NEW TECHNOLOGY REPORT
Transanal Minimally Invasive Surgical Approach to
Total Pelvic Exenteration
Naohito Beppu, M.D., Ph.D.1 • Jihyung Song, M.D.1
Yuuya Takenaka, M.D.1 • Kei Kimura, M.D., Ph.D.1
Kozo Kataoka, M.D., Ph.D.1 • Motoi Uchino, M.D., Ph.D.2
Hiroki Ikeuchi, M.D., Ph.D.2 • Masataka Ikeda, M.D., Ph.D.1
1 Division of Lower Gastrointestinal Surgery, Department of Gastrointestinal Surgery, Hyogo College of Medicine, Hyogo, Japan
2 Division of Inflammatory Bowel Disease Surgery, Department of Gastrointestinal Surgery, Hyogo College of Medicine,
Hyogo, Japan
See video on DCR YouTube Channel at https://youtu.be/
BiqXdoeLZ3k
BACKGROUND: Total pelvic exenteration, a surgical
procedure for patients with highly advanced primary and
recurrent rectal cancer, is technically demanding.
IMPACT OF INNOVATION: We report the utility of a
transanal minimally invasive surgical approach to total
pelvic exenteration.
TECHNOLOGY‚ MATERIALS‚ AND METHODS: A 2-team
approach with a laparoscopic transabdominal approach
and transanal minimally invasive surgery was adopted.
During the transabdominal approach in the pelvis,
dissection was performed to remove the pelvic organs
and visceral branches of the internal iliac vessels. The
dissection goal via the transabdominal approach is the
levator ani. During the transperineal approach, dissection
is performed along the levator ani, and the tendinous
arch of the levator ani is penetrated at the lateral side
to achieve rendezvous between the 2 approaches. The
levator ani is then dissected circumferentially, with
identification of the internal pudendal vessels passing
through the levator ani at the 4 o’clock and 8 o’clock
positions, known as Alcock’s canal. The anterior wall
Funding/Support: None reported.
Financial Disclosure: None reported.
Correspondence: Naohito Beppu, M.D., Ph.D., Department of
Gastrointestinal Surgery, Division of Lower Gastrointestinal Surgery,
Hyogo College of Medicine, 1-1 Mukogawa-tyo, Nishinomiya, Hyogo
663-8501, Japan. E-mail: beppu-n@hyo-med.ac.jp
Dis Colon Rectum 2023; 66: e951–e957
DOI: 10.1097/DCR.0000000000002764
© The ASCRS 2023
DISEASES OF THE COLON & RECTUM VOLUME 66: 9 (2023)
Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited.
of Alcock’s canal is formed by the coccygeus muscle
and sacrospinous ligament, which are dissected by the
transperineal approach to open Alcock’s canal, thus
obtaining a clear view of the internal pudendal vessels.
On the anterior side, the urethra is divided with a
laparoscopic linear stapler via the transperineal approach.
PRELIMINARY RESULTS: Eight patients with rectal cancer
underwent this procedure. The median (range) blood
loss was 200 (120–1520) mL and operating time was 467
(321–833) minutes. Reoperation was performed in 1
internal hernia case; however, there were no mortalities,
and there were no cases with severe complications or
conversion to open surgery.
CONCLUSIONS AND FUTURE DIRECTIONS: When
performing total pelvic exenteration, transanal minimally
invasive surgery offers direct visualization behind the
tumor from the anal side and shows the deep pelvic
structures, including the retroperitoneal space of the
pelvic sidewall.
T
ransanal minimally invasive surgery (TAMIS) has
widely expanded worldwide because of its good
visualization in the deep pelvis.1 In comparison
to a completely laparoscopic approach, this technique is
especially useful for patients with rectal cancer in popula-
tions in which surgery is difficult, such as male patients
with obesity, patients who have undergone radiotherapy,
and patients with advanced tumor.2
TAMIS has yet to be standardized for total pelvic
exenteration (TPE). The main reason for this may be the
anatomical difficulty associated with the retroperitoneal
space of the pelvic sidewall, especially around Alcock’s
canal. Recently, several studies have described the surgi-
cal technique of lateral pelvic lymph node dissection using
TAMIS in detail.3–5 Although both TPE and lateral lymph
e951
 e952 Beppu et al: Total Pelvic Exenteration

node dissection require the removal of the lateral pelvic
area, TPE requires en bloc resection of the main tumor
and levator ani. When removing the levator ani, there is a
risk of major bleeding from the branch of the internal iliac
vessels, especially the internal pudendal vessels. These ves-
sels penetrate the levator ani from the supralevator space
to the infralevator space at Alcock’s canal. However, the
anatomic structures around Alcock’s canal, from the trans-
perineal perspective, are still poorly understood.
By clarifying the details of this complex anatomy, we
believe that the technical benefits of TAMIS will increase
the safety and feasibility of TPE. Therefore, this article
establishes the standardized technique of the TAMIS
approach to TPE.
IMPACT OF INNOVATION
Even with advances in surgical modalities and increased
anatomical understanding, colorectal surgeons still have dif-
ficulty performing TPE. Because patients who require TPE
to achieve R0 resection tend to have large, bulky tumors, the
visualization of the tumor is extremely poor. To resolve this
issue, we introduced the TAMIS approach to TPE.
TECHNOLOGY‚ MATERIALS‚ AND METHODS
Anatomy
The Pelvic Floor Muscles and
Internal Pudendal Vessels
Figure 1A shows the pelvic floor muscles, namely the ilio-
coccygeal muscle, internal obturator muscle, piriformis
muscle, and coccygeus muscle. The important anatomi-
cal points to note when performing TPE using TAMIS
include 1) the internal obturator muscles form the lateral
wall of the pelvis, 2) the iliococcygeal muscle is a part of
the levator ani that is attached to the internal obturator
muscle to form the tendinous arch of the levator ani, and
3) the entrance of the Alcock’s canal is located in the infra-
piriformis foramen, which is formed by the piriformis

A
C

IOM
TA STL
ICM
PM SSL
CM
IPA
Infrapiriform foramen

D
B

TA
IOM
PM
ICM
STL SSL Alcock’s canal
CM IOM
PM

IPA

IPA
FIGURE 1. Dissection of the lateral pelvis (right side). A, Anatomy of the pelvic floor muscles. B, Route of the internal iliac vessels. C, Route
of the internal iliac vessels after deleting the pelvic floor muscles. D, Alcock’s canal from the dorsal side. CM = coccygeus muscle; ICM =
iliococcygeal muscle; IOM = internal obturator muscle; IPA = internal pudendal artery; PM = piriformis muscle; SSL = sacrospinous ligament;
STL = sacrotuberous ligament; TA = tendinous arch of levator ani.

Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited.
 DISEASES OF THE COLON & RECTUM VOLUME 66: 9 (2023)
and coccygeus muscles. In addition, Figure 1B shows the
route of the internal iliac vessels, which pass through the
infrapiriform foramen. Figure 1C shows the anatomical
correlation between the internal pudendal artery and the
sacrospinous and sacrotuberous ligaments by deleting the
pelvic floor muscles. Figure 1D shows those structures
from the dorsal side. The internal pudendal vessels pass
between the sacrospinous and sacrotuberous ligaments
and penetrate the levator ani. This is called Alcock’s canal,
and on the perineal side of the levator ani, these vessels
run along the internal obturator muscles.
Planes Dissected via the Transabdominal
and Perineal Approaches
There are 3 avascular planes of the retroperitoneal space
of the pelvic sidewall: the ureterohypogastric fascia, vesi-
cohypogastric fascia, and parietal fascia (Figs. 2A–C). The
ureterohypogastric fascia wraps around the hypogastric
nerve, pelvic plexus, and ureter. The bottom of this fascia is
attached to the levator ani. The transperitoneal landmark
of the vesicohypogastric fascia is the umbilical artery. This
fascia consists of the internal iliac vessels and their visceral
branches to the bladder, prostate, and rectum. The bottom
of this fascia also reaches the levator ani. The parietal fascia
covers the internal obturator muscle, piriformis muscle,
coccygeus muscle, and levator ani. Because TPE requires
the removal of the pelvic organs and visceral branches of
FIGURE 2. Dissection planes by the transabdominal approach. A, Ureterohypogastric fascia. B, Vesicohypogastric fascia. C, Parietal fascia.
Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited.
e953
the internal iliac vessels, dissection along the vesicohypo-
gastric fascia or parietal fascia is required. The anatomy of
these 3 fasciae has been described previously.6
The dissection planes via the transperineal approach are
shown in Figures 3A–E. Details from the inside are as follows:
A) the groove between the internal and external anal sphinc-
ter (Fig. 3B), B) the dorsal and lateral sides of the external
sphincter muscle and the levator ani and penetration of the
levator ani toward the area of total mesorectal excision (inner
side of the ureterohypogastric fascia; Fig. 3C), C) the dorsal
and lateral side of the external sphincter muscle and leva-
tor ani and penetration of the levator ani toward the lateral
pelvic area (outer side of ureterohypogastric fascia; Fig. 3D),
and D) along the internal obturator muscle to remove the fat
of the fossa ischiorectalis (Fig. 3E). Dissection planes A) and
B) can enter the supralevator space in the total mesorectal
excision area, but dissection planes C) and D) instead enter
the supralevator space in the lateral pelvic area, and these
dissection planes are used when performing TPE.
Surgical Technique
The Transabdominal Approach
The vesicohypogastric fascia and parietal fascia are 2 vital
embryological planes when performing TPE, and the dis-
section along those fasciae advances until reaching the
levator ani. The inferior vesical vessels are ligated under
 e954 Beppu et al: Total Pelvic Exenteration

FIGURE 3. Dissection planes by the transperineal approach. A, Coronal section around the LA. B, The IG. C, The dorsal and lateral side of the
ES muscle and LA and penetration of the LA toward the TME area (inner side of ureterohypogastric fascia). D, The dorsal and lateral side of the
ES muscle and LA and penetration of the LA toward the lateral pelvic area (outer side of ureterohypogastric fascia). E, Along the IOM to remove
the fat of IF. ES = external anal sphincter; Fat of IF = fat of the fossa ischiorectalis; GMM = gluteus maximus muscle; IG = groove between the
internal and external anal sphincter; IOM = internal obturator muscle; IS = internal anal sphincter; LA = levator ani; TA = tendinous arch of
levator ani; TME = total mesorectal excision.

the bifurcation of the umbilical artery while preserving
the internal pudendal vessels. In contrast, tumors or meta-
static lymph nodes that have invaded the internal iliac
vessels are ligated on the central side of those vessels to
achieve an en bloc dissection of the tumors.
The Transperineal Approach
After closing the anus, the skin around the anus is incised
circumferentially. The dissection plane is defined either
along the external sphincter muscle (Fig. 3D) or along the
internal obturator muscle (Fig. 3E). Because the dissection
plane along the internal obturator muscle makes it pos-
sible to remove the ischiorectal fossa, we dissect along this
plane for patients who require a wide resection margin to
achieve R0 resection on the perineal side.
When an open approach provides a poor visual field
and the mobility in the narrow surgical field is insuf-
ficient, multiple access ports (Gelpoint Mini, Applied
Medical, Rancho Santa Margarita, CA) are placed for
use in TAMIS. We set the tendinous arch of the leva-
tor ani as a landmark for the rendezvous point between
the transabdominal and perineal approaches. Because

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 DISEASES OF THE COLON & RECTUM VOLUME 66: 9 (2023) e955

FIGURE 4. Surgical procedure for the lateral side. A, TA from the transabdominal view. B, TA from the transperineal view. C, Alcock’s
canal from the transperineal view (before opening). D, Alcock’s canal from the transperineal view (after opening). E, Alcock’s canal from
the transabdominal view (after opening). F, Transection of the urethra from the transperineal view. G, Transection of the urethra from
the transabdominal view. Red triangles represent the route of the internal pudendal vessels. CM = coccygeus muscle; IOM, internal
obturator muscle; IPV = internal pudendal vessels; LA = levator ani; SSL = sacrospinous ligament; TA = tendinous arch of levator ani; T-AM =
transabdominal approach; T-PM = transperineal approach.

Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited.
 e956 Beppu et al: Total Pelvic Exenteration

the levator ani is thinned by the formation of the ten- the route of the internal pudendal vessels can be clari-
dinous arch at the attachment of the internal obturator fied (Figs. 4D and E), which helps prevent injury to these
muscle, this space was penetrated by the transperineal vessels.
approach (Figs. 4A and B). At the anterior side, the levator ani was dissected
After penetrating the tendinous arch of the levator toward the 12 o’clock position, and the puboprostatic
ani, the levator ani is then dissected circumferentially. ligament was cut and the Santorini venous plexus was
However, the internal pudendal vessels pass through exposed and dissected after coagulation via the transab-
the levator ani at the 4 and 8 o’clock positions, called dominal approach. The urethra was then dissected with a
Alcock’s canal, and there is a risk of major bleeding laparoscopic linear stapler via the transperineal approach
at this point. Therefore, we identify the route of the (Figs. 4F and G).
internal pudendal vessels via the transperineal view.
The anterior wall of Alcock’s canal is made up of the
coccygeus muscle and sacrospinous ligament, and the PRELIMINARY RESULTS
internal pudendal vessels run along the internal obtu- From July 2020 to December 2021, 8 patients underwent
rator muscles at the perineal side of the levator ani the TAMIS approach to TPE (T4b rectal cancer, n = 5;
(Figs. 1D and 4C). recurrent rectal cancer, n = 3). The patient character-
Therefore, by dissecting the coccygeus muscle and istics are shown in Table 1. All patients were male, and
sacrospinous ligament via the transperineal approach, the median (range) age was 55 (40–72) years old. The
median (range) blood loss was 200 (120–1520) mL, and
the median (range) operating time until the removal of
TABLE 1. Patient characteristics (N = 8) the specimen was 467 (348–833) minutes. Reoperation
Characteristics n was performed in 1 patient because of internal hernia;
however, there was no mortality, and there were no
Age, y, median (range) 55 (40–72)
cases with severe complications or conversion to open
Sex
Male 8 surgery. One case had a positive circumferential resec-
Female 0 tion margin, whereas a positive location was observed
BMI, median (range) 22 (14–25) at the anterior surface of the sacrum at the S2 level,
ASA physical status and this area was dissected via the transabdominal
1 5
approach. The median (range) follow-up period was
2 3
3 0 8 (1–19) months, no patients had local recurrence, 1
Type of tumor patient developed lung metastasis, and all patients were
Primary 5 alive.
Recurrent 3
Invaded organs of primary tumor (N = 5)
Bladder 3
Prostate 2
DISCUSSION
Recurrent site of recurrent tumor, central (N = 3) 3 This study describes the surgical procedure of the TAMIS
Distant metastasis
Yes 1 (liver)
approach to TPE. Although the effective application of
No 7 these techniques requires extensive knowledge of bottom-
Preoperative therapy to-top surgical anatomy, there are several advantages asso-
Total neoadjuvant therapy 33 ciated with the TAMIS approach to TPE.
Chemoradiotherapy 3 First, dissection of the deep pelvis in TPE via a trans-
Chemotherapy 1
None 1
abdominal approach provides a poor surgical view in
Histology certain cases, including cases with bulky and large-sized
Tubular 5 tumors or cases involving male patients with a narrow
Mucinous 3 pelvis. The difficulty associated with dissection behind
Pathological stage of primary tumor (N = 5) tumors can result in increased blood loss and lengthened
T3N2 1
T4bN0 3
operating time. TAMIS, by contrast, enables the direct
T4bN1 1 visualization behind the tumor from the anal side, regard-
Resectability less of the tumor status, namely the tumor size and tumor
R0 7 location, at the anal verge. Therefore, we believe that
R1 or R2 1 TAMIS is one way to solve this problem. Robotic surgery
Adjuvant chemotherapy
Yes 2
is another useful approach to solving this problem, but it
No 6 would be difficult to conclude that the problem has been
Data presented as n unless otherwise indicated.
completely solved.

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 DISEASES OF THE COLON & RECTUM VOLUME 66: 9 (2023)
Second, the area around Alcock’s canal is a common
location of local recurrence in recurrent rectal cancer. For
surgical resection in such cases, it is sometimes neces-
sary to dissect the internal pudendal vessels to maintain
the resection margins. When TAMIS is used, landmark
structures during TPE, such as the internal pudendal
vessels, coccygeus muscle, sacrospinous ligament, and
tendinous arch of the levator ani, can be identified with
direct visualization, resulting in safer dissection.
One limitation associated with the present study is
that the BMI values differ between Japanese and American
patients, thus making it necessary to determine whether
this procedure can be performed for American patients
in the same way as it is performed for Japanese patients
because Japanese patients tend to have lower BMI values
than American patients.
CONCLUSION AND FUTURE DIRECTIONS
We herein described the surgical procedure of the TAMIS
approach to TPE. When performing TPE, TAMIS enables
direct visualization behind the tumor from the anal side
and visualizes the deep pelvic structures, including the ret-
roperitoneal space of the pelvic sidewall.
Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited.
e957
KEY WORDS: Total pelvic exenteration; Transanal
minimally invasive surgery.
REFERENCES
1. Sylla P, Rattner DW, Delgado S, Lacy AM. NOTES transanal rec-
tal cancer resection using transanal endoscopic microsurgery
and laparoscopic assistance. Surg Endosc. 2010;24:1205–1210.
2. Gardner IH, Kelley KA, Abdelmoaty WF, Sharata A, Hayman
AV, Whiteford MH. Transanal total mesorectal excision out-
comes for advanced rectal cancer in a complex surgical popula-
tion. Surg Endosc. 2022;36:167–175.
3. Matsuda T, Yamashita K, Hasegawa H, et al. Two-team lat-
eral pelvic lymph node dissection assisted by the transanal
approach. Dis Colon Rectum. 2021;64:e719–e724.
4. Watanabe J, Ishibe A, Suwa Y, et al. Autonomic nerve-preserv-
ing lymph node dissection for lateral pelvic lymph node metas-
tasis of the pelvic floor using the transanal approach. Dis Colon
Rectum. 2020;63:113–114.
5. Aiba T, Uehara K, Mukai T, Hattori N, Nakayama G, Nagino
M. Transanal extended rectal surgery with lateral pelvic lymph
node dissection. Tech Coloproctol. 2018;22:893–894.
6. Beppu N, Ikeda M, Kimura K, et al. Extended total mesorectal
excision based on the avascular planes of the retroperitoneum
for locally advanced rectal cancer with lateral pelvic sidewall
invasion. Dis Colon Rectum. 2020;63:1475–1481.