Natural Orifice Approaches in Rectal Surgery: Transanal Endoscopic Proctectomy

  • Uma M. Sachdeva
  • Patricia SyllaEmail author


The concept of natural orifice translumenal endoscopic surgery (NOTES) was seamlessly adapted to colorectal resections, enabled by the availability of a wide array of transanal endoscopic platforms. Since the demonstration of the feasibility of this approach in experimental models and human cadavers, transanal endoscopic proctectomy has rapidly emerged as one of the most exciting new trends in rectal cancer surgery. Indications for this approach range from benign inflammatory conditions to malignant disease of the rectum, particularly of the mid- and low rectum, where transanal endoscopic access can be applied to completion proctectomy, total proctocolectomy, abdominoperineal resection (APR), restorative proctectomy or proctocolectomy with ileoanal J pouch reconstruction, and low anterior resection with total mesorectal excision (TME). Whether it is performed using a pure or hybrid approach, transanal endoscopic proctectomy has the potential to reduce the technical complexity, morbidity, and operative time associated with open and laparoscopic proctectomy. Preliminary outcomes from 16 published series on this approach for benign and malignant pathology suggest that this approach is safe in carefully selected patients. Specific indications, preoperative work-up, surgical techniques, and expected complications associated with transanal endoscopic proctectomy, as well as tips and tricks for success, will be reviewed, based on the rapidly expanding literature on this approach.


Transanal endoscopic proctectomy Total mesorectal excision NOTES Rectal cancer Inflammatory bowel disease Completion proctectomy 



Abdominoperineal resection


Body mass index


Crohn’s disease


Circumferential resection margin


Digital rectal examination


Inflammatory bowel disease


Ileoanal pouch anastomosis


Intersphincteric resection


Low anterior resection


Natural Orifice Endoscopic Surgery


Transanal minimally invasive surgery


Transanal endoscopic total mesorectal excision


Total mesenteric excision


Ulcerative colitis


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Authors and Affiliations

  1. 1.Department of SurgeryMassachusetts General HospitalBostonUSA
  2. 2.Division of Colorectal Surgery, Department of SurgeryMount Sinai Hospital, Icahn School of Medicine, Massachusetts General HospitalNew YorkUSA

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