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Total mesorectal excision (TME) is the standard surgical care for rectal cancer (1-3). Local recurrence rates have decreased from 45% using traditional techniques to less than 10% after TME alone, and to less than 6% after neoadjuvant chemoradiotherapy and TME (3-7). A core quality indicator of the surgical resection is the circumferential resection margin (CRM) (8-10), which is a strong predictor of local recurrence, distal recurrence and survival (11). The management of rectal cancer has evolved substantially over recent decades (12-14). Despite improvements in the rate of TME surgery for rectal cancer, decreased local recurrence rates and increased 5-year overall survival (15-18), there remains a large variation in the quality of treatment (19). The Consortium for Optimising the Treatment of Rectal Cancer (OSTRICH) demonstrated a 17.2% positive CRM rate (2,859/16,619 patients) (20). Several histological features, operative approach, type of surgery and facility location were all independent predictors of CRM positivity (20). Furthermore, concerns arose regarding the oncological safety with the introduction of laparoscopic TME. The COLorectal cancer Laparoscopic or Open Resection (COLOR) II trial showed improved short-term and similar long-term outcomes following laparoscopic TME compared with open TME resections (21,22). Moreover, comparable disease-free and overall survival rates between laparoscopy and open surgery for rectal cancer were demonstrated in the long-term results from the MRC CLASICC and COREAN trials (23,24). However, mid and low rectal cancers are technically more demanding via the transabdominal approach, particularly in obese male patients with bulky or distally located tumours, factors that predispose to positive CRM, incomplete TME and conversion to open surgery, highlighted by the ACOSOG Z6051, ALaCaRT and COLOR II trials (21,25,26). Transanal Total Mesorectal Excision (TaTME) was developed to overcome the limitations of the transabdominal approach and improve the oncological and functional outcomes of patients with mid and low rectal cancer. The COLOR III trial is a multi-centre superiority international trial comparing TaTME and conventional laparoscopic TME for mid and low rectal cancers, with the primary endpoint of positive CRM (27). Nevertheless, emerging evidence suggests that TaTME may not be superior to alternative methods.

Is the learning curve the Achilles heel of surgical innovation? —arguments against TaTME