Techniques in Coloproctology

, Volume 20, Issue 11, pp 775–778 | Cite as

Transanal total mesorectal excision: dissection tips using ‘O’s and ‘triangles’

  • M.-P. BernardiEmail author
  • A. L. A. Bloemendaal
  • M. Albert
  • M. Whiteford
  • A. R. L. Stevenson
  • R. Hompes
Multimedia Article



Transanal total mesorectal excision (taTME) requires specific technical expertise, as it is often difficult to ascertain the correct dissection plane. Consequently, one can easily enter an incorrect plane, potentially resulting in bleeding (sidewall or presacral vessels), autonomic nerve injury and urethral injury. We aim to demonstrate specific visual features, which may be encountered during surgery and can guide the surgeon to perform the dissection in the correct plane.


Specific features of dissection in the correct and incorrect planes are demonstrated in the accompanying video.


The ‘triangles’ created using appropriate traction can aid in performing a precise dissection in the correct plane. Recognition of features described as ‘O’s can alert surgeons that they are entering a new fascial plane and can avoid incursion into an incorrect plane.


Understanding and recognizing the described features which can be encountered in taTME surgery, a safe and accurate TME dissection can be facilitated.


Total mesorectal excision Transanal TME ‘O’sand ‘triangles’ 


Compliance with ethical standards

Conflict of interest

Matthew Albert is a paid consultant for Applied Medical and ConMed. Andrew Stevenson receives an Honorarium from Applied Medical for workshops and proctoring taTME. Roel Hompes is a regular faculty member of TAMIS courses for Applied Medical. The remaining authors have no conflicts of interest to declare.

Ethical approval

All procedures performed were in accordance with the ethical standards of the institutions and with the 1964 Helsinki declaration and its later amendments.

Informed consent

Informed consent was obtained from all individual participants included in the study for the purposes of video footage.

Supplementary material

Supplementary material 1 (MP4 474155 kb)


  1. 1.
    Sylla P, Rattner DW, Delgado S, Lacy AM (2010) NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance. Surg Endosc 24:1205–1210CrossRefPubMedGoogle Scholar
  2. 2.
    Araujo SE, Crawshaw B, Mendes CR, Delaney CP (2015) Transanal total mesorectal excision: a systematic review of the experimental and clinical evidence. Tech Coloproctol 19:69–82CrossRefPubMedGoogle Scholar
  3. 3.
    Atallah S (2015) Transanal total mesorectal excision: full steam ahead. Tech Coloproctol 19:57–61CrossRefPubMedGoogle Scholar
  4. 4.
    (NICE) NIfHaCE (2015), Transanal total mesorectal excision of the rectum, inteventional procedure guidance. Accessed 22 Feb 2016
  5. 5.
    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
  6. 6.
    Burke JP, Martin-Perez B, Khan A et al (2016) Transanal total mesorectal excision for rectal cancer: early outcomes in 50 consecutive patients. Colorectal Dis 18:570–577CrossRefPubMedGoogle Scholar
  7. 7.
    Knol JJ, D’Hondt M, Souverijns G, Heald B, Vangertruyden G (2015) Transanal endoscopic total mesorectal excision: technical aspects of approaching the mesorectal plane from below—a preliminary report. Tech Coloproctol 19:221–229CrossRefPubMedGoogle Scholar
  8. 8.
    Nicholson G, Knol J, Houben B, Cunningham C, Ashraf S, Hompes R (2015) Optimal dissection for transanal total mesorectal excision using modified CO2 insufflation and smoke extraction. Colorectal Dis 17:O265–O267CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2016

Authors and Affiliations

  • M.-P. Bernardi
    • 1
    Email author
  • A. L. A. Bloemendaal
    • 2
  • M. Albert
    • 3
  • M. Whiteford
    • 4
  • A. R. L. Stevenson
    • 1
    • 5
  • R. Hompes
    • 2
  1. 1.Royal Brisbane and Women’s HospitalBrisbaneAustralia
  2. 2.Oxford University Hospitals NHS Foundation TrustOxfordUK
  3. 3.Florida Hospital OrlandoWinter Park, OrlandoUSA
  4. 4.Providence Portland Medical CenterPortlandUSA
  5. 5.University of QueenslandBrisbaneAustralia

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