautery proximal to the IMA pedicle.
The anastomosis is then performed entirely
transanally. Either a stapled, double pursestring anastomosis can be chosen, or the colon
can be hand-sewn to the rectal cuff. In a double
purse- string anastomosis, when the transanal
team is placing the distal purse string, the
abdominal operator can place the camera into
the pelvis to visualize the suturing of the distal
rectum to assure full-thickness bites are taken
and extra- rectal tissue is not incorporated into
the purse- string suture. Prior to closure of the
distal purse string, the abdominal operator conrms that the colon and mesentery lay straight
across the retroperitoneum and that no small
bowel loops are caught under the colonic mesentery. The two ends of the EEA are mated and
the distal purse string is secured before closing
and ring the EEA stapler. The abdominal
operator can maintain pneumoperitoneum at
this point to assess for a “reverse” air leak by
having the taTME surgeon (bottom team) check
for air escaping into the lumen through defects
in the staple line. If present, this can be oversewn transanally. If a hand- sewn anastomosis is
preferred, it can be performed directly to the
cut edge of the rectal cuff using interrupted 2–0
chromic sutures. A 0.25 inch Penrose drain is
placed transanally.
Abdominal Team: TAP Block
andIleostomy Creation
While the transanal team is performing the anastomosis, the abdominal team performs a laparoscopic transversus abdominis plane (TAP) block
[12], places a pelvic drain through a 5mm port
site, and creates the diverting loop ileostomy.
Two-Team Coordination: Total
Proctocolectomy withIleal PouchAnal Anastomosis
Abdominal Team: Laparoscopic
Colectomy andAssessment
ofPouch Reach
Transanal Ileal pouch-anal anastomosis also uses
an abdominal team and a transanal team, each
with a surgeon and an assistant. The operating
room setup is unchanged from the description
above. The abdominal colectomy is rst performed by the abdominal team through a
single- port access system (GelPOINT® Mini
Advanced Access Platform, Applied Medical Inc.,
Rancho Santa Margarita, CA, USA) prepared
with three 10mm cannulas widely spaced in a triangle through the gel cap. An additional 5mm
port is placed at the suprapubic position to assist
in the dissection and tissue triangulation. After
complete colonic mobilization and mesenteric
division with preservation of the ileocolic pedicle,
the small bowel and its mesentery are assessed for
length to ascertain pouch reach. If there appears to
be adequate length, the terminal ileum is transected laparoscopically with a stapling device
(Echelon Flex™ Powered Plus 60, Ethicon Inc.,
Somerville, NJ, USA), and the terminal ileal
attachments to the level of the duodenal sweep are
mobilized. During this dissection, the patient
position is continuously changing as is the position of the surgeons across the operating table precluding any transanal work. Once the terminal
ileum is mobilized, it is exteriorized through the
GelPOINT® Mini and ileal pouch created. At this
point the transanal team may also commence
proctectomy.
While the transanal team begins the proctectomy, the abdominal team may create the ileal
pouch per standard fashion through the ileostomy
site. The pouch apex is secured by placing a
betadine- soaked gauze into the pouch and securing it with 2–0 Prolene purse-string suture to prevent spillage of bowel contents. This suture also
acts as a handle for pouch manipulation. The
pouch is then reinserted into the abdomen and
laparoscopy commenced.
21 Operating Theater Setup andTwo-Team Coordination
225
Transanal Team: Transanal Proctectomy
Once adequate pouch reach is assured, the transanal team begins as in the previous section. The
patient is positioned in Trendelenburg position.
The Lone Star® Retractor and GelPOINT® path
access channel are placed. Working directly
through the access channel, the purse string is
placed above the edge of the access channel. The
GelPOINT® is capped and AirSeal® insufation
begun at 12mmHg. At this time, if the abdominal
team is also working laparoscopically, they are
asked to also turn their abdominal insufation
pressure ≤12mmHg to avoid pressure mismatch.
However, if the abdominal team is still working
open through the GelPOINT® Mini to create the
pouch, transanal insufation can create a vacuum
effect in the de-insufated abdomen. Thus, lower
transanal AirSeal® pressures (8mmHg or lower)
may be necessary to maintain visibility and avoid
suctioning of the rectum upward into the abdomen. The rectal wall is scored and transected
1 cm distal to the purse-string closure, and the
taTME dissection proceeds. Dissection is carried
cephalad toward the abdominal operator.
Abdominal Team: Upper Rectal Mobilization
After creation of the pouch and re-insufation of
the peritoneal cavity, the upper rectum is mobilized
by dividing the superior hemorrhoidal artery near
the rectal wall to avoid hypogastric nerve injury.
The presacral space is entered and dissection carried out along the TME plane. A 5mm suprapubic
port is helpful during this portion of the procedure
for anterior retraction of the pelvic organs.
Transanal Team/Abdominal Team:
Bringing Down thePouch,
Anastomosis, andFinal Steps
At the point of top and bottom rendezvous, the
paired teams can work together to dismount the
rectum. The pelvis is irrigated and uid drained
transanally followed by transanal specimen
removal. A laparotomy pad is placed in the anus
to allow abdominal insufation with the transanal access channel removed. The abdominal
team then orients the pouch, places it at the pelvic
brim, and retracts the pelvic organs to allow the
pouch to be grasped and delivered down to the
anus by the transanal team.
The transanal surgeon delivers a ring forcep
alongside the laparotomy pad and, using the laparoscopic monitor as a guide, grasps the pouch
and gently delivers it toward the anus. The level
of the anastomosis and residual mucosa retained
can now be tailored to pouch reach. A hand-sewn
or double purse-string anastomosis can be chosen. While the transanal team is working on the
anastomosis, the abdominal team places a drain
(optional), performs a laparoscopic TAP block,
and creates a diverting loop ileostomy.
Perfecting theTwo-Team Approach
One of the largest challenges but also most
advantageous aspects of two-team taTME is the
transanal-abdominal rendezvous. As the dissections continue toward each other, coordination
between teams so that the same quadrant is being
worked on can be helpful. Furthermore, as more
of the rectum is mobilized, it can occlude the
transanal view. During this critical time, it is
often advantageous to have the abdominal team
pull up on the rectum to allow it to straighten out,
providing more working room for the transanal
team. Attempting to maintain a circumferential
transanal dissection so as to allow only a thin ring
of tissue to remain prior to rendezvous is most
ideal. When the transanal team proceeds too far
posteriorly, peritoneal entry can occur before the
anterior and other key portions of the taTME dissection have been completed. This can result in
spillage of air and uid from the abdominal dissection obscuring the transanal view.
However, when the rendezvous is reached, the
two teams must work together to completely dismount the rectum. The abdominal team can initially pull up on the rectum and provide anterior
retraction using a fan retractor through the 5mm
226
A. E. Gough et al.
suprapubic port. As the dissection continues circumferentially, the abdominal team can fully
deliver and evert the mobilized rectum into the
peritoneal cavity, thereby completing the dissection beyond the reach or vision of the transanal
team.
Insufation pressures during two-team taTME
also play a large role in a successful operation. In
the initial portions of the transanal dissection
prior to rectal transection, if using continuous
insufation platform (AirSeal®), the abdominal
pressure has little effect on the transanal dissection. Once the rectum is transected and the TME
dissection has begun, it is our experience that
maintaining equal abdominal and transanal pressure throughout the latter half of the transanal
dissection provides optimal transanal view. While
some authors have recommended maintaining
transanal pressure higher than abdominal pressure [13], in our experience, this can sometimes
displace the rectum proximally and atten the
TME plane along the sidewall making the dissection more challenging. It can also be challenging
for the abdominal team to operate at a lower
insufation pressure. Thus, being mindful of the
balance between abdominal and transanal pressure throughout the case is important, and generally a matched pressure of 12mmHg works well.
Lastly, the two teams must be able to work
together and maximize available resources to
assure successful and timely surgery. First, training and familiarity of the OR team with the procedure and necessary equipment as well as
having a dedicated team of nurses and surgical
technicians routinely assigned to taTME cases is
crucial to a successful program. Similarly, dual
training of surgeons planning to work together in
taTME surgery is important. During surgery,
compromise between transanal and abdominal
teams helps carry the case along. For example,
the use of a headlight during rectal suturing
allows the room lights to be kept dim so the
abdominal operator can continue laparoscopy.
The abdominal operators may need step stools to
compensate for the higher table position when
the transanal team is placing the purse string.
When the operating table is tilted to the right to
allow mobilization of the sigmoid colon, the
transanal team must adjust accordingly. Early
communication with the team when asking for
instruments is essential as these cases can become
overwhelming for the staff. Finally scheduling
the surgery so that both surgeons are available for
the entire duration of the surgery without other
commitments is essential, especially during the
implementation phase of a taTME program.
References
1. Lacy AM, et al. Transanal total mesorectal excision
for rectal cancer: outcomes after 140 patients. J Am
Coll Surg. 2015;221(2):415–23.
2. Penna M, et al. Transanal total mesorectal excision:
international registry results of the rst 720 cases.
Ann Surg. 2017;266(1):111–7.
3. Penna M etal. Incidence and risk factors for anastomotic failure in 1594 patients treated by transanal
total mesorectal excision: results from the international TaTME registry. Ann Surg. 2018. https://doi.
org/10.1097/SLA.0000000000002653. [Epub ahead
of print].
4. Motson R, Lacy A. The rationale for transanal
total mesorectal excision. Dis Colon Rectum.
2015;58(9):911–3.
5. Benlice C, Gorgun E. Single-port laparoscopic
restorative proctocolectomy with ileal-pouch anal
anastomosis using a left lower quadrant ileostomy
site– a video vignette. Color Dis. 2016;18(8):818–9.
6. de Buck van Overstraeten A, Wolthuis AM, D'Hoore
A.Transanal completion proctectomy after total colectomy and ileal pouch-anal anastomosis for ulcerative colitis: a modied single stapled technique.
Color Dis. 2016;18(4):O141–4.
7. Leo CA, Samaranayake S, Perry-Woodford ZL, Vitone
L, Faiz O, Hodgkinson JD, Shaikh I, Warusavitarne
J. Initial experience of restorative proctocolectomy
for ulcerative colitis by transanal total mesorectal
rectal excision and single-incision abdominal laparoscopic surgery. Color Dis. 2016;18(12):1162–6.
8. de Buck van Overstraeten A, Mark-Christensen A,
Wasmann KA, Bastiaenen VP, Buskens CJ, Wolthuis
AM, Vanbrabant K, D'Hoore A, Bemelman WA,
Tottrup A, Tanis PJ.Transanal versus transabdominal
minimally invasive (completion) proctectomy with
ileal pouch-anal anastomosis in ulcerative colitis: a
comparative study. Ann Surg. 2017;266(5):878–83.
9. Caycedo-Marulanda A, Jiang HY, Kohtakangas
EL. Outcomes of a single surgeon-based transanaltotal mesorectal excision (TATME) for rectal cancer.
J Gastrointest Cancer. 2017. https://doi.org/10.1007/
s12029-017-9989-7. [Epub ahead of print].
10. Burke JP, et al. Transanal total mesorectal excision
for rectal cancer: early outcomes in 50 consecutive
patients. Color Dis. 2016;18(6):570–7.
21 Operating Theater Setup andTwo-Team Coordination
227
11. Koedam TWA, etal. Transanal total mesorectal excision for rectal cancer: evaluation of the learning curve.
Tech Coloproctol. 2018;22(4):279–87.
12. Zaghiyan K, Mendelson B, Eng M, Ovsepyan G,
Mirocha J, Fleshner P. Randomized clinical trial
comparing laparoscopic vs. ultrasound-guided transversus abdominis plane block in minimally invasive
colorectal surgery. Dis Colon Rectum. 2019;62(2):
203–10.
13. Arroyave MC, DeLacy FB, Lacy AM. Transanal
Total Mesorectal Excision (TaTME) for rectal cancer: step by step description of the surgical technique for a two- teams approach. Eur J Surg Oncol.
2017;43(2):502–5.
Single-Team taTME
Antonio Caycedo-Marulanda, Shady Ashamalla,
and Grace Wai Ma
22
Introduction
The management of rectal cancer has evolved
rapidly over the last four decades. Clearly, the
contribution with the highest impact in the evolution of the surgical therapy of rectal cancer was
the description of the mesorectal plane by
Professor RJ Heald in the early 1980s [1].
Multiple advances have been made focusing on
enhancing outcomes while trying to minimize the
invasiveness of surgical therapy. There is a broad
range of approaches in rectal cancer– from the
traditional open surgical excision of the rectum
and mesorectum extending to the novel “watch
and wait” non-operative management pioneered
by Angelita Habr-Gama [2].
In recent decades, there have been signicant
improvements to surgical techniques with the
introduction of a minimally invasive or laparoscopic approach. Minimal invasion has been further modied with the introduction of
robotic-assisted surgery [3]. The past decade has
A. Caycedo-Marulanda (*) · G. W. Ma
Health Sciences North, Department of Surgery,
Sudbury, ON, Canada
Colorectal Surgery North, Sudbury, ON, Canada
e-mail: acaycedo@hsnsudbury.ca
S. Ashamalla
Odette Cancer Centre, Toronto, ON, Canada
Sunnybrook Health Sciences Centre, Department
of General Surgery, Toronto, ON, Canada
seen the introduction of local excision endoscopically and transanally [4]. Selection of the optimal surgical approach for rectal cancer depends
on intricate considerations including tumor and
patient characteristics, skills and expertise of the
surgical team, and resources available to the
institution.
In many instances the introduction of new
technology/procedures lacks robust evidence to
support their implementation; therefore it should
follow a careful and monitored process in order
to prevent unnecessary harm to patients; this is
relevant for any innovative surgery, but it is certainly of paramount importance in the singlesurgeon TaTME setting [5].
Transanal total mesorectal excision (taTME)
has recently been introduced to the surgical community as a surgical approach which enables the
surgeon to excise the mesorectum in a minimally
invasive approach while providing excellent
visualization of pelvic structures and the mesorectal fascia [6]. Some of the benets touted by
taTME advocates are enhanced visualization,
perpendicular division of the rectum, and potential for increased preservation of distal rectum.
The literature on this approach is rapidly
emerging with most experience focused on the
two-team, or Cecil, approach [7, 8]. There have
been several select centers which have published
their experience with a single-team (or single surgeon) approach [9, 10]. The description and early
results of the single team demonstrate that such
© Springer Nature Switzerland AG 2019
S. Atallah (ed.), Transanal Minimally Invasive Surgery (TAMIS) and Transanal Total Mesorectal
Excision (taTME), https://doi.org/10.1007/978-3-030-11572-2_22
229
230
A. Caycedo-Marulanda et al.
approach can be feasible in the correct environment and with careful considerations prior to
implementation of such a program. A dual-team
approach is most likely safer; however this might
not be feasible at every center. Perhaps, there will
be institutions that otherwise meet the criteria to
perform taTME surgery but lack the resources of
having a two rectal cancer surgeons available
simultaneously [11].
The single-team taTME approach provides a
formidable technical and logistical challenge to
surgeons and operating room personnel. Those
situations and all the relevant factors regarding
feasibility and sustainability of a taTME program
should be considered prior to any attempt to
introduce the technique. Adoption and successful
implementation of taTME may prove to be quite
difcult, in some situations even prohibitive.
In our experience, appropriate implementation
of a single-team taTME program requires an
insightful assessment of the local patient population, surgical expertise, availability of institutional
resources, and receptive culture of the team for
innovation and learning. Some of the key individuals include the following: (a) a colorectal surgeon or gastrointestinal surgical oncologist, (b) a
minimally invasive trained surgical assistant, (c) a
specialized nursing team, (d) supportive administration, and (e) dedicated surgical equipment and
product specialist support. While these considerations and key elements may coincide with those
described in other chapters regarding the twoteam approach, the technical and perioperative
considerations that are described herein are
unique to the single-team taTME technique.
Considerations
When a surgeon is motivated to introduce
taTME surgery at their respective institution,
they should start by asking themselves several
questions. Am I the right person to do this? Do I
have the volume to perform this procedure regularly and safely? Is my institution the right place
to do taTME? If the answer to all of those is yes,
then it is appropriate to consider taking steps
toward implementing a taTME program.
Whether it is a single-team or a two-team program does not change the need to follow an
organized pathway [12, 13].
Seeking institutional support becomes important to acquire the necessary resources to perform
the procedure. Having a dedicated team will
enhance the chances of success, which is particularly relevant for single-team taTME implementation. Adequate training and proctorship are also
vital to ensuring its safe introduction [11].
Institution
There is signicant evidence available to support
the concept of high-volume rectal cancer institutions obtaining better outcomes when compared
with those considered to have low volumes and
suboptimal expertise [14, 15]. It is challenging to
determine a specic number which denes high
vs low volume. Concern has risen around the
increasing complexity of the decision-making
and surgical technique of rectal cancer which
ultimately led to different organizations and
health-care systems to advocate for centralization
of the management of rectal cancer [16, 17]. The
advent of taTME has added a new level of complexity; therefore, most experts believe, this technique should only be considered in high-volume
specialized centers.
The institution should be equipped and situated to enable implementation of advanced surgical techniques. In general, minimally invasive
surgery requires a longer time than open procedures, particularly during the learning curve
period, and it is crucial to have administrators
who understand that single-team taTME surgery
will initially take much longer than the traditional
open or laparoscopic procedure. A progressive
and informed administration understands that
such a venture is worthwhile, since ultimately
patients benet through improved oncologic
outcomes.
Some institutions may evaluate current taTME
data and opt against a single-team program, due
to unfavorable operating room efciency. If the
institution is not supportive or the infrastructure
for surgical innovation or advancement is not