The trans-anal total mesorectal excision (TaTME) : What evidence have been reached ?

Harbi Houssem | Ben Amar Mohamed | Kardoun Nizar | Nozha Toumi | Dammak Nouha | Frikha Mohamed Foued | Boujelben Salah | Mzali Rafik |

La tunisie chirurgicale - 2017 ; Vol 2017


BACKGROUND : Transanal total mesorectal excision (TaTME) is a new concept that consists in « down to up » total excision of the meso-rectum (TME). The main goal alleged to this procedure is to offer more chances of sphincter preservation and ensure better oncological results.

OBJECTIVE : Review of specific technical features and outcomes of the transanal total mesorectal excision for mid and low-rectal cancer.

METHOD : We searched the MEDLINE, Cochrane, and Embase databases for articles pertaining to experimental and clinical studies of TaTME. Comparative studies of TaTME with laparoscopic total mesorectal excision were also reviewed. We also searched for publications dealing with both historic data and specific technical features of TaTME.

RESULTS : Preliminary short and mid-term oncological results of TaTME are good and very encouraging : it allows a better quality of TME and less invaded margins then laparoscopic TME particularly for cancer of the lower rectum. It is also associated with shorter operative time and fewer anastomotic leaks. Its most important intraoperative complication is urethral section.

CONCLUSION : The TaTME seems very useful in the surgical treatment of the lower and mid rectum cancers especially in difficult cases such as narrow pelvis, obesity and ultra-low rectal tumours. Its functional and long-term oncological results remain to be determined. The COLOR III trial should meet these objectives.

Mots Clés

Transanal, mesorectal excision, laparoscopy, rectal cancer, oncologic outcomes.

Introduction :

The treatment of rectal cancer has changed considerably in the last 3 decades with the advent of neo-adjuvant therapy and the concept of total mesorectal excision (TME) and the rate of locoregional recurrence decreased significantly. However according to CLASSICC trial (1) the recurrence rate remains relatively high. Moreover this trial showed a high rate of positive circumferential ressection margin (CRM).

Whereas validity of laparoscopic approach for rectal cancer has been established (2-5), anterior resection of low rectal tumors still technically difficult, especially in male patients, with morbid obesity, preoperative chemoradiotherapy, narrow pelvis, a thick (bulky) meso-rectum or with anterior low rectal tumor (2, 6, 7). In these cases there is a significant risk of both positive resection margins and anastomotic leakage (8-11).

In order to overcome these difficulties and to obtain lower rates of local recurrence and positive resection margins, Transanal total mesorectal excision (TaTME), a « down to up » resection technique, was developed.

Currently TaTME is a new concept which is supposed to revolutionize the surgical treatment of rectal cancer. A few series have been published since 2011 and the results look highly promising.



Three surgical techniques used in the treatment of Hirshprung disease mainly in children, can be considered as "ancestors" of TaTME.

These techniques are "Swenson" (12), "Soave-Boaley" (13-15) and "Swenson-like" techniques (16, 17). The latter is is a "pull through" technique with TME ("full thickness resection" of the rectum). It is to dissect the rectosigmoid down to up and gradually externalize the specimen without being reversed as required in "Swenson" technique.

By respecting the oncological resection rules (TME and distal, proximal and circumferential margins), total trans-anal "Swenson-like" technique is an authentic open TaTME (18).

The TaTME was described for the first time in 2011 and its feasibility was demonstrated later by several surgical teams on selected patients (19).

The first reproducible procedure was described by Hochenegg (20) in 1888: he described a colorectal anastomosis made by invagination and posterior approach. He named this method "through" ("Durchzug" in Deutch).

This first concept of the "pull-through" has undergone several changes thereafter. Indeed thanks to Babcock and Bacon’s technique (21), achieving low colorectal anastomosis has become easier since the posterior approach and the section of both external and internal anal sphincters were abondoned. Babcock and Bacon’s technique was widely circulated in the Anglo-Saxon countries in the 1950s to the 1970s despite the significant frequency of postoperative anal incontinence.

Then the "pull-through" was forgotten in the 1980s with the introduction of the concept of TME and especially with the advent of staplers. meanwhile trans-anal endoscopic operation (TEO) was introduced by Buess et al (22) in 1983 for the resection of rectal adenomas and early rectal cancers.

Thereafter and during the last decade the "pull-through" regained of interest as it has been integrated into the philosophy of minimally invasive colorectal surgery without laparotomy (23-25).

In 2010, Atallah et al (19) demonstrated the feasibility of trans-anal minimally invasive surgery (TAMIS) using the single incision laparoscopic surgery (SILS) trocar and usual laparoscopic instruments.

McLemore et al (26) published in 2012 the first successful experimental series of TAMIS as described by Atallah et al (19) with a laparoscopic abdominal assistance (multiport placed at the right ilium to the location of the ileostomy and a 5mm trocar placed at the left ilium to the location of the pelvic drain)


Four kinds of flexible or rigid trans-anal platforms are used for TaTME (26-29) :

- The multi-port trocar SILS (Covidien, Mansfield, MA, USA)

- The Endorec Trocar (Aspide, 42350 La Talaudière, France)

- The TEO platform (Karl Storz, Tuttlingen, Germany)

- The GelPOINT platform (Applied Medical, Rancho Santa Margarita, CA, USA)  platform would have the slightest impact on anorectal function. It also allows to add or change ports and it can be opened quickly.

Flexible platforms improve maneuverability and triangulation of instruments.

Few surgical teams (10%) use pure TaTME endoscopic procedure without associated abdominal approach (27).


The of TaTME has the following advantages :

- The major advantage is better definition of the distal resection margin as it is done under direct vision. This method is clearly safe and easier than standard anterior resection of the rectum (29, 30)

- Both closure of the rectum at this level (distal margin of resection) and washing the rectal stump reduces the risk of tumor cells spillage at the surgical site.

- In TaTME there is no need of staplers which are used in standard anterior resection. These instruments are difficult to handle when it comes to very low cuts on the rectum because of the very limited anatomical space at this level. This induces multiple or repeated staple firings and thus favors anastomotic leakage (7, 29, 31).

- It ensures a uniform circumferential incision of the rectum

- With direct vision and pneumo-pelvis dissection, TaTME allows easier dissection of the rectum respecting the fundamental oncological concept of  TME.

- Classic technical difficulties in « up to down » TME are avoided with TaTME. These difficulties are low rectal tumors (located less than 6 cm from the anal verge), narrow and / or rigid pelvis (particularly in males), morbid obesity and preoperative radiotherapy. Indeed in COLOR II trial (2),  reasons of laparoscopic conversion were narrow pelvis (22%), obesity (10%), fixed tumor (9%), technical and anatomical difficulties (6%), poor vision (5%), large tumor (4%) and pelvic fibrosis (4%). Moreover these conditions are risk factors for inadequate oncologic resection (7, 27, 29, 32-34).

- It is obvious that TaTME gives a better vision then laparoscopy in the most difficult anatomical areas that are the front of the rectum and the ultra-low portion of the posterior rectal wall (19)

- TaTME allows in most cases, trans-anal extraction of the specimen and thus avoid large abdominal incision (7). Furthermore there is no abdominal scar with exclusive TaTME.

TaTME is also presumed to have the following benefits : (10, 20, 35, 36)

- It would increase the sphincter preservation rate in tumors of the lower third of the rectum.

- It would reduce the rate of positive margins.

- It would ensure a higher rate of complete resection of the meso-rectum

- It would give fewer nerve lesions and therefore fewer urogenital complications

- It would ensure wider resection margins for tumors in the lower rectum


The manoeuvrability of laparoscopic instruments during TaTME, is limited mainly owing to the lack of triangulation. This technical problem arises particularly with surgeons unfamiliar with TEO and TaTME. Another technical problem is the urethral injuries which seems to be more frequent with this surgical procedure

Moreover, the learning curve of surgeons remains unclear. This is why many authors advocate the prior training on animal and/or human cadavers.

Taking into account these drawbacks, TaTME should be reserved for surgeons specializing in colorectal surgery.


Carefull selection of patients for TaTME is mandatory as it must be reserved for low-risk patients and for specialized surgical teams.

Safe oncological long-term outcomes of TaTME have to be confirmed before it becomes a valid alternative to standard laparoscopy. Its non-inferiority or superiority must be proven by randomized studies especially by Current COLOR III trial (39).

As TaTME offers oncological resection of rectal cancer, it is up to the surgeon to opt or not for this procedure. Therefore it would be more logical to review its contra-indications which are according to Tuech (40) and Lacy (28) as follows :

- T4 tumors with invasion of the prostate or vagina

- Tumors invading the external sphincter and / or levator ani muscle.

- Rullier (41) Type II or III rectal tumors.

- Tumors without any objective response to preoperative chemoradiotherapy

- Recurrent tumors

- Intolerance for pneumo-peritoneum

- Body mass index (BMI) > 35

Ferko et al (42) reported recently a very interesting study including 93 patients to show significant correlation between quality of TME (all types of resection) and pelvic A5 angle (Angle between the lower and upper borders of the pubic symphysis and promontory: this angle characterizes the pelvic entry. It is calculated on pre-operative CT or MRI pelvimetry). This study attested that the more acute A5 angle the more the resection is difficult and the TME quality is poorer. It also showed that neither BMI nor neoadjuvant treatment influenced significantly the quality of TME. So these authors concluded that predicting poor TME quality for mid and low rectal cancer (especially those locally advanced) is not suitable for TaTME and should be an indication for trans-abdominal TME.


The danger of fake plane of dissection during laparoscopic TaTME

Some authors (7, 36) found that the pneumo-pelvis might lead the surgeon astray during pelvic dissection as it could show a fake areolar dissection planes. This is most likely to occur laterally to mid rectum and posteriorly to mid and upper rectum. So the main risk is the breaking in presacral fascia with possible damage of pelvic nerves and presacral venous plexus.

Need for the assistance of abdominal laparoscopic approach

Abdominal laparoscopy assistance still used by the utmost of surgeons (27, 30, 43, 44).

Abdominal approach can be carried out before TaTME or simultaneously which clearly reduces the operative time (32, 40).

Abdominal laparoscopy seems necessary if the release splenic flexure is needed to achieve the CAA. Moreover laparoscopy is needed to carry out a protective ileostomy uneventfullly (45).

However exclusive or pure TaTME still an attractive procedure. For example Chouillard et al (44) opted for this technique in 62.5% of patients.

Transanal extraction of the tumour

It is not always feasible when it comes to narrow pelvis, to large meso-rectum or to enlarged prostate (7, 37). Furthermore, transanal extraction of a large specimen may cause anal divulsion. However, this situation is very rare not only because of tumour down-staging relevant to neo-adjuvant chemo-radiotherapy but also because rectal cancer is today frequently diagnosed at early levels (21).

In case of suspected or obvious positive circumferential margin the trans-anal extraction should be prohibited.

Immediate or delayed CAA (21)

There is a lack of evidence concerning functional results of delayed CAA. Nevertheless it remains a valuable procedure in the following situations: high risk of anastomotic leaks, re-interventions on the pelvis, pelvic fibrosis due to pre-operative radiotherapy and pelvic suppuration (pelvic abscess or recto-urethral /recto-vaginal fistula). Moreover, delayed CAA allows to avoid a protective stoma usually associated with immediate CAA.

Types of CAA (46)

CAA is one of the most delicate surgical steps after TaTME and it needs fastidious surgical skills. There are 4 types of CAA : Traditional hand-sewn anastomosis, circular stapled anastomosis 28–31 mm with transanal view, circular stapled anastomosis 28–31 mm with abdominal view and EEATM haemorrhoid stapled anastomosis. The best indication for each kind is a tumor distance from anorectal-junction respectively at <2cm, 2-3cm , 3-4cm and >4cm. However we still lack of studies comparing all these CAA techniques.

Ileostomy for protection of immediate CAA

Surgeons are used to protect systematically both CAA and low colorectal anastomosis with an ileostomy which have been proved to reduce significantly the severity and the frequency of anastomotic leakage (4).

However, technically ileostomy is not always easy especially in patients with multi-operated abdomen, morbid obesity, major abdominal fat or with refractory to treatment ascites. In addition ileostomy had specific complications such as invaginated stoma, stomial prolapse, peristomial hernia and its psychological impact.


The lack of triangulation is reponsible for difficult maneuverability of the instruments during single-port laparoscopic TaTME (most used procedure). Thus the use of robotic procedure helped to overcome this technical constraint.

The other advantages of this robotic surgery are the three-dimensional high-definition images, the ability to cross and to reverse (left-right) easily the operating arms (27, 48-50).

Atallah et al (38) were the first to perform a robotic TaTME called RATS-TME (robotic-assisted surgery for transanal TME). Afterwards they reported in 2014 (51) 3 cases of RATS-TME for low rectal cancer with no major complications after a short-term follow-up.

Gomez Ruiz et al (49) have also demonstrated the feasibility of robotic TaTME and had only 1 grade B (52) anastomotic leakage (among 5 operated patients). The resection margins were negative in all 5 cases.

These preliminary outcomes of robotic TaTME are hopeful, but further studies are needed to evaluate its long term results as for TaTME in general.


Open TaTME allows only partial mobilization of the meso-rectum (not more than 10cm from the anal verge according to a French study (53)) unlike to laparoscopic TaTME. The latter not only facilitates abdominal approach but also provides surgeons with better view for dissection and the pelvic gas insufflation (pneumo-pelvis) provides a valuable aid for better and easier dissection. Consequently, laparoscopic TaTME seems to improve the quality of TME (10, 54).


Seven recent studies (table 1) compared the two procdures. The short-term outcomes were very promising as they were favorable to TaTME: conversion rate, hospital stay, rate of readmissions, post-operative morbidity, rate of anastomotic leakage, length of distal margin, operative time, rate of complete TME and rate of positive CRM were either comparable or significantly better in the TaTME group. Furthermore, it is worth to note that 1 study (53) showed that abdominal dissection was the only independent risk factor for positive CRM.


Outcomes of preliminary experimental studies of TaTME in swine and fresh human cadavers

These studies (table 2) were successful and very encouraging as feasibility and safety of TaTME were proven.

Global outcomes

According to a recent systematic review of 510 patients (65), perioperative mortality and morbidity rates of TaTME were respectively 0.2% and 35%. Only 6.1% of patients had anastomotic leakage and 3.7% needed reoperation. Quality of TME was typified as complete in 88% of cases and almost complete in 6%. The CRM and the distal resection margins were negative respectively in 95% and 99.7% of cases.

Presacral abscess / pelvic collections

The risk of abscess or local collection after a TaTME must be properly assessed because it is a serious complication even if it seems rare in current literature (7).

Velthuis et al (36) found a positive pelvic culture among 39% of patients (who underwent TaTME) of which 4 (44%) developed a presacral abscess. None of the patients with a negative pelvic culture had a local infection.

These findings suggest to recommend a thorough washing of the rectum before and during the procedure, and mainly before rectotomy.

Urinary complications

Urinary retention and transient urinary dysfunction are the most commonly reported complications (of TaTME) : Sylla et al (66) observed 2 cases of urinary dysfunction associated with neurogenic bladder (the urodynamic study showed minimal detrusor activity 1 month after surgery) and Tuech et al (40) reported 5 cases of transient urinary dysfunction with complete remission after 3 months.

However the prospective study of Denost et al (53) found no significant difference (p = 0.715) between the abdominal and perineal dissection of the rectum in terms of urinary complications (respectively 6% and 10%)

The TaTME increases the risk of urethral section especially in its post-prostatic portion unlike to abdominal dissection of the rectum (Standard TME) which has virtually no such risk (34, 35, 67). This risk is increased by prior pre-operative radiotherapy.

It is worth noting unilateral urogenital functional nerve-sparing is compatible with satisfactory genital function (68).

Sexual complications

According to a recent french study (40) of 56 patients operated by TaTME, genital problems rate was 22,4%. Ejaculation disorders and sexual impotence rates were both at 11.2% which is substantially equivalent to standard approach (« up to down » TME) rates (7-11%) (49, 69). The recent study of Kneist et al (68) stipulated that bilateral urogenital functional nerve-sparing is mandatory to avoid sexual disturbances (68).

Histologic outcomes

The review of Monson et al (70) and other 3 recent studies (20, 71-73) showed that TaTME allowed very high rates of good quality TME (complete resection in 90% of cases), very high levels of satisfactory and uninvaded distal margin (at least 1 cm in most of the series), adequate lymphadenectomy (at least 10 nodes on average) and very low rates of positive CRM (<6 %) with the exception of Rouanet study (34) who reported high rates (13.3%) of positive CRM. This could be explained by the fact that this study focused on a series of 30 difficult male patients with overweight or obesity (54%), preoperative radiotherapy (96.7%) and threatened CRM in MRI (83.3%). So according to this sudy, TaTME is very promising even in presumed difficult patients.

TaTME seems also to ensure wider resection margins and higher rates of sphincter preservation (7, 10).

Short and mid term carcinologic outcomes of TaTME

TaTME allowed, as showed by table 3, low rate of local recurrence (<3,9%) and high rates of both global (> 88%) and free of disease (> 80%) survivals all with at least 24 months follow up.

These results are very promising but a long-term monitoring of patients is needed to determine long-term rates of local recurrence and to definitively conclude to oncologic efficacy and validity of TaTME (3, 7, 70, 74).

It is clear that most studies on TaTME involved low rates of T4 rectal cancer (32, 34, 53, 67) because this procedure would be logically associated with poor histologic and oncologic outcomes. However, for these T4 tumors, the ideal approach remains to be determined.

Functional outcomes

A third of patients who had a standard TME would theoretically have a varying degrees of temporary fecal incontinence (75) but functional results of TaTME are not yet well known and there is very few data about CAA stenosis (27) : Rouanet et al (34) reported 35% of incontinence gas, 15% of liquid incontinence and 25% of stool fragmentation 12 months after ileostomy closure. Atallah et al (33) found that most patients had moderate fecal incontinence 8 weeks after of ileostomy closure. Tuech et al (40) found that 28% of their patients had stool fragmentation and/or difficulties with defecation. They also performed permanent colostomy in 5.7% of patients because of severe fecal incontinence after intersphincteric resection and CAA.

These poor functional results were attributed to partial sacrifice of the internal anal sphincter and anal dilatation during TaTME but further research studies should find whether transanal platforms lead to neurogenic and/or structural lesions of the anal sphincter.


The main goal alleged TaTME to this technique is to offer more chances of sphincter preservation and to ensure better oncological results. It was designed to overcome technical difficulties in resection of low and mid rectal tumours. It was also developed to further reduce the rates of loco-regional recurrence and positive resection margins.

Currently approval of an ethics committee is mandatory prior to TaTME. It should be reserved to surgeons with expertise in minimally invasive and/or endoscopic trans-anal surgery for colorectal cancers. In addition, many authors advocate the prior learning of the technique on animals or human cadavers.

All published series on TaTME showed that it is feasible and reliable. Its preliminary results in terms of complications and short-term oncological outcomes are good and very encouraging.

The functional and oncological long-term results remain to be determined to draw definitive conclusions about the effectiveness of this procedure and its indication in the treatment of rectal cancer. The COLOR III trial should meet these objectives. We believe strongly that TaTME should very likely become the standard surgery for low rectal cancer, which is to present a technical challenge either for laparoscopic or open surgery.

Apart from its not yet known functional and long term oncological results, TaTME currently raises other issues as how to teach this technique and its direct and indirect costs.

Table 1 : Outcomes of comparative studies : TaTME versus Lap TaTME



Number of patients

Operative time (minutes)

Conversion rate


Hospital stay (day)

Complete TME


Distal margin

Lymph Node

Velthuis 2014 (55)



























< 0.05

> 0.05

> 0.05


Fernadez 2015 (32)























< 0.01


< 0.16 ***




< 0.01


Denost 2015 (53)

























> 0.05

> 0.05





Chen 2015
































Perdawood 2015 (57)































Marks 2016 (58)









0% (+)










0% (+)












Rasulov 2016 (59)









> 11mm  78%










> 11mm  77%












Lap TME : Laparoscopic TME ; NS : not specified

*     : operative time was significantly lower in TaTME subgroups (one team and two teams)

**   : intra-operative complications weren’t significantly different (p = 0.286).

*** : there was significant lower rates of pelvic collection (p = 0.08) and readmissions (p = 0.03) in the TaTME group.


Table 2 : Outcomes of experimental TaTME studies


Number of patients


Operative time

Specimen length


TME quality


Etudes sur les porcs

Sylla (60)


Pure TaTME (10)

TEM + TGE (10)

97.5 (80-120)

254.5 (205-355)

p < 0.0005

6.2 (4-8)

9 (7-12)

p < 0.0005


The narrow pelvis and an acute angle of the promontory impede trans-anal dissection of meso-sigmoid

Trunzo (61)


Pure TaTME

3 hours




Araujo (23)


Pure TaTME

190 minutes




Etudes sur cadavres humains

Whiteford (25)


TaTME pure

4.25 hours



3/3 succefull procedures verified by laparoscopy

Telem (62)


Pure TaTME (19)

TaTME + TGE (5)

TaTME + SL (8)

306 minutes





-  Specimen significantly longer if SL is      associated (p = 0.013)

- 9 perforated specimen during surgery

McLemore (26)



200 ± 55 minutes

37 (32-41)



Rieder (63)


Pure TaTME (4)

Pure SL (2)

247 ± 15 minutes

110 ± 14 minutes

P < 0.01

16 ± 4

31 ± 9

P < 0.01


- 6 simulated sigmoid lesions

- Non resected lesion (pure TaTME) : 1/4

- Pure TaTME for low rectal cancer is feasible

Kim (64)


TaTME + SL (5)


206.7 ± 55 minutes *

146.3 ± 8 minutes **

23.7 ± 5 *

24 ± 2 **

- 4 complete

- 1 nearly complete

- 1 incomplete


- 1 urethral injury and 2 rectal injuries during surgery

- 4 Hand-sewn anastomoses and 2

single-staple end-to-end anastomoses

TGE : Trans-gastric endoscopic surgery ; SL : Standard Laparoscopy  ; * : Rigid platform for TaTME  (3 cadavers) ; ** : Flexible platform for TaTME (3 cadavers)


Table 3 : Oncologic outcomes of the largest series of TaTME



Number of cases

Local recurrence (%)

Global survival (%)

FD survival (%)






0 - 80 months


5 years


5 years

Rouanet * (34)


30 men


21 months


24 months


24 months





1,7%                  24 months


29 months


5 years

Muratore (10)




21 months


21 months


21 months






18 - 24 months


30 months


30 months







24 months


24 months






10.7 months


25 months


25 months

* : It is a study of 30 patients with advanced or recurrent rectal tumors ;  FD : Free of disease ;  DM :distant metastasis



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