Transanal Total Mesorectal Excision Research Articles

Inflammatory stress response after transanal vs laparoscopic total mesorectal excision: a cohort study based on the TaLaR trial.

Transanal total mesorectal excision (taTME) is a novel approach to radical surgery for low rectal cancer; however, it is not clear whether taTME causes a more severe inflammatory stress response than laparoscopic total mesorectal excision (laTME). Therefore, the authors conducted this study to address this question, with the secondary objective of analyzing the predictive effect of inflammatory indexes on postoperative infective complications between laTME and taTME. A total of 545 cases of laTME and 544 cases of taTME from the TaLaR randomized controlled trial were included. Inflammatory stress response was assessed via C-reactive protein (CRP), white blood cell count, neutrophil-lymphocyte ratio, platelet-lymphocyte ratio, lymphocyte-monocyte ratio, and prognostic nutritional index. Inflammatory indexes were measured and calculated preoperatively (t1) and on postoperative days one (t2) and seven (t3). The accuracy of inflammatory indexes as predictor of infective complications was evaluated by areas under the receiver operating characteristic curve. Preoperative blood parameters were comparable between the two surgical methods. There were no significant differences in CRP, white blood cell count, neutrophil-lymphocyte ratio, platelet-lymphocyte ratio, lymphocyte-monocyte ratio, or prognostic nutritional index between the two surgical methods at any time point ( P >0.05). Among the inflammatory indexes at three time points, CRP on the first postoperative day was the most accurate predictor of infective complications, which is suitable for two surgical methods. The AUC was 0.7671 ( P <0.0001) with a cutoff of 39.84mg/l, yielding 94% sensitivity and 47% specificity. Compared with laTME, taTME surgery has no obvious disadvantage with respect to the postoperative inflammatory stress response. In addition, inflammatory indexes were favorable in predicting infective complications, with the best results for CRP on the first postoperative day. Defining the specific predictors for laTME and taTME is unnecessary.

Complications after TaTME in rectal cancer surgery

Introduction: Transanal endoscopic total mesorectal excision is an innovative surgical technique for the treatment of low rectal neoplasms. The method can improve both oncological outcomes and reduce the frequency of perioperative complications. However, there is no strong evidence to support such claims, and high-quality studies in the field are needed. Material and Methods: The study included 32 patients with rectal cancer who underwent transanal total mesorectal excision with laparoscopic assistance at the Department of Endoscopic, Endocrine Surgery and Coloproctology, Military Medical Academy in Sofia, Bulgaria, between 2017 and 2022. Perioperative complications were presented and classified according to the Clavien &amp; Dindo classification. Results: The mean age of the sample was estimated to be 66.09±8.94 years, with males accounting for 56.3%. No perioperative mortality was observed, and the postoperative complications rate was around 15% in the study group. Data were entered and processed using IBM SPSS Statistics® v20. Descriptive methods were used for the analysis of results for parametric and non-parametric variables. Conclusion: Based on the presented results and literature review, we can conclude that perioperative morbidity and mortality are comparable between the transanal and laparoscopic methods.

Can the Single-stapling Technique Following Intersphincteric Resection with Transanal Total Mesorectal Excision Become the New Standard Anastomosis?

For transanal total mesorectal excision (TaTME), the indication for single-stapling technique (SST) has been expanded to include lower anastomosis, even in intersphincteric resection (ISR). We focused on the anastomotic techniques following ISR with TaTME and examined the feasibility and safety of the SST below the anorectal junction (ARJ). Data on postoperative anastomosis-related complications and anorectal function was evaluated in comparison to conventional manual hand-sewn coloanal anastomosis in ISR with TaTME. We examined patients with 3-6 cm tumors from the anal verge who underwent ISR with TaTME between January 2018 and March 2020, and whose anastomotic line was located below the ARJ. Postoperative short-term outcomes and anorectal functions were compared. We also analyzed the effects of various factors on major low anterior resection syndrome (LARS) using multivariate logistic regression analysis. In total, 87 patients-48 in the hand-sewn anastomosis group and 39 in the SST group-were included in this study. SST below the ARJ in ISR with TaTME did not exacerbate surgical outcomes, including anastomosis-related complications. The SST group had a significantly lower LARS score as compared to the hand-sewn anastomosis group, and the proportion of major LARS was significantly lower. Only hand-sewn anastomosis was identified as a statistically significant independent risk factor for major LARS. In TaTME, SST below the ARJ was safe and feasible and had a lower negative impact on postoperative anastomosis-related complications and anorectal function as compared to hand-sewn anastomosis. Thus, SST is a promising anastomotic option for patients with low-lying rectal tumors.

Transanal Total Mesorectal Excision for Rectal Cancer: Toward Standardization of the Surgical Technique.

Laparoscopic surgery is widely used for rectal cancer; however, this technique is challenging due to tapering of the mesorectum in the pelvis, and the forward angle of the distal rectum, which renders this part of the rectum less accessible from the abdominal cavity. Hence, concerns regarding its safety and curability have been raised, particularly for inadequate distal and circumferential resection margins. Recently, transanal total mesorectal excision (TaTME), which involves endoscopic total mesorectal excision (TME) retrogradely from the anal side, has attracted attention worldwide as a solution to these problems. TaTME is superior to the conventional laparoscopic approach for rectal cancer in terms of both oncological and functional preservations. However, a shallow learning curve caused by the unfamiliar anatomical view from the anal side can pose challenges. Therefore, an efficient educational system needs to be established. Randomized controlled trials comparing conventional laparoscopic TME with TaTME are ongoing to demonstrate the usefulness of TaTME. This article reviews changes in the surgical treatment of rectal cancer, with a focus on TaTME, and describes the indications, surgical techniques, and training curricula for TaTME.

Comparing perioperative and oncological outcomes of transanal and laparoscopic total mesorectal excision for rectal cancer: a meta-analysis of randomized controlled trials and prospective studies.

Meta-analysis of the results of transanal total mesorectal excision (taTME) and laparoscopic TME (laTME) regarding perioperative and oncological outcomes have been conducted. Due to the lack of high-quality randomized controlled trials (RCTs) and prospective studies in the included literature, the conclusions are unreliable. This study included RCTs and prospective studies for analysis to obtain more reliable conclusions. Systematic searches of the PubMed, Embase, and Cochrane Library databases were conducted up to June 2023. To assess the quality, the Cochrane quality assessment tool and the Newcastle-Ottawa Scale were employed. The perioperative and oncological outcomes were then analyzed. The I2 statistic was used to evaluate statistical heterogeneity and sensitivity analyses was conducted. A total of 22 studies, comprising 5056 patients, were included in the analysis, of which 6 were RCTs and 16 were prospective studies. The conversion rate in the taTME group was significantly lower than that in the laTME group (OR 0.14, 95% CI 0.09 to 0.22, P < 0.01), and the circumferential resection margin (CRM) was longer (MD 0.99mm, 95% CI 0.66 to 1.32mm, P < 0.01), with a lower rate of positive CRM involvement (OR 0.68, 95% CI 0.47 to 0.97, P = 0.03). No statistically significant differences were found in terms of the operation time, intraoperative blood loss, complications, anastomotic leakage, uroschesis, obstruction, secondary operation, hospital stay, urethral injury, readmission, mortality rate within 30days, mesorectal resection quality, number of harvested lymph nodes, distal resection margin (DRM), positive DRM, local recurrence, and distance recurrence (P > 0.05). According to the findings of this meta-analysis, which is based on RCTs and prospective studies, taTME appears to have an advantage over laTME in terms of conversion rate and CRM involvement.

Impact of trans-anal versus laparoscopic total mesorectal excision on the surgical and pathologic outcomes of patients with rectal cancer: meta-analysis of randomized controlled trials.

Despite its profound impact on the oncologic outcomes of rectal cancer, the most optimal surgical approach to total mesorectal excision (TME) has not been identified yet. All previous meta-analyses on this subject have been based on observational studies. This meta-analysis was conducted to assess the surgical and oncologic outcomes of laparoscopic TME (LaTME) compared to trans-anal TME (TaTME), utilizing only randomized controlled trials. Systematic review and meta-analysis of randomized controlled trials. We searched electronic databases (MEDLINE, Cochrane CENTRAL, Clinicaltials.gov) from 2010 onwards, for all published clinical trials comparing TaTME to LaTME. Results are presented as risk ratios, with 95% CI, and pooled using the random effects model. A total of 1691 patients, from 6 eligible randomized controlled trials, were included for analysis. Analyzed data showed no significant difference in morbidity (RR: 0.85, p = 0.15), mortality (RR: 0.50, p = 0.44), conversion to open (RR: 0.40, p = 0.07), or anastomotic leakage (RR: 0.73, p = 0.10) between TaTME and LaTME. There was also no difference in the rate of positive distal resection margin (DRM) (RR: 0.55, p = 0.10) or positive circumferential resection margin (CRM) (RR: 0.67, p = 0.30). Patients undergoing TaTME were more likely to have a complete TME (RR: 1.06, p = 0.002) and shorter hospital stays (RR: - 0.97, p < 0.00001). Patients undergoing TaTME for rectal cancer were more likely to have a complete TME when compared to LaTME, though this did not translate into improved distal or circumferential resection margin. Additionally, TaTME and LaTME had similar surgical outcomes except for shorter length of stay with TaTME.

Transanal total mesorectal excision: single center study on risk factors for major complications.

Transanal total mesorectal excision (TaTME) as a novel surgical approach for mid and low rectal cancer has gained significant research interest in recent years. The main objective of this study is to identify the risk factors associated with major complications after TaTME and evaluate the perioperative clinical outcomes. A retrospective analysis was performed on the clinical data of patients with mid-to-low rectal cancer who underwent TaTME surgery and were admitted to the First Affiliated Hospital of Xiamen University from January 2018 to May 2023. Univariate and multivariate regression methods were employed to analyze the risk factors influencing the occurrence of major complications (Clavien-Dindo III-V). This study included a total of 179 eligible cases, with no perioperative deaths. The overall incidence of early complications was 25.1%, with a rate of 10.1% for mild complications and 15.0% for major complications. The postoperative anastomotic leakage rate within 30 days was 6.7%. Multivariate analysis demonstrated that male (P=0.030), pathological T ≥ 3 (P=0.018) and manual anastomosis (P=0.009) were independent risk factors for the development of major complications after surgery. In this study, the incidence of early complications and anastomotic leakage rate in TaTME were both relatively low. Male, pathological T stage ≥ 3 and manual anastomosis were independent risk factors for the occurrence of major complications in a cohort of patients with mid and low rectal cancer undergoing TaTME.

Transanal total mesorectal excision (TaTME) in rectal cancer treatment within an expert center

The objective of this study was to evaluate treatment outcomes in patients who underwent the TaTME procedure for cancer of the middle and low rectum in an expert center. Prospective analysis of the outcomes of all consecutive patients treated using the TaTME technique for cancer of the middle and distal rectum at the our medical center between March 1, 2015, and March 31, 2022. A total of 128 patients (34 women, 94 men; mean age 66.01 [38–85] years) with cancer of the middle and distal rectum qualified for TaTME. TaTME procedures were performed in 127/128 (99.22%) patients. Complications of surgery were observed in 22/127 (17.32%) patients. Negative proximal and distal margins were confirmed in all 127 patients. Complete (R0) resection of the mesorectum was confirmed in 125/127 (98.43%) and nearly complete (R1) resection was confirmed in 2/127 (1.57%) patients. The average follow-up period was 795 days (296–1522) days. Local recurrence was detected during the follow-up period in 2/127 (1.57%) patients. This study showed that the TaTME procedure is an effective and safe method for the minimally invasive treatment of middle and low rectal cancers, particularly within an expert center setting.

Robotic-assisted laparoscopic low anterior resection versus trans-anal total mesorectal excision for malignant rectal lesion: a prospective cohort trial

Introduction Colorectal carcinoma is one of the most common malignancies of the gastrointestinal tract. The aim of the present study was to compare the trans-anal total mesorectal excision (TaTME) to the robotic-assisted laparoscopic resection of mid- and low rectal carcinoma regarding the clinical and oncological outcome. Methods This was a prospective cohort study. This study was held on patients presenting with rectal cancer. Eighty patients were included divided into two groups, 40 patients were subjected to TaTME and 40 patients were subjected to robotic-assisted resection. Results Rectal resection was performed in both groups and the results were compared; total time was significantly less in TaTME group (mean time was 179.10 min in TaTME and 266.35 in robotic, P value &lt; 0.001), estimated blood loss was significantly less in TaTME group (mean was 130.50 ml in TaTME and 212 ml in robotic, P value=0.017), cost was significantly less in TaTME group (mean cost ×1000L.E was 46.15 in TaTME and 110.70 in robotic, P value less than 0.001), distal margin was significantly more in the robotic group (mean was 2.68 compared with 2.02 in TaTME, P value = 0.002), hospital stay was significantly less in the robotic group (mean of 4.6 days compared with 5.1 for TaTME, P value = 0.014) and there was no statistically significant difference concerning the total number of lymph nodes, proximal and circumferential margins. Conclusion This study suggests that robotic surgery is safe and effective and has some advantages concerning distal margins of low rectal resections. Also, TaTME can be compared with robotic surgery and represents an effective and less expensive alternative for robotic surgery.

Multicenter phase II trial of transanal total mesorectal excision for rectal cancer: preliminary results

BackgroundTransanal TME (taTME) combines abdominal and transanal dissection to facilitate sphincter preservation in patients with low rectal tumors. Few phase II/III trials report long-term oncologic and functional results. We report early results from a North American prospective multicenter phase II trial of taTME (NCT03144765).Methods100 patients with stage I–III rectal adenocarcinoma located ≤ 10 cm from the anal verge (AV) were enrolled across 11 centers. Primary and secondary endpoints were TME quality, pathologic outcomes, 30-day and 90-day outcomes, and stoma closure rate. Univariable regression analysis was performed to assess risk factors for incomplete TME and anastomotic complications.ResultsBetween September 2017 and April 2022, 70 males and 30 females with median age of 58 (IQR 49–62) years and BMI 27.8 (IQR 23.9–31.8) kg/m2 underwent 2-team taTME for tumors located a median 5.8 (IQR 4.5–7.0) cm from the AV. Neoadjuvant radiotherapy was completed in 69%. Intersphincteric resection was performed in 36% and all patients were diverted. Intraoperative complications occurred in 8% including 3 organ injuries, 2 abdominal and 1 transanal conversion. The 30-day and 90-day morbidity rates were 49% (Clavien–Dindo (CD) ≥ 3 in 28.6%) and 56% (CD ≥ 3 in 30.4% including 1 mortality), respectively. Anastomotic complications were reported in 18% including 10% diagnosed within 30 days. Higher anastomotic risk was noted among males (p = 0.05). At a median follow-up of 5 (IQR 3.1–7.4) months, 98% of stomas were closed. TME grade was complete or near complete in 90%, with positive margins in 2 cases (3%). Risk factors for incomplete TME were ASA ≥ 3 (p = 0.01), increased time between NRT and surgery (p = 0.03), and higher operative blood loss (p = 0.003).ConclusionWhen performed at expert centers, 2-team taTME in patients with low rectal tumors is safe with low conversion rates and high stoma closure rate. Mid-term results will further evaluate oncologic and functional outcomes.Graphical abstract

Beyond the transanal total mesorectal excision moratorium: local and distant recurrence among patients operated for low rectal tumours-5-year follow-up from a Norwegian University Hospital.

Beyond the transanal total mesorectal excision moratorium: local and distant recurrence among patients operated for low rectal tumours-5-year follow-up from a Norwegian University Hospital.

Bibliometric analysis and visualization of research trends in total mesorectal excision in the past twenty years.

Rectal cancer leads a major disease burden worldwide. Total mesorectal excision (TME) is the standard treatment for locally advanced or node-positive rectal cancer, while attempts to improve the surgery such as laparoscopic and transanal TME are widely used but have their inherent limitations. This bibliometric study analyzed research trends, cooperation, and knowledge dissemination on TME over the past 20 years to inform future directions. Relevant literature from 2003 to 2023 was extracted from the Web of Science Core Collection and analyzed with VOSviewer, CiteSpace, and R for publication patterns, countries, institutions, authors, and research hotspots. Five thousand three hundred forty-five related publications were included, with rising annual output and citations. The US and China contributed the most studies, while the Netherlands had greater influence. Leiden University ranked first in publications. The top authors were Heald, Kapiteijn, Sauer, Nagtegaal, and Peeters. Research shifted from cancer-focused to patient-centered care and from radiotherapy/chemotherapy to advanced surgery. Multicenter trials became more common. Although the United States and China have the largest number of publications, it should be noted that the influence of these two countries in the field of TME research is not the highest, which does not match the number of publications. In addition, telemedicine, interdisciplinary, medical-industrial integration, etc. may be potential directions for future research in the field of TME.

Transanal Total Mesorectal Excision and Fluorescence Ureteral Navigation for En Bloc Resection of Rectal Cancer With Pelvic Abscess.

Transanal Total Mesorectal Excision and Fluorescence Ureteral Navigation for En Bloc Resection of Rectal Cancer With Pelvic Abscess.

Consensus and operating guidelines of Chinese experts on transanal endoscopic surgery (2023 edition)

Although transanal endoscopic surgery has been developed for more than 40 years, it remains relatively unknown to most domestic colleagues. In 2019, the Chinese Society of Transanal Total Mesorectal Excision (CSTa) and the Chinese Society of Colon and Rectal Surgeons (CSCRS) organized domestic experts to write and publish the "Chinese Expert Consensus on Transanal Endoscopic Surgery (2019 Edition)", which elaborated on the definition, surgical methods, indications, contraindications, basic principles, key issues and complications of transanal endoscopic surgery, and provided a certain theoretical foundation for the development of transanal endoscopic surgery in China. In the past four years, the scope of application of transanal endoscopic techniques has been expanded, and many prospective and retrospective clinical research have provided more evidence-based medical evidence. Therefore, the Chinese Society of Transanal Total Mesorectal Excision (CSTa) once again organized domestic experts to write the "Expert Consensus and Operation Guidelines for Transanal Endoscopic Surgery in China (2023 Edition)", updating the expert consensus opinions on the definition, indications, complications and learning curve of transanal endoscopic surgery and adding operation guidelines. The aim is to promote the standardized practices in transanal endoscopic surgery and facilitate a shorter learning curve for surgeons.

Author response to: Comment on: Oncological outcomes after transanal total mesorectal excision for rectal cancer.

Author response to: Comment on: Oncological outcomes after transanal total mesorectal excision for rectal cancer.

SP5.5 Peri-operative, Oncological and Functional Outcomes of Robotic versus Transanal Total Mesorectal Excision in patients with Rectal Cancer: A Systematic Review and Meta-analysis

Abstract Background To evaluate comparative outcomes of robotic low anterior resection (RTME) and spinal Trans-anal total mesorectal excision (TaTME) in patients with low rectal cancer. Methods A systematic online search was conducted using the following databases: PubMed, Scopus, Cochrane database, The Virtual Health Library, Clinical trials.gov and Science Direct. Comparative studies comparing RTME versus TaTME for low rectal cancer were included. Primary outcomes were post-operative complications namely, anastomosis leak, SSI, overall complications rate, and Clavien-Dindo complications rate. Operative time, conversion to open, Intra-operative blood loss, ITU and hospital length of stay (LOS), post-operative complications, oncological outcomes, and functional outcomes were the evaluated outcome parameters. Results Twelve studies with a total number of 3025 patients divided between the Robotic group (n=1881) and TaTME group (n=1144) were included. There was a significant difference between the two groups regarding Operative time (P=0.39), conversion to open (P=0.29) and intra-operative blood loss (P= 0.62). Clavien-Dindo ≥ 3 complications rate (P=0.25), anastomosis leak (P= 0.89), re-operation (P=0.62), re-admission rate (P=0.92), R0 resection (P= 0.52), ITU LOS (P= 0.63) and total LOS (P=0.30) showed similar results between the two groups. RTME group showed a higher rate of harvested lymph nodes (P= 0.04) and completed TME (P=0.05). Wexner and LARS scores showed significantly better functional results in the RTME group compared to the TaTME group (P= 0.0009) and (P= 0.00001), respectively. Conclusion Compared to TaTME, RTME provides significantly better functional outcomes, a higher number of harvested lymph and complete TME with a similar postoperative complications rate.

130 Using Abdominal Fat Ratio to predict difficult laparoscopy – a potential indicator for Robotics/TaTME?

Abstract Introduction Minimally-invasive surgery has revolutionised colorectal cancer surgery. Intra-abdominal/visceral adiposity increases the chance of conversion to open surgery. Abdominal fat ratio (AFR) has been identified as predictive for this. New techniques, such as robotic platforms and Trans-anal Total Mesorectal Excision (TaTME), are generally less susceptible to visceral obesity. We hypothesise that AFR can predict difficult laparoscopic surgery and promote selective use of alternative surgical techniques. Methods Hospital coding data identified 117 anterior resection and abdominoperineal excision of the rectum procedures between April 2017 and March 2020. Planned/actual procedure and histological factors were recorded. AFR was calculated using the method from Scott et al (Ann R Coll Surg Engl 2017). Mann-Whitney U testing and binomial logistic regression were used to compare AFR between laparoscopic completed (LC) and conversion to open (CtO) groups. Results 73 cases were completed laparoscopically, 35 converted to open. 9 cases were planned open. AFR between LC and CtO groups was comparable (Median LC = 3.94; CtO = 3.64; U = 1220, p=0.71). Binomial logistic regression showed no relationship between AFR and conversion to open surgery (OR 1.11 95% confidence interval 0.92-1.36, p=0.27). Conclusion No statistically significant differences were found. This may result from the small numbers included but may also reflect the multifactorial nature of intra-operative decision-making. Post-chemoradiotherapy effects and difficulties obtaining safe views through inadequate small bowel retraction or bulky mesentery were cited more often in the conversion group than problematic visceral obesity. Other recognised factors should be considered in future, larger series analysis.

Comment on: Oncological outcomes after transanal total mesorectal excision for rectal cancer.

Comment on: Oncological outcomes after transanal total mesorectal excision for rectal cancer.

Predictors of Clostridium difficile infection after stoma reversal following TaTME surgery.

The aim of this study was to determine the incidence of Clostridium Difficile infection (CDI) after stoma reversal in patients who underwent transanal Total Mesorectal Excision (TaTME) and to evaluate variables correlated with this post-operative infection. Patients who underwent stoma reversal surgery following TaTME for rectal cancer between 2015 and 2023 at a high-volume Institution, were retrospectively reviewed for the post-operative occurrence of diarrhea and in-hospital CDI (positive toxin in the stools). Patients were divided into the following subgroups according to the post-operative course: Group A-no clinical symptoms; Group B-mild diarrhea (< 10 evacuations/day); Group C-severe watery diarrhea (> 10 evacuations/day) with CDI negative; and Group D-severe watery diarrhea (> 10 evacuations/day) CDI positive. Clinical and laboratory data were analyzed for their correlation with CDI. A machine learning approach was used to determine predictors of diarrhea following stoma reversal. A total of 126 patients were selected, of whom 79 were assessed as Group A, 16 Group B, 25 Group C and 6 (4.8%) Group D. Univariable analysis documented that delayed stoma reversal correlated with CDI (Group A mean interval 44.6weeks vs. Group D 68.4weeks, p 0.01). The machine learning analysis confirmed the delay in stoma closure as a probability factor of presenting diarrhea; also, diarrhea probability was 80.5% in males, 77.8% in patients who underwent neoadjuvant therapy, and 63.9% in patients who underwent adjuvant therapy. Stoma reversal surgery can result in moderate rate of in-hospital CDI. Time-to stoma reversal is a crucial variable significantly related with this adverse outcome.

Transanal Total Mesorectal Excision Considering the Embryology Along the Fascia in Rectal Cancer Patients.

Transanal total mesorectal excision (TaTME) remains a challenging technique for rectal dissection. This study aimed to evaluate the clinical and oncological outcomes of TaTME, compared to those of the laparoscopic TME (LaTME) in rectal cancer. Using propensity score-matched analyses, we analyzed retrospective data from 134 consecutive patients with rectal cancer who underwent TaTME or LaTME from January 2011 to June 2020 in our hospital. Clinical and oncological outcomes were evaluated. The primary endpoint was the 2-year local recurrence rate. Before data analysis, significant group-dependent differences were observed only in the tumor height (p<0.01). After analysis, preoperative patient demographics were similar between the TaTME and LaTME groups. The operative time was significantly shorter in the TaTME group (p=0.02), and the rates of hand-sewn anastomosis and protective loop ileostomy were significantly higher (p<0.01). The TaTME group showed a null conversion to open surgery compared to the LaTME group (5.9%). The postoperative complications, including anastomotic leak, were comparable between the two groups. However, the rate of Clavien-Dindo grade III tended to be lower in the TaTME group (p=0.07). There were no statistically significant differences in terms of pathological findings, and the 2-year local recurrence rate was similar between the two groups (both 5.9%). TaTME based on embryology along the fascia is feasible and seems a safe alternative to LaTME in selected patients with rectal cancer when considering the conversion rate and the operative time.