title: Transanal endoscopic total mesorectal excision: technical aspects of approaching the mesorectal plane from below--a preliminary report.
abstract: BACKGROUND
  Laparoscopic total mesorectal excision (TME) for low rectal cancer can be technically challenging. This report describes our initial experience with a hybrid laparoscopic and transanal endoscopic technique for TME in low rectal cancer.
  
  
  METHODS
  Between December 2012 and October 2013, we identified patients with rectal cancer < 5 cm from the anorectal junction (ARJ) who underwent laparoscopic-assisted TME with a transanal minimally invasive surgery (TAMIS) technique. A standardized stepwise approach was used in all patients. Resection specimens were examined for completeness and measurement of margins. Preoperative magnetic resonance imaging (MRI) characteristics and short-term postoperative outcomes were examined. All values are mean ± standard deviation.
  
  
  RESULTS
  Ten patients (8 males; median age: 60.5 (range 36-70) years) were included. On initial MRI, all tumors were T2 or T3, mean tumor height from the ARJ was 28.9 ± 12.2 mm, mean circumferential resection margin was 5.3 ± 3.1 mm , and the mean angle between the anal canal and the levator ani was 83.9° ± 9.7°. All patients had had preoperative chemoradiotherapy, TME via TAMIS, and distal anastomosis. There were no intraoperative complications, anastomotic leaks, or 30-day mortality. The pathologic quality of all mesorectal specimens was excellent. The distal resection margin was 19.4 ± 10.4 mm, the mean circumferential resection margin was 13.8 ± 5.1 mm, and the median lymph node harvest was 10.5 (range 5-15) nodes.
  
  
  CONCLUSIONS
  A combined laparoscopic and transanal approach can achieve a safe and oncologically complete TME dissection for low rectal tumors. This approach may improve clinical outcomes in these technically difficult cases, but larger prospective studies are needed.
authors.affiliation: Department of Abdominal Surgery, Jessa Hospital, Salvatorstraat 20, 3500, Hasselt, Belgium, joep.knol@jessazh.be.
authors.forename: J J
authors.initials: JJ
authors.lastname: Knol
authors.forename: M
authors.initials: M
authors.lastname: D'Hondt
authors.forename: G
authors.initials: G
authors.lastname: Souverijns
authors.forename: B
authors.initials: B
authors.lastname: Heald
authors.forename: G
authors.initials: G
authors.lastname: Vangertruyden
mesh_terms: D000328:Adult; D000368:Aged; D001003:Anal Canal / Q000473:pathology / Q000601:surgery*; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000379:methods; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods; D012004:Rectal Neoplasms / Q000473:pathology / Q000601:surgery*; D012007:Rectum / Q000473:pathology / Q000601:surgery*; D012189:Retrospective Studies; D000067368:Transanal Endoscopic Surgery / Q000379:methods*; D016896:Treatment Outcome