الفهرس 
Pelvic Anatomic Consideration For Transanal Total Mesorectal ExcisionOnly 14 pages are availabe for public view
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Abstract
Rectal cancer is a common and lethal disease as more than 40,000 people in the United States develop rectal cancer each year. Although rectal cancer mortality has been progressively declining since 1990 at a rate of about 3 percent per year, it still remains the second most common cause of cancer death in the US.
Surgery is the cornerstone of curative therapy for patients with rectal cancer. Surgery may be used as the sole treatment modality or in combination with chemotherapy and/or radiation therapy. The primary goal of surgery is complete removal of the primary rectal cancer along with the regional lymphatics and the superior hemorrhoidal artery pedicle.
Rectal cancer surgery has undergone major advances in the past century. Miles described abdominoperineal excision . Heald introduced TME, which has improved the oncological results. 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 . Surgical site infections are still common after laparoscopy, mostly at the specimen extraction sites.
taTME is a novel development has emerged during the past three years in the field of rectal surgery which combines the mini-invasive concept of natural orifice transluminal endoscopic surgery (NOTES), the technique of single-port laparoscopic surgery and the principle of total mesorectal excision with curative intent for treating rectal cancer.
Based on the platform of either TEM or TAMIS, it is an innovative way of retrograde TME dissection from bottom to up with or without laparoscopic assistance. It had a lot of advantages as it is supposed to facilitate distal rectal mobilization, thus achieving precise and sufficient distal margin and to reduced need for multiple stapler firings in transecting the rectum, consequently decreasing anastomotic leakage rates which is especially important for obese male patients with a narrow pelvis where exposure to the distal rectum from the abdominal approach can prove difficult. It could also protect neurovascular bundle with better visualization and exposure and has the advantage of better function and avoiding sacrificing sphincter.
After a series of preclinical trail of animal and cadaver, it has been successfully applied to humans and successional reports have proved its feasibility and safety. However, the majority of published series is hybrid NOTES, which need the assistance of conventional laparoscopic surgery from above to bottom and abdominal incision, scar, pain and incision related complications such as wound infection, abscess, hernia and implanted incisional tumors cannot be necessary avoided. It is also worried that the cost will increased since two groups of surgical equipment are needed (the abdominal and perineal) and more surgical staff are required if the two team operate at the same time (two-team approach). Up to date, as far as we have known, the pure taTME NOTES without any laparoscopic assistance has also been successfully performed in human patients though the cases are rare.