Search

Current international guidelines and consensus panels emphasize that nerve sparing is a crucial part of the total mesorectal excision (TME). The transanal approach (taTME) could be advantageous in this regard. However, even with taTME, pelvic autonomic nerve preservation requires perfect knowledge of the topographic and morphological aspects of the anatomy and requires surgeons to acquire specific skills. Unusual surgical topography presents a considerable risk of nerve injury, when attempting a TME with the “bottom-up” approach.

Transanal TME (taTME) is a new option for the treatment of mid and low rectal cancer. The approach to the rectum and the anatomy’s appearance is different when compared to standard laparoscopy. This could result in an increased risk of intraoperative morbidity, as well as new complications specifically associated with the transanal approach.

The transanal approach pioneered for rectal cancer brought to light all of the learning curve issues that could be imagined. As the era of taTME launched, a deja vu reminiscent of the implementation of laparoscopic cholecystectomy and laparoscopic colorectal surgery and their known early challenges existed. However, the learning curve issues have been clearly appreciated thanks to the taTME registry. Apart from a new set of short-term complications (such as injury to the male urethra) that have been realized, the long-term oncologic safety of the transanal approach still has to be established. The quality of resection with taTME, such as the risk of margin positivity with this technique, is still being established. Furthermore, taTME is unique in that the rectum is intentionally divided or “perforated,” and we are still uncertain about the risk of such specimen perforations as the potential exposure of the dissection area with tumor cells might negatively influence long-term outcomes.

Transanal total mesorectal excision is a viable minimally invasive approach initially developed for rectal cancer and now applied to benign disease as well. This chapter describes the application of this technique in performing a total proctocolectomy with ileal pouch-anal anastomosis (IPAA) through a transanal approach (TaIPAA). The abdominal colectomy may be performed laparoscopically with the J-pouch fashioned through the future ileostomy incision. Proctectomy is then performed transanally, and the pouch passed down for a stapled or hand-sewn anastomosis. The technique may be modified in the setting of a staged IPAA.

Transanal minimally invasive surgery (TAMIS) is an advanced videoscopic endoluminal platform that blends single-incision laparoscopy with local excision techniques. Since its inception, TAMIS has been used increasingly worldwide as an alternative to traditional transanal excision and transanal endoscopic microsurgery for local excision of benign and early-stage rectal cancers in the distal and mid rectum. With the benefits and success of rectal lesion excision, the applications have continued to evolve. In this chapter, we review several applications of TAMIS beyond local excision, for performing established procedures in a minimally invasive transanal approach, facilitating new technology and the development of new approaches, and managing complications.

For years, the conventional laparoscopically assisted colon resection has been the most accepted approach worldwide for all pathologies in the right colon, left colon, and rectum. The necessity of an abdominal incision to retrieve the specimen is accompanied by a significant number of complications, such as infection, incisional hernia, pain, longer hospital stay, and more discomfort for the patient.