Techniques in Coloproctology

, Volume 22, Issue 4, pp 279–287 | Cite as

Transanal total mesorectal excision for rectal cancer: evaluation of the learning curve

  • T. W. A. Koedam
  • M. Veltcamp Helbach
  • P. M. van de Ven
  • Ph. M. Kruyt
  • N. T. van Heek
  • H. J. Bonjer
  • J. B. Tuynman
  • C. Sietses
Original Article



Transanal total mesorectal excision (TaTME) provides an excellent view of the resection margins for rectal cancer from below, but is challenging due to few anatomical landmarks. During implementation of this technique, patient safety and optimal outcomes need to be ensured. The aim of this study was to evaluate the learning curve of TaTME in patients with rectal cancer in order to optimize future training programs.


All consecutive patients after TaTME for rectal cancer between February 2012 and January 2017 were included in a single-center database. Influence of surgical experience on major postoperative complications, leakage rate and operating time was evaluated using cumulative sum charts and the splitting model. Correction for potential case-mix differences was performed.


Over a period of 60 months, a total of 138 patients were included in this study. Adjusted for case-mix, improvement in postoperative outcomes was clearly seen after the first 40 patients, showing a decrease in major postoperative complications from 47.5 to 17.5% and leakage rate from 27.5 to 5%. Mean operating time (42 min) and conversion rate (from 10% to zero) was lower after transition to a two-team approach, but neither endpoint decreased with experience. Readmission and reoperation rates were not influenced by surgical experience.


The learning curve of TaTME affected major (surgical) postoperative complications for the first 40 patients. A two-team approach decreased operative time and conversion rate. When implementing this new technique, a thorough teaching and supervisory program is recommended to shorten the learning curve and improve the clinical outcomes of the first patients.


Transanal endoscopic surgery Rectal neoplasms Learning curve 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest, directly related to this study. H.J. Bonjer has received research grants from Applied, Medtronic, Olympus and Ethicon. J.B. Tuynman has received a research grant from the Dutch Cancer Society and speaker honorarium from Applied Medical. C. Sietses received a speaker honorarium from Applied Medical. T.W.A. Koedam, M. Veltcamp Helbach, P.M. van de Ven, Ph.M. Kruyt, and N.T. van Heek have nothing to declare.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

For this type of study formal consent is not required.

Data availability

The datasets during and/or analyzed during the current study are available from the corresponding author on reasonable request.


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Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • T. W. A. Koedam
    • 1
  • M. Veltcamp Helbach
    • 2
  • P. M. van de Ven
    • 3
  • Ph. M. Kruyt
    • 2
  • N. T. van Heek
    • 2
  • H. J. Bonjer
    • 1
  • J. B. Tuynman
    • 1
  • C. Sietses
    • 2
  1. 1.Department of SurgeryVU University Medical CenterAmsterdamThe Netherlands
  2. 2.Department of SurgeryHospital Gelderse ValleiEdeThe Netherlands
  3. 3.Department of Epidemiology and BiostatisticsVU University Medical CenterAmsterdamThe Netherlands

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