Transanal Total Mesorectal Excision.

Abstract

The ability to effectively manage patients with rectal cancer is perhaps the defining characteristic of colon and rectal surgeons. From a historical perspective, the first attempts at resection of the rectum were reported in the early 1800s by Lisfranc.[1] Kocher described the removal of the coccyx and Kraske popularized this perineal approach. The first abdominal attempts at rectal resection were performed at the turn of the 20th century.[2] Modifications to the abdominal perineal resection were reported into the 1920s. The introduction of the circular stapler in the 1970s changed the face of rectal cancer surgery and facilitated lower anastomoses.[3] This technical revolution greatly facilitated sphincter preservation. However, oncologic success in the management of rectal cancer lagged behind the avoidance of stomas. It was not until the importance of the mesorectum was understood that pelvic recurrence was significantly reduced. The “holy plane” of rectal surgery was described in 1988 by Heald[4]; soon thereafter the importance of tumor-free circumferential margins was realized. The understanding of the importance of the total mesorectal excision (TME) for oncologic success grew and became the standard approach for the treatment of rectal cancer. It has been 30 years since the concepts of TME and tumor-free circumferential resection margins were introduced. These three decades have brought many technological surgical advances enhancing our ability to accomplish the task with less invasive measures. However, there have been no changes to the technique of TME other than the size of the incision created. The introduction of the transanal TME (taTME) in 2010[5] was the first innovation in the technique of TME in the past 25 years. Facilitated by advances in instrumentation, the transanal approach grew from an access point for local excision to one, which offered surgeons the ability to perform a complete oncologic resection of the rectum. This method gives surgeons a totally new perspective to the lower third of the pelvis, which has historically been the most challenging portion of the TME from the traditional approach. TaTME requires a thorough understanding of the planes and pelvic anatomy from a new vantage point. Mastery of this novel approach to the treatment of rectal cancer offers patients a minimally invasive resection with potentially better visualization and therefore a better quality of the resected specimen. This volume is a compilation of informative references from many of the pioneers of the technique of taTME. This issue provides the reader with a thorough summary of the anatomical basis for TME and the development of transanal surgical techniques. With a comprehensive understanding of the anatomic principles of rectal cancer surgery and the technologic advances in transanal surgery, one can then make the transition to the new “down to up” taTME approach to rectal cancer treatment. The evolution of the technique is presented followed by detailed step-by-step instructions. After a comprehensive review of the results and potential complications of taTME, the final sections will guide the reader through the process of learning taTME with standardized platforms and tips for safe and successful adaption of the technique. This Clinics in Colon and Rectal Surgery issue will conclude with a look to the future and the potential for the approach of taTME to facilitate extended resections with technological advances. It is with a debt of gratitude and sincere thanks to the contributing authors that the editors offer this collection of thoughtful works prepared by the pioneers of taTME.