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Transanal total mesorectal excision (TaTME) has emerged as a surgical method for treating rectal malignancies in the middle and lower third of the rectum over the past 15 years. This approach was adopted because of the challenges encountered in secure total mesorectal excision (TME). Patient selection criteria and the rationale for TaTME have evolved, leading to improved oncological outcomes and patient quality of life. The procedure includes inserting a unique platform through the anus, forming a purse‐string closure, and endoscopically sealing the lower rectum. The mesorectum is then removed laparoscopically following a 'down‐to‐up' approach, finalised with a transabdominal laparoscopic phase and anastomosis. Pelvic anatomy complexity poses challenges, including potential injuries to the urinary tract, surgical site leakage, sinus damage, sagittal vein harm, nerve injury, carbon dioxide embolism, bowel function disturbance, sphincter mechanism issues, and rectal abscess formation. Proficient anatomy knowledge, precise surgical techniques, and advanced technologies contribute to their prevention. In conclusion, TaTME offers a promising approach to rectal surgery with satisfactory oncological outcomes. However, vigilance is required to eliminate potential complications. [ABSTRACT FROM AUTHOR]

Acute severe ulcerative colitis (ASUC) is a life-threatening medical emergency with considerable morbidity. Despite recent advances in medical IBD therapy, colectomy rates for ASUC remain high. A scoping review of published articles on ASUC was performed. We collected data, such as general information of the disease, diagnosis and initial assessment, and available medical and surgical treatments focusing on technical aspects of surgical approaches. The most relevant articles were considered in this scoping review. The management of ASUC is challenging; currently, personalized treatment for it is unavailable. Sequential medical therapy should be administrated, preferably in high-volume IBD centers with close patient monitoring and indication for surgery in those cases with persistent symptoms despite medical treatment, complications, and clinical worsening. A total colectomy with end ileostomy is typically performed in the acute setting. Managing rectal stump is challenging, and all individual and technical aspects should be considered. Conversely, when performing elective colectomy for ASUC, a staged surgical procedure is usually preferred, thus optimizing the patients' status preoperatively and minimizing postoperative complications. The minimally invasive approach should be selected whenever technically feasible. Robotic versus laparoscopic ileal pouch–anal anastomosis (IPAA) has shown similar outcomes in terms of safety and postoperative morbidity. The transanal approach to ileal pouch–anal anastomosis (Ta-IPAA) is a recent technique for creating an ileal pouch–anal anastomosis via a transanal route. Early experiences suggest comparable short- and medium-term functional results of the transanal technique to those of traditional approaches. However, there is a need for additional comparative outcomes data and a better understanding of the ideal training and implementation pathways for this procedure. This manuscript predominantly explores the surgical treatment of ASUC. Additionally, it provides an overview of currently available medical treatment options that the surgeon should reasonably consider in a multidisciplinary setting. [ABSTRACT FROM AUTHOR]

Background: Lateral lymph node metastases are a major cause of local recurrence after surgery for advanced low rectal cancer. Lateral lymph node dissection (LLND) may reduce the risk of local recurrence in patients with suspected lateral lymph node metastasis. Recent reports have shown that robotic-assisted LLND can help to reduce the postoperative complication rate, such as urinary disturbance. Furthermore, with the advent of transanal total mesorectal excision, a novel LLND procedure that combines a transabdominal approach with a transanal approach has been reported. This study aimed to clarify the safety and feasibility of robotic-assisted LLND supported by a transanal approach for advanced low rectal cancer. Methods: Thirty-nine patients diagnosed to have low rectal cancer between June 2019 and May 2023 were retrospectively enrolled and divided according to whether they underwent LLND via a robotic-assisted transabdominal approach alone (transabdominal group, n = 19) or in combination with a transanal approach (2team group, n = 20). The patient characteristics and short-term surgical outcomes were compared between the two groups. Results: The total operation time was significantly shorter in the 2team group than in the transabdominal group (366 min vs. 513 min, P < 0.001), as was the time taken to perform unilateral LLND (64 min vs. 114 min, P < 0.001). Furthermore, there was significantly less intraoperative bleeding in the 2team group (30 mL vs. 80 mL, P = 0.004). There was no significant between-group difference in postoperative complications. The incidence of postoperative urinary disturbance was satisfactory at 5% in both groups. Conclusions: The operation time for LLND performed by a robotic-assisted transabdominal approach was shortened when supported by a transanal approach. The frequency of postoperative urinary disturbance was low in both groups. Therefore, robotic-assisted abdominal LLND supported by a transanal approach can be considered a promising treatment option for advanced low rectal cancer. [ABSTRACT FROM AUTHOR]

Background: The efficacy and safety of transanal lateral pelvic lymph node dissection (TaLPLND) in rectal cancer has not yet been clarified. The aim of the present study was to evaluate the short-term results as an initial experience of TaLPLND. Methods: This retrospective study included patients with middle to lower rectal cancer who underwent TaLPLND from July 2018 to July 2021. Our institutions targeted lymph nodes in the internal iliac area and the obturator area for lateral pelvic lymph node dissection (LPLND). Results: A total of 30 consecutive patients with rectal cancer were included in this analysis. The median age was 60 years (range, 36–83 years), and the male–female ratio was 2:1. The median operative time was 362 min (IQR, 283–661 min), and the median intraoperative blood loss was 74 ml (IQR, 5–500 ml). Intraoperative blood transfusion was required in one case. No cases required conversion to laparotomy. TaLPLND was performed bilaterally in 13 patients (43.3%). Five patients (16.7%) underwent LPLND with combined resection of the internal iliac vessels. The median distance of the distal margin from the anal verge was 20 mm. The pathological radial margin (pRM) was positive in one case, and the negative pRM rate was 96.7%. Short-term postoperative complications (Clavien–Dindo classification grade ≥ II) were observed in nine cases (30.0%). There were no cases of reoperation or mortality. The median number of harvested lateral pelvic lymph nodes was 11 (range, 3–28). On pathological examination, lateral pelvic lymph nodes were positive for metastasis in seven cases (23.3%). Conclusions: TaLPLND appeared to be beneficial from an oncological point of view because it was close to the upstream lymphatic drainage from the tumor. The short-term outcomes of this initial experience indicate that this novel approach is feasible. [ABSTRACT FROM AUTHOR]

Background: An optimal surgical approach to lateral lymph node dissection (LLND) remains controversial. With the recent popularity of transanal total mesorectal excision, a two-team procedure combining the transabdominal and transanal approaches was established as a novel approach to LLND. This study aimed to clarify the safety and feasibility of two-team LLND (2team-LLND) and compare its short-term outcomes with those of conventional transabdominal LLND (Conv-LLND). Methods: Between April 2013 and March 2020, 463 patients diagnosed with primary locally advanced rectal cancer underwent a transanal total mesorectal excision; among them, 93 patients who underwent bilateral prophylactic LLND were included in this single-center, retrospective study. Among these patients, 50 and 43 patients underwent Conv-LLND (the Conv-LLND group) and 2team-LLND (the 2team-LLND group), respectively. The short-term outcomes, including the operation time, blood loss volume, number of complications, and number of harvested lymph nodes, were compared between the two groups. Results: The intraoperative and postoperative complications in the 2team-LLND group were equivalent to those in the Conv-LLND group; furthermore, the incidence of postoperative urinary retention in the 2team-LLND group was acceptably low (9%). Compared with the Conv-LLND group, the 2team-LLND group had a significantly shorter operation time (P = 0.003), lower median blood loss (P = 0.02), and higher number of harvested lateral lymph nodes (P = 0.0005). Conclusion: The intraoperative and postoperative complications of 2team-LLND were comparable with those of Conv-LLND. Thus, 2team-LLND was safe and feasible for advanced lower rectal cancer. Moreover, it was superior to Conv-LLND in terms of the operation time, blood loss volume, and number of harvested lateral lymph nodes. Therefore, it can be a promising LLND approach. [ABSTRACT FROM AUTHOR]

Transanal total mesorectal excision (taTME) has been rapidly accepted as a promising surgical approach to the distal rectum. The benefits include ease of access to the bottom of the deep pelvis linearly over a short distance in order to easily visualize the important anatomy. Furthermore, the distal resection margins can be secured under direct vision. Additionally, a two‐team approach combining taTME with a transabdominal approach could decrease the operative time and conversion rate. Although taTME was expected to become more rapidly popularized worldwide, enthusiasm for it has stalled due to unfamiliar intraoperative complications, a lack of oncologic evidence from randomized trials, and the widespread use of robotic surgery. While international registries have reported favorable short‐ and medium‐term outcomes from taTME, a Norwegian national study reported a high local recurrence rate of 9.5%. The characteristics of the recurrences included rapid, multifocal growth in the pelvis, which was quite different from recurrences following traditional transabdominal TME; thus, the Norwegian Colorectal Cancer Group reached a consensus for a temporary moratorium on the performance of taTME. To ensure acceptable baseline quality and patient safety, taTME should be performed by well‐trained colorectal surgeons. Although the appropriate indications for taTME remain controversial, the transanal approach is extremely important as a means of goal setting in difficult TME cases and as an aid to the transabdominal approach in various types of extended pelvic surgeries. The benefits in transanal lateral lymph node dissection and pelvic exenteration are presented herein. Watch a video of this article. [ABSTRACT FROM AUTHOR]

Endometriosis is a benign gynecologic affection that may lead to major surgeries, such as colorectal resections. Rectovaginal fistulas (RVF) are among the possible complications. When they occur, it is necessary to adapt the repair surgery as best as possible to limit their functional consequences. This video shows three different techniques for correcting RVF after rectal resection for endometriosis, with a combination of perineal surgery and laparoscopy: a mucosal flap, a transanal transection and single stapled anastomosis (TTSS) and a pull through. 4YKiHW8TnbR6vhEc_pCBZr Supplementary file1 (MP4 469658 KB) [ABSTRACT FROM AUTHOR]

Background Obstructed-defecation syndrome (ODS) is a condition characterized by the inability to completely evacuate or expel a fecal bolus in the presence of the urge to defecate. A series of mechanical lesions may cause OD, including rectocele, rectoanal intussusception, and rectal prolapse, which may be a cause or an end result of obstruction and chronic straining. The problem with OD, is mainly the difficulty in diagnosis and selection of cases, which could benefit from surgery. Moreover, it is very difficult to determine the suitable surgical technique for each individual case, that is, tailoring of cases. Aim Many surgical techniques have been established either through transanal or laparoscopic approach. Each of these techniques has its benefits and its hazards. Most of the studies in the literature focus on advocating or criticizing a specific surgical technique. This study, however, aims at comparing the results of different surgical techniques through laparoscopic (posterior rectopexy, ventral mesh rectopexy) or transanal (Altemeier's, Delorme's, stapled transanal rectal resection) approach in order to answer a simple question: which approach should be the default and when to use the other?Patients and methods A sample of 28 cases of OD was studied, 14 of which were done through laparoscopic and 14 through transanal approach. Comparison was based on the postoperative hospital stay, complications, and the change in OD score using the 'Altomare ODS questionnaire, 2008.'Results Bleeding was more in laparoscopic techniques, occurring in two (14.3%) of the patients, versus one patient (7.1%) only of those done transanally. Incontinence was more among the transanal group as it occurred in three (21.4%) patients, versus one (7.1%) patient only done laparoscopically. Only one (7.1%) patient done transanally (Delorme's technique), had postoperative anal stenosis requiring anal-dilation sessions. Besides, one (7.1%) of the female patients done through transanal approach, developed rectovaginal fistula. Two of the male patients done by laparoscopic posterior rectopexy developed erectile dysfunction. Laparoscopic techniques had more drop in the ODS score than transanal techniques with a mean of 9.5 ± 6 versus 4.64 ± 5.31, respectively, and a P value of statistical significance (P=0.042). Conclusions Laparoscopic approach is superior to transanal approach as regards improvement of OD manifestations, and thus should be the default, yet the techniques that involve dissection along the posterior rectal wall (posterior mesh rectopexy) are not recommended for males, especially adults. [ABSTRACT FROM AUTHOR]

Endometriosis is a benign gynecologic affection that may lead to major surgeries, such as colorectal resections. Rectovaginal fistulas (RVF) are among the possible complications. When they occur, it is necessary to adapt the repair surgery as best as possible to limit their functional consequences. This video shows three different techniques for correcting RVF after rectal resection for endometriosis, with a combination of perineal surgery and laparoscopy: a mucosal flap, a transanal transection and single stapled anastomosis (TTSS) and a pull through. 4YKiHW8TnbR6vhEc_pCBZr Supplementary file1 (MP4 469658 KB) [ABSTRACT FROM AUTHOR]

Rectal gastrointestinal stromal tumors (GISTs) are rare, and radical surgery such as abdominoperineal resection is necessary for large rectal GISTs to obtain tumor‐free resection margins. Here, we describe a 77‐year‐old man with a locally advanced non‐metastatic GIST in the left anterolateral wall of the lower rectum. Tumor size was estimated to be 73 mm, and invasion of the left seminal vesicle and prostate was suspected. Chemotherapy with imatinib mesylate reduced the tumor size, creating a slight gap between the tumor and anterior organs. Therefore, we performed sphincter‐sparing partial rectal resection using a hybrid method of laparoscopic and transanal approaches. The postoperative course was uneventful, and the patient remains disease‐free on adjuvant chemotherapy 12 months after surgery. This case suggests that a hybrid method of laparoscopic and transanal surgery allows oncological and function‐preserving excision of large rectal GISTs. [ABSTRACT FROM AUTHOR]

Aim: Synthetic rectal mesh erosion is a challenging complication following urogynaecological surgery. The aim of this study was to determine the optimal management of rectal mesh erosion following urogynaecological surgery. Method: A systematic review was undertaken following a pre‐defined protocol registered with PROSPERO (CRD42018112425) in accordance with PRISMA guidelines. Searches of MEDLINE online database, Cochrane Library and clinical trial registries (ClinicalTrials.gov, EU Clinical Trials, ISRCTN registry) were performed. The included articles were heterogeneous – therefore a narrative synthesis was performed. Results: Fourteen studies were included in the review: 11 case reports, one case series, one retrospective cohort and one prospective multicentre trial. Fourteen rectal mesh erosions were identified. Eight (57%) of the rectal erosions underwent major abdominal surgery. In two of these cases, the abdominal approach was used only after failure of the transanal route. Five (36%) of the mesh erosions were managed using a transanal approach. In one case, the mesh passed without intervention. Conclusion: Synthetic rectal mesh erosion can be managed successfully via either a transanal or a transabdominal approach with a partial or complete excision of the mesh. An examination under anaesthetic with an attempted transanal removal of mesh should be considered the first step in the management of this condition before consideration of more invasive surgery. [ABSTRACT FROM AUTHOR]

Background: Total mesorectal excision is the standard surgical treatment for mid- and low-rectal cancer. Laparoscopy represents a clear leap forward in the management of rectal cancer patients, offering significant improvements in post-operative measures such as pain, first bowel movement, and hospital length of stay. However, there are still some limits to its applications, especially in difficult cases. Such cases may entail either conversion to an open procedure or positive resection margins. Transanal endoscopic proctectomy (ETAP) was recently described and could address the difficulties of approaching the lower third of the rectum. Early series and case-control studies have shown favourable short-term results, such as a low conversion rate, reduced hospital length of stay and oncological outcomes comparable to laparoscopic surgery. The aim of the proposed study is to compare the rate of positive resection margins (R1 resection) with ETAP versus laparoscopic proctectomy (LAP), with patients randomly assigned to each arm.Methods/design: The proposed study is a multicentre randomised trial using two parallel groups to compare ETAP and LAP. Patients with T3 lower-third rectal adenocarcinomas for whom conservative surgery with manual coloanal anastomosis is planned will be recruited. Randomisation will be performed immediately prior to surgery after ensuring that the patient meets the inclusion criteria and completing the baseline functional and quality of life tests. The study is designed as a non-inferiority trial with a main criterion of R0/R1 resection. Secondary endpoints will include the conversion rate, the minimal invasiveness of the abdominal approach, postoperative morbidity, the length of hospital stay, mesorectal macroscopic assessment, functional urologic and sexual results, faecal continence, global quality of life, stoma-free survival, and disease-free survival at 3 years. The inclusion period will be 3 years, and every patient will be followed for 3 years. The number of patients needed is 226.Discussion: There is a strong need for optimal evaluation of the ETAP because of substancial changes in the operative technique. Assessment of oncological safety and septic risk, as well as digestive and urological functional results, is particularily mandatory. Moreover, benefits of the ETAP technique could be demonstrated  in post-operative outcome.Trial Registration: ClinicalTrial.gov: NCT02584985 . Date and version identifier: Version n°2 - 2015 July 6. [ABSTRACT FROM AUTHOR]

Background Rectourethral fistulas (RUFs) represent an uncommon complication of pelvic surgery, especially radical prostatectomy. To date there is no standardised treatment for managing RUFs. This represents a challenge for surgeons, mainly because of the potential recurrence risk. Objective To describe our minimally invasive transanal repair (MITAR) of RUFs and to assess its safety and outcomes. Design, setting, and participants We retrospectively evaluated 12 patients who underwent MITAR of RUF at our centre from October 2008 to December 2014. Exclusion criteria were a fistula diameter greater than 1.5 cm, sepsis, and/or faecaluria. Surgical procedure After fistula identification through cystoscopy and 5F-catheter positioning within the fistula, MITAR is performed using laparoscopic instruments introduced through Parks’ anal retractor. The fibrotic margins of the fistula are carefully dissected by a lozenge incision of the rectal wall, parallel to the rectal axis. Under the healthy flap of the rectal wall the urothelium is located and the fistulous tract is sutured with interrupted stitches. After a leakage test of the bladder, the rectal wall is sutured with interrupted stitches. Electrocoagulation is never used during this procedure. Measurements Fistula closure, postoperative complications, and recurrence. Results and limitations Median follow-up was 21 (range, 12–74) mo. Median operative time was 58 (range, 50–70) min. Median hospital stay was 1.5 (range, 1–4) d. Early surgical complications occurred in one patient (8.3%). Recurrence did not occur in any of the cases. Limitations included retrospective analysis, small case load, and lack of experience with radiation-induced fustulas. Conclusions MITAR is a safe, effective, and reproducible procedure. Its advantages are low morbidity and quick recovery, and no need for a colostomy. Patient summary We studied the treatment of rectourethral fistulas. Our technique, transanally performed using laparoscopic instruments, was found to be safe, feasible, and effective, with limited risk of complications. [ABSTRACT FROM AUTHOR]

Background: The quality of a total mesorectal excision (TME) is one of the most important prognostic factors for local recurrence of rectal carcinoma. The aim of this study was to clarify the manner in which lesser pelvis dimensions affect the quality of TME via the transabdominal approach, while simultaneously defining the criteria for selecting patients most likely to have Grade 3 TME outcomes for a transanal approach using the TaTME technique.Methods: An analysis from the registry was conducted using 93 of total 198 patients with rectal cancer of the mid- and lower third of the rectum who underwent: (1) a low anterior resection, (2) an ultra-low resection with coloanal anastomosis, or (3) an intersphincteric rectal resection, all with total mesorectal excision. The procedures were carried out at the Department of Surgery at the University Hospital Hradec Králové between 2011 and 2014. Rectal specimens were histopathologically examined according to a standardized protocol. Pelvimetry data were obtained using anteroposterior, transverse, and sagittal CT or MRI scans.Results: A correlation was found between the quality of the TME and pelvimetry parameter A5, i.e., the angle between the longitudinal axis of the symphysis, and the lines between the symphysis and the promontory (R(2) = -0.327, p < 0.001). The ordinal regression method was used to identify parameters of the model describing levels of probability for TME quality. These relationships were described by equations that provide probability of the achievement of each grade of TME.Conclusion: The correlation described by obtained equations between pelvimetry parameters and the quality of TME represents a new tool for use in preoperative decision-making with regard to resection via the transanal approach (TaTME). [ABSTRACT FROM AUTHOR]

In some cases, a J-pouch is not created after laparoscopic intersphincteric resection (Lap-ISR), because this procedure usually does not involve laparotomy. This study aimed to develop a new technique for Lap-ISR and J-pouch reconstruction without laparotomy and to assess the short- and long-term outcomes of this technique. After a rectal specimen is excised using the transanal approach, the reconstructed intestine is reinserted into the intra-abdominal space. To create the J-shape, the reconstructed intestine is looped back using Allis forceps, and the septum of the J-shape is divided using a surgical stapler. We performed 20 surgeries using the new technique. Although three patients developed pelvic infections, no J-pouch-related complications were noted. Intestinal continuity could be maintained in all patients who received a diverting stoma. [ABSTRACT FROM AUTHOR]

A set of new instruments was designed to establish an access to the abdominal cavity for NOTES via the rectosigmoid. It comprehends a metal overtube which is positioned using a modified TEM device. The entry point is targeted by transrectal ultrasound and secured by a purse-string suture. Closure is achieved by means of a linear stapler application. The applicability of the system could already be confirmed in animal survival studies. [ABSTRACT FROM AUTHOR]

Background: Transanal intersphincteric resection (ISR) was introduced and has been increasingly performed as an ultimate surgical treatment for extremely low rectal cancer. We considered that high quality and less invasive surgery could be achieved if ISR and laparoscopic surgery were combined. Methods: Between December 2003 and June 2004, we performed laparoscope-assisted ISR for two patients with very low rectal cancer and total colectomy for two patients with ulcerative colitis complicated by colorectal cancer. In all patients, the transanal procedure was preceded by trans-abdominal laparoscopic rectal excision. Results: Preceding transanal dissection facilitated muscle layer-oriented curative dissection, and more importantly, made subsequent laparoscopic rectal excision effortless as a result of penetrating to the dissected pelvic cavity. All patients showed favorable recovery including postoperative anal function with no complication or recurrent disease. Conclusions: This procedure is feasible and has favorable short-term results for radical treatment of very low rectal disease, while preserving anal function. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: The present video shows a rare case of erosion through the full rectal wall into the rectum after a transperineal implant of a double-arm polypropylene kit.Methods: A 70-year-old woman underwent a transperineal implant of a double-arm polypropylene kit. One year after surgery, she developed bothersome symptoms in the posterior perineum including heaviness, pain and rectal bleeding during defecation. A clinical examination showed the presence of a part of the prothesis traversing the rectal cavity. A minimally invasive transanal approach was performed to remove the mesh and restore the rectal integrity.Results: This surgical technique demonstrates rectal mesh removal with a transanal approach.Conclusions: To our knowledge, this is a rare complication of rectal erosion of a posterior transperineal mesh kit. The aim of this video is to show a complete transanal approach to treating this serious complication avoiding the more invasive and traumatic abdominal procedure. [ABSTRACT FROM AUTHOR]