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Transanal total mesorectal excision (taTME) for rectal cancer: a training pathway

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Abstract

Background

With increasing interest in natural orifice surgery, there has been a dramatic evolution of transanal and endoluminal surgical techniques. These techniques began with transanal endoluminal surgical removal of rectal masses and have progressed to transanal radical proctectomy for rectal cancer. The first transanal total mesorectal excision (taTME) was performed in 2009 by Sylla, Rattner, Delgado, and Lacy. The improved visibility and working space associated with the taTME technique is intriguing. This video manuscript outlines the training pathway followed by pioneers in the taTME technique, the process of implementation into clinical practice, and initial case report.

Methods

A double board-certified colorectal surgeon with expertise in rectal cancer, minimally invasive total mesorectal excision, transanal endoscopic surgery (TES), and intersphincteric dissection, underwent taTME training in male cadaver models. Institutional review board (IRB) approval for a phase I clinical trial was achieved. The entire operative team including surgeons, nurses, and operative staff underwent taTME cadaver training the day prior to the first clinical case. The case was proctored by an expert in taTME.

Results

A 66-year-old male with uT3N1M0 rectal cancer located in the posterior distal rectum, underwent taTME with laparoscopic abdominal assistance, hand sewn coloanal anastomosis, and diverting loop ileostomy. The majority of the TME was performed transanally with laparoscopic assistance for exposure, splenic flexure mobilization, and high ligation of the vascular pedicles. Operative time was 359 min. There were no intraoperative complications. Pathology revealed a ypT2N1 moderately differentiated invasive adenocarcinoma, grade I TME, 1 cm circumferential radial margin, and 2/13 positive lymph nodes.

Conclusion

Implementation of taTME into practice can be achieved by surgeons with expertise in minimally invasive TME, TES, pre-clinical taTME training in cadavers, case observation, proctoring, and ongoing mentorship. IRB peer review process and participation in a clinical registry are additional measures that should be employed.

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Acknowledgments

The authors wish to acknowledge Steven Wexner, MD, Dana Sands, MD, and Eric Weiss, MD, Cleveland Clinic Florida, for their dedication to training and mentoring colorectal surgery residents as well as their ongoing interest, support, and earnest enthusiasm toward advancing the field of minimally invasive colon and rectal surgery. The authors acknowledge the multitude of simulation and training thought leaders within the field of industry who have supported the taTME cadaver surgical training courses including but not limited to: Richard Wolf Medical Instruments Corporation, Karl Storz GmbH & Co, Applied Medical, Covidien/Medtronic, Nodadaq Inc., Stryker Endoscopy, and Novatract. The authors respectfully acknowledge Antonio Lacy for his excellent surgical technique, scientific approach to the evaluation and implementation of the taTME technique into clinical practice, and ongoing training, proctoring, and mentorship within the rectal cancer surgical community.

Author information

Authors and Affiliations

  1. Department of Surgery, Colorectal Surgery, Kaiser Permanente Los Angeles Medical Center, 4760 Sunset Blvd, 3rd Floor, Los Angeles, CA, 90027, USA

    Elisabeth C. McLemore, Vikram Attaluri & Anna T. Tsay

  2. Department of Surgery, Center for the Future of Surgery, University of California, San Diego, San Diego, CA, USA

    Christina R. Harnsberger, Ryan C. Broderick, Hyuma Leland, Alisa M. Coker, Hans F. Fuchs, Garth R. Jacobsen, Bryan Sandler & Santiago Horgan

  3. Department of Surgery, Colorectal Surgery, Mount Sinai Hospital and School of Medicine, New York, NY, USA

    Patricia Sylla

  4. Cleveland Clinic Florida, Weston, FL, USA

    Steven D. Wexner

  5. Stonybrook School of Medicine, Stony Brook, NY, USA

    Mark A. Talamini

Authors
  1. Elisabeth C. McLemore
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  2. Christina R. Harnsberger
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  3. Ryan C. Broderick
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  4. Hyuma Leland
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  5. Patricia Sylla
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  6. Alisa M. Coker
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  7. Hans F. Fuchs
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  8. Garth R. Jacobsen
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  9. Bryan Sandler
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  10. Vikram Attaluri
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  11. Anna T. Tsay
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  12. Steven D. Wexner
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  13. Mark A. Talamini
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  14. Santiago Horgan
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Corresponding author

Correspondence to Elisabeth C. McLemore.

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Disclosures

Dr. McLemore reports grants from Applied Medical, grants from Applied Medical, grants from Covidien, grants from Stryker Endoscopy, grants from Novatract, during the conduct of the study; personal fees from Applied Medical, personal fees from Novadaq, personal fees from Cubist, personal fees from Genomic Health, personal fees from Ethicon Endosurgery, personal fees from Covidien, outside the submitted work. Dr. Harnsberger has nothing to disclose. Dr. Broderick reports grants from Applied Medical, grants from Applied Medical, grants from Covidien, grants from Stryker Endoscopy, grants from Novatract, during the conduct of the study. Dr. Leland reports grants from Applied Medical, grants from Applied Medical, grants from Covidien, grants from Stryker Endoscopy, grants from Novatract, during the conduct of the study. Dr. Sylla has nothing to disclose. Dr. Coker reports grants from Applied Medical, grants from Applied Medical, grants from Covidien, grants from Stryker Endoscopy, grants from Novatract, during the conduct of the study. Dr. Fuchs reports grants from Applied Medical, grants from Applied Medical, grants from Covidien, grants from Stryker Endoscopy, grants from Novatract, during the conduct of the study. Dr. Jacobsen reports grants from Applied Medical, grants from Applied Medical, grants from Covidien, grants from Stryker Endoscopy, grants from Novatract, during the conduct of the study; personal fees from ValenTx, Inc., personal fees from Gore, personal fees from Davol, personal fees from Ethicon Endosurgery outside the submitted work. Dr. Sandler reports grants from Applied Medical, grants from Applied Medical, grants from Covidien, grants from Stryker Endoscopy, grants from Novatract, during the conduct of the study; personal fees from ValenTx, Inc., personal fees from Gore, personal fees from Davol outside the submitted work. Dr. Attaluri has nothing to disclose. Mrs. Tsay, NP, has nothing to disclose. Dr. Wexner reports other from Covidien, personal fees from Karl Storz Endoscopy America, other from Karl Storz Endoscopy America, during the conduct of the study. Dr. Talamini reports grants from Applied Medical, grants from Covidien, grants from Stryker Endoscopy, grants from Novatract, during the conduct of the study. Dr. Horgan reports grants from Applied Medical, grants from Applied Medical, grants from Covidien, grants from Stryker Endoscopy, grants from Novatract, during the conduct of the study.

Additional information

This video abstract received the 2014 SAGES Foundation Gerald Marks Rectal Cancer Award 4/2/14, SAGES Annual Meeting and Scientific Session, Salt Lake City, UT, USA.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Cadaveric taTME Dissection. Transanal total mesorectal excision in a male cadaver model (MP4 89577 kb)

Clinical taTME Dissection. Transanal total mesorectal excision, clinical case report and pelvic dissection (MP4 171823 kb)

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McLemore, E.C., Harnsberger, C.R., Broderick, R.C. et al. Transanal total mesorectal excision (taTME) for rectal cancer: a training pathway. Surg Endosc 30, 4130–4135 (2016). https://doi.org/10.1007/s00464-015-4680-1

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  • DOI: https://doi.org/10.1007/s00464-015-4680-1

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