From TEM to TME

Abstract

L eroy and colleagues 1 report their exceptional achievement in providing for a patient with rectal neoplasia an oncologically packaged TME entirely via a pure natural orifice (transanal, transrectal) approach. While the ultimate pathology proved benign (and so meaning that a more conventional intraluminal microsurgical/endoscopic resection would also have conferred a cure in this particular instance), Leroy and colleagues have studiously developed an operative strategy whose realization is more than just a potential additional niche in our therapeutic armamentarium for midto low-rectal tumors. Their implicit separation of the mesorectal excision component from the mesocolic lymphadenectomy inherent to the standard transabdominal operation (whatever the access) may also portend an era of stratified resective extent for colorectal cancer individualized by preoperative staging and molecular profiling. While clearly considerably extra effort is still required by the surgical team to optimize procedure standardization and patient selection criteria, the PROGRESSS technique reported by Leroy and colleagues in itself manifests a direct clinical end point of much cumulative work, experience, and expertise by the authors in collaboration and indeed collegiate competition with their peers around the world including dedicated developmental travail in allied, complimentary, evolutionary access procedures such as miniport, reduced port, and singleaccess laparoscopy as well as TEM/TEO. Rather than rely on the “future technological advances” much beloved as a concluding statement by many NOTES idealists, no experimental or prototype instrumentation was needed for this procedure’s performance and while principled (and perhaps prejudiced) TEM and TME advocates may critique the operation from their own specific perspectives, sound ethical, surgical, and oncological principles have been applied. Above all, this accomplishment should focus all our attention on surgical technical perfection and specialization to further drill down into specifications of operative precision for the presenting pathology.