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was the first surgeon to use a perineal approach to transanal dissection of the rectum for TME; his goal
was to avoid leaving the patient with a permanent colostomy [20,21] . In April 2003, we implemented the
TARD technique in laparoscopic SPR for LRC located ≤ 5 cm from the anal verge in order to achieve more
[22]
accurate TME and to maintain the function of the IAS as much as possible after ISR . A randomized trial
showed that a transanal approach to TME was more effective than the conventional laparoscopic approach
to TME in terms of negative circumferential resection margins and suggested that the perineal approach
[23]
could be the new standard for laparoscopic SPR in Western patients with LRC . However, in its long-term
results, lower positivity of the circumferential resection margin did not translate into a decreased inci-
dence of local recurrence . Marks et al. reported that the primary perineal approach reduces operative
[12]
[11]
time and is associated with similar short- and long-term outcomes compared with the primary abdominal
approach to laparoscopic ISR. On the other hand, two randomized controlled trials, the ALaCart and
[7]
[8]
ACOSOG Z6051 trials, failed to show the noninferiority of laparoscopic surgery compared with open
surgery for oncologic outcomes. Two multi-center, randomized, controlled trials, COLORIII and GREC-
[24]
[25]
CAR 11 , will provide more definitive results.
The feasibility and benefit of this approach for Asian patients, including Japanese patients, should be evalu-
ated. To our knowledge, although there are many reports of SPR including ISR in Japanese patients [26-35] ,
ours is the first to describe the long-term oncologic and functional outcomes of SPR via the transanal ap-
proach in the Japanese population.

In the reports by Rouanet et al. , Denost et al. , Lacy et al. , Burke et al. , and Veltcamp Helbach et al. ,
[39]
[38]
[23]
[36]
[37]
CRM positivity was 2.5%, 4%, 6.4%, 4%, and 2.5%, respectively. In this series, 17 patients (18.9%) required
conversion to APR. In 14 of these, salvage APR was performed because tumor invasion into the levator
ani muscle, prostate, or vagina was suspected during rectal dissection. As final histopathology revealed a
negative CRM for each of these patients, TARD could be a useful approach for clinical T4b tumors. A good
CRM of 93.1% was shown in the SPR group as well. Patients who underwent SPR had an overall survival
rate of 88.1% and a disease-free survival rate of 84.9% after 5 years. This was not significantly different from
patients who underwent APR. These results show that TARD has a potential benefit of being able to allow
immediate conversion to APR as a salvage procedure when tumor invasion to the rectal dissection plane is
suspected during SPR for advanced disease categorized as type II-III according to Rullier’s classification.
Local recurrence occurred in 6.8% of the SPR patients during a median follow-up period of 3958 days (range
[19]
2778-6583 days); these findings are similar to those of Rullier et al. who reported rates from 5% to 9% in
135 conventional CAA patients, 131 partial-ISR patients, and 55 total-ISR patients. For unclear reasons, lo-
cal recurrence was only observed after ISR in this series. All patients with local recurrence were male with
stage III disease, and 1 had received pre-CRT. Histologically, locally advanced disease was observed in
most patients. No technical errors were reported in the operative records.

Postoperative anorectal function is a significant concern for patients undergoing SPR, including ISR.
Although ISR has broadened the sphincter-preserving options for selected patients with LRC, impaired
anorectal function after ISR remains a major problem. Many studies have found that patients undergoing
SPR, including low anterior resection, conventional CAA, and ISR, are at risk for developing LARS (e.g.,
frequent bowel movements, urgency, and incontinence of flatus). A recent review found that, regardless of
the use of preoperative irradiation, 0% to 5.9% of patients who undergo ISR require a colostomy for post-
[40]
procedural anorectal dysfunction . It is well known that the IAS plays an important role in fecal conti-
nence, and that extensive resection of the IAS during SPR is likely to impair anorectal function. Some risk
factors associated with anorectal dysfunction after ISR include pre-CRT [41,42] , total resection of the IAS [43-45] ,
tumor level, height of the anastomosis , and patient age . In this series, pre-CRT was administered to 14
[46]
[30]
patients with locally advanced disease. Pre-CRT has been shown to negatively affect postsurgical function [47,48] .
Most researchers agree that anorectal dysfunction after ISR improves as time proceeds, but any remaining
postoperative anorectal dysfunction after IAS resection is significant.