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Yap et al. Mini-invasive Surg 2019;3:3 I http://dx.doi.org/10.20517/2574-1225.2018.57 Page 3 of 9

verge; (6) a tumor diameter > 4 cm; (7) distortion of tissue planes secondary to neoadjuvant radiotherapy;
[12]
and (8) an impalpable, low primary tumor requiring accurate placement of the distal resection margin .
They listed their contradictions as obstructing rectal tumours, emergency presentations and T4 tumors.
It is noted that many surgeons have used thinner female patients who have not undergone neoadjuvant
chemoradiotherapy as part of their learning curve. This is likely due to the fact that planes may be easier to
identify, the risk of urethral injury is possibly lower, and salvage from a conventional top-down approach is
more straightforward.

SURGICAL APPROACH
A brief description of the surgical technique will be listed below.

Equipment
It is assumed that equipment required for an open and laparoscopic low anterior resection is readily
available. Specialized equipment for this technique which the authors use include: (1) GelPoint Path
Transanal Access Platform (Applied Medical, Inc., Rancho Santa Maragarita, CA); (2) AirSeal Access Port
(CONMED Corp., Utica, NY); (3) Articulating hook diathermy (SILS hook, Medtronic, Minneapolis, MN).

We acknowledge that other platforms do exist and are also currently in development.

Preparation
All patients are given full mechanical bowel preparation. Standard pre-operative procedures such as
antibiotics, urinary catheter and deep vein thrombosis prevention are assumed. The patient is placed in
stirrups in the modified Lloyd-Davies position. Preparation of the abdomen and perineum should include
washing out of the vagina and rectum with betadine.

Technique
The operation may begin trans-anally, transabdominally or simultaneously from both approaches with two
surgical teams. The benefit of a simultaneous approach is that it is associated with significantly reduced
operating duration. If a simultaneous approach is embarked upon, there must be two separate scrub setups
and two laparoscopic towers/insufflators. Even in the single surgeon situation, two separate setups and
laparoscopic towers is recommended to aid transition between the two. The TaTME dissection can be
performed with the surgeon standing or sitting. However, if the surgeon stands, better ergonomic access is
afforded to the assistant as they try to fit under the patient’s right leg.

We routinely set the patient up as if having a laparoscopic total mesorectal excision. This includes some kind
of strapping to the chest, and use of gelfoam mat to ensuring the patient does not slide during the operation.
We do not routinely use a bean-bag.

Firstly, a purse-string suture (2/0 prolene) is placed with sufficient margin distal to the tumor. This can be
achieved transanally with the aid of a Lone-Star and anal retractors if the tumor is low enough [Figure 1].
If the tumor is higher, this can be done by inserting the GelPoint port, and establishing pneumorectum to
facilitate suturing through the TAMIS platform. A secure and airtight purse-string suture is mandatory as
any defect will allow leakage of tumor content from above, and air into the colon from below. A second lavage
with betadine is then performed and the GelPoint port channel inserted if it has not been already. Three
ports are inserted into the GelPoint cap at 10 o’clock (Airseal, 8 mm port), 2 and 6 o’clock (10 mm working
ports). The cap is then secured and pneumorectum is established with the AirSeal device at 10-12 mmHg.

Next, dissection is commenced. A 5 or 10 mm 30-degree rigid or flexible laparoscope is used for
visualization and inserted into the 6 o’clock port. The circumferential intraluminal line is marked out and