[Extract] Transanal total mesorectal excision (TaTME) is presented
as a promising new surgical technique for the approach to
the distal rectum, providing the ability to perform a highquality
resection, with technical advantages over the laparoscopic
approach. However, the new surgical anatomy
of the TaTME resection complicates surgical understanding
and increases the risks of inadvertent injuries to important
anatomic structures...info:eu-repo/semantics/publishedVersio

A. Goulart

AM Lacy

E Chouillard

F Aigner

GJ Wang

H. Rios

M. Sousa

P Leão

P. A. Silva

P. Leão

S. Atallah

Techniques in Coloproctology

Silva, PA

Goulart, A

Sousa, M

Rios, H

Atallah, S

Leão, P

Institutional repository of Hospital de Braga

Vol.:(0123456789) Tech Coloproctol (2017) 21:819–820 DOI 10.1007/s10151-017-1698-5VIDEO FORUMTransanal total mesorectal excision with triangle rules: a road map to prevent injuriesP. A. Silva1,2,3 · A. Goulart1,2 · M. Sousa1 · H. Rios1 · S. Atallah4 · P. Leão1,2,3 Received: 14 July 2017 / Accepted: 19 September 2017 / Published online: 24 October 2017 © Springer International Publishing AG 2017computed tomography scan of the chest and abdomen, pelvic magnetic resonance imaging scan and endorectal ultrasound identified a lesion at 3 cm from the anal verge, T2/T3a, and a lesion at 15 cm, T2N0, with no evidence of distant metasta-ses. A biopsy was taken and histology revealed an adenocar-cinoma. After a multidisciplinary oncology consultation, the patient had neoadjuvant chemoradiation followed by surgery.Circumferential rectal dissection was initiated at the level of the anorectal ring and proceeded posteriorly and crani-ally in the avascular presacral plane, between the fascia pro-pria of the rectum (enveloping the mesorectum and rectum) and presacral fascia (covering the presacral vein over the sacrum). In the beginning, the dissection needs to be in a downward direction, in order to avoid rectal perforation and respect the presacral plane. This posterior dissection can be more difficult because the posterior slope can be quite steep in some patients, so in these cases the sequence of TaTME does not need to be uniform and can be initiated by the ante-rior dissection. At the third and fourth sacral vertebra, the Waldeyer fascia is dissected, leading to a superior portion of the retrorectal compartment. The failure to recognize and divide it may result in perforation of the rectum or hem-orrhage from the presacral venous plexus. In addition, full mobilization of the rectum is not possible unless the rec-tosacral fascia is divided. At the level of the sacral promon-tory, the mesorectum becomes a thick envelope mainly in the dorsolateral position containing perirectal fat, the superior rectal vessels, lymphatic tissue and nerve structures. Usually, the rectal fascia surrounding the mesorectum adheres to the inferior hypogastric plexus (IHP). If careful dissection is not performed, the IHP could be injured and this could lead to postoperative autonomic dysfunction [4].The dissection is extended to the right and to the left of the rectum with the section of the lateral ligament and division of the middle rectal artery, if needed. The lateral ligament Transanal total mesorectal excision (TaTME) is presented as a promising new surgical technique for the approach to the distal rectum, providing the ability to perform a high-quality resection, with technical advantages over the lapa-roscopic approach [1]. However, the new surgical anatomy of the TaTME resection complicates surgical understanding and increases the risks of inadvertent injuries to important anatomic structures [2]. Detailed technical reports and step-wise description are necessary, to facilitate the surgeon’s familiarization with this new technique and to reduce the learning curve in a safe manner. This video describes, in both sexes, the TaTME approach highlighting the unique anatomic structures and pitfalls, organized into four virtual triangles (anterior, posterior and two laterals) defining a road map of anatomic landmarks [3].We report the case of a 47-year-old woman complaining of blood loss per rectum. A standard workup which included digital rectal examination, carcinoembryonic antigen, P. A. Silva and A. Goulart have contributed equally to this work.Electronic supplementary material The online version of this article (doi:10.1007/s10151-017-1698-5) contains supplementary material, which is available to authorized users. * P. Leão  pedroleao@ecsaude.uminho.pt1 Department of General Surgery, Braga Hospital, Apartado 2241, 4701-965 Braga, Portugal2 Life and Health Science Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal3 ICVS/3B’s – PT Government Associate Laboratory, Braga/Guimarães, Portugal4 Center for Colon and Rectal Surgery, Florida Hospital, Winter Park, FL, USA820 Tech Coloproctol (2017) 21:819–8201 3of the rectum consists of a broad band of dense connective tissues, which passes outward from the lateral walls of the rectum toward the base of the bladder at the point where the ureters terminate. This ligament appears lateral to the mid-rectum after dissection on the anterior and posterior sides of the rectum is completed. The lateral ligament is an extension of the mesorectum, anchoring it to the endopelvic fascia. It is divided into two segments by the IHP inside it and the visceral endopelvic fascia around it. The lateral ligament is a pathway of blood vessels and nerve fibers toward the rectum and lymphatic vessels from the lower rectum toward the iliac lymph nodes. Therefore, the lateral ligament plays a critical role in surgery for lower rectal cancer in two respects: the anatomic extent of resection for curing rectal cancer and the preservation of sexual function [5].After extending the dissection posterolaterally, the dissec-tion of the anterior mesorectum was performed to achieve circumferential rectal mobilization toward the peritoneal reflection. This is the unique triangle with the relevant ana-tomic differences between men and women. In men, the anterior part of the rectum is dissected from the seminal vesicle by incision of Denonvilliers’ fascia. This membrane should be dissected at its posterior surface, to avoid injury of the bundles of Walsh, running from the 10 o’clock and 2 o’clock directions. However, for anteriorly located tumors, the anterior dissection may be necessary to achieve a nega-tive margin. Even though the dissection is performed anteri-orly, the excellent views achieved with TaTME can prevent injury to the neurovascular bundles of Walsh. At the level of the junction of the prostate and the seminal vesicles, the anterolateral dissection can facilitate the identification of the neurovascular bundles of Walsh because of the exposure of small vessels penetrating the prostate (the prostatic capsular artery and veins). Injury to the membranous (pre-prostatic) urethra can occur during very distal anterior dissection.In women, the bundles of Walsh are identified at the level of junction of the lower and middle thirds of the vagina. The identification of the rectovaginal fascia also prevents injuries at the level of the bundles of Walsh. As a part of vaginal fascial structures, the rectovaginal fascia surrounds the posterior and lateral wall of the vagina and it could not be seen when the anterior rectal wall was dissected via an abdominal approach. Dissection in front of this fascia would destroy the integrity of the vaginal fascia and would dam-age the neurovascular bundle. Thus, dissection behind the rectovaginal ligament and in front of the fascia propria of the rectum should be more effective in preventing complica-tions of rectal cancer excision, such as sexual dysfunction. The vaginal wall should be dissected carefully and suffi-ciently from the rectum, to prevent injury to the vagina and postoperative iatrogenic rectovaginal fistula. This dissection can be performed with the help of a uterine manipulator and digital examination. This possibility of digital control of the anterior dissection makes the female patient the best for beginners in this approach.The peritoneal cavity was entered via a transabdomi-nal approach with mesosigmoid and left paracolic gutter dissection and ligation of the inferior mesenteric vessels. Specimen extraction and anastomosis were performed transanally. A protective ileostomy was made and closed 4 weeks after discharge.Operative time was 260 min, and blood loss was esti-mated to be 20 ml.On the third postoperative day, the patient presented a febrile peak. Screening for sepsis was negative. She was discharged on the eighth postoperative day.The cancer was staged as ypT2G1N0R0 (0/16 lymph nodes). The tumor size was 1 × 0.3 cm, and histologi-cally, the lesion was consistent with low-grade, well-dif-ferentiated, adenocarcinoma of the rectum with grade 1 tumor regression according to the modified Dworak tumor regression grading system. The specimen had intact meso-rectum with a smooth and regular surface. The proximal margin measured 11. 5 cm, the distal margin measured 3.5 cm, while the circumferential margin was 1.5 cm.Compliance with ethical standards Conflict of interest The authors declare that they have no conflict of interest.Ethical approval This video forum does not contain studies with the patient. The surgery was documented, with proper informed consent ant with prior authorization of the patient, it was edited for publication. This study is in accordance with the ethical standards.Informed consent Informed consent was obtained in accordance with the standards set forth by hospital regulations.References 1. Lacy AM, Rattner DW, Adelsdorfer C et al (2013) Transa-nal natural orifice transluminal endoscopic surgery (NOTES) rectal resection: ‘‘down-to-up’’ total mesorectal excision (TME)-short-term outcomes in the first 20 cases. Surg Endosc 27:3165–3172 2. Chouillard E, Regnier A, Vitte R-L et  al (2016) Transanal NOTES total mesorectal excision (TME) in patients with rectal cancer: is anatomy better preserved? Tech Coloproctol 20(8):537–544 3. Leão P, Goulart A, Veiga C et al (2015) Transanal total meso-rectal excision: a pure NOTES approach for selected patients. Tech Coloproctol 19:541–549 4. Aigner F, Hörmann R, Fritsch H, TAMIS TME Collaboration Group et al (2015) Anatomical considerations for transanal minimal- invasive surgery: the caudal to cephalic approach. Colorectal Dis 17(2):O47–O53 5. Wang GJ, Gao CF, Wei D, Wang C, Meng WJ (2010) Anatomy of the lateral ligaments of the rectum: a controversial point of view. World J Gastroenterol 16(43):5411–5415

English

Transanal total mesorectal excision with triangle rules: a road map to prevent injuries

Crossref

Silva, Pamela A.

Goulart, André

Sousa, Miguel F. M.

Rangel Ríos, H. A.

Atallah, S. Ben

Teixeira, Pedro Alexandre Leão Araújo Gonçalves

Universidade do Minho: RepositoriUM

Transanal total mesorectal excision with triangle rules: a road map to prevent injuries

Vol.:(0123456789) 
Tech Coloproctol (2017) 21:819–820 
DOI 10.1007/s10151-017-1698-5
VIDEO FORUM
Transanal total mesorectal excision with triangle rules: a road 
map to prevent injuries
P. A. Silva1,2,3 · A. Goulart1,2 · M. Sousa1 · H. Rios1 · S. Atallah4 · P. Leão1,2,3 
Received: 14 July 2017 / Accepted: 19 September 2017 / Published online: 24 October 2017 
© Springer International Publishing AG 2017
computed tomography scan of the chest and abdomen, pelvic 
magnetic resonance imaging scan and endorectal ultrasound 
identified a lesion at 3 cm from the anal verge, T2/T3a, and a 
lesion at 15 cm, T2N0, with no evidence of distant metasta-
ses. A biopsy was taken and histology revealed an adenocar-
cinoma. After a multidisciplinary oncology consultation, the 
patient had neoadjuvant chemoradiation followed by surgery.
Circumferential rectal dissection was initiated at the level 
of the anorectal ring and proceeded posteriorly and crani-
ally in the avascular presacral plane, between the fascia pro-
pria of the rectum (enveloping the mesorectum and rectum) 
and presacral fascia (covering the presacral vein over the 
sacrum). In the beginning, the dissection needs to be in a 
downward direction, in order to avoid rectal perforation and 
respect the presacral plane. This posterior dissection can be 
more difficult because the posterior slope can be quite steep 
in some patients, so in these cases the sequence of TaTME 
does not need to be uniform and can be initiated by the ante-
rior dissection. At the third and fourth sacral vertebra, the 
Waldeyer fascia is dissected, leading to a superior portion 
of the retrorectal compartment. The failure to recognize and 
divide it may result in perforation of the rectum or hem-
orrhage from the presacral venous plexus. In addition, full 
mobilization of the rectum is not possible unless the rec-
tosacral fascia is divided. At the level of the sacral promon-
tory, the mesorectum becomes a thick envelope mainly in the 
dorsolateral position containing perirectal fat, the superior 
rectal vessels, lymphatic tissue and nerve structures. Usually, 
the rectal fascia surrounding the mesorectum adheres to the 
inferior hypogastric plexus (IHP). If careful dissection is not 
performed, the IHP could be injured and this could lead to 
postoperative autonomic dysfunction [4].
The dissection is extended to the right and to the left of the 
rectum with the section of the lateral ligament and division 
of the middle rectal artery, if needed. The lateral ligament 
Transanal total mesorectal excision (TaTME) is presented 
as a promising new surgical technique for the approach to 
the distal rectum, providing the ability to perform a high-
quality resection, with technical advantages over the lapa-
roscopic approach [1]. However, the new surgical anatomy 
of the TaTME resection complicates surgical understanding 
and increases the risks of inadvertent injuries to important 
anatomic structures [2]. Detailed technical reports and step-
wise description are necessary, to facilitate the surgeon’s 
familiarization with this new technique and to reduce the 
learning curve in a safe manner. This video describes, in 
both sexes, the TaTME approach highlighting the unique 
anatomic structures and pitfalls, organized into four virtual 
triangles (anterior, posterior and two laterals) defining a road 
map of anatomic landmarks [3].
We report the case of a 47-year-old woman complaining 
of blood loss per rectum. A standard workup which included 
digital rectal examination, carcinoembryonic antigen, 
P. A. Silva and A. Goulart have contributed equally to this work.
Electronic supplementary material The online version of this 
article (doi:10.1007/s10151-017-1698-5) contains supplementary 
material, which is available to authorized users.
 * P. Leão 
 pedroleao@ecsaude.uminho.pt
1 Department of General Surgery, Braga Hospital, Apartado 
2241, 4701-965 Braga, Portugal
2 Life and Health Science Research Institute (ICVS), School 
of Medicine, University of Minho, Braga, Portugal
3 ICVS/3B’s – PT Government Associate Laboratory, 
Braga/Guimarães, Portugal
4 Center for Colon and Rectal Surgery, Florida Hospital, 
Winter Park, FL, USA
820 Tech Coloproctol (2017) 21:819–820
1 3
of the rectum consists of a broad band of dense connective 
tissues, which passes outward from the lateral walls of the 
rectum toward the base of the bladder at the point where the 
ureters terminate. This ligament appears lateral to the mid-
rectum after dissection on the anterior and posterior sides of 
the rectum is completed. The lateral ligament is an extension 
of the mesorectum, anchoring it to the endopelvic fascia. It 
is divided into two segments by the IHP inside it and the 
visceral endopelvic fascia around it. The lateral ligament is a 
pathway of blood vessels and nerve fibers toward the rectum 
and lymphatic vessels from the lower rectum toward the iliac 
lymph nodes. Therefore, the lateral ligament plays a critical 
role in surgery for lower rectal cancer in two respects: the 
anatomic extent of resection for curing rectal cancer and the 
preservation of sexual function [5].
After extending the dissection posterolaterally, the dissec-
tion of the anterior mesorectum was performed to achieve 
circumferential rectal mobilization toward the peritoneal 
reflection. This is the unique triangle with the relevant ana-
tomic differences between men and women. In men, the 
anterior part of the rectum is dissected from the seminal 
vesicle by incision of Denonvilliers’ fascia. This membrane 
should be dissected at its posterior surface, to avoid injury 
of the bundles of Walsh, running from the 10 o’clock and 2 
o’clock directions. However, for anteriorly located tumors, 
the anterior dissection may be necessary to achieve a nega-
tive margin. Even though the dissection is performed anteri-
orly, the excellent views achieved with TaTME can prevent 
injury to the neurovascular bundles of Walsh. At the level 
of the junction of the prostate and the seminal vesicles, the 
anterolateral dissection can facilitate the identification of the 
neurovascular bundles of Walsh because of the exposure of 
small vessels penetrating the prostate (the prostatic capsular 
artery and veins). Injury to the membranous (pre-prostatic) 
urethra can occur during very distal anterior dissection.
In women, the bundles of Walsh are identified at the level 
of junction of the lower and middle thirds of the vagina. 
The identification of the rectovaginal fascia also prevents 
injuries at the level of the bundles of Walsh. As a part of 
vaginal fascial structures, the rectovaginal fascia surrounds 
the posterior and lateral wall of the vagina and it could not 
be seen when the anterior rectal wall was dissected via an 
abdominal approach. Dissection in front of this fascia would 
destroy the integrity of the vaginal fascia and would dam-
age the neurovascular bundle. Thus, dissection behind the 
rectovaginal ligament and in front of the fascia propria of 
the rectum should be more effective in preventing complica-
tions of rectal cancer excision, such as sexual dysfunction. 
The vaginal wall should be dissected carefully and suffi-
ciently from the rectum, to prevent injury to the vagina and 
postoperative iatrogenic rectovaginal fistula. This dissection 
can be performed with the help of a uterine manipulator 
and digital examination. This possibility of digital control 
of the anterior dissection makes the female patient the best 
for beginners in this approach.
The peritoneal cavity was entered via a transabdomi-
nal approach with mesosigmoid and left paracolic gutter 
dissection and ligation of the inferior mesenteric vessels. 
Specimen extraction and anastomosis were performed 
transanally. A protective ileostomy was made and closed 
4 weeks after discharge.
Operative time was 260 min, and blood loss was esti-
mated to be 20 ml.
On the third postoperative day, the patient presented a 
febrile peak. Screening for sepsis was negative. She was 
discharged on the eighth postoperative day.
The cancer was staged as ypT2G1N0R0 (0/16 lymph 
nodes). The tumor size was 1 × 0.3 cm, and histologi-
cally, the lesion was consistent with low-grade, well-dif-
ferentiated, adenocarcinoma of the rectum with grade 1 
tumor regression according to the modified Dworak tumor 
regression grading system. The specimen had intact meso-
rectum with a smooth and regular surface. The proximal 
margin measured 11. 5 cm, the distal margin measured 
3.5 cm, while the circumferential margin was 1.5 cm.
Compliance with ethical standards 
Conflict of interest The authors declare that they have no conflict 
of interest.
Ethical approval This video forum does not contain studies with 
the patient. The surgery was documented, with proper informed 
consent ant with prior authorization of the patient, it was edited for 
publication. This study is in accordance with the ethical standards.
Informed consent Informed consent was obtained in accordance 
with the standards set forth by hospital regulations.
References
 1. Lacy AM, Rattner DW, Adelsdorfer C et al (2013) Transa-
nal natural orifice transluminal endoscopic surgery (NOTES) 
rectal resection: ‘‘down-to-up’’ total mesorectal excision 
(TME)-short-term outcomes in the first 20 cases. Surg Endosc 
27:3165–3172
 2. Chouillard E, Regnier A, Vitte R-L et  al (2016) Transanal 
NOTES total mesorectal excision (TME) in patients with 
rectal cancer: is anatomy better preserved? Tech Coloproctol 
20(8):537–544
 3. Leão P, Goulart A, Veiga C et al (2015) Transanal total meso-
rectal excision: a pure NOTES approach for selected patients. 
Tech Coloproctol 19:541–549
 4. Aigner F, Hörmann R, Fritsch H, TAMIS TME Collaboration 
Group et al (2015) Anatomical considerations for transanal 
minimal- invasive surgery: the caudal to cephalic approach. 
Colorectal Dis 17(2):O47–O53
 5. Wang GJ, Gao CF, Wei D, Wang C, Meng WJ (2010) Anatomy of 
the lateral ligaments of the rectum: a controversial point of view. 
World J Gastroenterol 16(43):5411–5415


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Transanal total mesorectal excision with triangle rules: a road map to prevent injuries

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Universidade do Minho: RepositoriUM