Page 160 - Read Online

Sriram et al. Mini-invasive Surg 2020;4:19 I http://dx.doi.org/10.20517/2574-1225.2019.40 Page 3 of 6

about 16% of peritoneal entry for lesions at the upper rectum. During local excision of malignant lesions,
[19]
it is necessary to excise the lesion in full thickness as there is a possibility of an invasive component .
Not surprisingly, partial excision will lead to significant positive margins, which translates to loco regional
[20]
[21]
recurrence . Dufresme et al. described the usage of a laparoscopic stapler for excision of high rectal
sessile polyps as an approach to prevent peritoneal breech. However, the evidence supporting this approach
is only backed by a short series of five cases.

LEARNING CURVE FOR TAMIS
[22]
Assessing the surgical technique competency in TAMIS, Maya et al. reported that four cases are
[18]
adequate. Chen et al. , however, mentioned that at least 10 cases are necessary to obtain proficient skills.
[23]
Clermonts et al. stated that a standardized institutional protocol with proficient proctorship could lead to
a shorter learning curve with only 6-10 cases, but ideally 18-31 cases, being required.

WHICH IS BETTER?
[24]
TEM and TAMIS have been compared in multiple papers. Lee et al. reported that there are no statistical
differences in the quality of obtained specimens, peritoneal entry, postoperative complications, five-year
disease free survival, and incidence of local recurrence for those who did not undergo salvage surgery. After
analyzing 428 patients (247 with TEM and 181 with TAMIS), it was concluded that the cost, availability,
and surgeon’s preference should determine the choice of the platform.

TAMIS FOR PROCTECTOMY AND TRANSANAL TME
Standardization of TME as well as the selective use of chemoradiotherapy has brought significant
[25]
improvement in the management of rectal cancer . Local recurrence rates have dropped to < 6% when
TME is performed with negative circumferential resection margin and distal resection margin, together
with neoadjuvant radiotherapy. The local recurrence was as high as 45% without TME and dropped to 10%
with TME alone [26,27] .

The first laparoscopic-assisted TME was performed on a 76-year-old woman with rectal cancer in 2009.
Since then, multiple articles have been published on TME. The concept of TME came into existence
due to the ease in reaching the distal rectum, which would otherwise be technically challenging with
the conventional transabdominal TME approach, especially for patients with high body mass index,
narrow male pelvis, or bulky low rectal tumors. Indirectly, this leads to a lower conversion rate and better
[28]
pathological outcomes (distal margin) compared to the transabdominal approach . A meta-analysis by
[29]
Jiang et al. demonstrated that TME leads to longer circumferential and distal resection margins. This
approach also reduces the risk of positive circumferential margin.

[30]
However, a Norwegian team reported an unexpectedly high local recurrence after TME (9.5%) but data
from two of The Netherland’s high-volume hospitals reported otherwise. Their data show local recurrence
[31]
of only 3.8% over a mean follow up of 54.8 months . The currently undergoing GRECCAR 11 and
COLOR III randomized control trials will be able to elucidate the long-term oncological outcomes of low
[32]
and mid rectal cancer with the transanal approach .

TAMIS FOR LATERAL PELVIC NODE DISSECTION AND PELVIC EXENTERATION
Lateral pelvic lymph node (LPLN) metastases in patients with colorectal cancers are usually seen in
advanced cases. Some studies have shown neo-adjuvant chemoradiotherapy to be inadequate and a surgical
approach remains an option to be considered [33,34] . Laparoscopic LPLN dissection is technically challenging,
especially in obese patients with narrow pelvis. It is difficult to access those lymph nodes at the inferior
[36]
[35]
margins of the lateral pelvis via laparoscopic approach. Aiba et al. and Zeng et al. demonstrated