进展期中低位直肠肿瘤经肛门微创手术的三种术式

Three procedures of transanal minimally invasive surgery（TAMIS） for advanced mid-low rectal tumor

经肛门微创手术（TAMIS），是将腹腔镜单孔通道置于肛管．利用常规腹腔镜器械经肛门途径实施的一项新型微创手术。TAMIS的应用为我们提供了一个经肛的手术平台和逆向操作理念。目前，利用该平台已经开展了3种术式．即TAMIS．全直肠系膜切除术（TAMIS．TME），TAMIS-腹会阴联合切除术（TAMIS-APE）和TAMIS．Hartman术式。利用TAMIS平台进行的由下至上的经肛门全直肠系膜切除术（taTME）亦称为TAMIS—TME。TAMIS—TME最大的优势则是解决了既往TME手术对中下段直肠系膜周围间隙暴露不佳而造成的标本切除质量差及其相关副损伤。在TAMIS—TME的应用基础上，TAMIS．APE和TAMIS．Hartman术式应运而生。TAMIS．APE术式首次实现了APE手术会阴区操作的微创化，在会阴区腔镜的引导下，会阴区术野显露更清晰，可依据肿瘤位置精准离断肛提肌。实现个体化APE手术。中低位直肠复发性肿瘤经腹游离常较困难，结合TAMIS平台于肿瘤下方沿正常解剖层次由下至上游离，可降低切除难度，如存在高复发风险．可直肠远端封闭，结肠近端造口。我们在国际上率先开展该术式．并命名为TAMIS—Hartman术式。

Transanal minimally mvaslve surgery （TAMIS） is a novel minimally invasive procedure which is performed by normal laparoscopic instruments through the single port transanally. Three kinds of procedures have been performed based on the TAMIS platform by now, including TAMIS-TME （total mesorectal excision）, TAMIS- APE （Abdominoperineal excision） and TAMIS-Hartman. Transanal total mesorectal excision （taTME） with dissection from bottom to up through the platform of TAMIS is also called TAMIS-TME. The greatest advantage of TAMIS-TME is that it increases the quality of specimen and decrease the adverse injury due to the sufficient vision of lower part of mesorectum in the operation. TAMIS-APE and TAMIS-Harman procedures emerge after the experience of TAMIS-TME. TAMIS-APE procedure not only firstly make the dissection of perineal phase minimally invasive, but also make the perineal vision more clear, the resection of levator ani muscle more precise, eventually the tailored APE procedure comes true under the laparoscopy of perineal phase. The dissection of mid-low mesorectum for recurrent tumor is usually difficult just from above, TAMIS facilitates the resection through entering the normal anatomical space under the tumor. If the tumor has the risk of recurrence, distal rectum is closed and proximal colostomy is made, we firstly performed this procedure and name it TAMIS-Harman. Therefore, TAMIS is not only a platform for taTME, but also it provides a transanal approach and a ＂button to up＂ conception for the mid-low rectal tumor.