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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 9 of 12

The debate will continue as to whether this should be an operation that is used selectively for the most
difficult cases - in which case, expect worse outcomes - or whether it is a panacea to improve all rectal
cancer surgery and therefore outcomes more widely [43,46] .

[68]
The distal third of the rectum remains challenging even in highly experienced surgical hands and could
be difficult to reach transabdominally, sometimes at the price of an unavoidable derogation to principles
of oncological radicality and nerve preservation. Even Bill Heald, the master of TME, in very challenging
[69]
conditions used manual dissection to get out of otherwise impossible situations .

For this reason, Heald himself has embraced and supported this conceptual revolution, considering the
pneumodissection and the vision from below of great help in the challenging steps of the distal dissection,
mainly on the anterior plane in the male pelvis, with a consequent better identification and preservation of
[70]
nerves. Excited by Lacy’s message, he considered it as the future of rectal cancer surgery .
With similar postoperative complications when compared to standard laparoscopic or open TME,
remarkable short-term pathological and surgical results, and promising long-term oncologic outcomes, the
available literature suggests that TaTME is safe and feasible in the hands of surgeons who have had proper
training and been supported through the early learning curve. If this technique is to be widely adopted,
then formal training programs with adequate resources will have to be available to facilitate wider adoption
[71]
without the increase in complications .

The multicentric randomized controlled trial COLOR III, designed to compare TaTME and Laparoscopic
TME is currently underway and will produce more reliable evidence concerning the quality of this type of
surgery.

If the results already demonstrated are confirmed, TaTME should be considered among the gold standard
approaches to be offered to selected high-risk patients with rectal cancer.

DECLARATIONS
Authors’ contributions
Substantial contributions to conception and draft of the manuscript: De Rosa M, Wynn G, Rondelli F
Critical revision: Ceccarelli G, Wynn G

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.

Consent for publication
Not applicable.

Copyright
© The Author(s) 2020.