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survival (91.5%), disease-free survival (91%) and local disease-free survival (97%) in the 43 patients who
[21]
fulfilled the criteria for watchful surveillance after local excision . A different study compared the func-
tional outcomes and quality of life of local excision vs. total mesorectal excision after chemoradiation, and
[22]
found that local excision achieved better results in both . The paucity of data will probably benefit from
prospective studies which have been set to assess the role of organ preserving strategies in a selected cat-
egory of rectal cancer patients, and TAMIS would probably be the ideal surgical approach [23,24] . One other
innovative indication for the TAMIS platform is the recently described transanal endoscopic submucosal
resection which is a hybrid procedure combining the skills of the endoscopist and the laparoscopic sur-
geon to remove large and complex rectal lesions (up to 18 cm in length). Preliminary results on 17 patients
from a tertiary referral centre, with complex lesions (> 5 cm lesions, recurrent polyps with submucosal
[25]
fibrosis) demonstrated the feasibility of the technique . Pioneers of the procedure reported 91% complete
endoscopic excision in a single session, sometimes requiring the combination of more than one endoscopic
[26]
technique (27% of cases) . Intraoperative bleeding (72.7%) was successfully controlled with clips and coag-
ulation; suturing was performed in 9%. Of those who completed the 3-6 months follow-up none developed
recurrences, whereas one patient was referred to surgery for a malignant polyp. Such innovations push the
boundaries of minimally invasive surgery as previously patients with large/complex lesions would have re-
quired an anterior resection.

WIDER APPLICATIONS OF THE TAMIS PLATFORM AND FUTURE DIRECTION
[12]
The TAMIS platform has seen rapid evolution, and the breath of applications continues to increase . Some
of these will be discussed below.

Transanal total mesorectal excision approach to rectal cancer excision
The spectrum of pathology that can be managed with TAMIS has broadened from excision of intralumi-
[28]
nal small rectal lesions to a full total mesorectal excision (TME) [14,27] . In 2015, Lacy et al. reported on
their experience in 140 cases, using a hybrid approach of transabdominal-taTME and several other series
have followed. The TaTME International registry is a prospective, secure online database where surgeons
can upload data of TAMIS proctectomy performed on a voluntary basis (https://tatme.medicaldata.eu/).
TaTME has been associated with poor pathological outcomes in less than 7.5% of patients, who - of note -
[29]
received surgery during the first years of technique development . The latest analysis available of patients
from the registry included data on 1540 rectal cancers, and confirmed the feasibility and safety of this
[30]
technique highlighting the key points for optimal short-term outcomes . The keenly anticipated COLOR
[31]
III trial aims to compare laparoscopic with taTME and should help address questions on the quality of
surgery in particular the oncological outcomes in the treatment of mid-low rectal cancers.
TAMIS for benign rectum excision
[32]
In 2012, Wolthuis et al. described a case report of transanal single port access to facilitate distal rectal
mobilization with hand-sewn coloanal anastomosis for a patient with refractory pelvic inflammation sec-
ondary to cryptoglandular fistula. In so doing, they proposed the further development of hybrid proce-
dures in paving the way to full transanal resection. TAMIS has since been used in hybrid technique with
transabdominal laparoscopic surgery/single incision laparoscopic surgery (SILS) for rectal excision in the
context of inflammatory bowel disease. This includes proctectomy in Crohn’s disease and also for restor-
ative proctocolectomy (RPC) or completion proctectomy and ileal pouch-anal anastomosis [i.e., transanal
ileal pouch anal anastomosis (IPAA) or ta-IPAA] in ulcerative colitis (UC) [33-36] . Ta-IPAA is done either as
a 2-stage (total proctocolectomy and IPAA/closure of ileostomy) or 3-stage procedure, i.e., with (subtotal
[34]
colectomy/proctectomy and IPAA/closure of ileostomy) . Ta-IPAA is often performed with close rectal
dissection and single stapled anastomosis. Early reports suggest the TAMIS platform is a feasible and safe
alternative to conventional laparoscopic RPC performed for UC. Advantages suggested include the facili-
tated pelvic dissection, avoidance of repeated application of staplers and when combined with SILS ap-