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

CONCERNS ON TRANSANAL APPROACH
TAMIS
Natural orifice specimen extraction
When the operation is performed by the transanal approach, the specimen should be discharged through
the anus. In addition, transanal or transvaginal extraction is possible after conventional laparoscopy
using the transabdominal approach. In the case of benign lesion or specimen by local excision, it is easy
to remove, but, when the lesion itself is large or the specimen is bulky by TaTME, transanal extraction
is relatively impossible due to the condition of anal sphincter (specimen-sphincter mismatch). In this
case, it is necessary to switch to transabdominal extraction. In some cases, it can be safely removed by
gentle and slow dilation; otherwise, excessive removal can cause sphincter injury and eventually lead to
dysfunction [13,14] .

While transanal extraction has the advantage that it can be applied irrespective of gender, transvaginal
extraction is only possible in women and in some cases. It is also known that the rate of protective
ileostomy is higher because of the relatively difficult incisions and the associated complications during the
[15]
removal of the extract .

However, there are advantages in that relatively large extracts, for example those after RHC, can be taken
[16]
out without large incisions and sphincter injury can be avoided .

Technical notes
Initially, a combination of surgical glove and wound protector was rolled down to create a homemade type
port. Later, readymade ports were introduced, and the SILS port, OCTO port, and mini port were used,
sequentially. Recently, however, a combination of Globe port and PPH’s circular anal dilator has been used.
This combination is easier and cheaper to install than the TEM system, and it is also superior in terms of
view, as it can see the side of the view that cannot be seen in the TEM system at the same time. It is also
advantageous for technical manipulation, as Atallah explained, with much more freedom and wider scope
of application (ROM).

Instead of an Airseal system, a homemade reservoir system using surgical gloves can be manufactured
easily and quickly. In this case, it is useful to secure a stable operative field at no additional cost [Figure 1].

TAMIS is a single port laparoscopic surgery format. Therefore, an inevitable jam is caused because the
narrow space must be shared with the camera assistant. This is inconvenient for both the operator and
the assistant. The answer to this inconvenience is solo surgery. The camera holder can be secured to the
bed rail and the procedure can be performed without an assistant according to operator’s own control and
fixed focus [Figure 2].

The level of lesion available with this type of surgery (TAMIS) is commonly considered as mid or low
rectal lesion. In practice, however, techniques such as access and excision are possible for lesions that
exist at higher heights. The peritoneal reflection is usually regarded as a height equivalent to the second
Houston valve level with some variation. Proximal lesions at higher heights are more likely to be perforated
when resected into the whole layer, and infiltration of air into the abdominal cavity may cause difficulty
in securing a stable field of vision and maintaining a stable surgical field. There is also a possibility of
contamination.

Given the structure of the peritoneal reflex, the probability of perforation is relatively high, especially in
lesions present in the anterior aspect.