Techniques in Coloproctology

, Volume 19, Issue 2, pp 69–82 | Cite as

Transanal total mesorectal excision: a systematic review of the experimental and clinical evidence

  • S. E. Araujo
  • B. Crawshaw
  • C. R. Mendes
  • C. P. Delaney


Achieving a clear distal or circumferential resection margins with laparoscopic total mesorectal excision (TME) may be laborious, especially in obese males and when operating on advanced distal rectal tumors with a poor response to neoadjuvant treatment. Transanal (TaTME) is a new natural orifice translumenal endoscopic surgery modality in which the rectum is mobilized transanally using endoscopic techniques with or without laparoscopic assistance. We conducted a comprehensive systematic review of publications on this new technique in PubMed and Embase databases from January, 2008, to July, 2014. Experimental and clinical studies written in English were included. Experimental research with TaTME was done on pigs with and without survival models and on human cadavers. In these studies, laparoscopic or transgastric assistance was frequently used resulting in an easier upper rectal dissection and in a longer rectal specimen. To date, 150 patients in 16 clinical studies have undergone TaTME. In all but 15 cases, transabdominal assistance was used. A rigid transanal endoscopic operations/transanal endoscopic microsurgery (TEO/TEM) platform was used in 37 patients. Rectal adenocarcinoma was the indication in all except for nine cases of benign diseases. Operative times ranged from 90 to 460 min. TME quality was deemed intact, satisfactory, or complete. Involvement in circumferential resection margins was detected in 16 (11.8 %) patients. The mean lymph node harvest was equal or greater than 12 in all studies. Regarding morbidity, pneumoretroperitoneum, damage to the urethra, and air embolism were reported intraoperatively. Mean hospital stay varied from 4 to 14 days. Postoperative complications occurred in 34 (22.7 %) patients. TaTME with TEM is feasible in selected cases. Oncologic safety parameters seem to be adequate although the evidence relies on small retrospective series conducted by highly trained surgeons. Further studies are expected.


Transanal TME TAMIS Transanal proctectomy NOTES TME TEM 


Conflict of interest



  1. 1.
    Heald RJ, Husband EM, Ryall RD (1982) The mesorectum in rectal cancer surgery: the clue to pelvic recurrence? Br J Surg 69:613–616PubMedCrossRefGoogle Scholar
  2. 2.
    Araujo SE, Seid VE, Bertoncini A et al (2011) Laparoscopic total mesorectal excision for rectal cancer after neoadjuvant treatment: targeting sphincter-pre- serving surgery. Hepatogastroenterology 58:1545–1554PubMedGoogle Scholar
  3. 3.
    Velthuis S, van den Boezem PB, van der Peet DL, Cuesta MA, Sietses C (2013) Feasibility study of transanal total mesorectal excision. Br J Surg 100:828–831PubMedCrossRefGoogle Scholar
  4. 4.
    Rouanet P, Mourregot A, Azar CC et al (2013) Transanal endoscopic proctectomy: an innovative procedure for difficult resection of rectal tumors in men with narrow pelvis. Dis Colon Rectum 56:408–415PubMedCrossRefGoogle Scholar
  5. 5.
    Buess G, Theiss R, Hutterer F et al (1983) Transanal endoscopic surgery of the rectum: testing a new method in animal experiments. Leber Magen Darm 13:73–77PubMedGoogle Scholar
  6. 6.
    Atallah S, Albert M, Larach S (2010) Transanal minimally invasive surgery: a giant leap forward. Surg Endosc 24:2200–2205PubMedCrossRefGoogle Scholar
  7. 7.
    Sylla P, Rattner DW, Delgado S et al (2010) NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance. Surg Endosc 24:1205–1210PubMedCrossRefGoogle Scholar
  8. 8.
    Hompes R, Arnold S, Warusavitarne J (2014) Towards the safe introduction of transanal total mesorectal excision: the role of a clinical registry. Colorectal Dis 16:498–501PubMedCrossRefGoogle Scholar
  9. 9.
    Atallah S, Martin-Perez B, Albert M et al (2014) Transanal minimally invasive surgery for total mesorectal excision (TAMIS–TME): results and experience with the first 20 patients undergoing curative-intent rectal cancer surgery at a single institution. Tech Coloproctol 18:473–480PubMedCrossRefGoogle Scholar
  10. 10.
    Wolthuis AM, de Buck van Overstraeten A, D’Hoore A (2014) Dynamic article: transanal rectal excision: a pilot study. Dis Colon Rectum 57:105–109PubMedCrossRefGoogle Scholar
  11. 11.
    Marks JH, Frenkel JL, D’Andrea AP et al (2011) Maximizing rectal cancer results: TEM and TATA techniques to expand sphincter preservation. Surg Oncol Clin N Am 20:501–520PubMedCrossRefGoogle Scholar
  12. 12.
    Atallah S, Albert M, Larach S (2010) Transanal minimally invasive surgery: a giant leap forward. Surg Endosc 24:2200–2205PubMedCrossRefGoogle Scholar
  13. 13.
    Atallah SB, Larach S, deBeche-Adams TC et al (2013) Transanal minimally invasive surgery (TAMIS): a technique that can be used for retrograde proctectomy. Dis Colon Rectum 56:931PubMedCrossRefGoogle Scholar
  14. 14.
    Heald RJ (2013) A new solution to some old problems: transanal TME. Tech Coloproctol 17:257–258PubMedCrossRefGoogle Scholar
  15. 15.
    Whiteford MH, Denk PM, Swanström LL (2007) Feasibility of radical sigmoid colectomy performed as natural orifice translumenal endoscopic surgery (NOTES) using transanal endoscopic microsurgery. Surg Endosc 21:1870–1874PubMedCrossRefGoogle Scholar
  16. 16.
    Sylla P, Willingham FF, Sohn DK et al (2008) NOTES rectosigmoid resection using transanal endoscopic microsurgery (TEM) with transgastric endoscopic assistance: a pilot study in swine. J Gastrointest Surg 12:1717–1723PubMedCrossRefGoogle Scholar
  17. 17.
    Sylla P, Sohn DK, Cizginer S et al (2010) Survival study of natural orifice translumenal endoscopic surgery for rectosigmoid resection using transanal endoscopic microsurgery with or without transgastric endoscopic assistance in a swine model. Surg Endosc 24:2022–2030PubMedCrossRefGoogle Scholar
  18. 18.
    Gomez Ruiz M, Martin Parra I, Calleja Iglesias A et al (2014) Preclinical cadaveric study of transanal robotic proctectomy with total mesorectal excision combined with laparoscopic assistance. Int J Med Robot. doi: 10.1002/rcs.1581
  19. 19.
    Araujo SE, Seid VE, Horcel L de A (2014) Transanal endoscopic proctectomy: a case in swine. Hepatogastroenterology 61:333–335PubMedGoogle Scholar
  20. 20.
    Trunzo JA, Delaney CP (2010) Natural orifice proctectomy using a transanal endoscopic microsurgical technique in a porcine model. Surg Innov 17:48–52PubMedCrossRefGoogle Scholar
  21. 21.
    Telem DA, Han KS, Kim MC et al (2013) Transanal rectosigmoid resection via natural orifice translumenal endoscopic surgery (NOTES) with total mesorectal excision in a large human cadaver series. Surg Endosc 27:74–80PubMedCrossRefGoogle Scholar
  22. 22.
    McLemore EC, Coker AM, Devaraj B et al (2013) TAMIS-assisted laparoscopic low anterior resection with total mesorectal excision in a cadaveric series. Surg Endosc 27:3478–3484PubMedCrossRefGoogle Scholar
  23. 23.
    Rieder E, Spaun GO, Khajanchee YS et al (2011) A natural orifice transrectal approach for oncologic resection of the rectosigmoid: an experimental study and comparison with conventional laparoscopy. Surg Endosc 25:3357–3363PubMedCrossRefGoogle Scholar
  24. 24.
    Atallah SB, Albert MR, deBeche-Adams TH et al (2011) Robotic transanal minimally invasive surgery in a cadaveric model. Tech Coloproctol 15:461–464PubMedCrossRefGoogle Scholar
  25. 25.
    Hompes R, Rauh SM, Hagen ME et al (2012) Preclinical cadaveric study of transanal endoscopic da Vinci® surgery. Br J Surg 99:1144–1148PubMedCrossRefGoogle Scholar
  26. 26.
    Atallah S, Parra-Davila E, DeBeche-Adams T et al (2012) Excision of a rectal neoplasm using robotic transanal surgery (RTS): a description of the technique. Tech Coloproctol 16:389–392PubMedCrossRefGoogle Scholar
  27. 27.
    Tuech JJ, Bridoux V, Kianifard B et al (2011) Natural orifice total mesorectal excision using transanal port and laparoscopic assistance. Eur J Surg Oncol 37:334–335PubMedCrossRefGoogle Scholar
  28. 28.
    Zorron R, Phillips HN, Coelho D et al (2012) Perirectal NOTES access: “down-to-up” total mesorectal excision for rectal cancer. Surg Innov 19:11–19PubMedCrossRefGoogle Scholar
  29. 29.
    Zhang H, Zhang YS, Jin XW et al (2013) Transanal single-port laparoscopic total mesorectal excision in the treatment of rectal cancer. Tech Coloproctol 17:117–123PubMedCrossRefGoogle Scholar
  30. 30.
    Atallah S, Albert M, DeBeche-Adams T et al (2013) Transanal minimally invasive surgery for total mesorectal excision (TAMIS–TME): a stepwise description of the surgical technique with video demonstration. Tech Coloproctol 17:321–325PubMedCrossRefGoogle Scholar
  31. 31.
    Dumont F, Goéré D, Honoré C et al (2012) Transanal endoscopic total mesorectal excision combined with single-port laparoscopy. Dis Colon Rectum 55:996–1001PubMedCrossRefGoogle Scholar
  32. 32.
    Jorge JM, Wexner SD (1993) Etiology and management of fecal incontinence. Dis Colon Rectum 36:77–97PubMedCrossRefGoogle Scholar
  33. 33.
    Velthuis S, Nieuwenhuis DH, Ruijter TE et al (2014) Transanal versus traditional laparoscopic total mesorectal excision for rectal carcinoma. Surg Endosc. doi: 10.1007/s00464-014-3636-1
  34. 34.
    Lacy AM, Adelsdorfer C, Delgado S et al (2013) Minilaparoscopy-assisted transrectal low anterior resection (LAR): a preliminary study. Surg Endosc 27:339–346PubMedCrossRefGoogle Scholar
  35. 35.
    Lacy AM, Delgado S, Rojas OA et al (2008) MA-NOS radical sigmoidectomy: report of a transvaginal resection in the human. Surg Endosc 22:1717–1723PubMedCrossRefGoogle Scholar
  36. 36.
    Sylla P, Bordeianou LG, Berger D et al (2013) A pilot study of natural orifice transanal endoscopic total mesorectal excision with laparoscopic assistance for rectal cancer. Surg Endosc 27:3396–3405PubMedCrossRefGoogle Scholar
  37. 37.
    De Lacy AM, Rattner DW, Adelsdorfer C et al (2013) Transanal natural orifice transluminal endoscopic surgery (NOTES) rectal resection: “down-to-up” total mesorectal excision (TME): short-term outcomes in the first 20 cases. Surg Endosc 27:3165–3172PubMedCrossRefGoogle Scholar
  38. 38.
    Quirke P, Steele R, Monson J et al (2009) Effect of the plane of surgery achieved on local recurrence in patients with operable rectal cancer: a prospective study using data from the MRC CR07 and NCIC-CTG CO16 randomised clinical trial. Lancet 373:821–828PubMedCentralPubMedCrossRefGoogle Scholar
  39. 39.
    Chouillard E, Chahine E, Khoury G et al (2014) Notes total mesorectal excision (TME) for patients with rectal neoplasia: a preliminary experience. Surg Endosc 28:3150–3157PubMedCrossRefGoogle Scholar
  40. 40.
    Quirke P, Durdey P, Dixon MF et al (1986) Local recurrence of rectal adenocarcinoma due to inadequate surgical resection. Histopathological study of lateral tumour spread and surgical excision. Lancet 2:996–999PubMedCrossRefGoogle Scholar
  41. 41.
    Atallah S, Nassif G, Polavarapu H et al (2013) Robotic-assisted transanal surgery for total mesorectal excision (RATS-TME): a description of a novel surgical approach with video demonstration. Tech Coloproctol 17:441–447PubMedCrossRefGoogle Scholar
  42. 42.
    Verheijen PM, Consten ECJ, Broeders IA (2014) Robotic transanal total mesorectal excision for rectal cancer: experience with a first case. Int J Med Robot. doi: 10.1002/rcs.1594
  43. 43.
    Leroy J, Barry BD, Melani A et al (2013) No-scar transanal total mesorectal excision: the last step to pure NOTES for colorectal surgery. JAMA Surg 148:226–230PubMedCrossRefGoogle Scholar
  44. 44.
    Lindsetmo RO, Delaney CP (2009) A standardized technique for laparoscopic rectal resection. J Gastrointest Surg 13:2059–2063PubMedCrossRefGoogle Scholar
  45. 45.
    Guillou PJ, Quirke P, Thorpe H et al (2005) Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet 365:1718–1726PubMedCrossRefGoogle Scholar
  46. 46.
    McLemore EC, Coker A, Jacobsen G et al (2013) eTAMIS: endoscopic visualization for transanal minimally invasive surgery. Surg Endosc 27:1842–1845PubMedCrossRefGoogle Scholar
  47. 47.
    Sachdeva AK, Russell TR (2007) Safe introduction of new procedures and emerging technologies in surgery: education, credentialing, and privileging. Surg Clin N Am 87:853–866PubMedCrossRefGoogle Scholar
  48. 48.
    Wexner SD, Berho M (2014) Transanal TAMIS total mesorectal excision (TME): a work in progress. Tech Coloproctol 18:423–425PubMedCrossRefGoogle Scholar
  49. 49.
    Zorron R, Phillips HN, Wynn G et al (2014) “Down-to-up” transanal NOTES total mesorectal excision for rectal cancer. Preliminary series of 9 patients. J Min Access Surg 10:144–150CrossRefGoogle Scholar
  50. 50.
    Atallah S, Martin-Perez B, Pinan J et al (2014) Robotic transanal total mesorectal excision: a pilot study. Tech Coloproctol 18:1047–1053PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Italia Srl 2014

Authors and Affiliations

  • S. E. Araujo
    • 1
  • B. Crawshaw
    • 2
  • C. R. Mendes
    • 3
  • C. P. Delaney
    • 4
  1. 1.Department of GastroenterologyUniversity of Sao Paulo Medical SchoolSão PauloBrazil
  2. 2.Department of SurgeryUniversity Hospitals Case Medical CenterClevelandUSA
  3. 3.Colorectal Surgery UnitHospital Santa IzabelSalvadorBrazil
  4. 4.Colorectal Surgery UnitUniversity Hospitals Case Medical CenterClevelandUSA

Personalised recommendations