A new solution to some old problems: transanal TME

Abstract

I predict that 2013 will be the year of endoscopic transanal approaches to radical low rectal dissection and anastomosis. The paper by Atallah et al. [1] and its video mirror the work of Lacy et al. [2] who recently presented in Barcelona and in Vienna the results of the first 40 cases of what he called abdomino-transanal TME. Last year, in this very journal, Zheng published the first case of transanal TME carried out entirely from below [3] shortly followed by Leroy et al. [4] who called it ‘‘no scar transanal TME’’, both using many of the same principles. It was too soon to claim oncological superiority to conventional laparoscopic TME, but Lacy’s principal message was that the dissection from below is ‘‘much easier’’ than either minimally invasive or open surgery from above. What could be more important for the management of a common cancer which continues to challenge the most experienced colorectal surgeons? You may never have heard of TAMIS TME which may or may not be the name finally attached by surgeons to the ideas in this paper—but these ideas are indeed of fundamental importance. The combination of the transanal approach, the use of a gas tight seal for anus or anorectum, and direct ‘‘holy plane’’ dissection around the mesorectum from below—these three together can revolutionise the practice of rectal cancer surgery. The authors of this paper describe the shortcomings of standard approaches from above—always particularly challenging in the obese male. They also describe the many problems of multi-stapling across the rectum which is almost entirely due to the obliquity of approach with straight instruments introduced via the abdomen. In my opinion, as a frequent ‘‘voyeur’’ of demonstration laparoscopic surgery, it is common for these difficulties to place the anastomosis lower down and nearer to the pubo-rectal sling than some cancers require from the oncological point of view. There is no doubt that the function enjoyed by a patient with an anastomosis at 6 cm from the anal verge is superior to that with one at 3 cm i.e. true colo-anal [5]. We can envisage an early approach to the lower end which starts by defining exactly the appropriate amount of ano-rectum to be retained for optimal function, washes out thoroughly beyond a carefully sealed tumour segment, and then optimises TME dissection and preservation of the autonomic nerves by gas assisted endoscopic ‘‘holy plane’’ dissection via the anus. The initial response by industry to the massively important challenge of optimising appropriate access is a space to watch over the coming months. At present the only specifically designed platform for TAMIS is the gel point path. Already approaches vary from the use of triports originally designed for single incision MIS through to the use of externally located robots, imaginatively introduced flexible cameras and the use of surgical gloves to convey a variety of instruments into the extra mesorectal space. The challenges are enormous but there will be rich rewards indeed for the companies that facilitate the access in the best possible way. More science will be required to measure the impact on anal function of the various devices and also the feasibility and indications for transanal extraction of the TME specimen. Whatever the instrumentation it seems probable that collaborative abdomino-transanal traction, counter-traction and peri-mesorectal dissection will achieve the major objectives better than our present reliance on the various trans-abdominal approaches. These are perhaps the means to achieve the precision that has hitherto eluded us in some areas of operative R. J. Heald (&) Pelican Cancer Foundation, Dinwoodie Drive, Basingstoke, Hampshire RG24 9NN, UK e-mail: j.peskett@pelicancancer.org