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Traditionally, rectal neoplasms that were not resectable by colonoscopy required segmental oncologic resection, either via abdominoperineal or low anterior resection. These procedures come with a high risk of operative and postoperative complications that can result in significant patient morbidity as well as significant perioperative costs. Transanal minimally invasive surgery (TAMIS) emerged in 2009, as there was a need for a more widely accessible (easier setup, easier to learn, less expensive) approach to transanal endoscopic excision that was safe and equivalent to transanal endoscopic microsurgery (TEM) for removal of rectal lesions. TAMIS is now a well-established technique for removal of benign lesions and select early rectal cancers (T1) not resectable by endoscopy. This chapter describes the operative and perioperative outcomes associated with TAMIS, emphasizing the technique and complications of this procedure.

Highlights • TAMIS can be considered for removal of rectal polyps and early rectal cancers. • A potential complication of TAMIS is abdominal entry. • Higher risk of entry if the lesion is located above the peritoneal reflection. • The use of laparoscopic staplers is a novel approach that should be considered. • The resection quality is comparable to the traditional approach to TAMIS., Introduction Transanal minimally invasive surgery (TAMIS) is a valuable surgical option for removal of rectal polyps and early rectal cancers. A potential complication of this technique is abdominal entry if the lesion is located above the peritoneal reflection. We present the first case series describing the use of a laparoscopic stapling device to remove a sessile lesion, and seal the resulting defect simultaneously with full thickness excision of the rectal lesion, avoiding abdominal entry. Presentation of cases Five patients with rectal lesions between 8 and 14 cm from the anal verge are described in this case series. Each underwent a stapled-TAMIS procedure as the lesion was suspected to be above the peritoneal reflection. The goal specimen was achieved in each procedure. Discussion This article demonstrates the feasibility of a novel technique to remove sessile polyps in the upper rectum using laparoscopic staplers trans-anally through the TAMIS port. More studies and long-term follow-up are needed to evaluate the oncologic outcomes including the recurrence rate for those lesions removed with a stapler. Conclusion For rectal lesions suspected to be above the peritoneal reflection, a stapled resection through a TAMIS port could prove be a valuable addition to the standard excisional approach to TAMIS.