Transanal Total Pelvic Exenteration: Pushing the Limits of Transanal Total Mesorectal Excision With Transanal Pelvic Exenteration

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Achieving complete total mesorectal excision while maintaining the completeness of the mesorectum is still challenging with the conventional transabdominal approach for up to T3 rectal cancer. Recently, the efficiency of transanal minimally invasive surgery for rectal cancer was demonstrated. Transanal total mesorectal excision with transanal minimally invasive surgery allows for excellent visibility during dissection of the distal rectum and can be accomplished with clear distal resection margins and circumferential resection margins.1–6 Transanal total mesorectal excision was developed to improve oncological and functional outcomes of patients with midrectal and low rectal cancer. For T4 locally advanced primary rectal cancer, total pelvic exenteration (TPE) is a potentially curative strategy for achieving an R0 resection.7–10 Previously, laparoscopic TPE was performed successfully by a few experienced laparoscopic surgeons.11–14 We introduced transanal minimally invasive surgery into TPE as transanal TPE based on the principle of transanal total mesorectal excision. Transanal TPE was performed for T4 rectal cancer as en bloc resection of the pelvic organs enveloped within the visceral pelvic fascia with a clear circumferential resection margin. This had significant advantages, including excellent visibility and reduced blood loss. Regarding division of the dorsal vein complex, transanal minimally invasive surgery seems to be feasible and safe because of a broader working field than the conventional transabdominal approach. It is important to prevent bleeding and injury of the visceral pelvic fascia. Unless oncological problems are present, the urethra should be divided at the junction with the prostate to prevent bleeding from the perineal membrane. In addition, the levator ani muscle should be dissected along the attachment of the internal obturator muscle to prevent injury of the visceral pelvic fascia. The ileal conduit was constructed extracorporeally through an extended umbilical incision. We demonstrate our procedure for transanal TPE in a short video (see Video, Supplemental Digital Content 1,
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