Techniques in Coloproctology

, Volume 21, Issue 10, pp 783–794 | Cite as

Operative vectors, anatomic distortion, fluid dynamics and the inherent effects of pneumatic insufflation encountered during transanal total mesorectal excision

  • S. Atallah
  • P. Gonzalez
  • S. Chadi
  • R. Hompes
  • J. Knol
Challenges in Coloproctology



Transanal total mesorectal excision (taTME) is an altogether different approach to rectal cancer surgery, and the effects of carbon dioxide (CO2) on this dissection remain poorly described.


This article critically examines the effect of carbon dioxide insufflation and the workspace it creates during the process of taTME. The unique aspects of insulation with this approach are governed by the laws of physics, especially the principles of fluid dynamics, an area that remains poorly described for laparoscopy and not at all described for taTME.


A summary of established factors which affect the operative field of the taTME surgeon is delineated and further explored. In addition, new concepts regarding gas delivery, such as insufflation vectors, anatomic distortion, hyper-dissection, and workspace volume rate of change as a function of taTME dissection time, are addressed. Collectively, these factors pose important challenges which increase case complexity and are thus essential for taTME trainers and trainees alike to understand.


Although an invisible gas, CO2 insufflation with taTME produces markedly visible effects which are imposed upon the operative field. This can result in anatomic distortion and misperception of operative planes. Thus, practicing taTME surgeons should be cognizant of these effects.


Operative vectors taTME Pneumopelvis TAMIS Anatomic distortion: insufflation vectors Hyper-TME Hyper-mesorectal excision Reverse polarity Fluid dynamics 



The authors appreciate the invaluable assistance of Stephanie Philippaerts and the iLappSurgery Foundation in development of medical illustrations contained herein.

Compliance with ethical standards

Conflict of interest

Dr. S. Atallah is a consultant for ConMed, Inc, Ethicon, Applied Medical, Inc, MedRobotics, Medicaroid, Inc and THD America. Dr. J. Knol, R. Hompes, P. Gonzalez and S. Chadi have no financial disclosures. Design of some illustrations included in this manuscript was funded by iLappSurgery Foundation.

Ethical approval

This research was performed in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained in accordance with the standards set forth by hospital regulations.


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Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  • S. Atallah
    • 1
  • P. Gonzalez
    • 2
  • S. Chadi
    • 3
  • R. Hompes
    • 4
  • J. Knol
    • 5
  1. 1.Center for Colon and Rectal SurgeryFlorida HospitalWinter ParkUSA
  2. 2.NOVA Southeastern University, College of Osteopathic MedicineDavieUSA
  3. 3.University of Toronto, UHN - Toronto Western HospitalTorontoCanada
  4. 4.Oxford University Hospitals NHS Trust OxfordOxfordUK
  5. 5.Jessa Hospital-HasseltHasseltBelgium

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