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Page 2 of 11 Jeong et al. Mini-invasive Surg 2019;3:38 I http://dx.doi.org/10.20517/2574-1225.2019.42

At the same time, as distal resections including for rectal cancer, the Hartmann operation was performed
by Henri A. Hartmann in 1921 and the anterior resection by Dixon in 1948. In 1967, the “No-touch
isolation technique” was introduced by Rubert Turnbull Jr., and in the same year the circular stapler
was first introduced by the Russian pediatric surgeon Mark Mitchell Ravitch, making it widely used for
convenient and easy anastomosis. In 1982, Bill Heald introduced the concept of total mesorectal excision
(TME), which led to a dramatic improvement in the local recurrence rate. Since then, the Holy plane has
[2]
been the gold standard for rectal cancer surgery .
[3]
In 1998, Maas et al. reported that autonomic nerves sparing could reduce the rate of postoperative
urinary and sexual dysfunction.

Recently, with the development of minimally invasive surgery such as laparoscopic surgery and robotic
surgery, favorable results of several studies (COST, CLASSIC, COLOR II, and COREAN trials) have been
[4,5]
published one after another .

HISTORY OF TRANSANAL APPROACH
As mentioned above, transanal resection of rectal cancer was first performed by Jacques Lisfranc in 1826
and was accompanied by a transanal or transperineal approach as a form of combined surgery. In 1983,
transanal endoscopic microsurgery (TEM) was introduced by Gerhard Buess. The system is inserted into
the anus using a metallic cylinder with a beveled end (proctoscope) of 40-mm diameter and can be operated
[6]
using laparoscopic instruments under a three-dimensional view after setting. In 2010, Atallah et al.
introduced TransAnal Minimally Invasive Surgery (TAMIS), a hybrid of TEM and single port laparoscopic
surgery.

This type of operation is advantageous because it enters the surgical field of view at both the end lumen
and the side wall of the intestinal tract, compared to the TEM, which has only the cylinder end area as the
operation field and a relatively short port length. In addition, it is larger and can provide a free range of
[7]
motion (ROM) .
Furthermore, experimental transanal total mesorectal excision (TaTME) surgeries were performed, mostly
[8]
on swine or cadaver. In 2010, the first laparoscopic transanal TME was reported by Sylla et al. after the
first clinical application in 2009. They used a two-team approach, transabdominal and transanal. While
the transabdominal team performed multiport laparoscopic colonic dissection and vessel ligation, the
[8]
transanal team met in the middle with TaTME through the anus .
[9]
[10]
In 2013, Leroy et al. and Zhang et al. reported surgery for rectal lesions using natural orifice transluminal
[9]
endoscopic surgery (NOTES) by transanal TME without transabdominal assistance. Leroy et al. used TEO
[10]
system and Zhang et al. used soft single port.
[11]
In 2014, Chouillard et al. reported small series of transanal “down-to-up” TME without any form of
abdominal assistance, namely the pure NOTES for rectal cancer. According to their experience, among the
total trial of 16 patients, operations on 10 patients could be finished by pure NOTES.

Since then, TaTME approaches to rectal cancer have been developed in various ways around the world.
In addition, some trials have already been made to combine robotic surgery. Recently, the pure NOTES
method for rectal cancer has been further developed. We performed transanal total proctocolectomy with
IPAA for triple colorectal cancer without abdominal assistance in 2017. This may be the end point or final
[12]
goal of minimally invasive surgery .