Complete Transanal Total Mesorectal Excision for Lower Rectal Cancer
It has been proposed that the adequacy of surgery after a total mesorectal excision (TME) could be determined by assessing the macroscopic quality of the excised mesorectum.1–4 Apart from the surgical technique, the distance between the tumor and the anal verge seems to influence the quality of the mesorectum. Some facilities have reported that tumors located in the lower third of the rectum, particularly within 6 cm of the anal verge, recur at a significantly higher rate than tumors in the middle or upper rectum.5,6 The primary cause seems to be the existence and composition of the lateral ligaments of the rectum (LLR), which are still the subject of anatomic confusion and surgical misconception.7–12 The LLR have been defined as constant dense connective tissues in either lateral side of the lower rectum, located between the rectal visceral fascia and the pelvic autonomic nervous system (PANS) on the pelvic parietal fascia above the levator ani muscle. The LLR also provide the pathways of blood vessels, nerve fibers, and lymphatic vessels.7–10 Therefore, removal of the LLR may reduce local recurrence of middle or lower rectal cancer, and an ideal dissection for a TME of the lower rectum, particularly at the lateral aspect of the rectum, should be performed along the PANS. However, there is a great risk of injuring the PANS, and care must be taken not to damage it. Recently, the transanal TME (TaTME) approach has attracted intense attention as a promising alternative to laparoscopic TME.13–15 The TaTME has several potential advantages: it provides excellent visibility, facilitates TME of the lower rectum, and requires less surgical time.13–19 In this video article, we show a complete TaTME for lower rectal cancer and a method for obtaining good mesorectum quality. See Video at http://links.lww.com/DCR/A349.