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Improvements in several tools enable surgeons to perform complex procedures in a reduced working field delivering the least aggressive approach to the patients. We currently use a comfortable and ergonomic transanal access platform equipped with a removable cap. It supports use of conventional laparoscopic instruments.
A 3D visualization system and a special insufflator device ensure image quality. Two surgical teams synchronize their work improving the quality of the dissection, saving surgical time, and enhancing the security of the procedure. The current insufflator continuously evacuates the smoke and maintains the pressure, delivering a stable cavity where the surgeon can dissect accurately.
Current experience leads to a standardized method of dissection. The pursestring should be closed tight to avoid pneumo leakage. An endoluminal stitch can solve this problem. The surgeon's goal during the entire procedure is to identify the “Angel’s Hair” described by professor Heald.
The plane must be followed from where it is identified to the point where the dissection must continue. Mobilization must be circumferential, imagining a cylinder inside the pelvis curve. Avoid getting deep in one plane as the rectum will retract and the quality of the dissection will be compromised.
The mesorectum is thinner in the anterior plane and structures like the urethra, prostate and vagina may be injured. In the posterior plane the presacral fascia can be damaged and there may be bleeding from the presacral vessels. The bipolar is a useful tool to control the situation.
Following this approach you can go as low as you want and extend the percentage of sphincter-preserving procedures, as well as perform a tailored type of anastomosis to deliver the best functional outcomes for patients without sacrificing a correct margin of resection.
Another advantage is the management of postoperative complications such as bleeding from a high colorectal anastomosis, which can be solved by means of the trans anal approach.