Transanal Total Mesorectal Excision - a New Approach to the Minimally Invasive Surgical Treatment of Rectal Cancer with Mid and Distal Location

Abstract

Introduction: Transanal reversed Total Mesorectal Excision is an innovative high-tech method with an exponentially increasing use worldwide since its introduction by Antonio Lacy in 2011. The technique was developed using a single port - platform to improve the quality of the total mesorectal excision of rectal cancer with low- and middle- third localization. The distal mesorectum is processed by a transanal access in the caudo-cranial direction which facilitates its dissection with adequate visual indication of the distal margin. This technology potentially offers a more precise performance of “acute” dissection with a higher percentage of complete removal of the specimen in ablastic borders and a lower percentage of tumor involvement of circumferential resection line. This approach is applied in highly specialized centers but there are still no randomized clinical trials examining the full advantages and drawbacks of this new technology. COLOR III, which launched in late 2015, is the first large-scale study of this kind. Despite the potential benefits and enthusiasm in introducing this method, the method of implementation is relatively complex, it requires serious technical security and a long learning curve. Certain relatively new serious complications associated with this procedure, which are not observed in conventional approaches, have been observed in smaller cohorts. Iatrogenic lesion of the urethra, injury to the structures of lateral pelvic wall with life-threatening bleeding as well as lesions on the lower hypogastric nerves are documented complications occurring less frequently in “conventional laparoscopic” cranio-caudal TME. Introduction of this technique requires serious training programs, preparation of guidelines and monitoring of results. These requirements are the target of the scheduled in May, 2016 TaTME Congress in Amsterdam.Materials and Methods: We used surgical treatment by a reversed (transanal) single port - technique with 3D - visualization of caudo-cranial (down to up) stage of TME in 19 patients with low and middle rectal cancer operated on by the author`s team in the university tertiary center KSSG - St. Gallen, Switzerland, following the criteria of COLOR III multicenter randomized trial with reporting of intra and early postoperative results. Transabdominal laparoscopic single-port approach was used simultaneously in the abdominal stage to mobilize the left colon. All patients were discussed at the preoperative tumor-board with their data from endoscopic, histological and imaging (MRI, PET-CT scan) examinations prior to being included in the study cohort.Results: The average age of the operated patients was 68.7 with the gender distribution being - 59% men and 41% women. All patients have received preoperative radiotherapy. 17 of the patients have been postoperatively histologically confirmed, according to the quality of TME as a whole (complete), performed with intact fascia propria recti and in two patients there was partly damaged fascia. pR0 resection was performed on all of the patients . In all patients underwent protective ileostomy for 6 weeks. There were no major intraoperative complications. During the early postoperative period, the postoperative complications were as follows: Clavien-Dindo I-IIIa - 4 patients; Clavien-Dindo IIIa-IV - 0 patients.Discussion: The evolving tendency towards minimally invasive surgical approaches to rectal cancer continues to face problems such as the necessity of adequate visual exposure of the pelvis, distal ablastic rectal division, lower pelvic anastomosis as well as the appropriate for all of this technical equipment. Laparoscopic transanal total mesorectal excision was developed as an innovative alternative that offers certain advantages over the problems of conventional open and laparoscopic rectal surgery but presented its own specific problems the solution of which requires a coordinated approach at a multinational level.