Techniques in Coloproctology

, Volume 19, Issue 4, pp 221–229 | Cite as

Transanal endoscopic total mesorectal excision: technical aspects of approaching the mesorectal plane from below—a preliminary report

  • J. J. Knol
  • M. D’Hondt
  • G. Souverijns
  • B. Heald
  • G. Vangertruyden
Original Article
First Online:
Received:
Accepted:

Abstract

Background

Laparoscopic total mesorectal excision (TME) for low rectal cancer can be technically challenging. This report describes our initial experience with a hybrid laparoscopic and transanal endoscopic technique for TME in low rectal cancer.

Methods

Between December 2012 and October 2013, we identified patients with rectal cancer < 5 cm from the anorectal junction (ARJ) who underwent laparoscopic-assisted TME with a transanal minimally invasive surgery (TAMIS) technique. A standardized stepwise approach was used in all patients. Resection specimens were examined for completeness and measurement of margins. Preoperative magnetic resonance imaging (MRI) characteristics and short-term postoperative outcomes were examined. All values are mean ± standard deviation.

Results

Ten patients (8 males; median age: 60.5 (range 36–70) years) were included. On initial MRI, all tumors were T2 or T3, mean tumor height from the ARJ was 28.9 ± 12.2 mm, mean circumferential resection margin was 5.3 ± 3.1 mm , and the mean angle between the anal canal and the levator ani was 83.9° ± 9.7°. All patients had had preoperative chemoradiotherapy, TME via TAMIS, and distal anastomosis. There were no intraoperative complications, anastomotic leaks, or 30-day mortality. The pathologic quality of all mesorectal specimens was excellent. The distal resection margin was 19.4 ± 10.4 mm, the mean circumferential resection margin was 13.8 ± 5.1 mm, and the median lymph node harvest was 10.5 (range 5–15) nodes.

Conclusions

A combined laparoscopic and transanal approach can achieve a safe and oncologically complete TME dissection for low rectal tumors. This approach may improve clinical outcomes in these technically difficult cases, but larger prospective studies are needed.

Keywords

Rectal cancer Total mesorectal excision Transanal Notes Distal washout Ballooning 
This is a preview of subscription content, log in to check access.

Notes

Acknowledgments

We acknowledge Mrs. Ria Raijmakers for creation of the illustrations used in this manuscript. The authors are grateful to Dr. Yarrow McConnell for assistance in writing the manuscript.

Conflict of interest

None.

References

  1. 1.
    Heald RJ (1988) The “holy plane” of rectal surgery. J R Soc Med 81:503–533PubMedCentralPubMedGoogle Scholar
  2. 2.
    Martling AL, Holm T, Rutqvist LE, Moran BJ, Heald RJ, Cedemark B (2000) Effect of a surgical training programme on outcome of rectal cancer in the County of Stockholm. Stockholm Colorectal Cancer Study Group, Basingstoke Bowel Cancer Research Project. Lancet 356:93–96CrossRefPubMedGoogle Scholar
  3. 3.
    Kapiteijn E, Putter H, Van de Velde CJ (2002) Cooperative investigators of the Dutch ColoRectal Cancer Group: impact of the introduction and training of total mesorectal excision on recurrence and survival in rectal cancer in The Netherlands. Br J Surg 89:1142–1149CrossRefPubMedGoogle Scholar
  4. 4.
    Heald RJ (2013) A new solution to some old problems: transanal TME. Tech Coloproctol 17:257–258CrossRefPubMedGoogle Scholar
  5. 5.
    Marks J, Mizrahi B, Dalane S, Nweze I, Marks G (2010) Laparoscopic transanal abdominal transanal resection with sphincter preservation for rectal cancer in the distal 3 cm of the rectum after neoadjuvant therapy. Surg Endosc 24:2700–2707CrossRefPubMedGoogle Scholar
  6. 6.
    Zorron R, Philips HN, Coelho D, Flach L, Lemos FB, Vassallo RC (2012) Perirectal NOTES access: “down-to-up” total mesorectal excision for rectal cancer. Surg Innov 19:11–19CrossRefPubMedGoogle Scholar
  7. 7.
    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 27:3478–3484CrossRefPubMedCentralPubMedGoogle Scholar
  8. 8.
    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 56:408–415CrossRefPubMedGoogle Scholar
  9. 9.
    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 27:3165–3172CrossRefPubMedGoogle Scholar
  10. 10.
    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 27:3396–3405CrossRefPubMedGoogle Scholar
  11. 11.
    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 18:473–480CrossRefPubMedGoogle Scholar
  12. 12.
    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 100:828–831CrossRefPubMedGoogle Scholar
  13. 13.
    Cahill RA (2013) Single port surgery for rectal cancer-going up or down? Dis Colon Rectum 56:1199–1200CrossRefPubMedGoogle Scholar
  14. 14.
    Wolthuis AM, van Overstraeten ADB, D’Hoore A (2014) Dynamic article: transanal rectal excision: a pilot study. Dis Colon Rectum 57:105–109CrossRefPubMedGoogle Scholar
  15. 15.
    Velthuis S, Nieuwenhuis DH, Ruijter TE, Cuesta MA, Bonjer HJ, Sietses C (2014) Transanal versus traditional laparoscopic total mesorectal excision for rectal carcinoma. Surg Endosc 28:3494–3499CrossRefPubMedGoogle Scholar
  16. 16.
    Zorron R, Philips HN, Wynn G, Neto MP, Coelho D, Vassallo RC (2014) “Down-to-up” transanal NOTES Total mesorectal excision for rectal cancer: preliminary series of 9 patients. J Minim Access Surg 10:144–150CrossRefPubMedCentralPubMedGoogle Scholar
  17. 17.
    Nivatvongs S, Stern HS, Fryd DS (1981) The length of the anal canal. Dis Colon Rectum 24:600–601CrossRefPubMedGoogle Scholar
  18. 18.
    Knol JJ, Wexner SD, Vangertruyden G (2014) Laparoscopic mobilization of the splenic flexure: the use of color-grading as a unique teaching tool. Surg Endosc 29:734–735CrossRefPubMedGoogle Scholar
  19. 19.
    Atallah S, Albert M, DeBeche-Adams T, Nassif G, Polavarapu H, Larach S (2013) Transanal minimally invasive surgery for total mesorectal excision (TAMIS–TME): a stepwise description of the surgical technique with video demonstration. Tech Coloproctol 17:321–325CrossRefPubMedGoogle Scholar
  20. 20.
    Quirke P, Durdey P, Dixon MF, Williams NS (1986) Local recurrence of rectal adenocarcinoma due to inadequate surgical resection: histopathological study of lateral tumor spread and surgical excision. Lancet 2:996–999CrossRefPubMedGoogle Scholar
  21. 21.
    Nagtegaal ID, van de Velde CJ, van der Worp E, Kapitein E, Quirke P, van Krieken JH (2002) Macroscopic evaluation of rectal cancer resection specimens: clinical significance of the pathologist in quality control. J Clin Oncol 1:1729–1734CrossRefGoogle Scholar
  22. 22.
    Dworak O, Keilholz L, Hoffmann A (1997) Pathological features of rectal cancer after preoperative radiochemotherapy. Int J Colorectal Dis 12:19–23CrossRefPubMedGoogle Scholar
  23. 23.
    Hamilton E (1892) Ballooning of the rectum. Transactions of the royal academy of medicine in Ireland, section of surgery 12(10):159–165CrossRefGoogle Scholar
  24. 24.
    Bondeven P, Hagemann-Madsen RH, Laurberg S, Pedersen BG (2013) Extent and completeness of mesorectal excision evaluated by postoperative magnetic resonance imaging. Br J Surg 100:1357–1367CrossRefPubMedGoogle Scholar
  25. 25.
    Brannigan AE, De Buck S, Suetens P, Penninckx F, D’Hoore A (2006) Intracorporeal rectal stapling following laparoscopic total mesorectal excision: overcoming a challenge. Surg Endosc 20:952–955CrossRefPubMedGoogle Scholar
  26. 26.
    Ito M, Sugito M, Kobayashi A, Nishizawa Y, Tsunoda Y, Saito N (2008) Relationship between multiple numbers of stapler firings during rectal division and anastomotic leakage after laparoscopic rectal resection. Int J Colorectal Dis 23:703–707CrossRefPubMedGoogle Scholar
  27. 27.
    Umpleby HC, Fermor B, Symes MO, Williamson RC (1984) Viability of exfoliated colorectal carcinoma cells. Br J Surg 71:659–663CrossRefPubMedGoogle Scholar
  28. 28.
    McGregor JR, Galloway DJ, McCulloch P, George WD (1989) Anastomotic suture materials and implantation metastasis: an experimental study. Br J Surg 76:331–334CrossRefPubMedGoogle Scholar
  29. 29.
    Matsuda A, Kishi T, Musso G et al (2013) The effect of intraoperative rectal washout on local recurrence after rectal cancer surgery: a meta-analysis. Ann Surg Oncol 20:856–863CrossRefPubMedGoogle Scholar
  30. 30.
    Koh PK, Tang CL, EU KW, Samuel M, Chan E (2007) A systematic review of the function and complications of colonic pouches. Int J Colorectal Dis 22:543–548CrossRefPubMedGoogle Scholar
  31. 31.
    Brown CJ, Fenech DS, McLeod RS (2008) Reconstructive techniques after rectal resection for rectal cancer. Cochrane Database Syst Rev 16:CD006040Google Scholar
  32. 32.
    Mang W, Lau K (2014) Synchronous laparoscopic low anterior and transanal endoscopic microsurgery total mesorectal excision. Minim Invasive Ther Allied Technol 23:70–73CrossRefGoogle Scholar

Copyright information

© Springer-Verlag Italia Srl 2015

Authors and Affiliations

  • J. J. Knol
    • 1
  • M. D’Hondt
    • 2
  • G. Souverijns
    • 3
  • B. Heald
    • 4
  • G. Vangertruyden
    • 1
  1. 1.Department of Abdominal SurgeryJessa HospitalHasseltBelgium
  2. 2.Department of Abdominal SurgeryGroeninge HospitalKortrijkBelgium
  3. 3.Department of RadiologyJessa HospitalHasseltBelgium
  4. 4.Colorectal Research Unit, The Ark Conference CentrePelican Cancer FoundationBasingstoke, HampshireUK

Personalised recommendations