Page 225 - Read Online

Kunkel et al. Mini-invasive Surg 2020;4:27 I http://dx.doi.org/10.20517/2574-1225.2020.05 Page 3 of 7

Figure 2. Transanal endoscopic microsurgical platform inserted transanally

[8]
In 1984, following the conception of the TATA, Kosinski et al. ventured to perform a full thickness local
excision (FTLE) of a distal rectal cancer after full-dose radiation. This early experience demonstrated that
local excision after neoadjuvant radiation could not only be performed successfully, but also safely with a
low rate of local recurrence. This approach was slowly adopted due to the engrained beliefs that operating
in an irradiated field leads to poor healing and high leak rates. However, due to superior oncological
outcomes, the advantages of multimodal therapy were ultimately accepted, and neoadjuvant therapy
became a standard practice in locally advanced cancers.

As is often the case with emerging technologies, the advent of minimally invasive surgery brought about
further advancement in the surgical treatment of rectal cancer. Prior to the first laparoscopic abdominal
[9]
procedure, in 1983, Dr. Buess developed the transanal endoscopic microsurgical (TEM) platform for
[10]
resection of rectal polyps and early stage cancer [Figure 2] . This technique used rigid laparoscopic
instruments via a single transanal port to provide superior reach and exposure to rectal pathology that
limited prior open transanal approaches. Dr. John Marks furthered this technique in 1996 when he
performed a transanal endoscopic microsurgery full thickness local excision (TEM-FTLE) following
neoadjuvant high-dose radiation. Later, in 2008, he used the TEM platform to perform the first transanal
total mesorectal excision, which he termed TEM-ATA.

TEM was the first example of natural orifice transluminal endoscopic surgery (NOTES), which led to
[11]
many advancements in minimally invasive surgery and specifically rectal surgery. In 2009, Atallah et al.
developed the transanal minimally invasive surgery (TAMIS) platform [Figure 3]. While similar to the
TEM technique, TAMIS allowed surgeons to perform radical rectal excisions via a more accessible single
[12]
incision port as opposed to the rigid TEM proctoscope. Lacy et al. further facilitated transanal access to
rectal pathology by conducting an IRB-approved study of the single incision laparoscopic surgery platform.
They are to be credited with popularizing transanal total mesorectal excision (taTME).

Both Drs. John Marks and Joel Leroy can be recognized for pushing the limits of transanal surgery using
the TAMIS technique. In 2012, Dr. Marks accomplished the first transanal splenic flexure release and IMA
transection. In 2013, Leroy et al. performed the first “pure” NOTES proctosigmoidectomy, which he
[13]
termed peri-rectal oncologic gateway for retroperitoneal endoscopic single site surgery. In the same year,
the first NOTES TATA was demonstrated by Marks et al. , who later published a dynamic manuscript
[14]