Repositioning transanal total mesorectal excision in the robotic era

Low rectal cancer lies deep in the pelvis, close to the pelvic autonomic nerves and urogenital structures. Surgery must therefore balance oncological clearance, sphincter preservation, and functional outcomes. Total mesorectal excision (TME) remains the fundamental oncological principle across open, laparoscopic, robotic, and transanal approaches. A deep, narrow male pelvis, obesity, a very low tumor, fibrosis after neoadjuvant treatment, and restricted distal transection can make transabdominal TME technically demanding. Robotic transabdominal TME (rTME) provides three-dimensional high-definition visualization, wristed instruments, tremor filtration, and a stable operating platform. These features address several limitations of conventional laparoscopy. rTME may therefore be suitable for most patients with mid-to-low rectal cancer when distal dissection and transection remain controllable from above. Against this background, the role of transanal total mesorectal excision (TaTME) should be reassessed rather than dismissed. Current evidence neither renders TaTME obsolete nor establishes a universal advantage across all low rectal cancers. Instead, TaTME is better positioned as a selective technical complement for very low tumors, restricted distal exposure or transection, and composite difficult-pelvis scenarios. At the same time, the development of robot-assisted TaTME (R-TaTME), hybrid TaTME, single-port robotic systems, and flexible transanal platforms offers new technological avenues. These platforms may improve procedural stability and instrument dexterity during transanal surgery. This review reappraises TaTME in the robotic era, focusing on indication refinement, pathological quality, training and quality assurance, functional preservation, and platform development.