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Page 2 of 7 Yellinek et al. Mini-invasive Surg 2018;2:22 I http://dx.doi.org/10.20517/2574-1225.2018.17

[3]
of TaTME was the introduction of transanal endoscopic surgery (TEM). In 1992, Buess et al. presented
their experience with TEM, which utilizes a 40-mm operating rectoscope sealed with an airtight face piece.
Carbon dioxide is constantly infused, thereby distending the rectum and maintaining visibility. A variety
of operating instruments can be inserted through the face piece to resect adenomas and selected early car-
[4]
[3]
cinomas of the mid and upper rectum . In 2010, Sylla et al. presented the first case of TaTME using TEM
and laparoscopy that had been performed in a 76-year-old patient with a T2N2 rectal cancer treated with
preoperative chemoradiation. The specimen was transanally transected followed by a hand sewn coloanal
anastomosis. TEM was not widely adopted due to its high costs, technical complexity and the long learning
[5]
curve. However, Maya et al. showed by Cussum analysis that the learning curve for TEM is associated
with a significant decrease in operative time after only four cases.

[6,7]
Atallah et al. presented the use of transanal single port laparoscopy through the anal canal (transanal
minimally invasive surgery; TAMIS). A single-incision laparoscopic surgery port was introduced into the
anal canal to gain endoscopic access to the rectum, pneumorectum was established, and transanal excision
was performed using laparoscopic instruments.

TaTME combines the TAMIS and trans-abdominal approaches in order to achieve TME. Several potential
advantages have been postulated. Atallah was the first to describe this combination of techniques including
[8,9]
a detailed video and the results of the 20 first cases . Rectal distention with CO combined with magni-
2
fied optics permits excellent visualization of tissue planes. Easier access to the low rectum may aid the
surgeon with better quality TME and precise selection of the distal resection margin under direct visual-
ization helps ensure an adequate margin. TaTME may potentially be a safer anastomosis by avoiding the
multiple stapler firings often required in the abdominal approach and may result in higher rates of sphinc-
ter preserving surgery. Finally, the two-team approach can shorten the length of surgery.

CLINICAL TRIALS
[10]
Lacy et al. reported a series of 140 patients who underwent TaTME for rectal cancer. The mean operative
time was 166 min and there were no conversions or intraoperative complications. Macroscopic quality as-
sessment of the resected specimen was complete in 97.1% and near complete in 2.1%. Thirty-day morbidity
was minor (Clavien-Dindo I-II) in 24.2% and major (Clavien-Dindo III-IV) in 10%, and no mortality oc-
curred within the first 30 days. The mean follow-up was 15 months, with a 2.3% local recurrence rate and a
7.6% rate of systemic recurrence.

[11]
De Lacy et al. subsequently reported the pathological results of 186 patients who underwent TaTME for
low (37%) or mid (63%) rectal cancer. Mesorectal resection quality was complete in 95.7%, near complete
in 1.6%, and incomplete in 1.1%. Overall positive CRM and DRM were 8.1% and 3.2%, respectively. The
composite of complete mesorectal excision, negative CRM, and negative DRM was achieved in 88.1% of
patients.

[12]
Penna et al. reported the short-term clinical and oncological results of the first 720 patients on behalf of
the International Registry for TaTME. Seven hundred and twenty consecutive patients from 66 registered
units in 23 countries included 634 patients with rectal cancer and 86 with benign pathology. Conversion to
open surgery was 6.3% and the mesorectum was complete in 86%, near complete in 11%, and incomplete
in 4%. The R1 resection rate was 2.7%. Post-operative morbidity and mortality were 32.6% and 0.5%, re-
spectively. Risk factors for poor specimen (incomplete specimen, perforation, R1 resection) on multivariate
analysis were positive CRMs on preoperative MRI and very low rectal tumors (< 2 cm from anal verge).

[13]
Using the same TaTME registry, Penna et al. reported the incidence and risk factors for anastomotic
failure in 1594 patients who underwent TaTME, 96.6% of which were performed for cancer and the rest for