LAUSR

641 DISEASES OF THE COLON & RECTUM VOLUME 61: 5 (2018) For locally advanced, primary T4 rectal cancer, total pelvic exenteration (TPE) is a curative strategy for achieving an R0 resection. We previously introduced transanal minimally invasive surgery into the TPE strategy to achieve en bloc resection of pelvic organs within the visceral pelvic fascia. This method had significant advantages, including excellent visibility, reduced blood loss, and less operative time, when combined with a laparoscopic approach. However, this method comprised double stomas, including an ileal conduit and a permanent colostoma, in a iles operation, the transperineal TPE, which did not preserve the sphincter. Double stomas should be avoided, unless oncological problems are present, to attain a better quality of life. Therefore, this time we introduced a sphincter-preserving surgery into the reverse TPE strategy as transanal TPE (TaTPE) for locally advanced T4 rectal cancer. The anal canal as the access to the pelvic cavity in TaTPE is narrower than with the perineal incision as the access to the pelvic cavity in transperineal TPE. So, transanal minimally invasive surgery is essential to accomplish the TaTPE. The specimen is to be extracted through the abdominal incision, through which the ileal conduit is constructed extracorporeally. The TaTPE with sphincter-preserving surgery is quite suitable, particularly for a huge rectal cancer with widespread invasion to the adjacent pelvic organs, because it is difficult to mobilize and remove these pelvic organs within the visceral pelvic fascia with a laparoscopic approach. Furthermore, the TaTPE with sphincter-preserving surgery is superior to the laparoscopic approach for dividing the dorsal vein complex and the internal iliac vessels, when they are located under a huge tumor. In fact, division of the dorsal vein complex and the internal iliac vessels with the transanal approach is quite feasible from the perspective of pelvic morphology. Here, we demonstrated the procedure for TaTPE with sphincter-preserving surgery. See Video at http://links.lww.com/DCR/A536.