Transanal endoscopic surgery as a pathway to NOTES

At the vanguard of colorectal minimally invasive surgery is transanal natural orifice translumenal surgery (NOTES). Building on extensive pre-clinical research, transanal NOTES innovators have extended the capacity of established endorectal surgical platforms to achieve safe and efficacious endoscopic colorectal resection for both benign and malignant disease. Transanal TME (taTME) for rectal cancer is the fastest growing clinical application of transanal NOTES, with nearly 100 cases now reported. In addition to potentially minimizing the morbidity of transabdominal operations, taTME improves access to and visualization of the distal rectum during difficult pelvic dissections. This may be most advantageous in challenging patients with hostile anatomy and very low tumors who frequently experience suboptimal outcomes with standard TME. Current equipment limitations require laparoscopic assistance for safe visualization, splenic flexure takedown, and vascular control. However, two recent case reports of pure NOTES TME explore the potential for a totally transanal approach to proctectomy in the future. Preliminary oncologic results of taTME are promising but long term, a multicenter study is required. Continued research, technical innovation, and commitment to training and expertise are required for transanal NOTES to reach its potential.