Total Mesorectal Excision Technique Research Articles

Total mesorectal excision in MRI-defined low rectal cancer: multicentre study comparing oncological outcomes of robotic, laparoscopic and transanal total mesorectal excision in high-volume centres.

The routine use of MRI in rectal cancer treatment allows the use of a strict definition for low rectal cancer. This study aimed to compare minimally invasive total mesorectal excision in MRI-defined low rectal cancer in expert laparoscopic, transanal and robotic high-volume centres. All MRI-defined low rectal cancer operated on between 2015 and 2017 in 11 Dutch centres were included. Primary outcomes were: R1 rate, total mesorectal excision quality and 3-year local recurrence and survivals (overall and disease free). Secondary outcomes included conversion rate, complications and whether there was a perioperative change in the preoperative treatment plan. Of 1071 eligible rectal cancers, 633 patients with low rectal cancer were identified. Quality of the total mesorectal excision specimen (P = 0.337), R1 rate (P = 0.107), conversion (P = 0.344), anastomotic leakage rate (P = 0.942), local recurrence (P = 0.809), overall survival (P = 0.436) and disease-free survival (P = 0.347) were comparable among the centres. The laparoscopic centre group had the highest rate of perioperative change in the preoperative treatment plan (10.4%), compared with robotic expert centres (5.2%) and transanal centres (2.1%), P = 0.004. The main reason for this change was stapling difficulty (43%), followed by low tumour location (29%). Multivariable analysis showed that laparoscopic surgery was the only independent risk factor for a change in the preoperative planned procedure, P = 0.024. Centres with expertise in all three minimally invasive total mesorectal excision techniques can achieve good oncological resection in the treatment of MRI-defined low rectal cancer. However, compared with robotic expert centres and transanal centres, patients treated in laparoscopic centres have an increased risk of a change in the preoperative intended procedure due to technical limitations.

Customized Denonvilliers' Fascia Excision: An Advanced Total Mesorectal Excision Technique for Anteriorly Located Rectal Cancer.

The role of Denonvilliers' fascia in achieving a negative circumferential resection margin during anterior total mesorectal excision has been controversial. Opinions on whether to dissect in the anterior or posterior surgical plane varies among researchers. We performed total mesorectal excision with selective en bloc resection of Denonvilliers' fascia based on preoperative MRI staging, preoperative clinical tumor stage, and tumor level in selected patients with anterior rectal tumors adherent to Denonvilliers' fascia. Between March and August 2021, 5 patients who underwent robotic (n = 4) and laparoscopic (n = 1) total mesorectal excision for anteriorly located low rectal adenocarcinomas after neoadjuvant chemoradiotherapy were enrolled in this study. Transabdominal total mesorectal excision dissection is performed by changing to a plane anterior to Denonvilliers' fascia, with partial or total excision tailored to the tumor level and depth of invasion as a further step in circumferential resection margin clearing. Customized excision of Denonvilliers' fascia was performed by dissecting through the extramesorectal plane. This anterior plane permits resection of Denonvilliers' fascia, exposing the prostate and seminal vesicles. Two tumors were located at the seminal vesicle level and 3 were found at the prostate level. The mean distance from the anal verge to the distal margin of the tumor was 4.8 ± 0.9 cm. Denonvilliers' fascia was preserved in 1 patient and partially excised in 4. Customized Denonvilliers' fascia excision was performed in 3 robotic ultralow anterior resections with coloanal anastomosis, 1 laparoscopic ultralow anterior resection with coloanal anastomosis, and 1 robot-assisted abdominoperineal resection. The circumferential resection margins in all patients were negative. Anterior dissection in front of Denonvilliers' fascia can be selectively performed during total mesorectal excision based on preoperative planning, tumor location, and clinical tumor stage. Preoperative MRI and magnified operative views in minimally invasive platforms provide access to more precise surgical planes for clear circumferential resection, achieving optimal functional outcomes and oncological safety.

Transanal Total Mesorectal Excision for Malignant Rectal Lesion: A Prospective Cohort Study

AIMS: The main outcome of this study was to use the transanal total mesorectal excision (TaTME) technique for rectal cancer resection and to assess as a primary endpoint the short-term oncological outcome; in terms of circumferential resection margin, longitudinal resection margins (proximally and distally), and lymph nodes (LN) retrieval, while secondary endpoints were operative time, estimated blood loss, length of hospital stay, cost per case, and overall complication rate. METHODS: This was a prospective cohort study. Forty patients were included and subjected to TaTME from May 2018 to January 2020 and patients were followed up for a period of 6 months. RESULTS: Primary endpoint: Depending on the post-operative specimen pathological assessment; circumferential resection margin (CRM) was free in all patients, proximal resection margins had a mean 14.37 2.87 cm, distal resection margins had a mean 2.08 ± 0.4 cm and LNs retrieval had a mean 13.27 ± 5.9, and number of positive LNs had a mean 2.40 ± 3.77. Secondary endpoints: Mean total operative time (from induction of anesthesia till skin closure) was 179.10, estimated blood loss (using gauze visual analog plus what was obtained in the OR suction device) was 133.67 66.59 ml, the length of hospital stay (admission till discharge) was 5.27 ± 1.08 days, cost per case had a mean (in 1000 USD) 2.95 ± 0.12, and overall complication rate was 10%. CONCLUSION: TaTME represents a promising complementary technique to laparoscopic TME in the step of low rectal dissection.

Rectal washout does not increase the complication risk after anterior resection for rectal cancer

BackgroundTo reduce local recurrence risk, rectal washout (RW) is integrated in the total mesorectal excision (TME) technique when performing anterior resection (AR) for rectal cancer. Although RW is considered a safe practice, data on the complication risk are scarce. Our aim was to examine the association between RW and 30-day postoperative complications after AR for rectal cancer.MethodsPatients from the Swedish Colorectal Cancer Registry who underwent AR between 2007 and 2013 were analysed using multivariable methods.ResultsA total of 4821 patients were included (4317 RW, 504 no RW). The RW group had lower rates of overall complications (1578/4317 (37%) vs. 208/504 (41%), p = 0.039), surgical complications (879/4317 (20%) vs. 140/504 (28%), p < 0.001) and 30-day mortality (50/4317 (1.2%) vs. 12/504 (2.4%), p = 0.020). In multivariable analysis, RW was a risk factor neither for overall complications (OR 0.73, 95% CI 0.60–0.90, p = 0.002) nor for surgical complications (OR 0.62, 95% CI 0.50–0.78, p < 0.001).ConclusionsRW is a safe technique that does not increase the 30-day postoperative complication risk after AR with TME technique for rectal cancer.

Robot-Assisted Nerve-Sparing Eradication of Deep Endometriosis

Study Objective To demonstrate anatomical and technical highlights of a robot-assisted nerve-sparing surgery for deep endometriosis (DE). Design Stepwise demonstration of the technique. Setting An urban general hospital. Laparoscopic nerve-sparing techniques represented by the Negrar method have been described as resulting in lower rates of postoperative bladder, rectal, and sexual dysfunctions than classical approaches. However, few papers have shown the surgical technique for this procedure using a robotic approach in DE. Patients or Participants N/A Interventions Robot-assisted nerve-sparing excision of DE was performed using the following 8 steps: Step 1, adhesiolysis and adnexal surgery; Step 2, checking the ureteral course; Step 3, separation of the nerve plane [Step 3-1, dissection of the avascular layer below the hypogastric nerve, between the prehypogastric nerve fascia and presacral fascia); and Step 3-2, dissection of the avascular layer above the hypogastric nerve, between the prehypogastric nerve fascia and the fascia propria of the rectum]; Step 4, reopening of the pouch of Douglas; Step 5, complete removal of DE lesions while avoiding injury to the nerve plane; Step 6, hysterectomy (if the patient desires non-fertility-sparing surgery); Step 7, checking for rectal injury using an air leakage test; and Step 8, barrier agents for adhesion prevention. Measurements and Main Results No patients developed postoperative bladder, rectal, and sexual dysfunctions after the surgery. This nerve-sparing method is a modification of the technique of total mesorectal excision (TME) and total mesometrial resection (TMMR). We considered that this nerve-sparing technique is also applicable to segmental bowel resection and radical hysterectomy. Conclusion Robot-assisted nerve-sparing eradication of DE is as technically feasible as the conventional laparoscopic approach. The step-by-step technique should help perform each part of the surgery in a logical sequence, making the procedure easier and safer to complete.

Fertility- and Nerve-Sparing Laparoscopic Eradication of Deep Endometriosis with Anterior and Posterior Compartment Peritonectomy

Study Objective To show anatomical and technical highlights of novel nerve-sparing laparoscopic eradication of deep endometriosis (DE) with anterior and posterior compartment peritonectomy. Design Stepwise demonstration of the technique. Setting An urban general hospital. Laparoscopic nerve-sparing techniques represented by the Negrar method have been described as resulting in lower rates of postoperative bladder, rectal, and sexual dysfunctions than classical approaches. In addition, a recent paper showed that complete excision of DE with the posterior compartment peritonectomy could be surgical treatment of choice to decrease postoperative pain, improve fertility rate, and prevent future recurrence. However, a fertility- and nerve-sparing procedures are even more challenging than oncologic radical procedures because the pathology resembles advanced cervical cancer and ovarian cancer. Patients or Participants N/A Interventions After adhesiolysis and ovarian surgery, we developed retroperitoneal space at the level of promontory. The hypogastric nerve consists of the upper edge of pelvic plexus, so autonomic nerves were separated as a “nerve plane“ by sharp interfascial dissection of the loose connective tissue layers both above (between fascia propria of rectum and prehypogastric nerve fascia) and below (between prehypogastric nerve fascia and presacral fascia) the hypogastric nerve. As a result of these dissections, autonomic nerves in pelvis were separated like a sheet with surrounding fascia. We then completely resected all DE lesions including peritoneal endometriosis while avoiding injury to the nerve plane. Measurements and Main Results No patients (n=40) developed postoperative bladder, rectal, and sexual dysfunctions after the surgery. This nerve-sparing method is a modification of the technique of total mesorectal excision (TME) and total mesometrial resection (TMMR). We considered that this nerve-sparing technique is also applicable to segmental bowel resection and radical hysterectomy. Conclusion Our novel nerve-sparing surgery based on detailed meso-anatomy reproducibly simplify this complex procedure. Step-by-step technique help to perform each part of the surgery in a logical sequence, making the procedure easier and safer to complete.

New trends in neoadjuvant therapy of locally advanced rectal cancer from a surgeons perspective - a commentary.

Rectal cancer treatment advanced rapidly during last decades. The most important factors of this progress are new neoadjuvant therapy options, improvement in imaging (allowing for quality staging and restaging) and routine implementation of the total mesorectal excision technique. For the best outcomes, it is crucial to combine the treatment methods in the best way possible with ideal timing. It is necessary to keep in mind both advantages and complications of the individual kinds of approach. Therefore, interdisciplinary agreement is essential in the treatment of rectal cancer. Considering these new therapeutic possibilities, the debate about timing, indication and radicality of the surgical procedures is reopened. Surgical approaches are currently focused on mini-invasive methods and robotic surgery. New trend with promising potential seems to be clinical complete response achievement with watch and wait follow-up strategy. This approach, in the spirit of the organ sparing philosophy, however asks new questions about indication, timing and conception of this method. Proper answers are essential for sparing, yet radical oncotherapy of this disease.

Robotic Surgery for Rectal Cancer: Hype or Hope? (Indian Experience).

The primary goal to achieve cure in oncology is to reduce recurrence, maximize disease-free survival, maintain function, and optimize quality of life. Surgery remains the mainstay treatment modality in rectal cancer. The current trend is to perform least invasive method of doing complex surgeries while not compromising in the oncological of functional outcomes of patients. Total mesorectal excision (TME) for rectal cancer surgery entails removal of the rectum with its fascia as an intact unit while preserving surrounding vital structures. The procedure is technically challenging because of the narrow and deep pelvic cavity housing the rectum encased by fatty lymph vascular tissue within the perirectal fascia, distally the anal sphincter complex, and an intimate surrounded by vital structures like ureter, vessels, and nerves. Robotic technology enables overcoming these difficulties caused by complex pelvic anatomy. This system can facilitate better preservation of the pelvic autonomic nerve and thereby achieve favorable postoperative sexual and voiding functions after rectal cancer surgery. The nerve-preserving TME technique includes identification and preservation of the superior hypogastric plexus nerve, bilateral hypogastric nerves, pelvic plexus, and neurovascular bundles.

Transanal Total Mesorectal Excision.

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.

Total Mesorectal Excision Technique-Past, Present, and Future.

While the treatment of rectal cancer is multimodal, above all, a proper oncological resection is critical. The surgical management of rectal cancer has substantially evolved over the past 100 years, and continues to progress as we seek the best treatment. Rectal cancer was historically an unsurvivable disease, with poor understanding of the embryological planes, lymphatic drainage, and lack of standardized technique. Major improvements in recurrence, survival, and quality of life have resulted from advances in preoperative staging, pathologic assessment, the development and timing of multimodal therapies, and surgical technique. The most significant contribution in advancing rectal cancer care may be the standardization and widespread implementation of total mesorectal excision (TME). The TME, popularized by Professor Heald in the early 1980s as a sharp, meticulous dissection of the tumor and mesorectum with all associated lymph nodes through the avascular embryologic plane, has shown universal reproducible reductions in local recurrence and improvement in disease-free and overall survival. Widespread education and training of surgeons worldwide in the TME have significantly impact outcomes for rectal cancer surgery, and the procedure has become the gold standard for curative resection of rectal cancer. In this article, we discuss the evolution of the standard abdominal approach to the TME, with emphasis on the history, relevant anatomy, standard procedure steps, oncologic outcomes, and technical evolution.

Oncological safety of transanal total mesorectal excision (TaTME) for rectal cancer: mid-term results of a prospective multicentre study.

There is no consensus regarding the gold standard technique for rectal cancer as Total Mesorectal Excision (TME) may be safely performed either by open or minimally invasive surgery. The laparoscopic approach, however, may carry technical difficulties. For this reason, a novel technique has emerged in the last decade combining a dual laparoscopic dissection (abdominal and transanal) to perform the TME technique (TaTME). When focusing on oncological outcomes, there is a lack of literature regarding mid-long term results. The aim of this study is to evaluate the mid-term oncological impact of TaTME for treating rectal cancer. A prospective multicentre study was performed in four tertiary centres including consecutive patients who underwent TaTME for mid-low rectal cancer by the same group of experienced surgeons. The analysed data included pathological results on the quality of TME and mid-term oncological outcomes. In total, 173 patients were included throughout a study period of 6years. Our series included 70% males and 68% of patients with neoadjuvant treatments. The median follow-up was 23 [15-37.5] months. Regarding pathological results, a complete TME was achieved in 72.8%, while circumferential and distal margins were affected in 1.4 and 1.1%, respectively. Five patients developed local recurrences (3%) and 8.1% presented distant disease during the follow-up. The 2-year disease-free survival and the overall survival rates were 88% and 95%, respectively. There is currently a lack of evidence in the literature regarding TaTME and oncological outcomes with no data available from randomized clinical trials. In the meantime, the reported results from different multicentre series are controversial. This study showed positive mid-term outcomes at 2 years of follow-up and supported notable oncological outcomes with TaTME. However, it must be emphasized that previous experience in minimally invasive and transanal surgeries is essential for surgeons before intending to perform TaTME.

A seven-step dissection technique for robotic total mesorectal excision of rectal cancer.

A seven-step dissection technique for robotic total mesorectal excision of rectal cancer.

Comparison of posterior rectal dissection techniques during rectosigmoid colon resection as part of cytoreductive surgery in patients with epithelial ovarian cancer: Close rectal dissection versus total mesorectal excision

ObjectiveThe aim of this study was to evaluate the clinical outcomes of close rectal dissection (CRD) compared with those of total mesorectal excision (TME) as the posterior rectal dissection procedure during rectosigmoid colectomy performed as part of cytoreductive surgery in patients with epithelial ovarian cancer. MethodsWe retrospectively reviewed the medical records of 163 patients who underwent posterior rectal dissection for rectosigmoid resection, including low anterior resection or subtotal colectomy, as part of ovarian cancer surgery from 2006 to 2018. The TME technique was mainly performed by colorectal surgeons, and the CRD technique preserving the mesorectal tissue was performed by an experienced gynecologic oncology surgeon. The patients were divided into the TME group and the CRD group, and their clinical outcomes were analyzed. ResultsA total of 163 patients with ovarian cancer underwent rectosigmoid colon resection. Among the patients, 87 (53.4%) underwent CRD and 76 (46.6%) underwent TME as the posterior rectal dissection technique. The disease severity according to FIGO stage (p = .390) and the residual disease status (p = .412) were not statistically different between the 2 groups. However, the postoperative incidences of anastomotic leakage (p = .045) and prolonged ileus (>7 days, p = .055) were higher in the TME group. The pelvic recurrence rate and progression-free survival did not differ between the 2 groups (p = .663 and .790, respectively). ConclusionsConsidering the perioperative outcomes, CRD may be an alternative technique for rectal dissection in ovarian cancer with less perioperative morbidity and equivalent oncologic outcomes.

A New Technique for Safe and Nerve Preserving Total Mesorectal Excision

Summary Our purpose was to present a technique of pneumodissection applied with total mesorectal excision that ensured effective pelvic nerve preservation. Its detailed description emphasized the role of the proper definition of optimal dissection plane around the rectal cancer, the so-called ‘holy plane’ for total mesorectal excision. The study covered 28 rectal cancer patients at a mean age of 58±7.6 years (range 53 to 69 years). Rectal cancers were of TNM stages I-III and differentiation grades of G1-G3. Total mesorectal excision with pneumodissection between 2011 and 2016 was performed. Inflation of the pararectal space with CO2 improved visualization of the operative field between visceral and parietal fascia thus preserving plexus (pl.) vesicalis, pl. deferentialis, pl. prostaticus and pl. cavernosus penis. A fast and clean mesorectum mobilization was made without any damage to the visceral fascia, and total mesorectal excision was performed in the embryonal plane. Pl. hypogastricus superior in the region of the aortic bifurcation nervi (nn.) hypogastrici dextri et sinistri laterally to the rectum and pl. hypogastricus inferior were preserved, too. Encouraging postoperative results included pelvic nerve preservation and absence of complications. A broader application of the safe method of pneumodissection in open and laparoscopic rectal cancer surgery should be recommended.

Impact of multidisciplinary tumor boards on patients with rectal cancer.

Οncological outcomes in patients with primary rectal cancer have markedly improved over the last few years, mainly due to the widespread application of the total mesorectal excision technique. This improvement should also be largely attributed to multiple specialties, other than colorectal surgery, such as radiology, oncology and pathology. Therefore, a multimodal approach is key to efficient and appropriate rectal cancer management. Multidisciplinary tumor (MDT) boards have become an important asset for the management and treatment of patients with rectal cancer, and a number of studies published to date suggest the beneficial effect of the multidisciplinary approach on the management of such patients. The available evidence demonstrates a modification of the treatment plan, attributed to the MDT implementation, in a non-negligible proportion of these patients. However, more studies are required in order to assess the exact impact of MDT boards on disease-free and overall survival of patients with primary rectal cancer.

Transanal conformal resection for super low rectal cancer

Intersphincteric resection(ISR) is a valuable anus-preserving operation that avoids the need for permanent stoma in patients with super low rectal cancer. Recently, with the application and promotion of ISR, the rate of anus-preservation has been greatly elevated, however, some patients following ISR had poor anal function. Based on the knowledge of anal canal anatomical features for better anal function, we propose conformal sphincter-preserving operation (CSPO) for super low rectal cancer, which is a new integrated anus-preservation procedure with total mesorectal excision (TME), coloanal anastomosis, pull through resection, anal canal dissection, local resection and natural orifice transluminal endoscopic surgery technology. CSPO includes pull through conformal resection (PTCR) and transanal conformal resection (TaCR). This article focuses on the problems about TaCR for very low rectal cancer and introduces TaCR combined with our practical experience. The indications for the TaCR operation should be according to the conventional laparoscopic surgery. In addition, the TaCR operation has its special indications: the tumor location is within 2 cm of the dental line; the tumor is well differentiation (moderately to well differentiation); the diameter of the tumor is not more than 3 cm or no more than the 1/3 circle of intestinal wall; and the depth of invasion is T1-T2. Patients with a clinical complete remission after neoadjuvant radiochemotherapy can receive TaCR. The laparoscopic five hole method is used to carry out the abdominal operation with TME technique. It is unnecessary to dissection intersphincter space. The incisional line is made according to the tumor location and shape to preserve the opposite normal rectal wall, internal sphincter and dentate line as more as possible via transanal resection. After closing the rectal stump by interrupted sutures, a circular stapler or hand suture is use to perform the anastomosis as far from the dentate line as possible. Protective loop ileostomy is performed. Postoperative complications, including anastomotic leakage, abdominal infection, and anastomotic bleeding, should be remembered. If there is any signs of these complications, intervention should be done as soon as possible.

Reappraisal of the lateral rectal ligament: an anatomical study of total mesorectal excision with autonomic nerve preservation.

The term "lateral rectal ligament" in surgery for rectal cancer has caused confusion regarding its true existence and contents. In previous studies, investigators claimed the existence of the ligament and described its topographical features as neurovascular structures and their surrounding connective tissues located at the anterolateral aspect of the distal rectum or the posterolateral aspect of the middle rectum. The purpose of this study is to evaluate the structure of the so-called "lateral rectal ligament" in cadaver dissections. Dissection was performed in nine cadavers (eight males and one female, aged 73 to 94years) in accordance with typical total mesorectal excision techniques. During dissection, structures related to "the ligament" were examined and images recorded. At the anterolateral aspect of the distal rectum, the middle rectal artery was noted to be crossing the fusion of Denonvilliers' fascia and the proper rectal fascia. At the posterolateral aspect of the middle rectum, there was a structure which consisted of the rectal nerves running through the fusion of the pelvic fasciae. Although called "ligaments," neither structure contained discrete strong connective tissue fixing the rectum to the pelvic wall. The proper rectal fascia and surrounding pelvic fasciae fuse firmly anterolaterally and posterolaterally where neurovascular structures course toward the rectum. During a total mesorectal excision, the surgical dissection plane coincides with the fused part of the fasciae, which had long been considered the "lateral rectal ligament."

Update on robotic surgery for rectal cancer treatment

Laparoscopic total mesorectal excision (TME) is technically demanding and has a steep learning curve. Moreover, two recent randomized controlled trials have questioned the oncological safety of laparoscopic treatment for rectal cancer. Robotic surgery, thanks to its technical advantages, could potentially overcome the intrinsic limitations of standard laparoscopy. In this paper we will describe the surgical technique of robotic TME and review the recent literature on robotic rectal surgery. Short term, functional and oncological outcomes will be taken into consideration, as well as learning curve and costs. Robotic rectal resection is reported to have lower conversion rates (CRs), better functional outcomes and shorter learning curve, with comparable oncological results. Robotic surgery remains more time consuming and affected by higher costs. The technological advantages provided by the robotic system could probably facilitate the widespread adoption of minimally-invasive TME, that still has a low penetration worldwide. The educational capabilities of the platform, together with structured training programs, could allow novice surgeons to safely approach colorectal surgery.

Update on robotic surgery for rectal cancer treatment

Laparoscopic total mesorectal excision (TME) is technically demanding and has a steep learning curve. Moreover, two recent randomized controlled trials have questioned the oncological safety of laparoscopic treatment for rectal cancer. Robotic surgery, thanks to its technical advantages, could potentially overcome the intrinsic limitations of standard laparoscopy. In this paper we will describe the surgical technique of robotic TME and review the recent literature on robotic rectal surgery. Short term, functional and oncological outcomes will be taken into consideration, as well as learning curve and costs. Robotic rectal resection is reported to have lower conversion rates (CRs), better functional outcomes and shorter learning curve, with comparable oncological results. Robotic surgery remains more time consuming and affected by higher costs. The technological advantages provided by the robotic system could probably facilitate the widespread adoption of minimally-invasive TME, that still has a low penetration worldwide. The educational capabilities of the platform, together with structured training programs, could allow novice surgeons to safely approach colorectal surgery.

Advantages of transanal approach in low rectal cancer resections

Laparoscopic surgery is proven equal technique to open rectal surgery. Despite advantages, some problems in case of low rectal surgery are existing: visualization of the pelvis, securing safe distal resection margin, preparing single stapled rectal stump with safe conjunction to the colorectal anastomosis. Approximately 500 procedures have been performed worldwide until today by applying Transanal Total Mesorectal Excision (TaTME) technique, which evolved from a combination of laparoscopy and transanal approach. TaTME presents a solution to the low and mid-level rectal cases. The transanal path provides a better opportunity for preparing safe distal resection margin, an easier way for making a secure distal stump closure, and also offers perfect visualization even in the most difficult area, supporting the aim of nerve-sparing. We present a case, where we performed a synchronous laparoscopic and transanal TaTME resection of a down-sized low rectal tumor at 5 cm, after neoadjuvant radio-chemotherapy. To the best of our knowledge, this was the first case in Hungary, when TaTME was administered in a synchronous way.