Transanal total mesorectal excision: dissection tips using 'O's and 'triangles'

Transanal total mesorectal excision (taTME) requires specific technical expertise, as it is often difficult to ascertain the correct dissection plane. Consequently, one can easily enter an incorrect plane, potentially resulting in bleeding (sidewall or presacral vessels), autonomic nerve injury and urethral injury. We aim to demonstrate specific visual features, which may be encountered during surgery and can guide the surgeon to perform the dissection in the correct plane.

Specific features of dissection in the correct and incorrect planes are demonstrated in the accompanying video.

The 'triangles' created using appropriate traction can aid in performing a precise dissection in the correct plane. Recognition of features described as 'O's can alert surgeons that they are entering a new fascial plane and can avoid incursion into an incorrect plane.

Understanding and recognizing the described features which can be encountered in taTME surgery, a safe and accurate TME dissection can be facilitated.