Trans-anal total mesorectal excision - reflections on the introduction of a new procedure
COLORECTAL DISEASE(2020)
摘要
The introduction of novel surgical techniques requires careful scrutiny to establish their efficacy and ensure against complications. The novel procedure of trans-anal total mesorectal excision (TaTME) was developed to facilitate resection of low rectal cancers. The rectum is mobilised laparoscopically per abdomen and the trans-anal component, performed by a second surgeon, is intended to follow the same anatomical planes as the abdominal phase, allowing the two approaches to join up, with the rectum being transected and a very low anastomosis fashioned. Difficulties encountered by the operator when performing the trans-anal component may arise from anatomical disorientation due to a lack of conceptualisation, understanding and visualisation of the anterior pre-rectal space as well as confusion as to the nature, composition and orientation of Denonvilliers' fascia. This disorientation may lead to injury of vital structures adjacent to the rectum as well as the pelvic sidewall with subsequent significant morbidity. TaTME is currently being performed internationally and is undergoing evaluation of the risk of iatrogenic injury and oncological outcomes. We believe that, as yet, there is inadequate evidence to support the routine use of TaTME. Important considerations are the intrinsic complexity of the operation, the frequency of postoperative morbidity, the impact of neoadjuvant treatment, and most importantly the need for an intimate understanding of key anatomical planes in the context of this procedure. In addition, long term outcomes need to be evaluated systematically to demonstrate its oncological efficacy.
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