Synchronous laparoscopic low anterior and transanal endoscopic microsurgery total mesorectal resection.

BACKGROUND Laparoscopic low anterior resection (Lap LAR) and total mesorectal excision (TME) is the standard minimally invasive surgery (MIS) for mid and low rectal tumours. However, the pelvic resection in particular for bulky tumour in the narrow male pelvis has always been a challenge for surgeons. Transanal endoscopic microsurgery (TEM) is a well-established technique and synchronous abdomino-perineal excision of rectum (APER) is also a standard procedure. Hence, we applied the same concept to Synchronous Lap LAR and Transanal-TME. MATERIAL AND METHODS Transanal TME was carried out with TEM instruments and rectoscope. Synchronous Lap LAR was performed and dissection joined to the pelvic part. The specimen was then retrieved via extension of the left lower quadrant port. An anvil was inserted into the proximal colon and intracorporeal transrectal anastomosis was performed to reconstitute the continuity of the bowel. RESULTS We reported the feasibility of transanal total mesorectal excision (TME) by combination of Synchronous Lap LAR and TEM. We operated on three cases, two male patients and one female patient. We performed an intracorporeal transanal stapled coloanal anastomosis in all of them using the KOL perineal set (Touchstone, Suzhou, Jiangsu, China). The trans-abdominal and transanal dissection can be joined together with ease and accuracy. CONCLUSIONS Transanal total mesorectal excision (TME) by synchronous Lap LAR and TEM is feasible. We combine operative techniques which are well established, currently available and cost-effective for bulky tumour in the narrow pelvis.