Transanal total mesorectal excision: full steam ahead

Abstract

The article by Araujo [1] in this month's issue documents the dramatic climb of transanal total mesorectal excision (transanal TME) with the most comprehensive review on this topic to date and a revelation of published numbers that are approximately double what they were just 1 year ago [2]. While it may seem as if transanal TME materialized overnight, in actuality, its foundation had been quietly in development for three decades. The seeming sudden ascent of transanal TME is analogous to a building under construction. Developing a proper foundation is a time-intensive and critical first step. To naïve observers of a construction site, it may appear as though no progress is underway, until the foundation is completed and suddenly a building begins to rise ten stories high, filling in the skyline with striking speed.The foundation for transanal TME began 30 years ago with the innovative efforts of Gerald Marks and later carried on with his son John Marks. In the early 1980s, G. Marks pioneered the technique of what he termed the transabdominal-transanal (TATA) operation for rectal cancers involving the distal one-third of the rectum [3], performing a meticulous dissection from below and adapting Bill Heald's concept of TME, albeit 'in reverse.' This predated the era of laparoscopy and the first TATA operations were completed with an open approach before transitioning to the use of laparoscopic assistance in the 1990s [4]. For 30 years, Marks' TATA operation laid down the foundation for modern transanal TME, spelling out very clearly why this approach was preferred for distal rectal cancer. Principally, the advantages of TATA were (a) definition of the distal margin from below, thereby assuring no tumor involvement at the line of distal division and (b) obviating the need for stapling devices for transection, which do not comply with boney constraints ofin particular-the narrow male pelvis. Even when staplers could be negotiated into pelvic confines from above, there was still the risk of inadvertently stapling across tumor, thereby irreversibly compromising the oncologic integrity of the operation. While Marks' rationale behind TATA was perfectly on point, the technique required specialized retractors with limited exposure, and thus few were able to replicate this approach.In parallel with TATA, the transanal endoscopic microsurgery (TEM) scope was developed by Buess [5] and considerable experience was gained with TEM for local excision of rectal neoplasia, though primarily for nonmalignant lesions. TEM was, for many, an unaffordable privilege of the elite; most colorectal surgeons, to this day, are not privy to TEM nor have they had formal training with this exquisite device. TEM's penetration had remained limited due to prohibitive upfront costs and also the complexity it mandates from surgeons.During a recent lectureship webcast, a renowned colorectal surgeon remarked that, 'in [the year] 2000, TEM was dead.' This statement was not intended to discredit the otherwise precocious TEM marvel. Implicit, however,...

The new approach to the rectal cancer: ‘down-to-up’ double endolaparoscopic pelvic access. Preliminary evaluation of outcomes

“…According to us, this is the less important aspect that this technique could offer; however, maintaining the integrity of the abdominal wall may allow a more rapid postoperative hospital stay, with a faster recovery of intestinal peristalsis, and a reduced pain. These theoretical advantages come from combination of NOTES experience, TEM experience, mini-invasive surgery or MANOS (minilaparoscopy-assisted natural orifice surgery), and of traditional laparotomic colorectal surgery (intersphincteric resection) [16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33].…”

Image-guided real-time navigation for transanal total mesorectal excision: a pilot study

“…Special departmental approval was granted for this approach from our institution under the guidelines of a pilot study. Male patients with anterior rectal cancers were selected because it was hypothesized that stereotactic navigation could help achieve negative margins while preventing urethral injury-an important technique-specific morbidity of transanal [7,8].…”

Stereotactic navigation for TAMIS-TME

“…Essentially, the transanal approach provides the surgeon with an in-line vantage point that progressive technologic advancements for abdominal minimally invasive approaches have simply not been able to achieve (33).…”