Fig. 1

Transanal rectal dissection (TARD) procedure. The distal side at the lower margin of the tumor is closed with a purse-string suture under direct vision, followed by irrigation of the anal canal with 5% povidone-iodine. The division of the rectum is then initiated at the posterior side ≧2 cm distal to the distal margin. First, a circular incision of the rectum is performed by closing the cut end of the rectum with an interrupted suture (a). Second, the distal rectum is mobilized proximally while developing a surgical field using a self-holding retractor (Lone Star Retractor) and a spatula. At the posterior side of the rectum, the distal rectum can be easily mobilized using an electronic scalpel and a pusher after incising the ligament between the rectum and the coccyx (b). At the anterior side of the rectum, the recto-urethral muscle is incised while developing a surgical field by using a spatula, and then both anterolateral sides of the rectum are dissected. However, where the neurovascular bundle is located, the anterolateral sides of the rectum would be dissected transabdominally (c and d). Division and mobilization of the rectum, including the mesorectum, is performed as possible until the peritoneal reflection at the anterior side and the rectosacral ligament at the posterior side are identified (e). Finally, a lap disc mini is adapted to the anal canal to maintain pressure during laparoscopy (f)