International Journal of Colorectal Disease

, Volume 30, Issue 1, pp 71–78 | Cite as

Topography of the extrinsic internal anal sphincter nerve supply during laparoscopic-assisted TAMIS TME: five key zones of risk from the surgeons’ view

  • Werner Kneist
  • Andreas D. Rink
  • Daniel W. Kauff
  • Moritz A. Konerding
  • Hauke Lang
Original Article



Sparing the extrinsic autonomic innervation of the internal anal sphincter during total mesorectal excision is important for the preservation of anal sphincter function. This study electrophysiologically confirmed the topography of the internal anal sphincter nerve supply during laparoscopic-assisted transanal minimally invasive surgery for total mesorectal excision.


This prospective study was conducted at two large multispecialty referral centers. Six patients (five males and one female) aged between 45 and 65 years with low rectal cancer (≤5 cm from the anal verge) were enrolled. Surgery was performed under electric stimulation of the pelvic autonomic nerves with observation of the electromyographic signals of the internal anal sphincter.


The minimally invasive transanal surgical approach enabled advantageous visualization of the pelvic autonomic nerves in all patients. In particular, extrinsic innervation to the internal anal sphincter near the levator muscle was consciously spared under electrophysiological confirmation. The evoked absolute electromyographic amplitudes of the internal anal sphincter during transanal minimally invasive surgery were significantly lower than the initial results of the laparoscopic approach [3.7 μV (interquartile range 2.4; 5.7) vs. 4.3 μV (interquartile range 3.1; 8.6); p = 0.002]. Five key zones of risk for pelvic autonomic nerve damage were identified. No complications occurred.


The electromyographic results of this preliminary study indicate advantages for sparing the internal anal sphincter innervation during transanal minimally invasive mesorectal dissection considering the specific in situ neuroanatomical topography.


Rectal cancer Minimally invasive Transrectal Autonomic nervous system Intraoperative monitoring Internal anal sphincter 



Specific staff and instrumentation necessary to carry out TAMIS TME was funded by the German Research Foundation (DFG) (INST 371/8-1 FUGG).


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Copyright information

© Springer-Verlag Berlin Heidelberg 2014

Authors and Affiliations

  • Werner Kneist
    • 1
  • Andreas D. Rink
    • 2
  • Daniel W. Kauff
    • 1
  • Moritz A. Konerding
    • 3
  • Hauke Lang
    • 1
  1. 1.Department of General, Visceral and Transplant Surgery, University Medical CenterJohannes Gutenberg University of MainzMainzGermany
  2. 2.Department of General, Visceral and Thoracic SurgeryLeverkusen General HospitalLeverkusenGermany
  3. 3.Institute of Functional and Clinical Anatomy, University Medical CenterJohannes Gutenberg University of MainzMainzGermany

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