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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_869_Библиотеки_им_академика_М_И_Перельмана.pdf
252
a
e
G. Dapri
a
e
b
f
c
g
d
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
Robotic instruments
(Medrobotics, Raynham,
Massachusetts, USA):
handle and shaft (a),
laser holder tip (b),
fenestrated grasper tip
(c), Maryland dissector
tip (d), scissors (e),
needle driver (f), spatula
(g), needle knife (h)
b
c
d
f
g
h
23 Transanal Access Platform Options andInstrument Innovations
253
operative length is 24cm. They’re inserted
through an instrument support and follow
guide tubes positioned along the robotic
scope. They allow triangulation from the
anus, through the rectum and into the distal
colon [27, 29]. The handles are similar to the
laparoscopic handles, including the ring for
the rotational tip.
Conclusion
Recent advancements in transanal surgery, specically the development of TAMIS and taTME,
have led to a surgery interest in developing new
forms of access and new instrumentation that can
aid the operator to perform complex procedures.
What was once only possible through TEM is
today feasible with multiple, equally effective
platforms. This provides surgeons and hospitals
with more options.
Editor’s Comment While transanal access platforms
are most often divided by whether or not they are rigid or
exible, this is really an oversimplied division, and it
does not highlight the most important difference between
the TEM and TAMIS techniques. It is important to realize
that TEM and TAMIS are techniques associated with
platforms– not platforms alone. Perhaps one of the most
important differences in technique is that with TEM, the
shaft of the access channel is meant to be navigated to a
localized target. In contrast, with TAMIS, the access
channel remains seated above the anorectal ring, while
the TAMIS instrumentation alone is delivered to the target of interest. TAMIS’ short access channel and free
moving camera have made this design quite suitable for
working in multiple sectors at various distances from the
anal verge without having to reposition the platform, as
is the case for most rigid platforms, which require constant readjustment of the Martin Arm. This is one key reason why the TAMIS technique and platform are so
commonly used for taTME as opposed to others.
Notwithstanding, surgeon preference and resource availability govern which approach is selected for this
operation.
Authors’ Disclosures The author keeps the patent
license for the D-Port platform and monocurved instruments manufactured by Karl Storz Endoskope, Tuttlingen,
Germany.
References
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endoscopic surgery of the rectum – testing a new
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2. Atallah S, Martin-Perez B, Keller D, Burke J, Hunter
L. Natural-orice transluminal endoscopic surgery.
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3. Rattner D.Introduction to NOTES white paper. Surg
Endosc. 2006;20(2):185.
4. Franklin ME Jr, Liang S, Russek K. Integration of
transanal specimen extraction into laparoscopic anterior resection with total mesorectal excision for rectal cancer: a consecutive series of 179 patients. Surg
Endosc. 2013;27(1):127–32.
5. Whiteford MH, Denk PM, Swanstrom LL.Feasibility
of radical sigmoid colectomy performed as natural
orice translumenal endoscopic surgery (NOTES)
using transanal endoscopic microsurgery. Surg
Endosc. 2007;21(10):1870–4.
6. Sylla P, Rattner DW, Delgado S, etal. NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance.
Surg Endosc. 2010;24(5):1205–10.
7. Atallah S.Transanal minimally invasive surgery for
total mesorectal excision. Minim Invasive Ther Allied
Technol. 2014;23:10–6.
8. Atallah S, Albert M, Larach S.Transanal minimally
invasive surgery: a giant leap forward. Surg Endosc.
2010;24(9):2200–5.
9. Cahill RA, Hompes R. Transanal total mesorectal
excision. 448. Br J Surg. 2015;102(13):1591–3.
10. Rullier E. Transanal mesorectal excision: the new
challenge in rectal cancer. Dis Colon Rectum.
2015;58(7):621–2.
11. Heald RJ. A new solution to some old problems:
transanal TME.Tech Coloproctol. 2013;17(3):257–8.
12. Atallah S, Martin-Perez B, Albert M, deBeche-Adams
T, Nassif G, Hunter L, Larach S. Transanal minimally invasive surgery for total mesorectal excision
(TAMIS-TME): results and experience with the rst
20 patients undergoing curative-intent rectal cancer surgery at a single institution. Tech Coloproctol.
2014;18(5):473–80.
13. Atallah S, Albert M, DeBeche-Adams T, Nassif
G, Polavarapu H, Larach S. Transanal minimally
invasive surgery for total mesorectal excision
(TAMIS-TME): a stepwise description of the surgical technique with video demonstration. Tech
Coloproctol. 2013;17(3):321–5.
14. Heald RJ.The ‘Holy Plane’ of rectal surgery. J R Soc
Med. 1988;81(9):503–8.
15. Koedam TWA, Veltcamp Helbach M, van de Ven
PM, et al. Transanal total mesorectal excision for
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rectal cancer: evaluation of the learning curve. Tech
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16. Barendse RM, Dijkgraaf MG, Rolf UR, et al.
Colorectal surgeons' learning curve of transanal endoscopic microsurgery. Surg Endosc.
2013;27(10):3591–602.
17. Lee L, Kelly J, Nassif GJ, Keller D, Debeche-Adams
TC, Mancuso PA, Monson JR, Albert MR, Atallah
SB.Establishing the learning curve of transanal minimally invasive surgery for local excision of rectal neoplasms. Surg Endosc. 2018;32(3):1368–76.
18. Martin-Perez B, Andrade-Ribeiro GD, Hunter L,
et al. A systematic review of transanal minimally
invasive surgery (TAMIS) from 2010 to 2013. Tech
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19. Benson AB 3rd, Bekaii-Saab T, Chan E, et al.
Rectal cancer. J Natl Compr Cancer Netw.
2012;10(12):1528–64.
20. Atallah S, Albert M, Debeche-Adams T, Larach
S. Transanal minimally invasive surgery (TAMIS):
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2013;17(2):239–43.
21. Dapri G, Guta D, Grozdev K, Antolino L, Bachir N,
Jottard K, Cadière GB.Colorectal anastomotic leakage corrected by transanal laparoscopy. Color Dis.
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etal. TAMIS a new option for the treatment of postoperative haemorrhage. Color Dis. 2015;17(2):105.
23. Dapri G, VanGossum M, Muls V, Cadière
GB. Transanal endolaparoscopic circumferential
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24. Waheed A, Miles A, Kelly J, Monson JRT, Motl JS,
Albert M.Insufation stabilization bag (ISB): a costeffective approach for stable pneumorectum using a
modied CO2 insufation reservoir for TAMIS and
taTME.Tech Coloproctol. 2017;21(11):897–900.
25. Atallah S, Gonzalez P, Chadi S, Hompes R, Knol
J. Operative vectors, anatomic distortion, uid
dynamics and the inherent effects of pneumatic insufation encountered during transanal total mesorectal
excision. Tech Coloproctol. 2017;21(10):783–94.
26. Atallah S, Hodges A, Larach SW.Direct target NOTES:
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27. Atallah S. Assessment of a exible robotic system
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28. Lee L, Edwards K, Hunter IA, Hartley JE, Atallah SB,
Albert MR, Hill J, Monson JR.Quality of local excision for rectal neoplasms using transanal endoscopic
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Intraoperative Decision-Making:
Converting totaTME, When
andforWhom?
IsaccoMontroni andAntoninoSpinelli
24
Introduction
Converting from one approach to another always
comes as a tough pill to swallow. It is so for the
surgeon, whose plans have to change while
accepting that the initially preferred strategy has
failed. It also poses challenges for the operating
room (OR) staff who must rapidly modify the
work setting in order to create the best possible
environment to complete the case. There are
challenges for the hospital administration as well,
since there is evidence that conversion increases
the intraoperative and postoperative costs of the
surgical process [1]. Most importantly, for the
patient, as in the vast majority of cases, converting from a minimally invasive approach to open
surgery leads to worst short- and long-term outcomes [2].
With the introduction and adoption of transanal total mesorectal excision (taTME), we may
assist, for the rst time, at a situation when the
majority of those downsides can be potentially
I. Montroni
Colorectal Surgery, AUSL- Romagna, Ospedale per
gli Infermi- Faenza, Faenza, Italy
e-mail: isacco.montroni@auslromagna.it
A. Spinelli (*)
Division of Colon and Rectal Surgery, Humanitas
Clinical and Research Center, Milan, Italy
Department of Biomedical Sciences, Humanitas
University, Milan, Italy
nullied, or reduced to a minimum, allowing surgeons to complete their task in a minimally invasive fashion promoting better outcomes for
complex patients. In sum, it is one of the few
exceptions in which conversion is not to a more
invasive approach, but rather to an approach
which conserves minimally invasive principles.
Because of the extreme paucity of published
material on this matter, the following chapter,
probably a rst in itself, will be based on authors’
personal experiences and from the limited available current scientic literature.
Anatomy ofaConversion
By the Cambridge English Dictionary, “conversion” means “the process of converting something from one thing to another.” [3]. The word
comes from Latin, conversiō/convertō, and it
was originally used to describe a change of
direction while turning toward something or
someone else. The concept was then adopted in
the religious eld to signify a change in someone’s beliefs, while most American football lovers became familiar with it as it’s used when an
extra point (or two) is scored by kicking a eld
goal or carrying the ball into the end zone after
scoring a touchdown! Instead of a “touchdown,”
in the medical eld, conversion is equitable to
“failure” of one’s original approach and pursuing something different, which is usually less
© 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_24
255
256
I. Montroni and A. Spinelli
“appealing” (otherwise it would have been the
initial option). Surgeons convert to strategies
that may be suboptimal in regard to modern surgical principles (e.g., conversions which increase
the degree of abdominal wall access trauma) but
which carry the advantage of control and
familiarity.
Since minimally invasive approaches have
been developed and broadly adopted the word
conversion has been used to describe the shift
from a laparoscopic/robotic approach to open
surgery. With increased experience in minimally
invasive surgery (MIS), the conversion rate has
been widely reduced, and it is now globally
accepted at around 5–6%, in expert hands, for
colonic surgery [4]. Bahma etal. described data
from the American College of Surgeons National
Surgical Quality Improvement Project (NSQIP)
database, and they pointed out that on multivariate analysis, conversion was higher in patients
with advanced age (>80years old), BMIs classied as overweight or obese, ASA 3 or 4, history
of smoking, history of weight loss, and, most signicantly, the presence of ascites. While conversion rates have been consistently reduced with
increased expertise in minimally invasive colonic
surgery, a high number of minimally invasive
rectal resections still require conversion to laparotomy. This appears to be one of the major
unmet needs of laparoscopic or robotic rectal
cancer surgery. The COLOR II randomized controlled trial (RCT) showed a conversion rate near
17% [5], while the ROLARR trial reported a nonsignicant difference in conversion between
robotic and laparoscopic TME of one in ten
patients (8.1% for robotic and 12.2% for laparoscopic surgery) [6]. Interestingly, the ROLARR
study did not report data about conversion from
robotic surgery to laparoscopic surgery. Both
laparoscopic and robotic cases were more likely
to fail completion in cases of obese, male patients
undergoing low anterior resection (vs abdominoperineal resection). The problems associated
with those characteristics are obviously increased
by the presence of a large tumor, above all if the
tumor is located on the anterior side of the rectum
where the very thin mesorectum makes the procedure far more challenging.
Once these clear unmet needs of MIS are
accepted, three more elements should be considered. First, there are signicant concerns about
the possible worse outcome for patients requiring
conversion to open surgery. Second, even after
converting to laparotomy, performing a good
quality TME– in a case of an obese male with a
narrow pelvis and a bulky tumor– may not come
as a simpler task. Third, converting to a different
technique still requires prociency at the new
strategy of choice, which may require a different
skill set by the surgeon.
In order to answer the rst question, Yang
etal. [7] demonstrated that of the many factors
that may lead to conversion including bowel
injury, bleeding, unclear anatomy, and lack of
progression. All of these factors can be classied
into two categories: (a) reactive or (b) preemptive
conversion [8]. Reactive conversion (RC) has
been dened as one that follows an intraoperative
complication such as bleeding or organ injury,
whereas preemptive conversion (PC) is dened
as one undertaken to avoid complications. The
reasons for PC included poor progression caused
by unclear anatomy, obesity, or adhesions, inability to identify the ureter, and other similar situations. After analyzing a total of 222 laparoscopic
procedures that had been converted to laparotomy, authors were able to show that patients
whose conversion was reactive to intraoperative
adverse events were more likely to have a postoperative complication (50% vs 27%; p=0.02), to
require a longer time to tolerate a regular diet (6
vs 5days; p=0.03), and to have a longer hospital
stay (8.1 vs 7.1days; p=0.08) than patients who
underwent a PC. Based on these ndings, the
authors advocated for not considering conversion
a “surgical complication” and that an early (preemptive) conversion should be preferred over a
delayed laparotomy when major intraoperative
complications have occurred.
In order to address the second and third
issues, there are unfortunately very little published evidence, but it’s a common experience
that even with the best self-retaining (e.g.,
Bookwalter, St. Mark’s) retractors in place, it’s
sometimes extremely complex to access the pelvis when conversion to an open approach occurs.
24 Intraoperative Decision-Making: Converting totaTME, When andforWhom?
257
The limited visibility of the lower third of the rectum together with suboptimal access may lead to
several surgical mistakes, from injuring surrounding structures (presacral vessels, prostate,
vagina, etc.) to performing a suboptimal cancer
operation while tearing the mesorectum or proceeding with an intra-mesorectal dissection. In
addition, when hostile pelvic anatomy is present,
poor access to the most distal margin of the rectum, below the mesorectal fat, may occur. In
addition, passing a linear stapler distal to the
bulky mesorectum down to the pelvic oor and
then safely ring it, at the determined level, could
be extremely challenging and lead to suboptimal
results with the need for multiple rings or inadvertently ring through the distal tumor.
Nevertheless, this is what most colorectal surgeons have prociently learned to do over the
course of their operative experience, as attested
by progressively improved oncologic outcome of
rectal cancer over time.
Regarding the third issue previously raised,
this is of crucial importance. Converting to a different approach does require increased condence in the newly adopted strategy, and this can
only be achieved with experience. Deciding to
move from a transabdominal MIS approach to a
taTME approach requires more than a theoretical
knowledge of the potential benet of this technique. Being procient at dissecting the rectum
from the bottom up in complex cases is absolutely feasible, as showed by several studies [9],
but specic, advanced skills have to be previously established.
Prociently Converting
fromMinimally Invasive Surgery
toMinimally Invasive Surgery
fortheFirst Time... AndWhat About
fromOpen toaMinimally Invasive
Approach?
Converting from a robotic procedure to standard
laparoscopy has been previously described.
Nevertheless, this is rarely performed because
abdominal laparoscopy can very infrequently
overcome issues not solvable with the same trans-
abdominal approach already facilitated by robotic
instrumentation. The only occasion this may prociently happen is when a technical problem is
encountered in the robotic system or in case of
difculty mobilizing the splenic exure and the
case is switched to standard laparoscopy, often in
a planned, hybrid, robotic-assisted MIS approach.
Given the paucity of reports in the literature, this
might be considered quasi- anecdotical [10].
On the other end, converting from laparoscopy/robotic transabdominal approach to taTME
seems to have the potential to ll the gap of about
10% of these rectal cancer cases that are reported
to be converted to open [6]. This will allow, for
the rst time, to provide a large number of
patients with an oncologically appropriate procedure, despite the presence of those challenging
features that prompted a conversion, without
trading the benets of MIS. Moreover, a transanal approach to the pelvis could also be a viable
option in those open cases where laparoscopy
could not be successfully completed because of a
number of reasons (e.g., a history of numerous
previous surgery, inability to maintain pneumoperitoneum, limited access to the pelvic inlet, and
so on). All these patients may still benet from
better visualization and a better dissection of the
lower third of the mesorectum, while directly
visualizing the pelvic autonomic nerves, without
“ghting with” and torqueing with signicant
force on St. Mark’s retractors.
The benets of the taTME technique are
related to both the dissection and the ability to
execute a double purse-string, single-stapled
anastomosis. Even in the case that the dissection
is performed with an open approach, but issues
are encountered at the moment of the rectal wall
transection or during the double-stapled anastomosis (i.e., breakdown of the cross section on the
distal rectum/anal canal), a transanal approach
could still be utilized. In these cases, performing
a purse string via the transanal platform (TAMIS
or TEM) as well as the proctotomy could be of
absolute value. At the same time, in case of disruption of the staple line along the anorectal cuff,
being able to perform an anastomosis “taTME”style may help the surgeon overcome this hurdle.
This is probably the rst time we can discuss a
258
I. Montroni and A. Spinelli
very likely procient, nontheoretical, nonctitious conversion from open surgery to MIS
for rectal surgery.
Converting Laparoscopy/Robotic
totaTME Approach
While discussing conversion from a laparoscopic/robotic to a transanal approach, it should
be kept in mind that performing a taTME should
be planned in advance (as a potential alternative)
since in rectal cancer surgery, there is very little
room for improvisation. Prerequisite read of the
pelvic MRI together with an accurate physical
examination of the patient are the key elements to
reduce to a minimum the risk of inappropriate
surgical planning. Colorectal surgeons should
always remember that taTME is a complex operation, not just from a technical point of view, and
that it may also require extra equipment (and surgical staff preparedness) not routinely available
or immediately available in the OR.For this reason, a preemptive conversion should be promoted
over a reactive change of mind in order to reduce
the risks for the patients while giving the OR staff
the time to arrange the proper setup.
The reason for converting from abdominal
MIS TME to taTME is usually when identifying,
for the rst time during the surgery, those conditions that are considered the “classic” indications
for a transanal approach, namely, difcult access
to the distal third of the rectum for the dissection,
rectal wall cross-stapling, and/or the safe creation
of a colo-anal anastomosis. Patients who are routinely considered at higher risk for conversion
(obese males with a narrow pelvis and bulky
rectal tumor) should rarely surprise the surgeon,
and evidence is present that a well-planned transanal approach can reduce the risk of conversion
to a laparotomy while promoting a good oncological operation with extremely low circumferential and distal margin cancer involvement [11].
On the other hand, unplanned anatomical situations can occur, perhaps in the case of the presence of an unusually narrow female pelvis or a
particularly bulky uterus that cannot be prociently retracted. Extreme cases of disproportionally 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 circumstances, the approach could be amenable for
conversion to taTME.Exploiting the utility of a
transanal approach, in those cases, can provide
clear benets worth the added effort of
conversion.
Because an intraoperative conversion is performed in particularly difcult cases, a two-team
approach might be advisable; and surgeons
should plan to have this resource available when
conversion to taTME becomes necessary. The
help of a synchronous transanal and transabdominal approach, not just in the dissection, but also
in the specimen retraction and countertraction in
the phase of the rendezvous, can allow the most
difcult part of the case to become greatly simplied and to be carried out more precisely. This
could potentially improve patient short- and
long-term outcomes. No literature is available in
this regard, but it seems logical, in those challenging cases, to benet not only from a dynamic
abdominopelvic approach but also to gather
together the experience of two trained colorectal
surgeons, one for each team.
Converting fromTAMIS totaTME
Over the last 5years, local techniques to reduce
the impact of surgery while effectively treating
rectal cancer have been exponentially growing.
Among those, transanal local excision techniques
are currently playing a rising role in the armamentarium of every colorectal surgeon. First
developed by the precocious Gerhard Buess in
1983, transanal endoscopic microsurgery (TEM),
created for higher reach of principally benign
neoplasia, almost immediately showed superiority over the standard local excision for earlystage rectal cancer [12]. Despite clear advantages
[13], the technique disseminated slowly in the
surgical community, because of the steep learn-
24 Intraoperative Decision-Making: Converting totaTME, When andforWhom?
259
ing curve, high upfront cost of the apparatus, and
the small number of eligible cases. In recent
years, a renewed interest for transanal endoscopic
surgery, due to increased knowledge on the
natural history of rectal cancer, increasing number of patient candidates for an organ-sparing
approach, and development of easy-to-use platforms which utilize transanal minimally invasive
surgery (TAMIS) techniques. Among the possible indications for TAMIS, large tubulovillous
adenomas of the rectum are probably the ones
with the greatest benet from this approach.
Those lesions would most likely necessitate prolonged and often piecemeal endoscopic mucosectomies, while a TAMIS full-thickness excision
can be achieved in a reasonable amount of time
and in a single outpatient operation. TAMIS
allows both the possibility of precisely resecting
the neoplasia in one piece and, by establishing
full- thickness dissection, a potential cure
(depending on a number of parameters) in cases
where T1 invasive adenocarcinoma is diagnosed
at nal pathology. Because of the growing skill
set of colorectal surgeons, tumor location and
extension have been increasingly challenged.
While excision of circumferential neoplasia is no
longer considered a contraindication for TAMIS,
the distance from the anal verge still is, to some
degree. In particular, the more proximal the
lesion is (especially when positioned anteriorly),
the greater the challenge for full-thickness local
excision. This is due to the higher risk of entering
the abdominal cavity, above the pouch of
Douglas, during the dissection, which often
results in loss of pneumatic distention of the rectum and which typically requires laparoscopicassisted sutured closure of the point of peritoneal
violation.
Other options include completing the resection and closing the defect endoluminally, but in
some instances it may be advisable to convert the
TAMIS local excision to a standard TME. In
order to complete the resection and stich the gap
closed, the pneumorectum might be safely maintained for a prolonged amount of time. This may
not be achievable if the dissection is just at the
initial step or if the gap is too large, even after
counterbalancing the abdominal pressure with a
Veress needle or laparoscopic insufation. If this
occurs, the surgeon becomes committed to a
TME, and conversion to a transanal approach
appears to be the most logical solution.
Figures24.1, 24.2, and 24.3 report a case of an
anteriorly located large rectal polyp (tubulovillous adenoma at two consecutive biopsy sets).
The tumor was considered to be located inside
the pelvis by two expert radiologists that
described it as below the peritoneal reection for
its entire extension. The lesion was instead
located a signicant distance above the peritoneal
reection, and the abdominal cavity was entered
very soon after beginning the transanal dissection
with immediate loss of the pneumorectum despite
the use of an advanced insufation device.
Among the advantages of converting to a taTME
are:
Fig. 24.1 Preoperative MRI of a large neoplasia in the mid-rectum, radiological report displayed a T1N0 rectal mass
260
Fig. 24.2 Intraoperative pictures of the TAMIS procedures; abdominal cavity is entered anteriorly, and the local excision cannot proceed safely even after insertion of an abdominal trocar and induction of the pneumoperitoneum
I. Montroni and A. Spinelli
Fig. 24.3 Intraoperative pictures of the conversion to taTME from the previously unsuccessful TAMIS attempt. Final
pathology showed a T3N0 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
cancer operation since a “virgin” mesorectal
plane is entered from below without interference by the gap at the level of the lesion.
• The opportunity to perform a minimally
invasive restorative procedure while also
exploiting the transanal equipment already
in place.
• The lesion in the case turned out to be a
T3N0 (0/23 lymph nodes, negative circumferential resection margins, extramural vascular invasion negative), and despite the
obvious higher risk of perforation, resection
was carried out in the same operation without
delay, in an oncologically radical fashion via
taTME.
Modern rectal cancer care cannot be an extemporary attempt but needs to be planned and prepared
in advance. Nevertheless, nding unpredicted
situations when a conversion is needed might
occur to any colorectal surgeon. Above all, if
considering conversion to taTME, this should be
performed preemptively rather than reactively,
especially because specialized equipment is
necessary.
The sense of conversion is to switch from one
approach to another in which the surgeon considers her/himself more procient or familiar. Thus,
converting to taTME requires procient taTME
surgeons.
Converting from a laparoscopy/robotic
approach to a transanal one could potentially not
24 Intraoperative Decision-Making: Converting totaTME, When andforWhom?
261
be a rare event given the recently published 10%
conversion rate from reasonably high-quality
studies. This is the rst time we have a reliable
option to convert from MIS to MIS and also from
open to a MIS approach.
Conversion from TAMIS to taTME might
also become more frequent as the indications to
perform TAMIS increase and surgeons are
tempted to push the boundaries to treat anteriorly located tumors in the mid-rectum. In these
cases, conversion to taTME offers an immediate
and oncologically appropriate restorative
approach.
References
1. Cleary RK, Mullard AJ, Ferraro J, Regenbogen
SE.The cost of conversion in robotic and laparoscopic
colorectal surgery. Surg Endosc. 2018;32(3):1515–
24. https://doi.org/10.1007/s00464-017-5839-8. Epub
2017 Sep 15.
2. de Neree Tot Babberich MPM, van Groningen JT,
Dekker E, Wiggers T, Wouters MWJM, Bemelman
WA, Tanis PJ, Dutch Surgical Colorectal Audit.
Laparoscopic conversion in colorectal cancer surgery;
is there any improvement over time at a population
level? Surg Endosc. 2018;32(7):3234–46.
3. https://dictionary.cambridge.org/dictionary/english/
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