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27 An Overview ofOperative Steps andSurgical Technique
283
especially in the setting of android narrow pelvises, where both the specimen and the sphincter
complex are at risk of damage. A Pfannenstiel
incision can be carried out in most cases, with the
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 compulsory 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
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 monolament 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 stapler 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 stapler for ultralow taTME anastomoses. Such staplers tend to provide wider doughnuts and robust
staple lines. However, its larger diameter (33mm)
may sometimes represent a handicap, depending
on patient anatomy. In either case, with low anas-
tomoses, the open rectal cuff can be handsewn
(Figs.27.11 and 27.12). Anastomotic techniques
are discussed in more detail in a separate
chapter.
Fig. 27.11 Handsewn colorectal anastomosis
Fig. 27.12 Presacral dissection, venous plexus vessel
can be seen
284
F. B. deLacy et al.
References
1. Kumar AS, Kelleher DC, Sigle GW. Bowel prepara-
tion before elective surgery. Clin Colon Rectal Surg.
2013;26(3):146–52.
2. Chouillard E, Regnier A, Vitte RL, Bonnet BV,
Greco V, Chahine E, Daher R, Biagini J. Transanal
NOTES total mesorectal excision (TME) in patients
with rectal cancer: is anatomy better preserved? Tech
Coloproctol. 2016;20:537–44.
3. Marks JH, Lopez-Acevedo N, Krishnan B, Johnson
MN, Montenegro GA, Marks GJ.True NOTES TME
resection with splenic exure reléase, high ligation of
IMA, and side-to-end hand-sewn coloanal anastomosis. Surg Endosc. 2016;30(10):4626–31.
4. Leroy J, Barry BD, Melani A, Mutter D, Marescaux
J.No-scar transanal total mesorectal excision: the last
step to pure NOTES for colorectal surgery. JAMA
Surg. 2013;148(3):226–30. discussion 231.
5. Heald RJ, Husband EM, Ryall RD.The mesorectum
in rectal cancer surgery–the clue to pelvic recurrence?
Br J Surg. 1982;69:613–6.
6. Rullier E, Denost Q, Vendrely V, Rullier A, Laurent
C.Low rectal cancer: classication and standardization of surgery. Dis Colon Rectum. 2013;56:560–7.
7. Lopez-Kostner F, Lavery IC, Hool GR, Rybicki
LA, Fazio VW. Total mesorectal excision is not
necessary for cancers of the upper rectum. Surgery.
1998;124:612–7. discussion 617–8.
8. 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 surgery. Tech Coloproctol. 2016;20(7):483–94.
https://doi.org/10.1007/s10151-016-1475-x. Epub
2016 May 17.
9. Knol J, Chadi SA. Transanal total mesorectal excision: technical aspects of approaching the mesorectal plane from below. Minim Invasive Ther Allied
Technol. 2016;25(5):257–70. https://doi.org/10.1080
/13645706.2016.1206572.
10. Penna M, Cunningham C, Hompes R.Transanal total
mesorectal excision: why, when, and how. Clin Colon
Rectal Surg. 2017;30:339–45.
11. Deijen CL, Tsai A, Koedam TWA, Veltcamp
Helbach M, Sietses C, Lacy AM, Bonjer HJ,
Tuynman JB. Clinical outcomes and case volume
effect of transanal total mesorectal excision for rectal cancer: a systematic review. Tech Coloproctol.
2016;20(12):811–24.
Strategies for Ultralow-Lying Rectal Cancer
Sam Atallah and Eric Rullier
28
Introduction
While taTME has in general been a useful modality for managing rectal cancer, its greatest appeal
remains toward the management of ultra- distal
rectal tumors that are extremely difcult to clear
from the abdominal approach without adjunctive,
perineal techniques. Such techniques include
those that preserve at least a portion of the sphincter complex, as well as those that sacrice the
anorectal complex altogether. Due to the technical complexity of sphincter preservation for
ultralow-lying tumors, the vast majority of such
clinical cases were historically managed with
abdominoperineal resection, subjecting patients
to signicant morbidity and to life with a permanent stoma.
As technical expertise advanced, paradigms
shift, and surgeons explored options to permit
sphincter preservation for low-lying rectal cancer
with the intent for cure. It was the renement of
the technique for intersphincteric resection coupled with neoadjuvant therapy that made sphincter preservation for low rectal cancers an eligible
S. Atallah (*)
AdventHealth Orlando, Oviedo Medical Center,
and University of Central Florida College
of Medicine, Orlando, FL, USA
e-mail: Atallah@post.harvard.edu
E. Rullier
Department of Colorectal Surgery, Haut-Levèque,
Pessac, France
surgical option, with the singular exception being
those lesions which invade the external sphincter
mechanism. It is possible to combine perineal
techniques with taTME, but this requires subtle
yet important modications. In this chapter, the
strategies for radical resection for ultralow-lying
rectal tumors using the taTME technique are
outlined.
The Development of ISR for Rectal Cancer and a Farewell to the 2 cm Rule
Prior to the introduction of sphincter preservation
techniques, the only oncologic surgical option for
ultralow-lying, advanced-stage rectal cancer was
the Miles’ Operation (aka, abdominoperineal
resection, APR); developed in 1908 and named
after William Ernest Miles (1869–1947) [1]. The
operation could be complete with one or even two
teams [2] as is the case for the current approach to
taTME.For most of the twentieth century, it was
not that the technical ability to perform ultralow,
sphincter-preserving surgery did not exist but
rather that such techniques were not applied to
surgical management of cancer. Interestingly, the
techniques were developed as early as 1888 by
Hochenegg [3, 4], and the so- called pull-through
was quite commonly employed during the 1950s
and 1960s, but this was performed principally in
the pediatric population [5].
© 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_28
285
286
S. Atallah and E. Rullier
With the advent of modern instrumentation,
such as endoluminal surgical staplers developed
by Mark Mitchell Ravitch in 1972 [6–8], and
with important, new approaches to restorative
proctocolectomy introduced by Sir Alan Parks at
St. Mark’s Hospital (London, UK) in the late
1970s [9], the concept of total removal of the
ultralow rectum with maintenance of a functional sphincter mechanism became quite achievable. While at the time such radical techniques
were only applied toward removing the at-risk
rectum and colon for benign pathology (especially ulcerative colitis) and, subsequently, for
premalignant conditions such as familial adenomatous polyposis syndrome [10, 11], the challenge of removal of the rectum for low rectal
cancer remained – since cure was difcult and
local failure rates were quite high. Thus, for this
subset of tumors, surgical treatment was historically radical, with complete removal of the anorectum by APR.
During the 1980s, RJ Heald introduced surgeons to the importance of proper embryonicbased resection [12, 13]. Meanwhile, neoadjuvant
therapy for local control together with the unique
perineal techniques proposed by G. Marks was
combined to, for the rst time, provide patients
with a curative-intent resection for ultralowlying, advanced-stage rectal cancer [14–16]. This
technique is commonly referred to as the “TATA”
(transanal abdominal transanal) operation and is
a well-known, important prequel to the modernday taTME operation– as it is essentially the rst
description of a “down-to-up,” sphincterpreserving technique for curative, rectal cancer
surgery. Interestingly, TATA predated TAMIS
[17] and the rst report of taTME in a human [18]
and the melding of TAMIS and taTME [19–23]
by almost a quarter century.
It was during the 1990s and early to mid2000s that the true maximal distal limits of radical rectal resection and reconstruction were
nally achieved with acceptable oncologic outcomes [24–29]. By recognizing that a part or all
of the internal sphincter muscle could be sacriced (especially with tumor downstaging), intersphincteric resection (ISR) for extremely
low-lying lesions became a feasible option, obvi-
ating the need for a permanent stoma for many
patients. Increasingly, a rethink of the 5cm minimum distal margin requirement shifted the new
“safe margin” to just 2cm [30]. This was partly
based on the earlier work of Golligher and subsequently others investigators who demonstrated
tumor spread to be rarely distal to the tumor’s
caudal extent [31–33]. Meanwhile, increasing
data suggested that any grossly negative margin
was acceptable [34] and a renewed focus on
assuring circumferential margin clearance in
conjunction with resection quality (i.e., TME
grade) was paramount to all else [35, 36].
In 2005, Rullier et al. (Bordeaux, France)
reported the results of 92 patients with invasive
carcinoma localized to the distal rectum (≤4.5cm
from the anal verge) who underwent curative
radical resection with ISR [37]. With an 89% R0
resection rate, 2% local recurrence rate, and a
5-year overall survival rate of 81%, it was concluded that the technique of ISR permits curative
intent radical resection and sphincter preservation without oncologic compromise, and therefore rectal tumor distance from the anal verge
should “no longer [be] a limit for sphinctersaving resection.” This put an ofcial end to the
2 cm rule, without oncologic compromise, thus
creating a new and important axiom in rectal cancer surgery. Namely, candidacy for sphincter
preservation for patients with ultralow-lying rectal cancer depends not on the tumor’s distal
extent but rather the lateral extent (specically,
the presence or absence of external sphincter
invasion).
A Standardized Classification
System for Low Rectal Cancers
The relationship of low-lying rectal tumors with
respect to the anal sphincter complex can be
dened in a standardized fashion and is based
upon the Rullier Classication System for distal
rectal cancer [38] (Fig. 28.1). There are essentially four types of ultra-distal rectal cancer
which can be dened in relation to the anorectal
ring and levator plate muscles. The four types are
as follows:
AR
AV
28 Strategies for Ultralow-Lying Rectal Cancer
Fig. 28.1 A standardized
classication system for
low rectal cancers. AR,
Anorectal Ring; DL,
Dentate Line; AV, Anal
Verge
DL
Type I : Supra-anal Type II : Juxta-anal
287
Type III : Intra-anal Type IV : Transanal
Type I: Supra-anal, >1cm from the anorectal ring
Type II: Juxta-anal, <1 cm from the anorectal
ring
Type III: Intra-anal, with internal anal sphincter
(IAS) invasion or encroachment
Type IV: Trans-anal, with invasion of tumor into
the levator ani muscle or the external anal
sphincter (EAS)
The suggested surgical options for these
tumors are as follows:
Type I: (Ultralow) anterior resection
Type II: Partial ISR
Type III: Total ISR
Type IV: Abdominoperineal resection (APR)
While taTME has been applied to Types I–IV,
in this chapter, we examine the technical nuances
of taTME for Type I, II, and III rectal cancers
providing a practical approach to the management of these special problems in rectal cancer
surgery. The technique described herein is with
the utilization of the TAMIS platform; similar
modications are possible with TEM but are not
addressed. The special application of taTME for
APR (such as for extirpation of Rullier Type IV
tumors) is addressed in detail elsewhere.
Standard Educational Programs for taTME
The introduction of taTME into surgical practice has required specic training programs to
be implemented so as to assure the safe delivery
of this new kind of surgery [39–46]. Even online
learning modules and web-based, deffered live
(d-LIVE) surgery are available for taTME education [47–49]. While most courses provide
comprehensive education and practical instruction on this novel approach through cadaveric
training session(s), such training primarily
focuses on taTME as applied to distal rectal
cancer, but not necessarily for extreme distal
lesions (Rullier Types I–III). Ironically, it is this
group of ultralow rectal cancers which are best
suited for the taTME approach, and descriptions
288
S. Atallah and E. Rullier
of this technique are rarely reported in the literature [50, 51]. Here, the technical steps necessary
to approach Type I–III rectal cancers are
delineated.
General Technical Principles
The general approach to taTME for Type I–III
rectal cancer (Fig. 28.2) should follow a standardized protocol. While some authors have
advocated a perineal-rst approach [52, 53], it is
prudent to perform an abdominopelvic oncologic
survey, such as through diagnostic laparoscopy,
as a rst step prior to any radical oncologic surgery [54].
For mid-rectal cancers and the majority of low
rectal cancers (excluding ultralow-lying Type I–
III tumors), the taTME approach utilizing TAMIS
and specically the GelPOINT path transanal
access platform (Applied Medical, Inc., Rancho
Santa Margarita, CA, USA) requires the placement of the TAMIS access channel with one of
two options utilized. Option 1: The access channel is seated in position with its inner lip secured
just above the anorectal ring. Next, the rectum is
sutured closed using a handheld, conventional
needle driver, and then the gel cap is secured to
the access channel. After establishing pneumatic
insufation, the dissection is carried out using
standard taTME techniques. Option 2: The access
channel is seated in position, and the gel cap is
placed, pneumatic inow is established, and lap-
aroscopic needle drivers and instruments are then
used to conduct every step, including securing
the purse string. Knot-tying can be accomplished
via a knot pusher with handmade extracorporeal
knot creation; however, the entire process of
knot-tying is commonly done by hand using conventional hand-tying techniques. For these two
common options, the use of a self-retaining anorectal retractor (most typically, the Lone Star
Retractor System, Cooper Surgical, Inc.) is
optional.
As a footnote, it should be realized that the
general technique of TAMIS and the design of
the GelPOINT access channel and apparatus
were created with the objective of local excision
of higher neoplasia, not low-lying lesions which
are approachable with the Parks technique [55].
This “higher reach” was precisely the impetus
behind the 1984 development of the TEM scope
by G. Buess as well [56, 57]. Furthermore, the
development of TEM, TEO, and TAMIS all predated the evolution of taTME, and, thus, no
transanal access platform has yet been designed
specically for the purpose of taTME.
In the following sections, the detailed
approach to taTME for resection of more complex, ultralow-lying rectal cancer is discussed.
taTME for Type I tumors will be discussed separately from the approach to Type II/III rectal cancer, as there are important differences.
taTME for Rullier Type I Tumors
Fig. 28.2 A posterior ulcerated 3cm rectal cancer is vis-
ible with direct exposure using a handheld anal retractor.
The tumor’s relationship to the dentate line is clearly visible. As the lesion is positioned within 1cm of the anorectal junction, this is classied as a Type II rectal cancer and
requires at least partial ISR for tumor clearance
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 rst step is to perform a digital examination to localize the position of the primary tumor,
and, in males, it is strongly recommended to digitally inspect the prostate gland [58]. An intraoperative review of MRI to assess pelvic geometry,
the rectum, and the tumor in relation to the anorectal junction is particularly important as it provides a road map for the taTME surgeon [59].
28 Strategies for Ultralow-Lying Rectal Cancer
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 facilitates access to the ultralow rectum. Such retractors 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 anastomoses that are either handsewn or stapled;
however, Rullier Type I–III anastomoses, when
performed post-resection, are typically
handsewn.
With a self-retaining retractor in place, and the
patient positioned in modied lithotomy, for
Type I rectal cancers, it is best to close the rectal
lumen with the aid of a handheld anorectal retractor prior to the introduction of the access channel
(Fig.28.3). The reason for this is because, if the
access channel is placed rst, 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 rst step for management of Type I lesions (Fig.28.4).
After application of the purse string, the anorectum is irrigated once more in preparation for
289
Fig. 28.4 Upon completion of the purse string, usually
utilizing 2–0 monolament suture on an SH needle, the
purse string is tightened and the lumen closed by knottying manually. Note the distal extent of the purse string.
This is far too distal to apply and seat the TAMIS port’s
access channel, and so the dissection must proceed initially under direct vision until adequate operating space
has been created
Fig. 28.5 Bactericidal and tumoricidal agents can be
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
Fig. 28.3 For Type I rectal cancers, a self-retaining
(Lone Star) retractor can be positioned to efface the anal
verge and improve exposure. Next, under direct vision, a
handheld anorectal retractor (in this case, a small-size
Hill- Ferguson) is used to access the anal canal so that a
purse- string suture can be applied just distal to the lesion,
which should be in direct view of the surgeon. This step is
an important departure from standard taTME and is necessary to address low-lying, Type I tumors
transanal dissection (Fig.28.5). This commences
with dissection under direct vision, with fullthickness rectotomy. Here, care is given to create
a circumferential incision that opens all quadrants, in a plane and level that is equidistant from
the dentate line, so as to facilitate further steps of
the anatomical taTME dissection. The transanal
dissection then proceeds in a sequential manner
cephalad, allowing enough distance to admit and
position the TAMIS port’s access channel. At this
point, the access channel can be suspended with
the aid of a self-retaining retractor (Fig. 28.6).
Next, the gel cap is secured to the “suspended”
290
Fig. 28.6 An important adaption to access is illustrated.
Ordinarily, the TAMIS access channel is delivered transanally where the inner lip is designed to seat above the anorectal ring. Since this would not allow for exposure of the
ultra-distal rectum, a modication is performed whereby
the hooks of the Lone Star retractor are used to anchor the
channel (arrows). In such a setting, the channel is only
partly inserted and is instead “suspended” by the Lone
Star Retractor pegs. This signicantly improves distal rectal access and allows taTME to be performed at a lower
than normal distal starting point
access channel, and the dissection proceeds along
a plane (that does not require ISR) using the
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 completed, a handsewn anastomosis is commonly
performed, although stapled anastomosis is possible, depending on the length of the rectal cuff.
S. Atallah and E. Rullier
anal canal. The dissection then proceeds so as to
include the entire IAS within the scope of dissection 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 dissection (Fig.28.8a, b). Recently, this component of
the operation has been described with the robotic
taTME approach [51], whereby the da Vinci
Surgical System is “dry-docked” (without a
TAMIS platform) to perform this dissection
meticulously (Fig.28.9a, b).
Upon completion of the ISR (partial or complete) (Fig.28.10), the dissection proceeds cephalad under direct vision, until there is enough
mobility of the distal anorectum to form an airtight purse string. This can then be completed
manually or with the aid of a robotic surgical system (Fig.28.11). Next, the access channel can be
secured by suspending it onto the self-retraining
taTME for Rullier Type II and III Tumors
As for Type I tumors, the operative approach to
taTME for Type II/III tumors commences with
the standardized approach with either singleteam or two-team approach. However, modications for taTME for Type II lesions (which require
a partial ISR) and Type III tumors (requiring a
total ISR) are necessary. To perform this, a selfretraining retractor is positioned, thereby effacing the anorectum and providing exposure to the
Fig. 28.7 The distal-most extent of dissection has been
initiated under direct vision. The white muscle bers of
the internal sphincter muscle can be seen, and the internal
anal sphincter itself has been dened at its distal-most
extent. In this case, a total ISR is being performed for a
Type III rectal cancer. Whether for partial or total ISR, this
portion of the operation is completed prior to purse-string
application, thus underscoring an important technical difference in operative management between Type I and
Type II/III rectal cancers
28 Strategies for Ultralow-Lying Rectal Cancer
291
a
b
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) electrocautery; meticulous dissection is crucial
a
b
retractor as described previously. Finally, the
TAMIS port’s gel cap can be secured, pneumatic
inow is established, and taTME then proceeds
along embryonic fusion planes until the point of
rendezvous at the anterior peritoneal reection
(Fig.28.12).
Functional Outcomes
In the 1950s, J. Goligher and E.Hughes rightly
concluded that anorectal function after reconstructive, sphincter-preserving surgery is directly
related to rectal cuff length [60]. That is, the longer the rectal cuff (e.g., distance from the anorectum to the anastomotic line), the more likely
defecatory function will be preserved. Therefore,
even when perfectly executed, taTME for
ultralow tumors (Types I–III) with reconstruction
will invariably result in functional compromise.
These effects can be further compounded by
Fig. 28.9 (a) ISR can be completed by “dry-docking” a
da Vinci Surgical System with only a Lone Star or similar
retractor to maintain exposure (Photograph (a) courtesy
of J.Kuo). Both Xi and Si da Vinci systems have been used
and (b) demonstrate the use of 5mm instruments and the
Si platform to perform a total ISR.Note that a gauze has
been placed within the rectal lumen and the distal tumor is
visible posteriorly
radiation- induced brosis, age, gender, local sepsis, and other factors.
Despite these challenges, the outcomes after
ISR for rectal cancer have been quite acceptable.
In a series of n=101 patients who had undergone
ISR, although two-thirds reported having <3
bowel movements per day, about half reported
having defecatory urgency, while one-quarter
reported difculty evacuating [61]. Although
general data on taTME is now available through
single- center series and registry data [62, 63], the
functional outcomes specically for the subset of
patients who have undergone ISR in conjunction
292
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
access channel using the Lone Star Retractor and then initiation of the formal taTME dissection
Fig. 28.11 For Type II and Type III tumors which require
ISR, purse-string application is not the rst step but is
rather placed after initiation of the dissection. Most typically this is performed under direct vision, but recently
some centers have demonstrated feasibility utilizing the
da Vinci Surgical System. Here shown is the robotic Si da
Vinci Surgical System which is being used to create the
purse string after ISR
S. Atallah and E. Rullier
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 dissection, TME quality, and local factors (especially 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.
Oncologic Outcomes
Although the outcomes specically 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 etal., n=100
patients were randomized to either a transanal
approach with ISR or standard laparoscopic anterior resection. With mean 60.2-month follow-up,
the local recurrence rate was 3% for those undergoing ISR, while 5-year, disease-free survival
was 72%. The study reported no statistically signicant difference in either the rate of local
recurrence or 5-year disease-free survival for
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 37.9months [16].
Fig. 28.12 A partial ISR has been completed, the purse
string applied under direct vision, and then the access
channel suspended onto the Lone Star Retractor. The
TAMIS apparatus is then connected to pneumatic inow
(in this case, using AirSeal®) after placement of the gel
cap, and the dissection then proceeds cephalad to the level
of the peritoneal reection using standard taTME techniques, as shown
Future Directions
The ability to address ultralow-lying tumors
denes the most useful advantage of taTME.
Thus, advanced training and curricula should
focus on this important application. Next steps
toward the mastery of this complex technique