TOTAL MESORECTAL EXCISION THROUGH THE NATURAL ORIFICE (TRANS ANAL) NOTES

1. “No-Scar Transanal Total Mesorectal
Excision”-The Last Step to Pure NOTES
for Colorectal Surgery
CHAIRPERSON :-DR B.P SANGANAL
ASSISTANT PROFESSOR
DEPT OF GENERAL SURGERY
KIMS HUBLI
SPEAKER:- DR ABHISHEK KUMAR
JUNIOR RESIDENT
DEPT OF GENERAL SURGERY
KIMS HUBLI

2. Transanal total mesorectal excision

3. Rectum & Anal canal

4. • The rectum (from the
Latin rectum intestinum,
meaning straight intestine)
is the final straight portion
of the large intestine. The
human rectum is about 12
centimetres long
• begins at the rectosigmoid
junction , at the level of S3
or the sacral promontory
depending upon what
definition is used.

5. 1 inch infront of
coccyx
Location and peritoneal relations of the rectum
S3
At the level of the middle
of the sacrum, the sigmoid
colon loses its mesentery
and gradually becomes the
rectum, which, at the
upper limit of the pelvic
diaphragm, ends in the
anal canal
The rectum has neither
mesentery nor haustra, and
it has an almost complete
outer longitudinal muscular
coat rather than teniae.

6. • In the upper third of the rectum, its front and
sides are covered by peritoneum; in its middle
third, the front only; its lower third is devoid of
peritoneum.

7. • Its caliber is similar to that of the sigmoid colon at
its commencement, but it is dilated near its
termination, forming the rectal ampulla.
• It terminates at the level of the anorectal ring (the
level of the puborectalis sling) or the dentate line.
• In humans, the rectum is followed by the anal canal,
before the gastrointestinal tract terminates at
the anal verge.

8. Shape (flexures) of the rectum
- Anteroposterior curve
- 3 flexures
1. Upper concave to
left
2. lower concave to
left
3. Middle concave to
right
Rectal ampulla

9. Supports of the rectum include:
• Pelvic floor formed by levator ani muscles.
• Waldeyer's fascia
• Lateral ligaments of rectum which are formed by
the condensation of pelvic fascia
• Rectovesical fascia of Denonvillers, which extends
from rectum behind to the seminal vesicles and
prostate in front.
• Pelvic peritoneum
• Perineal body

10. In males: In females
Anterior - Recto-vesical pouch containing coils of
ileum and sigmoid colon.
- Base of urinary bladder.
- Ampulla of vas deference.
- Seminal vesicles.
- Prostatic gland.
- Terminal part of ureter.
- Recto-uterinepouch, coils of ileum and
sigmoid colon.
- Posterior wall of vagina.
Posterior Muscles : (3)
- Piriformis
- LevatorAni
-Coccygeus
Bones: (2)
- Sacrum
-Coccyx
Vessels: (2)
- Superior Rectal Artery
- MedianSacral Artery
Nerves: (3)
- Sympathetic Trunks
- Lower 3 Sacral Nerves
- Coccygeal Nerves
As males
Laterally -LevatorAni
- Coccygeus
-Pararectal Fossa
As males
Relations of rectum

11. Arterial supply Venous drainage
1. Superior rectal artery:
- It is the continuation of inferior
mesenteric artery.
- It supplies the rectum and upper half
of anal canal.
2. Middle rectal artery:
It arises from the anterior division of
internal iliac artery.
3. Inferior rectal artery:
It arises from internal pudendal artery.
1. Superior rectal vein continues up as
inferior mesenteric vein which drains
into the splenic vein.
(Portal circulation)
2. Middle rectal vein:
Drains into internal iliac vein.
(Systemic circulation)
3. Inferior rectal vein:
Drains into internal pudendal vein.
(Systemic circulation)
Clinical note:
Superior, middle, and inferior rectal veins
anastomose with each other in
submucosa of rectum and anal canal.
Hemorrhoids (piles): is the dilation of
the veins at the site of anastomosis.
Hemorrhoids
(Piles)
Blood supply of rectum

12. Arterial supply of
the rectum and anal
canal
median sacral artery
superior rectal artery
(inferior mesenteric)
middle rectal artery
(internal iliac)
inferior rectal artery
(internal pudendal)

13. Veins of the rectum

14. Lymph drainage of rectum:
1.Upper half drains to para rectal L.Ns which
drain to inferior mesenteric L.Ns.
2.Lower half drains to internal iliac lymph
nodes.

15. Lymphatic drainage of the rectum

16. Anal canal
• Beginning: It begins one inch below and anterior to the tip of the
coccyx at the recto-anal junction.
• Course: It runs down and backwards.
• Termination: It ends at the anus.
• Relations:
• Laterally: Ischioanal fossae.
• Posteriorly: Anococcygeal raphe between it and tip of coccyx.
• Anteriorly: Perineal body between it and bulb of penis in males.
Perineal body between it and vagina in females.

17. Upper part Lower part
Blood
supply
-It is supplied by superior rectal
artery.
- It is drained by superior rectal vein
(portal circulation).
-It is supplied by:
1- Middle rectal artery of internal iliac
artery.
2. Inferior rectal artery of internal
pudendal artery.
-The corresponding veins drain into internal
iliac vein (systemic circulation.)
Nerve
supply
Above pectinate line by autonomic
nerve fibers.
Below pectinate line by inferior rectal nerve
(Sensitive to pain &touch).
Lymphatic
drainage
Above pectinate line into internal
iliac LNs.
Below the pectinate line into superficial
inguinal LNs.
Blood supply, nerve supply and lymph drainage of anal canal:

18. Anal sphincters:
Internal anal sphincter:
-It is the thickened inner involuntary circular muscle layer of the anal canal.
-Surrounds the upper 3/4th of the anal canal, extending from ano-rectal
junction till the white line (Hilton’s line).
Nerve supply: autonomic
External anal sphincter:
-Striated voluntary muscle fibers.
-Surrounds the whole length of the anal canal outside the internal anal
sphincter.
-Parts: I) Subcutaneous Part:
-Surrounds the anus just under the perianal skin.
-Attached to perineal body &anococcygeal raphe.
II) Superficial Part:
-Surrounds the lower part of the internal sphincter above the subcutaneous
part.
III) Deep Part

19. Relations of the Anal Canal
• The anal canal is related:
• posteriorly to the fibrous tissue between it and the
coccyx (anococcygeal body),
• laterally to the ischiorectal fossae containing fat,
• anteriorly to the perineal body separating it from
the bulb
• of the urethra in the male or the lower vagina in the
female.

20. Sphincters of the anal canal
12

21. Introduction
• Adjuvant therapy for rectal carcinoma has been the
subject of much debate over the past two decades.
The controversy has centered on defining the
cohort of patients who would benefit from
chemoradiotherapy regimens and whether this
should precede definitive surgical intervention.
Surgical intervention itself has been somewhat
undervalued in these trials, evidenced by poor
control of the procedural technique in many
adjuvant trials. This imbalance is beginning to be
redressed in trials specifically designed to evaluate
new methods of surgical therapy.

22. • Surgical therapy for rectal cancer has
evolved since Ernest Miles first described
the abdominoperineal resection in 1908.
• By the 1920s, he had reduced the
recurrence rate from almost 100% to
approximately 30%, thus ensuring his
technique as the gold standard.
• In retrospect, it is perplexing that such
extreme surgery was standard, given its
considerable local failure rate and its
potential to engender urinary, sexual, and
gastrointestinal dysfunction. Several
modifications were proposed to promote
locoregional control and survival, with
little success.

23. • Better suture material, as
well as devices enabling low
anastomoses, heralded a
shift toward sphincter-saving
approaches with respect to
cancer of the rectum.
Anterior resection replaced
abdominoperineal resection
as the mainstay of therapy.

24. Not surprisingly, there was
concern that sphincter-
saving surgery might
increase local recurrence. It
was in this setting that total
mesorectal excision (TME)
was first described in 1982
by Heald and colleagues
Many surgeons have
practiced this concept of
surgery prior to the
introduction of the term
“TME”
.
Dr. R.J. Heald

26. • The TME concept is based on the locoregional
recurrence preference of rectal carcinoma.
• It follows intuitively that adequate en bloc clearance of
the rectal mesentry, including its blood supply and
lymphatic drainage, would minimize possible disease
relapse.
• Early experience by Heald et al documented a 0% 2-
year local recurrence rate, without the benefit of
adjuvant radiotherapy, in their initial series of 100
cases.

27. • Further independent analysis of this
prospectively collected series demonstrated an
actuarial 4% recurrence rate in patients who had
curative resection at 5 years. Hence, precisely
controlled surgical technique can offer superior
results even in patients who have received
combination adjuvant therapy with inadequate
surgery.

28. • Several other names have been proposed for
essentially the same technique: circumferential
and sharp mesorectal excision, endofascial and
extrafascial excision of the rectum, and total
anatomical dissection.” The Tripartite Consensus
Conference held in Washington, DC, in 1999
clarified semantics by defining the complete
excision of visceral mesorectal tissue to the level
of the levators as TME”.

29. • Currently,TME is the gold standard for treatment of
middle and lower third rectal cancers in many
European countries and will probably be adopted as
such in others.
• Also, advocates in the United States are currently
supporting the use of TME as the gold standard for
treatment of these cancers.

30. Principles of TME
• Although TME has been modified over time, the basic
principle of excising tumor and the mesorectum en
bloc remains its foundation. This principle is based on
the original observations of Moynihan in 1908
regarding potential pathways for lymphatic spread and
also on the hypothesis of Heald that the mesorectum
represents embryological advantages conferring
protection against tumor dissemination until the
terminal stages. Lymphoscintigraphy further
demonstrated this in an anatomical study of the
lymphatics that drain the rectum.

70. "Down-to-Up" transanal NOTES
Total mesorectal excision for
rectal cancer

71. While open TME is associated with significant
morbidity and impairment of urogenital function ,
laparoscopy has improved the short-term results
and with equivalent oncological outcomes .
Laparoscopic TME is, however, challenging in the
lowest part of the rectum . An abdominal incision
may therefore be needed to facilitate transection,
and in some cases conversion to open procedure is
required. The rate of conversion from a
laparoscopic to open TME remains significant,
12.9% . Robotic surgery has been shown to
decrease rates of conversion, but are more
expensive .

72. Transanal TME (TaTME) potentially overcomes
these difficulties. It involves a “bottom-up”
dissection of the lowermost part of the
mesorectum. The procedure may solve “some old
problems” . It is presently done mostly with
abdominal assistance. Various nomenclatures are
used in the literature such as transanal TME
(TaTME), transanal minimally invasive TME
(TAMIS-TME), perirectal natural orifice
transluminal endoscopic surgery (NOTES) access,
natural orifice TME, transanal endoscopic TME,
endoscopic transanal proctectomy (ETAP),
transanal transabdominal resection (TATAR), and
transanal endoscopic proctectomy (TAEP) etc

73. Introduction
• Natural orifice translumenal endoscopic surgery
(NOTES) has emerged in recent years as a promising
new alternative to open and laparoscopic access for
abdominal surgery. Potential benefits in avoiding
the complications of surgical incisions encouraged
the first successful series of clinical applications for
transvaginal and transgastric NOTES

74. • Access via the anal canal in the form of
transrectal or transcolonic NOTES appears to be
an attractive option for treating both colorectal
and other abdominal diseases
• In fact, full thickness rectal wall excision
extending into the peritoneal cavity with hand-
sewn closure by transanal endoscopic
microsurgery (TEM) is not a new concept.

75. • Technical obstacles such as the risk of infection,
safe entrance into the abdominal cavity and
reliable closure of the bowel wall have been
inhibiting factors that have prevented the progress
of transrectal and transcolonic applications in
particular. Development of innovative techniques
in transanal perirectal access in animal studies and
subsequently in human subjects.

76. • Access via this method, Perirectal NOTES Access
(PNA), allows access to the mesorectal fascia and
therapy in the retroperitoneal space and ultimately
the abdominal cavity if needed. Total mesorectal
excision (TME) with high lymphadenectomy is the
standard of care for curative resection of rectal
cancer and there is good evidence showing that
minimally invasive surgery has equivalent
oncological outcomes.

77. Surgical Technique
• Technique 1: Transanal Down-to-Up (retrograde)
NOTES TME using a single port device
• Single Port devices suited for umbilical surgery have a
simple adaption when inserted transanally, allowing for
intralumenal insufflation of CO 2 , avoiding gas leaks
and getting a good view and angle for dissection of the
rectum especially above 4cm from the anal verge .

79. Triport (Olympus, Japan)
with a 10mm
30 o laparoscope, a
standard laparoscopic
grasper and either
ultrasonic shears or
semiflexible monopolar
hook for performing
rectal dissection. Other
standard laparoscopic
instruments (Karl Storz,
Germany) were used for
the laparoscopic
assistance.

81. Patients were positioned in the Lloyd-Davies position under general
anaesthesia.

82. • Antibiotic prophylaxis was given
at induction using 400 mg
ciprofloxacin and 500 mg
metronidazole intravenously.
• An anoscope was inserted and
the rectum was disinfected
using iodine irrigation. The
single port was inserted and
CO 2insufflation to a pressure of
8-10 mmHg was used

85. • The distal limit of the tumour was identified by the
single port visualisation in all cases. After the level
of the circumferential resection line was identified,
a 2-0 Vicryl purse string suture was placed below
the tumour to avoid potential cell spillage and
subsequently to maintain pressure of
CO 2 insufflation to the retroperitoneal space
during dissection.

86. A Distal resection margin,
B closure with a
purse string suture and transection of the
mucosa

87. • In patients with lower tumours with difficult
exposition, the purse-string suture is positioned
about 1.5 cm above the dentate line and a first
circular incision with monopolar cautery and
perirectal dissection is performed (for further
coloanal anastomosis) until there is sufficient room
to place the port. Fixation of the port was achieved
with 4 Vycril 2.0 sutures from the perianal skin to
the external part of the port.

88. • In some patients, the method didn't promote an
adequate fixation with significant gas leak. After the
closure above the limit of rectal resection, the distal
rectum was disinfected using topic Betadine
irrigation. A transverse incision was made
posteriorly in the planned line of rectal resection
using monopolar cautery or ultrasonic shears.

90. • Once a full thickness rectal wall incision is made,
the anatomical plane between the pelvic floor and
the mesorectal fascia becomes apparent.
Developing this plane laterally and circumferentially
allows a retrograde TME to evolve . Sharp dissection
progressed until the peritoneal reflection was
breached anteriorly.

92. • High vascular ligation has not yet been possible in
some series using transanal access. Therefore, using a
standard 3 trocar transabdominal technique this was
achieved under 30° laparoscopic surveillance using a
2.0 Prolene double ligature of the inferior mesenteric
artery at the level of aorta.
• Laparoscopic mobilization of the left colon and
splenic flexure allowed liberation of the proximal
colon and upper rectum.

94. • The specimen was then grasped transanally and fully
delivered through the anus . The exposed colorectum
was resected at an appropriate level in preparation
for the anastamosis. For low tumours with limited
rectal wall remaining, a hand-sewn coloanal
anastamosis was performed. For cases with more
than 30 mm of bowel wall above the dentate line, a
low stapled anastamosis was possible. The anvil of a
circular stapler was inserted into the proximal colon
with or without a colonic pouch.

96. • The prepared proximal colon was reinserted transanally into
the pelvis.
• Closure of the rectal stump was performed using an anal
retractor and a 2.0 Prolene purse string suture which was
then tightened over the spike of the circular stapler. Transanal
stapled anastomosis was performed under laparoscopic
surveillance. A defunctioning stoma was performed to protect
the low anastomosis and a pelvic drain inserted. The resected
specimen was assessed for the quality of the mesorectal
resection and adequacy of the distal margin from the tumour.

97. F suturing of stapler head,
G second purse string and
stapled
anastomosis.

99. No-Scar Transanal Total Mesorectal
ExcisionThe Last Step to Pure NOTES
for Colorectal Surgery

100. • The patient underwent our
standard preoperative
preparation: 3 to 8 days of low-
residue diet
• admission the day before the
procedure, and enemas the day
before the procedure.
• The patient was positioned in
the lithotomy/Lloyd Davies
position.

101. • The surgical platform used
was a transanal endoscopic
operation (TEO) device (Karl
Storz Endoscopy).

102. • After positioning the TEO
device, we performed an
initial proctoscopy,
identified the level of the
tumor, and placed a
purse-string suture distal
to it (to prevent any fecal
and/or cell contamination
during the case).

103. • The rectum was
then scored
circumferentially
and a posterior
rectotomy,
performed from
the 2-o'clock to
the 10-o'clock
positions

104. • The initial plane of
dissection was at the 6-
o'clock position, just
posterior to the Waldeyer
fascia.
• Once adequate space was
created posteriorly, the
TEO device was advanced
through the viscerotomy
and used as a retractor to
aid with the dissection of
the remainder of the
posterior and lateral
rectum. At the proximal
portion of the Waldeyer
fascia,the “Holy Plane” was
entered.

105. • This plane was then
continued proximally to
the sacral promontory. At
this point, changed from
the “short” to the “long”
TEO device

106. • Dissection was
continued laterally,
paying particular
attention to avoid the
pelvic nerves and
ureters. Once the
posterolateral portion of
the rectum was
completely mobilized,
the division of the
anterior portion of the
viscerotomy was
completed

107. • Then the
rectovaginal plane
was dissected up to
the level of the
peritoneal reflection
and then through
the peritoneum,
into the pouch of
Douglas.

108. • The rectum was then advanced cephalad,
through the peritoneal defect, via the pouch
of Douglas, into the peritoneal cavity. This
cephalad mobilization then allowed for the
adequate tenting of the sigmoid mesentery
and peritoneal attachments.

109. • The sigmoid mesocolon was then mobilized
anteriorly from the retroperitoneum using the
plane between the Gerota fascia and Toldt fascia
until the root of the mesosigmoid, at the level of
the left colic artery, was reached

110. • The medial and lateral attachments of the
mesosigmoid were divided as high as possible
including along the descending colon.

111. • Once adequate length was mobilized, the
specimen was delivered transanally. With the
specimen now pulled transanally, the TEO device
was reinserted transanally, parallel to the bowel.
This allowed for further mobilization of the
proximal bowel. The resection site was then
identified.

112. • The superior hemorrhoidal artery was ligated
and divided distal to the left colic artery (a
“low-tie” technique). Subsequently, the
sigmoid mesentery was ligated and divided
and the bowel, transected with an articulating
linear stapling device.

113. • The specimen was then delivered and the
standard of the TME, inspected. The Lone Star
retractor (Cooper Surgical) was then inserted, and
a side-to-end, coloanal anastomosis was fashioned
transanally with 3/0 polyglyconate sutures

115. • The procedure was successfully completed.
• It was performed completely by a pure transanal
NOTES approach.
• No abdominal incisions, trocars, “grasping” needles,
or proximal stomas were used. The whole
procedure was completed within 190 minutes.
There was minimal blood loss, no fecal soilage, and
no adverse incident during the case.
• In the initial postoperative period, the patient
required only paracetamol for pain control. She had
only mild, vague abdominal. She was easily able to
mobilize.

116. Pure transanal NOTES overcomes many of the
problems
(1) the anus is an easily accessible natural orifice with
a short distance to the site of operation
(2) the TEO system provides a solid surgical platform
that can easily be manipulated as required
(3) because the viscerotomy is made in a section of
bowel being removed, there is no accidental organ
injury

117. (4) the viscerotomy is incorporated into the
anastomosis (or removed in the case of a circular
stapling technique) so the concern of an
additional viscerotomy closure site is removed
(5) the technique allows for in-line operating but is
adaptable to retroflexed views if required
(6) it uses currently available laparoscopic
instrumentation
(7) it uses a surgeon's innate laparoscopic abilities

118. • One of the main factors in the successful completion of this
operation was the ability to use high-definition cameras
and screens.
• In fact, standard laparoscopic and endoscopic video
equipment would not allow for adequate definition of the
tissue planes required for a bottom-up TME.
• It is essential to develop tools particular to the surgical
technique being performed because this allows for
standardization of the technique.

119. • The potential advantage of this approach is that it
combines the perioperative benefits of a
minimally invasive approach with the oncological
benefits of major resectional surgery. This is a
monumental achievement that highlights years of
surgical research and development.
• While the development of NOTES has otherwise
slowed, its application in pure transanal colorectal
surgery is intuitive.