Aim Laparoscopic surgery is well established for colon cancer, with defined benefits. Use of laparoscopy for the performance of restorative proctocolectomy (RPC) with ileoanal anastomosis is more controversial. Technical aspects include difficult dissection of the distal rectum and a potentially increased risk of anastomotic leakage through multiple firings of the stapler. In an attempt to overcome these difficulties we have used the technique of transanal rectal excision to perform the proctectomy. This paper describes the technique, which is combined with an abdominal approach using a single-incision platform (SIP).Method Data were collected prospectively for consecutive operations between May 2013 and October 2015, including all cases of restorative proctocolectomy with ileoanal pouch anastomosis performed laparoscopically. Only patients having a transanal total mesorectal excision (TaTME) assisted by SIP were included. The indication for RPC was ulcerative colitis (UC) refractory to medical treatment. ResultsThe procedure was performed on 16 patients with a median age of 46 (26-70) years. The male:female ratio was 5:3 and the median hospital stay was 6 (3-20) days. The median operation time was 247 (185-470) min and the overall conversion rate to open surgery was 18.7%. The 30-day surgical complication rate was 37.5% (Clavien-Dindo 1 in four patients, 2 in one patient and 3 in one patient). One patient developed anastomotic leakage 2 weeks postoperatively.Conclusion This initial study has demonstrated the feasibility and safety of TaTME combined with SIP when performing RPC with ileal pouch-anal anastomosis for UC.Keywords Ulcerative colitis, RPC, laparoscopy, single incision laparoscopic surgery, IBD, IPAA What does this paper add to the literature? The paper reports the novel approach of combining single-incision surgery and transanal rectal excision for restorative proctocolectomy. The technique has the ability to minimize surgical trauma and allow safe distal rectal dissection, especially in men with a narrow pelvis.

IntroductionTrans anal minimal invasive surgery (TAMIS) is a novel technique gaining popularity in colorectal surgery due to its precision in pelvic dissection and easy accessibility to the distal rectum. Its use in colorectal cancer surgery is well documented although inflammatory bowel disease (IBD) poses a unique set of disease-specific and procedure-related challenges. Unlike in cancer surgery, the wide disease spectrum with varying morphological changes in IBD would require the surgeon to adapt accordingly from port insertion to wound closure. This article describes our experience with the first 60 procedures. MethodologyPatients affected by IBD requiring proctectomy with or without total colectomy from 2013 to 2016 were offered Trans anal total mesorectal excision (TaTME) on a TAMIS and Single Incision Laparoscopy (SILS) combined platform. Airseal ® insufflation on GelpointPath ® platform with monopolar diathermy was used for rectal surgery. A second team using ultrasonic dissection carried out concomitant abdominal dissection. Procedural modifications were adopted based on authors' personal experience. Standard ileoanal S pouch with stapler anastomosis was performed. Surgical time, blood loss and patient demographics were recorded. ResultsAll 60 patients (male -44; median age 42.5; range 19-75) presented during the study period underwent TaTME for the rectal dissection with an 8% conversion rate. Of the total 38 (63%) were done for ulcerative colitis and the perineal phase has taken a median time of 141.8 minutes. Ileo-anal pouch surgery was performed in 27 (45%) patients. Two patients (3.3%) required re-intervention due to complications in the abdominal procedure. Two patients required vacuum dressing for wound closure. ConclusionTaTME is a safe and feasible procedure in IBD surgery. Specific difficulties due to the inflammatory process which results in difficult dissection can be overcome with attention to anatomical details and the use of specific instruments. 1,2 2 2 2