Short-term results of down-to-up TME by TAMIS following trans-anal intersphincteric dissection for very low rectal cancer

Masaaki Ito, Yuji Nishizawa, Takeshi Sasaki, Akihiro Kobayashi. National Cancer Center Hospital East

Objective: The aim of this study was to clarify the short-term results and surgical tips of down-to-up TME by TAMIS following trans-anal intersphincteric dissection (ISD+TAMIS-TME) for very low rectal cancer near the anus.

Methods: We experienced this procedure in thirty-one C-Stage  lower rectal cancers locating within 5cm from the anal verge. In the first step of this procedure, transanal intersphincteric dissection was performed from 2cm distal side of the tumor till the level that the puborectal muscle was fully exposed and then placed Gelpoint path in the anal canal. Distal stump was closed to prevent cancer cell dissemination and irrigate the anal canal. Down-to-up TME was performed under pneumoperitoneum using conventional laparoscopic devices till the level of the peritoneal reflux. Next, we moved to the abdominal side and did conventional laparoscopic procedures to make resection of the specimen. Reconstruction was made by hand-sewn colo-anal anastomosis. Diverting ileostomy was created in all the patients. 

Results: Of 31 patients, laparoscopic pelvic side-wall dissection was performed in 20 cases. Median total operative time and median blood loss was 251min and 75ml in patients without pelvic side-wall dissection and 352 min and 81ml in patients with one. Median operating time in the part of TAMIS was 76 min in all the cases. No complications were found in TAMIS related procedures. Conversion was found in one. We had grade III postoperative leakages in 3 patients and grade IV in 1 patient. R0 operation was achieved in all patients. Urinary dysfunction with residual urine of > 100ml at 5 POD was found in 5 patients, who would all recover in one month. As the greatest merit of this procedure, we could get the clear exposure at the anterior side of the rectum which could not be seen in conventional laparoscopic TME. We could identify the recto-urethral muscle here and we could get to the prostate clearly after cutting the structure. Denonvillier’s fascia could also be seen as next important structure. The seminal vesicle was exposed after cutting this fascia, and we could reach to the peritoneal reflux under TAMIS.

Conclusion: Down-to-up TME by TAMIS following trans-anal intersphincteric dissection could offer feasible procedures in any lower rectal cancer patients with the various morphology of the pelvis. We should learn specific surgical anatomies in performing TAMIS.