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Course Description/Overview

The utilization of minimally invasive techniques in performing colon resections has increased significantly since the 2004 publication of the COST trial. Despite solid evidence supporting improved patient outcomes, adoption of minimally invasive approaches for rectal cancer has been relatively slow. With the introduction of the Total Mesorectal Excision (TME) by Heald in 1979 and subsequent dissemination worldwide, rectal cancer recurrence rates have decreased and survival rates have increased. Concomitant with this, laparoscopic surgery has been shown to have equivalent outcomes to open surgery for rectal cancer with proper experience and expertise. In addition to improvements in short- term benefits such as decreased length of stay, reduced pain, and improved morbidity, a proposed technical benefit of a laparoscopic approach to rectal cancer is improved visualization in the small operative field.

Despite these benefits, the anatomic challenges presented in rectal cancer surgery, especially in patients with a bulky tumor, mid-to-low location, and/or narrow pelvis, have not been completely solved by laparoscopic surgery. For early stage lesions, transanal platforms [i.e., local excision, transanal endoscopic microsurgery (TEM), transanal minimally invasive surgery (TAMIS)] have been developed to provide near equivalent outcomes with lower morbidity. However, these methods only address the local disease in the rectal wall, potentially leaving local-regional disease in the mesorectum. Robotics have filled in much of this gap, allowing for improved visualization, “wrist-like” movement at the instrument level as well as additional arms and retraction at the pelvic floor.

More recently, the transanal TME (taTME) approach has found to be feasible in animal models and cadavers prior to the first case report in humans in 2010. Since 2010, there have been multiple studies reporting on safety and feasibility of taTME, with the largest study including 140 cases. Recent concerns regarding local recurrence and high learning curve have slowed the growth of this approach, but techniques gained from taTME can be applied to the TaTa approach (transanal transabdominal proctosigmoidectomy) and allow for a single stapled anastomosis.

Similar to other disease processes, the ideal approach needs to be individualized based on tumor and patient-specific criteria (size of lesion, recurrent operations, distance from anal verge). Additionally, surgeon expertise and experience factor critically into the ability to possess all approaches safely and effectively into the armamentarium and to ensure optimal outcomes.

This course will focus on laparoscopic and robotic approaches for rectal cancer and also highlight the TaTa approach for single stapled anastomosis.

• Robotic approaches to TME
• Transanal transabdominal approaches to rectal cancer
• Laparosocopic approaches to rectal cancer

Who Should Attend?

The symposium is directed to all surgeons treating rectal cancer. Colorectal surgeons looking to expand their skillset and general surgeons and trainees performing more complex colorectal surgery.

Learning Objectives

After completing this educational activity, the participant will be able to do the following:

• Discuss the potential advanced approaches to complex situations encountered during laparoscopic colorectal resection.
• Describe the appropriate utilization of available stapling and energy technology for proctectomy.
• Reproduce the basic approaches to a proctectomy including the principles of a total mesorectal excision (TME) from an abdominal and transanal approach.
• Explain tips and tricks of laparoscopic, transanal and robotic rectal mobilization.
• Describe potential advantages to the laparoscopic, transanal and robotic approaches to pelvic dissection.
• Identify the capabilities and tools associated with different minimally invasive platforms.
• Recall the proper technical issues of both abdominal and pelvic rectal surgery