Transanal endoscopic total mesorectal excision: technical aspects of approaching the mesorectal plane from below-a preliminary report

Laparoscopic total mesorectal excision (TME) for low rectal cancer can be technically challenging. This report describes our initial experience with a hybrid laparoscopic and transanal endoscopic technique for TME in low rectal cancer. Between December 2012 and October 2013, we identified patients with rectal cancer < 5 cm from the anorectal junction (ARJ) who underwent laparoscopic-assisted TME with a transanal minimally invasive surgery (TAMIS) technique. A standardized stepwise approach was used in all patients. Resection specimens were examined for completeness and measurement of margins. Preoperative magnetic resonance imaging (MRI) characteristics and short-term postoperative outcomes were examined. All values are mean +/- A standard deviation. Ten patients (8 males; median age: 60.5 (range 36-70) years) were included. On initial MRI, all tumors were T2 or T3, mean tumor height from the ARJ was 28.9 +/- 12.2 mm, mean circumferential resection margin was 5.3 +/- 3.1 mm , and the mean angle between the anal canal and the levator ani was 83.9 degrees +/- 9.7 degrees. All patients had had preoperative chemoradiotherapy, TME via TAMIS, and distal anastomosis. There were no intraoperative complications, anastomotic leaks, or 30-day mortality. The pathologic quality of all mesorectal specimens was excellent. The distal resection margin was 19.4 +/- 10.4 mm, the mean circumferential resection margin was 13.8 +/- 5.1 mm, and the median lymph node harvest was 10.5 (range 5-15) nodes. A combined laparoscopic and transanal approach can achieve a safe and oncologically complete TME dissection for low rectal tumors. This approach may improve clinical outcomes in these technically difficult cases, but larger prospective studies are needed.