Transanal total mesorectal excision (TaTME) has been introduced as a novel approach for low rectal cancer, providing excellent visualization and potentially improving distal margin control. However, TaTME often requires a two-team approach, leading to increased equipment and personnel costs, as well as technical complexity. Moreover, dissection of the anterior plane remains anatomically challenging and has been associated with a higher risk of urethral injury 1, 2. To address these limitations, we developed a new single-team technique in which perineal dissection is first performed under direct vision to safely mobilize the posterior and lateral planes, while the more complex anterior plane is preserved for a subsequent laparoscopic approach. During this step, the rectourethral muscle or rectovaginal septum is dissected with precise anatomical understanding. This report describes the concept, technical details and potential advantages of this modified approach. With the patient in the lithotomy position, perineal dissection is initiated under direct vision and advanced to a level above the levator ani. The posterior and lateral dissection planes are identified, leaving the anterior plane intact. The rectal lumen is temporarily closed, and the procedure then proceeds laparoscopically. The laparoscopic phase continues with conventional total mesorectal excision, connecting to the perineal dissection plane. Finally, a thin band of the rectourethral muscle in males (or longitudinal muscle in females) remains, which can be simply divided to complete the full-thickness rectal excision. This approach eliminates the need for a second surgical team or specialized perineal platforms. The surgical procedure is demonstrated in Video 1. Between July 2024 and October 2025, six patients underwent this procedure (male/female ratio: 4/2; median age: 72 years, range: 66–77 years). Robotic and laparoscopic approaches were used in four and two cases, respectively. The procedures included ISR, APR and Hartmann operations in three, three and one case, respectively. The median perineal dissection time was 33 min (range: 14–52), the total operative time was 386 min (range: 243–642) and median blood loss was 69 mL (range: 5–770). No Clavien–Dindo grade ≥III complications occurred, and all patients achieved R0 resection. Our single-team, perineal-first approach offers a simplified, cost-effective and anatomically safer alternative, providing a precise understanding of the anterior structures of the anal canal for selected patients requiring low rectal resection. Hisanori Miki was responsible for conceptualization, methodology, software, investigation, validation, formal analysis, data curation, visualization, project administration, resources, funding acquisition and writing the original draft. Takumi Yamamoto and Yusuke Kitagawa contributed to conceptualization and data curation. Jun Watanabe and Yosuke Fukunaga contributed to supervision. All authors contributed to writing, reviewing and editing the manuscript, and approved the final version. This research did not receive any specific grant or funding from agencies in the public or not-for-profit sectors. All authors have no conflicts of interest to declare. The study protocol was approved by The Institutional Review Board for Clinical Research of Kansai Medical University (2024199). The patient provided informed consent prior to receiving the treatment. Written informed consent was obtained from the patient for publication of this case report and any accompanying images. Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.
Miki et al. (Fri,) studied this question.