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Page 4 of 7 Yellinek et al. Mini-invasive Surg 2018;2:22 I http://dx.doi.org/10.20517/2574-1225.2018.17

TRAINING PROGRAM
Although the early results from the international TaTME registry are encouraging, the participating sur-
geons encountered intraoperative complications and difficulties in up to 40% of procedures. These difficul-
ties include unstable pneumorectum, ineffective smoke evacuation, and difficulty developing the correct
plane. The specific intraoperative complications associated with TaTME included wrong plane dissection,
which may cause presacral bleeding if the dissection plane is too posterior, or injury to the hypogastric
nerve bundles if the dissection plane is too lateral. The membranous urethra in males is also vulnerable
when dissection is too anterior. Those specific complications and difficulties highlight the need for struc-
tured and accredited training program. Several authors have addressed the proper training pathway to the
incorporation of TaTME into clinical practice [19-25] .

[24]
McLemore et al. developed 6 key elements for the safe practice of TaTME. The authors recommended ex-
pertise in TME, laparoscopic colorectal surgery, transanal minimally invasive surgery, and intersphincteric
dissection. Appropriately qualified individuals should then practice in cadaver models and enter all data in
a clinical registry.

[22]
Francis et al. conducted a consensus agreement from 207 colorectal surgeons across 18 countries includ-
ing 52 TaTME specialists. They recommended that prerequisites to learn TaTME should include 3 factors:
the trainee, the mentor, and the training facility. The trainee must be an accredited laparoscopic colorectal
surgeon with experience of more than 30 laparoscopic TME cases, more than 5 TEM/TAMIS cases, and
that the anticipated volume of TaTME cases will be more than 20 per year. The mentor must have per-
formed at least 30 TaTMEs, is experienced in cadaveric training, and has at least two publications per year
in the field of TaTME. The training facility should have a cadaveric lab and at least 10 trainees and at least 2
courses per year. For the training curriculum, the authors’ recommendation includes 4 stages: self-learning,
cadaver workshop, proctorship of the initial 5-10 cases, and, finally, independent practice with continued
collection input into the registry.

[26]
Koedam et al. evaluated the learning curve of TaTME in 138 patients with rectal cancer over a 60-month
period. The authors reported improvement in postoperative outcomes after the first 40 patients, showing a
decrease in major postoperative complications from 47.5% to 17.5% and leakage rate from 27.5% to 5%. In
addition, the mean operative time (42 min) and conversion rate (from 10% to 0%) was lower after transi-
tioning to a two-team approach, although neither endpoint decreased with experience.

PRESENT AND FUTURE
Anatomical factors that may make TaTME a preferred approach for rectal cancer include male gender, low
cancers, narrow pelvis, high body mass index, and distorted tissue planes due to neoadjuvant radiother-
apy [27-29] . Although the use of TaTME seems clearly advantageous for the treatment of mid and low rectal
cancer, there are potential advantages to its use in upper rectal cancer, above the peritoneal reflection. Early
in the learning curve it is easier to perform TaTME in higher tumors and use those cases in order to gain
experience in TaTME for the more challenging, distal cancer cases. The second reason to approach upper
rectum cancer transanally is the fact that the rectal specimen is of better quality in TaTME approach [30,31] .
TaTME may also serve as a useful platform for proctectomy for benign diseases such as inflammatory
bowel disease requiring proctectomy, rectal stricture, radiation proctitis, and Hartmann’s procedure
reversal.

[32]
Leo et al. reported their experience of 16 total proctocolectomies and ileal pouch anal anastomoses (TPC
+ IPAA) for refractory mucosal ulcerative colitis using TaTME-assisted single port laparoscopy. The medi-
an operative time was 247 (185-470) min and the overall conversion rate to open surgery was 18.7%. The 30-