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De Rosa et al. Mini-invasive Surg 2020;4:34 I http://dx.doi.org/10.20517/2574-1225.2019.53 Page 3 of 12

Because of these potential advantages, TaTME has gained wide interest in the colorectal community and
represents an opportunity to improve patient outcomes; however, it remains a technically challenging
operation and further research is required to prove its oncological efficacy when more widely adopted.

DEVICE AND TECHNIQUE
In 1983, Prof. Gerard Buess conceived transanal endoscopic microsurgey (TEM) and, in cooperation
with Richard Wolf, created and developed the platform for endoscopic rectal surgery, with the aim to
treat benign lesions of the upper and middle rectum not previously reached with conventional transanal
approaches [18,19] .

Based on this model, the Transanal Endoscopic Operation (TEO; Karl Storz, Tuttlingen, Germany) was
developed, which provides a rigid operative rectoscope, compatible with many standard laparoscopic
instruments without the need for a dedicated platform.

In 2009, in Orlando, Florida, Atallah and colleagues introduced the concept of transanal minimally invasive
surgery (TAMIS). This was inspired by devices already created for single-site surgery in the abdomen but
were adapted for transanal access. This essentially created a flexible, transanal multiport device that could
[20]
be used with a conventional laparoscope and laparoscopic instruments .
To date, two transanal platforms, GelPoint Path (Applied Medical, Rancho Santa Margarita, Ca) and SILS
Port (Covidien, Mansfield, Ma), have gained FDA approval for TAMIS. Clinical studies published thus far
demonstrate that both these and rigid platforms such as TEM/TEO can be used for TaTME, but the review
[21]
by Araujo et al. shows that only the 24.7% (37/150) of the preliminary TaTME cases reported were
performed with a platform TEM/TEO.

TAMIS ports have now become the preferred option for surgeons dedicated to TaTME because, compared
to rigid platforms, the soft, flexible port offers more versatile access to the whole circumference of the rectal
lumen without multiple position changes during surgery, the equipment is quicker and easier to set up, and
there may also be economic advantages [22,23] .

With improving experience and the dissemination of this approach through research and training, many
different technical modifications have been introduced, although the cardinal principles of this procedure
remain the same: to provide a complete mobilization of the mesorectum from the pelvic floor upwards
[24]
according to the eight steps described by Whiteford and colleagues in 2007 .
TaTME can be performed either with two different surgical teams working simultaneously with abdominal
and transanal dissection or with a two-step approach, using the same surgical team for both operative
phases in sequence.

Abdominal phase: the abdominal phase is performed according to the standard approach and preference of
the operating surgeon. It should be noted that either a planned open approach or a laparoscopic conversion
does not preclude a transanal approach to the pelvis. If a sequential approach is used (usually due to the
lack of two operating teams being available), then transabdominal dissection proceeds into the pelvis along
the mesorectal fascia until it becomes technically challenging and the specimen or the surrounding key
pelvic structures are at risk. Even in extremely challenging cases, the peritoneum will be divided anteriorly
before changing to a transanal approach as this will facilitate entry into the abdominal cavity from below.
Abdominal pneumoperitoneum is deflated, the insufflator is turned off, and the ports are closed prior to
the legs being positioned for the transanal phase.