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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 5 of 9

Figure 2. “O” sign. Marked in yellow

Table 1. Steps of the transanal total mesorectal excision
Bottom (transanal total mesorectal excision) Top (intraperitoneal)
1. Placement of purse-string suture distal to the tumor. 1. Complete mobilization of the descending and sigmoid colon.
2. Introduce advanced endoscopic platform transanally. 2. Splenic flexure mobilization.
3. Circumferential full-thickness proctotomy. 3. Inferior mesenteric artery high ligation.
4. Distal to proximal dissection within the avascular mesorectal plane. 4. Proximal rectal dissection.
Joint
5. Transection of proximal colon.
6. Securing of proximal anvil and insertion of transanal distal purse string.
7. Passing down of anvil from intraperitoneal to transanal space.
8. Securing of transanal distal purse string.
9. Firing of stapler.
10. Concluding steps (e.g., Leak test, drains, closure) as per conventional technique.

the anterior pelvis for urethral injury to occur. Methods to avoid this in these low dissections are to continue
the inter-sphincteric dissection as high as possible in an open fashion, to clearly identify the prostate
either endoscopically or in an open fashion, and finally when entering the plane anteriorly, to allow for
pneumodissection as this plane will open up once it has been entered. Extreme anterior angles of the port
should also be avoided to lessen the risk of this devastating injury.

A brief summary of the steps required for TaTME are demostrated in Table 1.

TRAINING AND DEVELOPMENT
As mentioned previously, the technical complexity of TaTME and the occurrence of otherwise rare
complications should bring pause to any surgeon considering the technique. Proponents of the technique
have attempted to set a framework had through which TaTME could be widely adopted in a responsible
[17]
manner. This was published by the International TaTME Educational Collaborative in 2013 .

Surgeons seeking to develop this technique should have experience with TAMIS or TEMs, as well as open
and laparoscopic rectal dissection. It has been suggested a minimum of ten TAMIS or TEMs cases and at
least twenty rectal dissections have been completed before embarking on this journey, although these are
guidelines only.

Currently, surgeons are encouraged to participate in one or more multi-day courses that are run at expert
centers. These involve a structured learning curriculum combining theory sessions, observation of live cases
and technical simulation with human cadaveric models. Further education is performed through a number