ABSTRACT
Surgical resection of rectal cancer, and particularly low rectal cancer, poses a significant technical challenge for surgeons. Limited access to the confined space within the bony pelvis can impede a meticulous oncological dissection and lead to damage to critical neurovascular structures. Various patient and tumour-related features can further add to the complexity of a low rectal dissection. Standardisation of transanal total mesorectal excision requires a detailed stepwise description of the procedure providing technical pearls and possible pitfalls. Although the surgical principles are based on experience of transabdominal rectal cancer surgery, knowledge of specific steps and the different view on the anatomy are crucial for one’s understanding of the technique. The patient is placed in lithotomy position, with the lower extremities in Lloyd-Davies leg rests or Allen universal stirrups. One should ensure good access to the anus, therefore sometimes needing a ‘cushioned bump’ underneath the sacrum for better exposure.
