Techniques in Coloproctology: New transanal TME techniques

The upcoming June issue of Techniques features a multimedia article by Atallah et al. from Florida Hospital in Orlando [1]. It is about a novel technique that allows to perform a TME starting from below, called the TAMIS-TME. I have followed this technique from early 2012, when Matt Albert showed me the unedited video of his first case. It was an obese patient whose pelvis was so narrow that they could not get below the tumor, neither laparoscopically nor open. So they purse-stringed close the rectum from below and started an intersphincteric dissection, like in the transanal-abdominal-transanal (TATA) procedure. But here the authors, with the Gelpoint Path, create a “pneumo-pelvis” and do most of the dissection around the tumor from below. You have to look at the video to believe the ease or retraction and the exposure afforded by this route of dissection. So I showed it to Bill Heald, and he was so impressed that in the accompanying editorial wrote that “The combination of the transanal approach, the use of a gas tight seal for anus or anorectum, and direct holy plane dissection around the mesorectum from below—these three together can revolutionise the practice of rectal cancer surgery” [2]. The journal is also thrilled of publishing in these months the first colorectal resections carried out entirely through the anus [3] and the vagina [4], without the use of abdominal ports. The transanal approach by Zheng et al (published months before the similar article of Leroi et al. on Archives of Surgery [5]) initially uses the same principles of Atallah’s TAMIS-TME but the authors manage, through a transanal single-port device, to enter the peritoneal cavity, tie the inferior mesenteric artery and mobilize the descending colon. The transvaginal resection is of a sigmoid volvulus, once the SILS port is placed through the vagina the sigmoid colon is right there, just look at the pictures. These last 2 papers seem more like a virtuoso exercise, one wonders what an extra 5mm umbilical port for extra traction can add in terms of morbidity. However, Leroi et al. final comment to their first entirely transal case was that “this monumental case could pave the way for a new era in pure transanal NOTES for colorectal surgery” [5]. As one of my mentors used to say, you can’t argue with success.

1) Transanal minimally invasive surgery for total mesorectal excision (TAMIS–TME): a stepwise description of the surgical technique with video demonstration
2) Heald RJ (2013) A new solution to some old problems: transanal TME Tech Coloproctol
3) Zhang H et al (2013) Transanal single-port laparoscopic total mesorectal excision in the treatment of rectal cancer Tech Coloproctol 17:127-123
4) D’Hondt et al (2013) Transvaginal pure NOTES sigmoid resection using a single port device Tech Coloproctol
5) Leroy J, Barry BD, Melani A, Mutter D, Marescaux J (2012) No-scar transanal total mesorectal excision: the last step to pure NOTES for colorectal surgery. Arch Surg 19:1–5. doi:10.1001/jamasurg.2013.685

TIC articles and videos can all be accessed by members of SICCR and other affiliated societies by clicking on the above links.

Giuseppe Gagliardi, MD
Editor
Techniques in Coloproctology