Transanal minimally invasive surgery (TAMIS) was introduced as an alternative to transanal endoscopic microsurgery in 2010. Over the past 4 years, considerable international experience has been gained with this approach. Most published reports focus on TAMIS for local excision of rectal neoplasia, but there are other important applications such as transanal mesorectal excision for rectal cancer. This comprehensive review details the progress with TAMIS since its inception. Robotic transanal surgery is a natural evolution of TAMIS still in its early infancy, which is also reviewed. A comprehensive search of PubMed, EMBASE, the Cochrane Library, and Web of Knowledge was performed. Since the inception of TAMIS in 2009, 33 retrospective studies and case reports, and 3 abstracts have been published on TAMIS for local excision of rectal neoplasms, which represents a combined n = 390 TAMIS procedures performed worldwide using eight different types of TAMIS platforms. A total of 152 lesions were excised for benign disease including adenomas and high-grade dysplasias (39 %), 209 for malignancy for carcinomas in situ and adenocarcinomas (53.5 %). Twenty-nine (7.5 %) of TAMIS resections were for other pathology, of which the majority (23/29) were neuroendocrine lesions. The remaining resections were for mucocele, gastrointestinal stromal tumor, melanoma, and fibrosis. Robotic-TAMIS has also been reported, however, data are extremely limited as there are only 7 case reports (combined n = 11) in the published literature. Success with Robotic-TAMIS has been demonstrated with various patient positions and by use of a special glove port. Transanal total mesorectal excision using the TAMIS platform has also been demonstrated is several small series, and the feasibility of performing pure transanal total mesorectal excision has also been reported. Combined, n = 78 cases of transanal total mesorectal excision have been performed using TAMIS. The advantages of TAMIS-assisted transanal total mesorectal excision are discussed.

A systematic review of transanal minimally invasive surgery (TAMIS) from 2010 to 2013

Background:Previous publications have suggested that endoscopic transanal proctectomy (ETAP) is a promising technique and may be an alternative to conventional low anterior resection for rectal cancer. The aim of this study was to evaluate the technical feasibility of ETAP, with a particular focus o

/pdf/a-step-toward-notes-total-mesorectal-excision-for-rectal-2u5sj2mo3y.pdf

A step toward NOTES total mesorectal excision for rectal cancer: endoscopic transanal proctectomy.

Background:Laparoscopic sphincter preservation for low rectal cancer is challenging because of the high risk of positive circumferential resection margin. We hypothesized that perineal dissection of the distal rectum may improve quality of surgery, compared with the conventional abdominal dissection

Perineal transanal approach: a new standard for laparoscopic sphincter-saving resection in low rectal cancer, a randomized trial.

Aim The surgical technique used for transanal total mesorectal excision (TaTME) was reviewed including the oncological quality of resection and the peri-operative outcome. Method A literature search of MEDLINE, Embase, Science Citation Index Expanded and Cochrane was performed in order to identify studies reporting on TaTME. Results Thirty-six studies (eight case reports, 24 case series and four comparative studies) were identified, reporting 510 patients who underwent TaTME. The mean age ranged from 43 to 80 years and the mean body mass index from 21.7 to 31.8 kg/m(2). The mean distance of the tumour from the anal verge ranged from 4 to 9.7 cm. The mean operation time ranged from 143 to 450 min and mean operative blood loss from 22 to 225 ml. The ratio of hand-sewn coloanal to stapled anastomoses performed was 2:1. One death was reported and the peri-operative morbidity rate was 35%. The anastomotic leakage rate was 6.1% and the reoperation rate was 3.7%. The mean hospital stay ranged from 4.3 to 16.6 days. The mesorectal excision was described as complete in 88% cases, nearly complete in 6% and incomplete in 6%. The circumferential resection margin was negative in 95% of cases and the distal resection margin was negative in 99.7%. Conclusion TaTME is a feasible and reproducible technique, with good quality of oncological resection. Standardization of the technique is required with formal training. Clear indications for this procedure need to be defined and its safety further assessed in future trials.

A systematic review of transanal total mesorectal excision: is this the future of rectal cancer surgery?

Over the last 20 years, laparoscopic colorectal surgery has shown equal efficacy for benign and malignant colorectal diseases when compared to open surgery. However, a laparoscopic approach reduces postoperative morbidity and shortens hospital stay. In the quest to optimize outcomes after laparoscopic colorectal surgery, reduction of access trauma could be a way to improve recovery. To date, one method to reduce access trauma is natural orifice specimen extraction (NOSE). NOSE aims to reduce access trauma in laparoscopic colorectal surgery. The specimen is delivered via a natural orifice and the anastomosis is created intracorporeally. Different methods are used to extract the specimen and to create a bowel anastomosis. Currently, specimens are delivered transcolonically, transrectally, transanally, or transvaginally. Each of these NOSE-procedures raises specific issues with regard to operative technique and application. The presumed benefits of NOSE-procedures are less pain, lower analgesia requirements, faster recovery, shorter hospital stay, better cosmetic results, and lower incisional hernia rates. Avoidance of extraction site laparotomy is the most important characteristic of NOSE. Concerns associated with the NOSE-technique include bacterial contamination of the peritoneal cavity, inflammatory response, and postoperative outcomes, including postoperative pain and the functional and oncologic outcomes. These issues need to be studied in prospective randomized controlled trials. The aim of this systematic review is to describe the role of NOSE in minimally invasive colorectal surgery.

Laparoscopic natural orifice specimen extraction-colectomy: a systematic review.

This study reports the short- and long-term results for a prospective rectal cancer management program using laparoscopic radical transanal abdominal transanal proctosigmoidectomy with coloanal anastomosis (TATA) after neoadjuvant therapy. A prospective database included 102 rectal cancer patients treated with laparoscopic TATA from 1998 to 2008. Patients with distant metastasis at presentation, patients with a tumor more than 3 cm from the anorectal ring, and patients not undergoing neoadjuvant therapy were excluded, leaving 79 patients (54 men and 25 women) with a mean age of 59.2 years (range, 22–85 years) for this study. 13 patients completed neoadjuvant therapy before the original evaluation, and they are excluded from the report of initial clinical assessment. Before treatment, 50 patients were staged as T3 and 16 patients as T2. The mean level in the rectum superior to the anorectal ring was 1.2 cm (range, −0.5 to 3 cm). In terms of fixity, 31 of the tumors were mobile, 27 were tethered, and 8 showed early fixation. Ulceration was absent in 8 cases, minimal in 12 cases, superficial in 7 cases, moderate in 22 cases, and deep in 17 cases. The mean pretreatment tumor size tumor was 4.8 cm (range, 1.5–12 cm). The median external beam radiation was 5,400 cGy (range, 3,000–8,040 cGy), and 77 patients underwent chemotherapy. The mean follow-up period was 34.2 months (range, 1.9–113.9 months). There were no perioperative mortalities. The conversion rate was 2.5%, and the mean largest incision length was 4.3 cm (range, 1.2–21 cm). For 84% of the patients, the incision was less than 6.0 cm, and 46% of the patients had no abdominal incision for delivery of the specimen. The mean estimated blood loss was 367 ml (range, 75–2,200 ml). All the patients had a temporary diverting stoma. The major morbidity rate was 11%, and the minor morbidity rate was 19%. The major complications included four full-thickness rectal prolapses with repair, one ischemic neorectum with successful reanastomosis, two bowel obstructions, and two failed anastomoses requiring stoma. The ypT stages included 22 complete responses, 12 cases of ypT1, 22 cases of ypT2, 23 cases of ypT3; 65 cases of ypN0, and 14 cases of ypN + (T3 = 7, T2 = 4, T1 = 3). The local recurrence rate was 2.5% (2/79), and the distant metastases rate was 10.1% (8/79). The KM5YAS rate was 97%. Overall, 90% of the patients lived without a stoma. Neorectal loss was due to positive margins or recurrence and was followed by abdominoperineal resection in three cases and ischemia in two cases. The condition of two patients was not reversed due to comorbidities, and one patient had a stoma secondary to bowel obstruction. The study results indicate excellent local recurrence (2.7%) and 5-year survival rates without the need for permanent colostomy in patients with cancers in the distal one-third of the rectum. Laparoscopic total mesorectal excision (TME) with the TATA approach is safe and can be performed laparoscopically. Multi-institutional studies are required to establish the reproducibility of this promising approach.

Laparoscopic transanal abdominal transanal resection with sphincter preservation for rectal cancer in the distal 3 cm of the rectum after neoadjuvant therapy

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Laparoscopic transanal abdominal transanal resection with sphincter preservation for rectal cancer in the distal 3 cm of the rectum after neoadjuvant therapy