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Anastomotic leak rates in colorectal surgery remain persistently high despite increased awareness of contributing factors, low threshold for proximal fecal diversion, and modern technologies to better assess bowel perfusion. Leak rates for low colorectal anastomoses range 3–30% with risk factors including malnutrition, smoking, immunosuppression, prior radiation therapy, obesity, and male gender. Technical factors such as tension on the anastomosis and adequacy of the blood supply also play a critical role in the occurrence of leaks. This chapter will review intraoperative strategies to assess the integrity of colorectal anastomoses, reduce the risk of anastomotic leaks, and salvage a failed anastomosis and ischemic colonic conduit. Reconstructive techniques to salvage intraoperative and postoperative anastomotic leaks will also be reviewed.

Anorectal physiology and bowel continence is a complex and dynamic coordination of the reservoir functional capacity of the rectum, dynamic interplay with pelvic floor musculature, and timely contraction and relaxation of the sphincter muscle complex. Surgical alteration of the rectum in the form of partial or complete resection significantly impacts the patient’s bowel habits. Transanal surgical partial or total resection is associated with postoperative functional impairment in bowel incontinence. This chapter reviews the impact of TAMIS and taTME on bowel functional outcomes.

There has been a significant evolution of the transanal excision technique over the past 3–4 decades. In 1983, Gerhard Buess introduced a disruptive technique in colorectal surgery, transanal endoscopic microsurgery (TEM). The initial results comparing TEM to the standard of care, transanal excision (TAE), revealed that TEM was associated with superior quality of resection demonstrated by the higher rate of achieving negative margins. Longer-term results revealed that TEM resection of rectal lesions also resulted in a lower local recurrence rate compared to TAE. TEM is one of the first colorectal surgical techniques with superior operative outcomes compared to the standard of care at the time (TAE). Over the last decade, multiple transanal platforms have been developed, and new techniques and terminology such as TAMIS (transanal minimally invasive surgery) have broadened the utility and applications of TEM. More broadly, the various terminologies used to describe the transanal endoluminal resection irrespective of the transanal access platform is TES (transanal endoscopic surgery). This chapter reviews the history and evolution of TES as well as comparing it to new endoluminal techniques such as EMR (endoscopic mucosal resection) and ESD (endoscopic submucosal dissection) for rectal lesions.