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442
Fig. 43.14 Team and patient installation for pure taTME
Fig. 43.15 Perfect purse string closing the distal rectum
The surgeon works in a seated position between the
patient’s legs with one or two assistants who will
manipulate the TEO® in order to change its position during the surgical maneuver (Fig.43.14).
Dissection
Step 1: Closing the Distal Stump of the Rectum Placing a Purse-String Suture
A purse-string suture is placed 1cm distal to the
inferior boarder of the tumor (Fig.43.15), in order
to prevent fecal and cancer cell contamination and
to avoid colonic insufation. The closure must be
perfect to avoid insufation of the proximal rectum and colon (Fig.43.16). The distal rectum is
then irrigated copiously with a povidone-Iodine®
solution in an attempt to sterilize the distal
anorectum.
J. Leroy et al.
Fig. 43.16 Purse string minimum 1 centimeter under the
tumor
Step 2: Posterior Rectal Space Opening
The rectal mucosa is initially incised from a 10 to
a 2 o’clock position (Fig.43.17), and then a fullthickness posterior rectotomy is performed
(Fig.43.18). The plane of dissection begins just
posteriorly to the rectal fascia and is developed
up to the promontory along a plane anterior to the
sacral fascia in the posterior midline. The
pneumo-dissection performed using insufation
facilitates the identication of this space
(Fig.43.19). In our experience and in the majority of cases, the dissection was performed behind
the presacral fascia. Recently, we have successfully dissected along a plane between the presacral fascia and the propria fascia. In so doing, this
opens the plane just above their fusion point (i.e.,
Waldeyer’s ligament) leading to entry in the
“holy plane” (Fig. 43.1), as described by RJ
Heald [2]. This embryonic plane not only provides oncologically precise but also allows for an
avascular and thus safe plane which does not
encroach upon the pelvic autonomic nerves. As
the dissection progresses cephalad beyond the
sacral promontory, the retroperitoneal space
becomes exposed just inferior to the aortic bifurcation. In the pure NOTES taTME technique, the
dissection can be continued from down-to-up by
advancing the TEO® rectoscope forward and laterally reaching the level of the sacral promontory.
Anterior and medial retraction of the mesorectum
is done via the transanal approach by using the
TEO® platform’s access channel as a circular
retractor that “stents open” the operative eld.
ab
43 Pure NOTES Transanal TME
Fig. 43.17 Drawing of the incision under the purse string
(A posterior, B anterior)
Fig. 43.18 Full-thickness rectotomy from 2 to 10
Fig. 43.19 Retrorectal and presacral dissection with
monopolar spatula. TEO® is pushed slowly to open the
space without another retractor
Step 3: Cranial and Lateral Progression of the Dissection
If the plane initially entered is not the “holy
plane” but the presacral space just posterior to the
presacral fascia, care must be taken to avoid dissecting too posteriorly, which can result in injury
to the autonomic plexus and presacral veins.
While entering the presacral space and not the
443
Fig. 43.20 Left lateral dissection, sliding along the lateral side wall fascia (white structure). Nerve branch crossing the space
“holy plane,” it becomes more challenging as
progress is made more cranially and laterally.
As the lateral dissection progresses, the 15cm
length TEO® rectoscope is advanced to a position between the rectum and the side wall fascia.
This will slowly expose the middle rectal vessels
and the autonomic branches of the lateral plexus
(including the nervi erigentes) crossing the lateral side wall pelvic fascia to reach the lateral
side of the rectum and mesorectum (Figs.43.20
and 43.21). It is important to note that until this
point in the pure NOTES taTME dissection, the
abdominal cavity has not opened as the peritoneal reection has not been violated. In this technique of dissection, the pressure of the CO
gas is
2
not the principle factor in creating the operative
exposure, but it is rather the retraction of the
TEO® rectoscope shaft. The CO
is only used
2
with a low pressure (12–15mmHg) – with the
purpose of clearing the eld of view. Landmarks
for doing a safe lateral pelvic dissection is to follow the medial side of the side wall pelvic fascia,
which appears white. In so doing, iatrogenic
injury to anatomical structures including the lateral aspects of the inferior hypogastric plexus can
be avoided (Fig.43.22).
Step 4: Extending the Perirectal Dissection Anteriorly
Once the posterior and lateral dissection of the
mesorectum has been completed, the remainder
of the distal rectal transection is performed anteriorly from a 2 o’clock to a 10 o’clock position
444
J. Leroy et al.
Fig. 43.21 Right lateral dissection. Visualization of
nerves plexus branches
Fig. 43.22 Right side wall fascia (white). Resistant
structure which protect laterally the inferior hypogastric
plexus
(Figs.43.17 and 43.23). The rectal wall must be
completely dissected to enter into the rectovaginal plane in female patients (Fig.43.24) and the
rectoprostatic plane in males (Fig. 43.25).
Dissection is developed until the level of the peritoneal reection is reached.
Fig. 43.23 Full-thickness anterior rectotomy from 10 to 2
Fig. 43.24 Female patient: Denonvilliers’ fascia (white).
Douglas pouch visible
Step 5: Dividing the Anterior Peritoneal
Reflection and Opening the Abdominal
Cavity
This maneuver reveals the rectouterine pouch
(Douglas’ pouch) in women (Fig.43.26) and the
recto-vesicular pouch in men (Fig.43.27). As in
transabdominal resections, this step is more difcult in men. In men with anterior lesions, the
dual-layered Denonvilliers’ fascia is kept on the
Fig. 43.25 Male patient: Denonvilliers’ fascia anterior,
rectum posterior, and Douglas pouch
43 Pure NOTES Transanal TME
445
Fig. 43.26 Female patient: opening the Douglas pouch
Fig. 43.27 Male patient: opening of Douglas pouch
mesorectum (to assure oncologic clearance), and
care is taken to prevent urogenital tract injuries
(prostate, seminal vesicles, and urethra). For
these steps, the TEO® platform provides excellent exposure by retracting the fasciae, and this
facilitates precise and safe dissection.
Step 6: Proceeding with the Dissection Toward the Root of the Mesorectum and the Retroperitoneal Abdominal Space
Once the anterior peritoneal reection has been
opened, the rectum is gently distracted downward to expose and divide the lateral attachments of the root of the mesorectum (Fig.43.28).
Next, the rectum is pushed cephalad into the
Fig. 43.28 Proximal lateral division on left of the root of
the mesorectum
abdominal cavity through the peritoneal entry
point along the pouch of Douglas. It is at this
moment that the patient is positioned in steep
Trendelenburg to obtain retraction of the bowel
in the upper part of the abdominal cavity above
the pelvic brim, to better expose the upper
aspect of the pelvis. The pressure of the intraabdominal CO
gas completes the retraction of
2
the small bowel maintaining it away from the
pelvis and operative eld, as during classical
laparoscopy. Pushing the rectum anteriorly
results in tenting of the root of the mesorectum
(Fig. 43.29) at the level of the promontory
exposing the lateral peritoneal attachments of
the mesorectum we divide to open the retroperitoneal space.
Step 7: Reaching the Root of the Inferior Mesenteric Vessels
The TEO® long rectoscope (20 cm length) is
now utilized. The shaft is advanced behind the
rectum toward the promontory by dissecting
planes posteriorly with a monopolar spatula electrode. Care is taken to prevent injury to presacral
veins posteriorly, to the mesorectal envelope
medially, and to pelvic nerves, ureters, and distal
branches of iliac vessels coursing laterally. With
anterior retraction of the root of the mesorectum,
the retroperitoneal space anterior to the aorta is
entered, with care to preserve the preaortic fascia
and hypogastric plexuses (Figs.43.30 and 43.31).
As stated previously, exposure of the space is
maintained by the circular TEO® retractor
(Fig.43.32), which allows for the dissection to be
446
Fig. 43.29 Root of the mesorectum tented anteriorly
exposing the anterior aspect of the promontory
J. Leroy et al.
Fig. 43.32 Vison of a 20 cm TEO® in intra-abdominal
position during a pure taTME (view through a right iliac
fossa trocar, before doing diverting stoma)
Fig. 43.30 Male patient: 20cm TEO® pushed above the
promontory inside the retroperitoneal space, in front of
the aorta
Fig. 43.31 Female patient: 20cm TEO® pushed above
the promontory inside the retroperitoneal space, in front
of the aorta
Fig. 43.33 Dissection origin IMA
extended toward the root of the sigmoid mesentery, following the dorsal aspect of the vascular
sheet of the inferior mesenteric vessels. The retroperitoneal dissection of the sigmoid mesentery
is continued to reveal the origin of the inferior
mesenteric artery (IMA) (Fig.43.33). This step
may be facilitated by the division of the medial
and lateral peritoneal attachment of the sigmoid
colon and the ventral lifting of the mesentery. For
this step, longer instruments (43cm) are helpful
to achieve better operative angles and improved
operative ergonomics.
Step 8: Dividing the Inferior Mesenteric Vessels and the Sigmoid Mesentery
For oncological purposes (as well as to improve
conduit reach), a high ligation of the IMA is the
standard approach (Fig. 43.34). Otherwise, for
early tumor and benign lesions, a distal division
of the superior rectal artery may be performed
[15–17]. Distal or high divisions of the inferior
mesenteric vessels are performed after sealing
43 Pure NOTES Transanal TME
Fig. 43.34 Clipping IMA trunk before division
447
Fig. 43.36 Division of the mesosigmoid
Fig. 43.35 Dissection and division IMV with a sealing
device
[with THUNDERBEAT™ Type S (Olympus,
Tokyo, Japan) or with LigaSure™ (Covidien, New
Haven, CT, USA)] or after clipping. Division of the
IMV (Fig. 43.35) is done afterward, and the left
colic artery is also divided after high tie of the IMA.
Division of the sigmoid mesentery (Fig.43.35)
is performed intra-abdominally after selecting the
best segment (summit of sigmoid loop). One can
divide the mesentery rst or divide the sigmoid
colon rst with a linear stapler introduced into the
12mm operative channel of the TEO® faceplate
(stapler access can be obtain removing the silicone obturator). Division of the mesentery is performed with a sealing device (Fig.43.36). At the
end of the division, we observe the quality of the
vascularization with visual comparison of the
color; alternatively indocyanine green (ICG) can
be used to assess bowel perfusion (Fig.43.37). So
as to more easily divide the mesentery, it is useful
to retract (by a pushing maneuver) all the rectum
mesorectum laterally toward the right iliac fossa.
Fig. 43.37 Control of the vascularization with ICG®
When the division of the sigmoid mesentery
has been completed, the distal extremity of the
rectum is grasped and pulled slowly through
the TEO® rectoscope; a transanal extraction is
then performed at the same time (Fig.43.38).
The specimen is gently exteriorized, with care
to maintain the integrity (Fig.43.39) and quality of the mesorectal envelope, the vascular
pedicle, and the mesenteric lymphadenectomy
(Fig. 43.40); the proximal margin and distal
limit of the resection are determined as well
(Fig.43.41).
Next, the now transanally exteriorized sigmoid
colon is divided extracorporeally. To perform this, a
suitable portion of sigmoid colon (demonstrating
adequate vascularity) is prepared and then divided
with a linear Endo-GIA stapler (Fig. 43.42). A
suture is xed on the bowel maintain its orientation.
448
Fig. 43.38 Transanal exteriorization of the specimen
J. Leroy et al.
Fig. 43.39 Macroscopic view of rectal specimen
Then, the pelvis is explored and cleansed with irrigation through the anus. A LoneStar™ retractor is
positioned transanally to expose the anorectum.
Intra-abdominal inspection (e.g., to assess for active
sites of bleeding) is done after the TEO® operating
Fig. 43.40 Control of the quality of oncologic resection
and vascular package
Fig. 43.41 Resection: distal margin
platform has been reintroduced. If required, further
mobilization of the sigmoid and even descending
colon can be done at this time.
43 Pure NOTES Transanal TME
449
Fig. 43.42 Division of the sigmoid with a linear stapler Fig. 43.43 Exposure with LoneStar® retractor and prep-
aration of a side-to-end manual low colorectal anastomosis with separated stiches
Step 9: Construction of Low Colorectal or Coloanal Anastomosis
The anastomosis may be an end-to-end or a sideto- end colorectal or coloanal anastomosis. It can be
stapled or hand-sewn, but it may depend on the
clinical scenario. The side-to-end hand-sewn anastomosis is the easier technique to perform and is
done utilizing either the TEO® platform or the
pneumoperitoneum. The catheter on the anvil’s
spike is removed, and the spike is grasped with the
aid of Kelly forceps. The arm portion of the circular stapler is inserted and mated to the anvil, before
performing the anastomosis and controlling it
endoscopically.
LoneStar® Retractor (Fig. 43.43) depending the
level of the anastomosis. Interrupted sutures (preferred) or a running suture may be used.
Postoperative Care
In a side-to-end stapled anastomosis, a colostomy is performed just distal to a well- vascularized
segment of bowel along the antimesenteric border
in preparation for the anastomosis [9]. The spike
of the anvil is delivered through this colostomy
and brought out through the antimesenteric side of
the proximal colon. The conduit is then transected
Patients should follow an enhanced recovery
after surgery (ERAS) protocol, and standard
analgesia is offered (paracetamol and oral opiates). Sips of uid are given on the evening of
surgery and diet started the next day. Early patient
mobilization is encouraged.
with a single ring of a linear stapling device, just
distal to the anvil and proximal to the colostomy. A
purse-string suture is placed around the spike of
Discussion
the anvil. A catheter is attached over the spike of
the anvil to be used as a handle to prevent excessive retraction of the anvil cranially into the abdomen. The anvil is pushed back into the pelvis and
the short TEO ® is reinserted transanally. The pelvis is inspected for bleeding, and the orientation of
the proximal bowel is controlled to ensure that it is
not twisted. A purse-string suture is placed to close
the orice around the spike of the anvil. Prior to
cinching the purse-string suture, a drain is briey
advanced into the pelvis to evacuate any residual
Why Pure taTME?
Pure NOTES transanal rectal extirpation has
attracted our attention. By providing superior
visualization and more accurate distal TME dis-
section (particularly in early rectal cancer), such
an approach may improve clinical, oncological,
and functional outcomes. In particular, a no-scar
radical resection signicantly improves healing
and recovery after surgery. Thus, not only can
patients return to full activity and function
450
J. Leroy et al.
post- operatively, but, when indicated, they can
receive adjuvant therapy without signicant delay.
Following the Japanese experience in retroperitoneal oncologic right and left colectomies [18]
and the experience of pure retroperitoneal lymphadenectomies in gynecologic cancers [19, 20], our
center has replicated these approaches for the rectum via a transanal access. Our experimental and
clinical experience concluded the feasibility and
safety of pure NOTES taTME.In the literature,
most of papers report results of hybrid techniques
with transanal rectal dissection completed from
below, but not above the level of the S2 vertebra
[21–30]. Only a few teams have performed pure
NOTES taTME [31, 32]. As previously stated,
even with proper expertise, only selected patient
will benet of this advanced procedure.
Why TEO® Platform?
The TEO® platform is not a mere “point-ofaccess” device equitable to a trocar. When Gerhard
Buess develop the revolutionary TEM apparatus,
he proposed an automatic gas distension to expose
the rectal cavity [13]. Doing only full-thickness
excision of rectal neoplasia, he did not, at that
time, envision the advantage of using the device’s
rectoscope as “tunneling machine” to provide
retraction in a circular manner that would enable
more radical, en bloc resections. In our opinion,
such rigid platforms (TEM or TEO®) provide the
advantage to expose the plan of dissection, and
CO2 gas ow aids in clearing the operative eld.
The TEO® scope can be navigated around the rectum and, subsequently, in the retroperitoneal
space, stenting the operative eld open, in a similar fashion to how the cap is used to do so by interventional endoscopists during EMR (Fig.43.8).
Currently at our center, we are exploring the
possibility to eventually connect the TEO® platform to a foot pedal or a voice-piloted robotic
arm to improve the ergonomic and functional
arrangement, allowing a surgeon to operate more
autonomously, expeditiously, and without the
need for a skilled assistant. Combined, these factors can reduce the cost of the procedure.
Why a Retroperitoneal Approach?
Decades of experience with conventional, up-todown TME taught us that the dissection of the
rectum and sigmoid colon is an operation predicated upon embryological planes –.
even along the retroperitoneum. All critical
blood vessels and relevant autonomic nerves lie
within the retroperitoneal space. The main challenges for TME are dissection along this plane,
whereby preservation of vital vascular and nerve
structures is paramount during the dissection.
Today, the pure NOTES down-to-up transanal
rectosigmoid dissection is now well standardized
at our center and select centers worldwide. With
appropriate training and experience, this retroperitoneal approach, particularly for the management and control of the vascular pedicles, appears
to be optimal [6, 8, 9]. Conrmatory data reported
by other experts subsequent to our published
ndings are also available [33].
Is Mobilization of Splenic Flexure Necessary?
For most authors, mobilization of splenic exure
is a step of TME’s procedure. Increasingly, however, there is a growing consensus not to perform
mobilization systematically and thus leading
most experts to recommend a case-by-case selection. It is one of the techniques available to obtain
adequate length, especially for construction of an
ultra-low anastomosis, but has little direct effect
on blood supply, and splenic exure mobilization
can increase operative and postoperative morbidity. If it is necessary for anatomic reasons (specically, to gain reach) or because it is otherwise
deemed necessary, transanal exure mobilization
is, in fact, feasible with the adaption of long
instruments– as John Marks has demonstrated to
be successful [34]. An operative berscope can
be useful as an adjunct, as well [9], and in this
manner, pure NOTES taTME including splenic
exure mobilization is possible.
Teaching and Training
TME procedure for rectal cancer remains a technically demanding operation, whether completed in
the open, laparoscopic, robotic, and now via the
transanal approach. Through experience, and since
the inception of laparoscopic digestive surgery, a
standardized methodology of these procedures is
essential to reproduce and to teach surgeons so that
they may gain prociency. Thus, a new procedure
43 Pure NOTES Transanal TME
451
should be mastered and perfectly understood before
it is taught to delegate surgeons. Today, substantial
experience with pure NOTES taTME (in highly
selected patients) has been realized and, at our center, has become standardized. Most recently, a pure
NOTES taTME for curative-intent rectal resection
was completed in 2h (female patient, T2 mid-rectal
tumor, long sigmoid loop, with a virgin abdomen
(Figs.43.4, 43.5, and 43.6). Teaching taTME is not
easy. Sam Atallah (2017) demonstrates perfectly in
a recent paper how difcult it can be (35). Training
in fresh cadaveric model seems for us the best
approach. Some advanced programs have been
developed worldwide [35–37].
Conclusion
Performing a pure oncologic transanal TME
without abdominal scars is feasible. This concept is based mainly on the objective of providing surgical cure for patients with rectal cancer.
Patient selection is highly important. The best
indications for this approach are currently for
early rectal cancers of the mid/high rectum, with
or without neoadjuvant therapy. The pure NOTES
taTME can also be applied for rectal extirpation
of carpeting benign rectal tumors for which a
complete endoscopic excision is impossible. In
our primary experience, a diverting stoma may be
avoided in patients in whom there is no neoadjuvant radiochemotherapy.
Its principle limitations seem to be locally
advanced rectal cancer and obesity.
Up-to-down or down-to-up TME are surgeries
of embryological planes. Before doing down-to up pure taTME, it is necessary to memorize the
technique of up-to-down to perform easier dissection of embryological planes as described above.
References
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