Modified Two-Team Approach to Laparoscopically Assisted Transanal Total Mesorectal Excision (TaTME) Suitable to Lower Resource Hospitals

Abstract

Objectives

Transanal total mesorectal excision (TaTME) in the management of patients with low rectal cancer have been increasingly adopted. Laparoscopically assisted two-team TaTME has been utilized by the majority to reduce operative time. As the procedure requires several operators working simultaneously, it remains mainly in the scope of practice of large colo-rectal centers. We propose a modified two-team approach with a reduced number of surgeons and assistants to be suitable for lower resource facilities, such as community hospitals.

Methods

A modified two team approach to laparoscopically assisted TaTME was utilized in eight patients with stage II and III rectal cancer treated by multidisciplinary team at our community hospital from 2023 to 2025.

Results

TaTME were successfully completed in all eight patients. The mean operative (OR) time was 325.5 minutes. The median length of hospital stay (LOS) was 2 days. R0 resection with intact mesorectal envelop and adequate resection margin distance was achieved in all patients. Three patients had complete pathological response. One patient had presacral absence managed endoscopically. All patients underwent ileostomy reversal and reported good functional outcomes.

Conclusion

Modified two team approaches to laparoscopically assisted TaTME could be safe and feasible for utilization in lower resource facilities. The early results of this short series are encouraging, yet longer case series will be needed to confirm wider applicability of this method.

 

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Keywords

rectal cancer - TaTME - community hospital

Introduction

A laparoscopically assisted two-team transanal total mesorectal excision (TaTME) has been shown to be safe and feasible in the recent large multicenter trial in North American patients.[1] The technique combines minimally invasive abdominal and transanal approaches. Normally, one team of surgeons performs laparoscopic mobilization of the left colon while another team performs transanal (bottom-up) perirectal dissection via rigid endoscopic platform. As the latest portion could be time consuming, the main advantage of the two-team approach is a potential reduction of the total operative time.[2] This approach may not be suitable to smaller centers with established care for patients with rectal cancer. In facilities where surgical residents or qualified mid-level assistants are not available, scheduling of a second surgeon for a long case may be challenging. We developed a modified two-team technique including an intermittent involvement of a second surgeon to key portions of the procedure without significant prolongation of the operative time that may facilitate the wider adoption of TaTME.

 

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Methods

A modified two team approach for laparoscopically assisted TaTME was utilized for eight patients with mid and low rectal cancer undergoing multimodality treatment in our community hospital from February 2021 to March 2023.

 

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Patient Selection

The patients with stage II-III mid and low rectal cancer amenable for sphincter preserving proctectomy were selected by multidisciplinary tumor board. CT scan of chest, pelvis and abdomen, CEA level and pelvic MRI were performed for staging. All patients received neoadjuvant chemo-radiation therapy (CRT). The patients were taken into OR after a 12-week waiting period followed the last chemo-radiation session. Preoperative patients' characteristics are shown in [table 1]. All patients signed informed consent forms included agreement for their medical data to be used in research purposes without person identification.

Table 1 Preoperative patients' characteristics

Patient #	Gender	Age	BMI kg/m2	Location of distal tumor margin from anal verge, cm*	Pretreatment stage*
1	F	78	24.3	6.0	T3N2
2	F	68	26.2	7.8	T3N0
3	M	65	23.8	6.7	T3N2
4	M	72	35.0	6.5	T3N2
5	F	66	24.4	4.5	T2N0
6	F	52	23.7	5.0	T3N1
7	F	49	22.8	3.4	T3N0
8	M	65	25.1	5.2	T3N2

*Based on measurement on pretreatment MRI.

 

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Surgical Technique

After anesthesia induction and intubation, cystoscopy with bilateral fiber optic ureteral stents is performed by a urologist. A team of two surgeons performs laparoscopic mobilization of the left colon and splenic flexure utilizing two or three 5 mm and one 12 mm ports. High ligation of IMA is performed. Elevation of the mesorectum just passed the promontorium and opening pelvic peritoneum around the rectum are initiated. The sigmoid colon is then divided with 60 mm stapler for air seal during rectal insufflation. The peritoneal cavity is desufflated for improved transanal insufflation. The assisting surgeon is released. Patient's legs are further elevated to high lithotomy position. A rigid transanal platform, GelPOINT^® (Applied Medical, Santa Margarita, CA, USA) with four 12-mm ports is introduced. AirSeal^® (ConMed, Largo, FL, USA) device is used for maintaining intraluminal CO2 insufflation at 20 mmHg. Conventional 30-degree 5-mm camera and laparoscopic instruments: grasper, cautery hook and suction/irrigation device are utilized for TaTME portion. The distal margin of the tumor is visualized. A purse string suture is applied just distally to it, closing the rectal lumen to seal. After the rectal mucosa is marked with cautery, a circumferential full-thickness incision into mesorectal fat is done. Bottom-up TME is then performed evenly in 4 directions taking great attention to correct plans recognition to pass the mid rectum. The assistant surgeon is now scrubbed in for laparoscopic assistance as the peritoneal cavity is reinsufflated. Now, utilizing a two-team approach, the mobilized rectum is detached and secured in the peritoneal cavity. Fluorescent indocyanine green (ICG) mesenteric angiography is preformed to ensure adequate perfusion of the sigmoid colon. A purse string suture is applied to the remaining rectal cuff transanally for future circular stapling leaving long strings untied. The rigid transanal platform is then removed. In case of transanal specimen extraction, the anal canal is protected with Alexis^® (Applied Medical, Santa Margarita, CA, USA) wound retractor. Otherwise, a suprapubic access incision is performed. The rectum is retrieved out via a dilated and protected anal canal or via suprapubic transverse incision. The specimen is transected at the recto-sigmoid level. The mesocolon is transected by keeping the IMA pedicle with the specimen. We assess the intactness of the mesorectal envelope on visual inspection of the specimen. We normally use a 31-mm circular stapling device for anastomosis. A J-pouch is created to compensate for lost rectum volume when possible. As we introduce an anvil and pursestring it in the sigmoid colon lumen, the colon is placed back into the pelvic cavity through the anal canal or suprapubic incision. The anastomosis is then performed utilizing a two-team approach. The rectal cuff sutures are tied around the guiding tube connected to the spike anvil of the stapler device. Once the spike anvil is introduced via pursestring suture of the rectal stamp, the guiding tube is detached and retrieved via 5 mm post by the laparoscopic assisting surgeon, who then connects the colonic stump anvil to the stapling device and ensures correct alignment of the colonic conduit. After the stapler device is fired and retrieved, the completeness of the anastomotic line is confirmed by both digital and endoscopic control using a flexible sigmoidoscope. The operation is completed by creating a diverting ileostomy using the right lower quadrant laparoscopic port (12 mm).

 

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Postoperative Care

All patients were followed according to our ERAS protocol. Opioid use for pain control is minimized. Anti-emetics, early feeding with clears and same day ambulation are utilized. The patients are given regular diet once the ileostomy function is confirmed, typically the next morning after the operation. The patient would be normally discharged home on a second postoperative day (POD) and evaluated in clinic in 2 and 6 weeks. Ileostomy reversal is performed in 2 months postoperatively.

 

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Results

A modified two-team approach resulted in successful TaTME completion and anastomosis creation in all 8 patients. All patients received diverting ileostomy. The mean total OR time was 325.5 min. The mean OR time of abdominal portion was 28.9 min. The mean blood loss was 45 ml. The median LOS was 2 days. Postoperative patients' characteristics are in [table 2]. There was one complication, a retro-rectal (presacral) abscess due to partial dehiscence of the anastomotic line. The patient underwent endoscopic abscess evacuation and drainage. He was readmitted and treated with IV antibiotics and scheduled endoscopic wash outs. The absence has been resolved, and the patient underwent successful ileostomy reversal in 10 weeks after index surgery. His anal sphincter function remained normal on subsequent follow up. All other patients underwent ileostomy reversal in 8 weeks postoperatively. All patients reported preserved anal sphincter function post ileostomy reversal on 2-week and 6 weeks follow up visits. All patients had complete mesorectal excision with intact mesorectal envelop. Three patients had complete pathological response. Five patients with residual tumor in their specimens with negative circumferential and distal resection margins. These 5 patients underwent adjuvant chemotherapy. The results of pathology and final staging are summarized in [Table 3].

Table 2 Postoperative patients' characteristics

Patient #	OR time, abdominal portion, min	OR time, total, min	EBL, mL	LOS, days	Complications
1	23	347	50	2	none
2	28	343	100	2	none
3	26	317	75	3	none
4	45	402	200	3	none
5	33	278	50	2	none
6	25	320	50	4	none
7	21	276	25	2	none
8	30	321	20	2	Retrorectal abscess

Abbreviations: EBL, estimated blood loss; OR, operative time.

Table 3 Pathology stage and margins

Patient #	Final pathological stage	CRM, cm	DRM, cm
1	T2N0	1.7	0.9
2	No residual tumor	n/a	n/a
3	T3N2	0.8	1.2
4	No residual tumor	n/a	n/a
5	No residual tumor	n/a	n/a
6	T3N1	0.2	0.7
7	T2N0	0.5	0.8
8	T3N1	0.3	0.5

Abbreviations: CRM, circumferential resection margin; DRM, distal resection margin.

 

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Discussion

TaTME technique has well known advantages over pure transabdominal approaches in surgical management of patients with low rectal cancer. Among them are higher rates of negative distal and circumferential margins of the resected specimens.[3] The most technically difficult portion of TME is performed in reverse fashion (bottom up), allowing for direct visualization and isolation of distal tumor margin and straight shot precise dissection under direct view. This technique could be a valuable armamentarium for many surgeons who treat patients with rectal cancer at smaller facilities with established care for patients with rectal cancer. Yet, to date, TaTME technique remains in the scope of practice of selected large colo-rectal centers. An access to care at these hospitals is limited to majority of US population. According to surveillance by National Cancer Institute, over 70% of patients with rectal cancer are still managed in mid and low volume hospitals despite of recent trend for centralization of cancer care in USA.[4] At the same time, laparoscopically assisted two team TaTME has been shown to be safe and feasible in the recent large multicenter trial in North American patients.[1] While the expertise in diagnostic and medical oncology treatment modalities could be easier implemented in smaller facilities, a full range surgical options may be in delay. In the meanwhile, the adoption of TatME in lower resource facilities may improve surgical management of the patients with rectal cancer. Specifically, the rate of anal sphincter preservation operations could be increased, while the rates of loco-regional recurrence and permanent colostomies decreased.

A time and effort consuming one team TaTME approach may not be optimal for community hospitals due to prolonged OR time and known difficulties with after-hours resource allocation. The most used two-team approach requires several operators and assistants working simultaneously during entire case, which given limited resources, is not practical for smaller centers. We proposed a modified two-team approach that could be suitable to specifics of a mid-size community center.

In our 211-bed community hospital we have established multidisciplinary care for patients with rectal cancer. The patients are managed by the team including medical and radiation oncologists, radiologists, pathologists and surgeons. Our surgical team of two surgeons perform sphincter-preserving rectal resections and minimally invasive transanal operations for over a decade. We performed our first laparoscopically assisted TaTME in 2017.[5] Over past years we came to optimization of the two-team approach based available resources. All surgical candidates with low rectal cancer receive neoadjuvant treatment and are selected for TaTME based on decision of a multidisciplinary tumor board.

In our small study of eight highly selected patients we aimed to demonstrate the feasibility of a modified two-team approach designed for utilization of TaTME at a community hospital where workforce resources are limited. An intermittent involvement of a second team to those portions of the operation where laparoscopic assistance is necessary for liberation of an assistant surgeon for the most time-consuming portion of TaTME itself. Unlike in conventional two-team approach, the transabdominal portion of left colon mobilization was performed by the team of two surgeons, after which the second surgeon is released. The abdominal portion is done using well established standardized laparoscopic technique and would normally take a short period of time with no significant range in time difference among the cases. As there is no need for an assistant present at the abdominal position after completion of the abdominal portion, the peritoneal cavity is desufflated and the legs could be further adjusted to create more space for the transanal team as needed. In addition, prior sigmoid colon stapling transection and complete peritoneal desufflation augmented stable transanal CO2 insufflation and improved rectum distention and tissue exposure for TaTME portion of the procedure. We summarized the comparative patterns of the three TaTME approaches in [table 4].

Table 4 Comparative patterns of three TaTME approaches

Approach/features	One team	Two-team	Modified two team
Laparoscopic portion	Completed before TaTME	Completed simultaneously with TaTME	Colon mobilization - before TaTME. Specimen detachment, retrieval and anastomosis creation – simultaneously
Colonic occlusion for optimization of rectal insufflation seal	Not performed	Performed with grasper by laparoscopic team	Transection with linear stapler is performed prior to TaTME
Leg position	Optimized for transanal approach	Suboptimal middle position to accommodate both teams	Optimized for transanal approach
Time sparing	no	yes	yes
Recourse sparing	yes	no	yes

Abbreviation: TaTME, transanal total mesorectal excision.

The mean OR time in our study was within the range of OR time reported in larger series where a two-team approach was used.[1] [6] All criteria of an adequate TME were met: all specimens had intact mesorectal envelopes, negative distal and circumferential margins. Our study has two inherent limitations: small number of patients and short follow up. We did not include formal LARS or other QOL scores as those could change over time and may be more adequately assessed in a longer follow-up period. Yet, all patients in this series reported nearly normal sphincter control after ileostomy reversal. We had one complication of presacral abscess due to partial staple line dehiscence. This was managed with endoscopic wash outs while the patient had diverting ileostomy in place. After resolution and ileostomy reversal the patient reported normal sphincter control with 1 to 2 bowel movements per day.

Although the modified two-team approach may be suitable for community hospitals as a resource sparing strategy, a larger number of series are needed to confirm the feasibility of wider implementation of TaTME technique at lower resource hospitals.

 

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Conflict of Interest

The authors declare that there is no conflict of interest.

Data Availability Statement

The data that support the findings of this study are available from the authors upon reasonable request.

ORCID ID

Victor Bochkarev – https://orcid.org/0009-0000-7359-942X

• References

• 1 Sylla P, Sands D, Ricardo A. et al. Multicenter phase II trial of transanal total mesorectal excision for rectal cancer: preliminary results. Surg Endosc 2023; 37 (12) 9483-9508
• 2 Nguyen TX, Ho HT, Phan HT, Vu HA, Pham NH. The effectiveness of double team for transanal total mesorectal excision in treatment of mid-low rectal cancer. Int J Surg Open 2021; 34: 100359
• 3 de Lacy FB, van Laarhoven JJEM, Pena R. et al. Transanal total mesorectal excision: pathological results of 186 patients with mid and low rectal cancer. Surg Endosc 2018; 32 (05) 2442-2447
• 4 Charlton ME, Hrabe JE, Wright KB. et al. Hospital characteristics associated with stage II/III rectal cancer guideline Concordant Care: Analysis of Surveillance, Epidemiology and End Results-Medicare Data. J Gastrointest Surg 2016; 20 (05) 1002-1011
• 5 Bochkarev V. Two-Year Follow-Up of the First Transanal Total Mesorectal Excision (TaTME) Case Performed in Community Hospital in Hawai'i: A Case Report and Literature Review. Hawaii J Health Soc Welf 2021; 80 (07) 159-164
• 6 Ma B, Gao P, Song Y. et al. Transanal total mesorectal excision (taTME) for rectal cancer: a systematic review and meta-analysis of oncological and perioperative outcomes compared with laparoscopic total mesorectal excision. BMC Cancer 2016; 16: 380

Publication History

Received: 07 April 2025

Accepted: 16 July 2025

Article published online:
09 October 2025