Education and training on transanal minimally invasive surgery and transanal total mesorectal excision: a narrative review

Introduction

Technological advancements have significantly driven the evolution of surgical techniques. Minimally invasive surgery (MIS) has established itself as the gold standard for numerous surgical procedures, attributed to its undeniable benefits including reduced postoperative pain, shorter hospital stays, accelerated recovery periods, and enhanced cosmetic outcomes (1,2). Nonetheless, in the context of rectal cancer surgery, traditional laparoscopic methods often prove to be inadequate and the transanal approach has emerged as an excellent alternative: transanal minimally invasive surgery (TAMIS) and transanal total mesorectal excision (TaTME) have brought great advantages in the treatment of rectal cancer in the last years (3-5).

TAMIS technique affords enhanced visualization and direct access to the rectum, allowing local excision and organ preservation in selected patients with early rectal cancer thereby sparing patients from the morbidity associated with more invasive procedures like proctectomy and stoma formation (3,4), while maintaining low recurrence rates (6,7). Similarly, TaTME provides improved access to dissection of the distal rectum and its mesorectum, especially in patients with a deep and narrow pelvis, which translates into safe oncological outcomes, including high rates of complete mesorectal excision and reduced positive circumferential resection margins (CRM) (5,8).

Despite these advantages, both TAMIS and TaTME are constrained by a significant learning curve (LC). Surgeons encounter technical challenges, such as unfamiliar anatomical perspectives and procedural complexities, which can lead to intraoperative complications including incorrect plane dissection, pelvic bleeding and visceral injuries (3-5). Consequently, professional societies have underscored the necessity of structured training and proctorship to ensure the safe integration of these techniques into clinical practice. Comprehensive training programs and mentorship are imperative to minimize complications and optimize patient outcomes (8).

The objective of this review is to synthesize the existing literature on the education and training methodologies for TAMIS and TaTME, examining various training models and their effectiveness. We present this article in accordance with the Narrative Review reporting checklist (available at https://ales.amegroups.com/article/view/10.21037/ales-24-41/rc).

Methods

The search strategy is summarized in Table 1. A literature review was performed between 29^th May and 10^th June 2024 using the PubMed database to identify relevant articles on education and training in TAMIS and TaTME. Keyword searches included: “TAMIS surgical education”, “TaTME surgical training”, “Transanal endoscopic surgery training”, “Transanal mesorectal excision simulation”, “Competency-based training in TAMIS”, “Learning curve TaTME”, and “Simulation training in transanal surgery”. Only English articles were included. After the identification of relevant articles, the abstracts were read to select eligible articles for full-text revision. References of identified articles were searched for additional relevant articles. Case reports, editorial letters, and non-English articles were excluded.

History and evolution of TAMIS and TaTME

The total mesorectal excision (TME) described by Heald in 1988 marked a significant milestone in rectal cancer surgery. This technique, grounded in anatomical and embryological knowledge, revolutionized the oncological resection of one of the most common and deadly cancers worldwide (9,10). However, despite its effectiveness in reducing recurrence and improving survival outcomes, TME represents still nowadays a technically demanding procedure with high morbidity due to the confined pelvic working space and limited visibility (11,12). These challenges delayed the adoption of the laparoscopic approach for TME, compounded by its failure to meet non-inferiority criteria compared to open surgery in several randomized trials (13,14).

In an attempt to seek minimally invasive alternatives to the laparoscopic approach, TAMIS emerged in 2009, introduced by Dr. Sam Atallah (3) as a novel approach to excise rectal lesions through a transanal route, leveraging the advantages of laparoscopy and natural orifice surgery. This technique quickly gained attention as it promised enhanced visualization and direct access to the rectum while minimizing surgical aggression (3). Oncological knowledge allowed this surgical strategy to be reserved for early-stage rectal cancers (T1) without lymph node involvement, thus achieving high rates of negative margins and low recurrence (6,7). Unlike its predecessor, transanal endoscopic microsurgery (TEM) developed by Gerhard Buess in the early 1980s (15), the development achieved of single-port laparoscopic devices was crucial for adapting the necessary tools for effective transanal access. On the contrary, the use of familiar laparoscopic equipment through a single site access port, implied less capital investment for the equipment, lengthy set-up time, or specific LC for using the equipment which were, over the time and companied with the standardization of the procedure, the main contributors to the widespread acceptance and implementation of TAMIS in clinical practice (3,4).

On the other hand, with the ongoing need to provide a solution for other more advanced stages of rectal cancer, TaTME emerged in the early 2010s designed to address the limitations of traditional laparoscopic TME, especially for tumors in the mid and lower rectum, by combining the benefits of MIS and natural orifice transluminal endoscopic surgery (NOTES). This technique involved a combined transanal and abdominal laparoscopic approach, allowing for a more precise and complete mesorectal excision (5,8). The dual approach of TaTME enhances the surgeon’s ability to operate in the confined pelvic space and reduces the risk of positive CRM in experienced hands, guaranteeing safe oncological outcomes (5). The international surgical community played a pivotal role in the dissemination of TaTME through the establishment of standardized protocols and comprehensive training programs, validated by multicenter studies and clinical trials (8). Multicenter studies and clinical trials have validated the safety and efficacy of TaTME, leading to its incorporation into treatment guidelines for rectal cancer. Furthermore, innovations such as the use of robotic assistance and advanced imaging techniques have continued to push the boundaries of what TaTME can achieve, enhancing its precision and reducing the LC for surgeons (5,8).

Challenges in education and training: the LC

The LC for TAMIS and TaTME is notably steep, presenting a significant challenge for surgeons transitioning from traditional approaches. One of the primary challenges is the intricate anatomy of the pelvis and the need for precise dissection to avoid damaging critical structures. This complexity is heightened in TaTME, where the transanal approach requires navigation in a confined space with limited visibility. Additionally, the coordination between the transanal and abdominal teams adds another layer of complexity, necessitating excellent communication and teamwork (5,16,17).

Regarding the LC in TAMIS, Barendse et al. (18) were the first to evaluate the surgical LC, highlighting its negative effect on conversion rate, procedure time, and complication rate. Their retrospective study did not identify an influence on recurrence rates, possibly due to evolving patient populations, and they were also unable to report an approximate number of cases where competence was achieved. However, they did provide insight into the importance of quality monitoring and centralization of care. In contrast, Maya et al. (19) conducted a prospective study with 23 patients, estimating stabilization of the LC after the first four cases by measuring a decrease in the average rate of excision (ARE) from 13.8 min/cm² for the first four cases to 7.9 min/cm² for the last 19 cases (P=0.001), indicating a significant reduction in operative time. They also noted an additional rise and leveling of the LC after the first 10 cases, when more difficult lesions were resected. In contrast to this shorter initial LC, Helewa et al. (20) established in their retrospective study of 108 patients that ARE improved with each additional case until 16 cases were completed. Moreover, they reported that age <50 years, experience with fewer than five cases, and carcinoid/gastrointestinal stroma tumor (GIST) or scar histology were significant predictors of higher ARE in multivariable analysis. Lee et al. (21) focused their LC study on margin positivity rate (R1 resection) as the main proficiency outcome. With 254 TAMIS procedures included, they reported that a minimum of 14–24 cases were required to reach an acceptable R1 resection rate and shorter operative times, as well as stabilization in mean operative times and the resection of larger lesions as proficiency was gained. Similar results were obtained by Clermonts et al. (22), who suggested that 18–31 procedures are needed to achieve satisfactory results in TAMIS. However, they also evaluated the effect of proctoring on the LC by comparing an early adopter of the technique with a second surgeon who benefited from proctorship and a standardized training program. They highlighted that standardized institutional operative protocols, combined with proficient proctorship, may contribute to a shorter LC, with fewer cases 6–10 required to reach proficiency. The details of the referenced articles are summarized in the Table 2.

Based on this reported evidence, the consensus on a structured training curriculum for TaTME stated that only experienced colorectal surgeons should be considered candidates to learn this technique. These surgeons should perform a minimum of 20 rectal resections per year, have completed at least 30 laparoscopic resections, and have executed 5 TAMIS cases (23). Following these guidelines, Koedam et al. (24) noted in their retrospective study with 138 patients that improvements in postoperative outcomes were clearly seen after the first 40 patients, with a decrease in major postoperative complications from 47.5% to 17.5% and a reduction in leakage rates from 27.5% to 5%. They also highlighted that the mean operating time (by 42 minutes) and conversion rate (from 10% to zero) were lower after transitioning to a two-team approach, although neither endpoint decreased further with increased experience. Similar results were reported by Lee et al. (25), who focused their proficiency analysis on achieving high-quality TME [complete or near-complete mesorectal envelope, negative distal resection margin (DRM), and CRM (>1 mm)]. With 87 patients analyzed, they found that a minimum of 45–51 cases were needed to achieve an acceptable incidence of high-quality TME and reduced operative time. Zeng et al. (26) analyzed the LC of the TaTME procedure and compared its results with laparoscopic TME. While in the so-called “first phase”, operative time was longer in the TaTME group, these differences disappeared after 42 procedures were performed. Moreover, in the “third phase”, after 95 TaTME procedures, operative time, intraoperative blood loss, and postoperative hospital stay were all lower than in the laparoscopic group. Similarly, Matsuda et al. (27) reported a comparable division in the LC based on its impact on intraoperative adverse events, overall operative time, and TME completion time: phase I (learning phase: cases 1 to 38), phase II (consolidation phase: cases 39 to 70), and phase III (maturing phase: cases 71 to 128). They concluded that after 70 operations, the surgeon could enter the mastery phase of TaTME based on TME completion time, and they emphasized that oncological safety could be guaranteed from the start. Finally, Persiani et al. (28) analyzed 121 consecutive TaTME procedures performed by the same team and found that the anastomotic leakage rate began to decrease after the 27^th case and remained stable at 5–5.1%. Meanwhile, major complications and reoperation rates only started to decrease after the 54^th case and further dropped after the 69^th case. The details of the referenced articles are summarized in the Table 3.

In this sense, the LC of TaTME has been a source of controversy, being considered responsible for the unfavorable oncological outcomes reported by the Norwegian Colorectal Cancer Group in 2020, which led to a national moratorium in Norway due to concerns about oncological safety (29). Subsequent studies, such as the one conducted by the Oncology Plan Directorate in 2022 (30), highlighted the importance of progressive implementation programs in selected centers and structured training programs to ensure the safety and effectiveness of TaTME in clinical practice.

Training models and methods of instruction

Several surgical societies have developed guidelines and recommendations to standardize the training and implementation of TAMIS and TaTME, aiming to ensure high-quality surgical outcomes and patient safety while addressing the challenges associated with the LCs of these complex procedures (23). The European Society of Coloproctology (ESCP) and the American Society of Colon and Rectal Surgeons (ASCRS) have both emphasized the importance of structured training programs that typically include didactic sessions, hands-on workshops, and supervised clinical practice (23,31-33). The ASCRS recommends that surgeons perform a minimum of 20 supervised TAMIS procedures and 40 supervised TaTME procedures before attempting these surgeries independently (23). Both societies highlight the role of mentorship and proctoring in the initial phases of a surgeon’s training, with experienced mentors providing critical feedback and guidance to shorten the LC and reduce complication rates (32). These mentorship programs ensure that trainees gain sufficient practical experience and confidence in performing these complex procedures (23,31,32).

Simulators

Simulators are crucial in providing a risk-free environment for surgeons to practice and refine their skills (17,34). The effectiveness of simulators has been demonstrated through improvements in surgical performance and confidence, as they replicate the operative steps, potential points of risk, and situational awareness for a surgical procedure, facilitating the acquisition and assessment of technical skills in a controlled setting before attempting the procedure on a live patient (17). Simulation-based training methods are divided in wet laboratories, which offer both in vivo modules with live anesthetized animal and ex vivo modules with animal tissues serving as the basis of the model, and dry laboratories, provided with box trainers and computer-based reality platforms simulators (35,36).

In the field of transanal surgery, Campbell et al. pioneered the development of a TAMIS wet laboratory creating an ex vivo porcine anorectal model complete with pseudopolyps of various sizes for transanal excision training (37). On the other hand, following consensus on structured training (23,31), cadaveric simulation is an indispensable key in TaTME training courses that has shown to provide high levels of trainee satisfaction and the knowledge and technical skills essential for attendees to start performing TaTME (38).

Referring to dry laboratories, a wide range of possibilities has been described in the literature for training in TAMIS and TaTME. Mann et al. (39) have developed a box trainer type simulator specifically for TaTME, which effectively reduces task completion time and error rates, demonstrating significant benefits in enhancing the foundational skills required for transanal surgery among novice surgeons. On the other hand, hybrid simulators that combine synthetic materials with biological components, such as those proposed by Imai et al. (40), offer advantages by providing a more comprehensive and realistic training experience. These hybrid simulators are focused on the step-by-step practice of entire surgical procedures, thereby significantly improving the technical proficiency of surgeons across various levels of experience; however, today’s simulators still need to improve the simulation of the anatomical space of the pelvis.

Live courses

Structured live courses and workshops are integral components of TAMIS and TaTME training, combining didactic sessions, hands-on practice in simulated environments, live surgery observations and the invaluable opportunity of mentorship of experts (17,34,41). As has been previously mentioned, courses involving cadaveric models allow participants to experience realistic anatomical variations and surgical challenges, leading to better surgical outcomes and lower complication rates in initial independent procedures (37,38). Medical equipment manufacturers offer formalized courses for TAMIS that combine didactic training, case observation, and hands-on wet laboratory practice (42). For TaTME, society-sponsored and private centers provide courses and workshops focusing on basic skills, surgical approach, and technical pearls to optimize safe implementation (23,31-33). These courses typically require pre-learning, hands-on practice, and proctored introduction into clinical practice (23,31-33).

Innovations in surgical training

Recent innovations in surgical training have focused on integrating advanced technologies to enhance the learning experience and effectiveness. These innovations are continually evolving, providing surgeons with diverse tools and methods to improve their learning experience and surgical proficiency.

On the one hand, the advent of online learning platforms has revolutionized surgical education by providing access to a wealth of resources and interactive training modules. These platforms offer video tutorials, virtual dissections, and interactive case studies that trainees can access at their convenience. Libraries from Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), WebSurg or GibLib, and multimodal online platforms, such as the Advances In Surgery (AIS) Channel, provide free, high-quality, innovative content from elite surgeons in scheduled events and continuously available “Open Classroom” formats (43). The Synchronized Deferred Live Surgery application dLive provides the benefit of employing synchronized deferred live surgery for educational purposes, ensuring the patient remains the primary focus during the procedure and thereby reducing patient risk when the surgeon’s performance is the main event (44).

On the other hand, simulation apps are being developed offer real-time access freely available on mobile devices to facilitate effective learning (45). The LappSurgery Foundation’s free downloadable app “TaTME” includes high-quality illustrations and teaching videos that clarify abdomino-pelvic anatomy through video-based educational modules; a library with highlights selected publications of relevance to TaTME; and educational events information (46). Another example is Touch Surgery, a free interactive smart device application that aims to provide a realistic, cognitive motor skill simulation and surgical step rehearsal based on technique and sequential steps that are hallmarks of a given surgical intervention through an array of various surgical specialties (47), including a detailed step-by-step video of TaTME procedure.

Finally, telementoring allows experienced surgeons to remotely guide and assist trainees during live surgeries using real-time video communication (48). This method enables expert supervision without the need for the mentor to be physically present, thus expanding access to specialized training and expertise (49). Telementoring has been particularly beneficial in remote or resource-limited settings where access to experienced mentors is scarce (48,49).

Future perspectives

Innovations in surgical training have increasingly focused on the integration of advanced technologies such as augmented reality (AR), virtual reality (VR), and artificial intelligence (AI). These technologies offer immense potential to revolutionize the training landscape by providing immersive, interactive, and personalized learning experiences. It is crucial to continuously assess and improve these educational frameworks to keep pace with technological advancements and emerging best practices (23).

AR, VR, and 3D models are currently fundamental elements of many simulators, having demonstrated their ability to improve the laparoscopic skills of both inexperienced and experienced surgeons (50-52). There are various types of platforms and devices available on the market, including the Microsoft HoloLens (Microsoft, Redmond, WA, USA), Oculus Rift, and the HTC Vive Virtual Reality System (43). These tools have shown their role in surgical planning and intraoperative navigation in transanal surgery (53,54). In the educational field, this technology is not commonly available or necessary for training, but it promises early incorporation into TaTME training (55).

AI holds tremendous potential to revolutionize surgical training by providing intelligent tutoring systems that offer personalized learning experiences. AI can analyze a trainee’s performance in real-time, identify areas for improvement, and provide tailored feedback and recommendations, ensuring a continuous and progressive learning experience (56). AI-powered simulators can adapt to the skill level of the trainee, facilitating more efficient and effective training sessions. Furthermore, AI can assist in developing predictive models to identify trainees who may require additional support, optimizing the allocation of educational resources and improving overall training outcomes (57).

The use of big data analytics in surgical education further enhances this potential. By analyzing large datasets from various training programs, educators can identify trends, evaluate the effectiveness of different training methods, and develop evidence-based best practices (58). This data-driven approach ensures that surgical training remains aligned with the latest advancements in medical science and technology. For instance, AI can process vast amounts of surgical data to provide insights into performance metrics, enabling continuous improvement and refinement of training programs. This integration of AI and big data analytics promises to significantly elevate the quality and efficacy of surgical education (56,57).

Conclusions

In conclusion, the future of surgical training for TAMIS and TaTME is poised to be transformed by innovative technologies such as simulation-based education, telementoring, AR, and AI. These advancements offer the potential to enhance the quality, accessibility, and efficiency of surgical education, ultimately improving patient outcomes. As these technologies continue to evolve, it is essential for surgical training programs to integrate them into their curricula, ensuring that future generations of surgeons are well-equipped to meet the challenges of modern surgical practice.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://ales.amegroups.com/article/view/10.21037/ales-24-41/rc

Peer Review File: Available at https://ales.amegroups.com/article/view/10.21037/ales-24-41/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ales.amegroups.com/article/view/10.21037/ales-24-41/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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References

1. Steele SR, Bleier J, Champagne B, et al. Improving outcomes and cost-effectiveness of colorectal surgery. J Gastrointest Surg 2014;18:1944-56. [Crossref] [PubMed]
2. Feroci F, Kröning KC, Lenzi E, et al. Laparoscopy within a fast-track program enhances the short-term results after elective surgery for resectable colorectal cancer. Surg Endosc 2011;25:2919-25. [Crossref] [PubMed]
3. Atallah S, Albert M, Larach S. Transanal minimally invasive surgery: a giant leap forward. Surg Endosc 2010;24:2200-5. [Crossref] [PubMed]
4. Albert MR, Atallah SB, deBeche-Adams TC, et al. Transanal minimally invasive surgery (TAMIS) for local excision of benign neoplasms and early-stage rectal cancer: efficacy and outcomes in the first 50 patients. Dis Colon Rectum 2013;56:301-7. [Crossref] [PubMed]
5. de Lacy AM, Rattner DW, Adelsdorfer C, et al. Transanal natural orifice transluminal endoscopic surgery (NOTES) rectal resection: “down-to-up” total mesorectal excision (TME)--short-term outcomes in the first 20 cases. Surg Endosc 2013;27:3165-72. [Crossref] [PubMed]
6. Moore JS, Cataldo PA, Osler T, et al. Transanal endoscopic microsurgery is more effective than traditional transanal excision for resection of rectal masses. Dis Colon Rectum 2008;51:1026-30; discussion 1030-1. [Crossref] [PubMed]
7. Clancy C, Burke JP, Albert MR, et al. Transanal endoscopic microsurgery versus standard transanal excision for the removal of rectal neoplasms: a systematic review and meta-analysis. Dis Colon Rectum 2015;58:254-61. [Crossref] [PubMed]
8. Penna M, Hompes R, Mackenzie H, et al. First international training and assessment consensus workshop on transanal total mesorectal excision (taTME). Tech Coloproctol 2016;20:343-52. [Crossref] [PubMed]
9. Heald RJ. The ‘Holy Plane’ of rectal surgery. J R Soc Med 1988;81:503-8. [Crossref] [PubMed]
10. Salerno G, Sinnatamby C, Branagan G, et al. Defining the rectum: surgically, radiologically and anatomically. Colorectal Dis 2006;8:5-9. [Crossref] [PubMed]
11. Emile SH, de Lacy FB, Keller DS, et al. Evolution of transanal total mesorectal excision for rectal cancer: From top to bottom. World J Gastrointest Surg 2018;10:28-39. [Crossref] [PubMed]
12. Akiyoshi T, Kuroyanagi H, Oya M, et al. Factors affecting the difficulty of laparoscopic total mesorectal excision with double stapling technique anastomosis for low rectal cancer. Surgery 2009;146:483-9. [Crossref] [PubMed]
13. Fleshman J, Branda ME, Sargent DJ, et al. Disease-free Survival and Local Recurrence for Laparoscopic Resection Compared With Open Resection of Stage II to III Rectal Cancer: Follow-up Results of the ACOSOG Z6051 Randomized Controlled Trial. Ann Surg 2019;269:589-95. [Crossref] [PubMed]
14. Stevenson ARL, Solomon MJ, Brown CSB, et al. Disease-free Survival and Local Recurrence After Laparoscopic-assisted Resection or Open Resection for Rectal Cancer: The Australasian Laparoscopic Cancer of the Rectum Randomized Clinical Trial. Ann Surg 2019;269:596-602. [Crossref] [PubMed]
15. Buess G, Kipfmüller K, Hack D, et al. Technique of transanal endoscopic microsurgery. Surg Endosc 1988;2:71-5. [Crossref] [PubMed]
16. Park SS, Park SC, Kim H, et al. Assessment of the learning curve for the novel transanal minimally invasive surgery simulator model. Surg Endosc 2022;36:6260-70. [Crossref] [PubMed]
17. Dawe SR, Pena GN, Windsor JA, et al. Systematic review of skills transfer after surgical simulation-based training. Br J Surg 2014;101:1063-76. [Crossref] [PubMed]
18. Barendse RM, Dijkgraaf MG, Rolf UR, et al. Colorectal surgeons’ learning curve of transanal endoscopic microsurgery. Surg Endosc 2013;27:3591-602. [Crossref] [PubMed]
19. Maya A, Vorenberg A, Oviedo M, et al. Learning curve for transanal endoscopic microsurgery: a single-center experience. Surg Endosc 2014;28:1407-12. [Crossref] [PubMed]
20. Helewa RM, Rajaee AN, Raiche I, et al. The implementation of a transanal endoscopic microsurgery programme: initial experience with surgical performance. Colorectal Dis 2016;18:1057-62. [Crossref] [PubMed]
21. Lee L, Kelly J, Nassif GJ, et al. Establishing the learning curve of transanal minimally invasive surgery for local excision of rectal neoplasms. Surg Endosc 2018;32:1368-76. [Crossref] [PubMed]
22. Clermonts SHEM, van Loon YT, Stijns J, et al. The effect of proctoring on the learning curve of transanal minimally invasive surgery for local excision of rectal neoplasms. Tech Coloproctol 2018;22:965-75. [Crossref] [PubMed]
23. Francis N, Penna M, Mackenzie H, et al. Consensus on structured training curriculum for transanal total mesorectal excision (TaTME). Surg Endosc 2017;31:2711-9. [Crossref] [PubMed]
24. Koedam TWA, Veltcamp Helbach M, van de Ven PM, et al. Transanal total mesorectal excision for rectal cancer: evaluation of the learning curve. Tech Coloproctol 2018;22:279-87. [Crossref] [PubMed]
25. Lee L, Kelly J, Nassif GJ, et al. Defining the learning curve for transanal total mesorectal excision for rectal adenocarcinoma. Surg Endosc 2020;34:1534-42. [Crossref] [PubMed]
26. Zeng Z, Liu Z, Huang L, et al. Transanal Total Mesorectal Excision in Mid-Low Rectal Cancer: Evaluation of the Learning Curve and Comparison of Short-term Results With Standard Laparoscopic Total Mesorectal Excision. Dis Colon Rectum 2021;64:380-8. [Crossref] [PubMed]
27. Matsuda T, Sawada R, Hasegawa H, et al. Learning Curve for Transanal Total Mesorectal Excision for Low Rectal Malignancy. J Am Coll Surg 2023;236:1054-63. [Crossref] [PubMed]
28. Persiani R, Agnes A, Belia F, et al. The learning curve of TaTME for mid-low rectal cancer: a comprehensive analysis from a five-year institutional experience. Surg Endosc 2021;35:6190-200. [Crossref] [PubMed]
29. Wasmuth HH, Faerden AE, Myklebust TÅ, et al. Transanal total mesorectal excision for rectal cancer has been suspended in Norway. Br J Surg 2020;107:121-30. [Crossref] [PubMed]
30. Manchon-Walsh P, de Lacy FB, Pera M, et al. Transanal Total Mesorectal Excision Versus Anterior Total Mesorectal Excision for Rectal Cancer: A Propensity Score Matched, Population-Based Study in Catalonia, Spain. Dis Colon Rectum 2022;65:207-17. [Crossref] [PubMed]
31. Adamina M, Buchs NC, Penna M, et al. St.Gallen consensus on safe implementation of transanal total mesorectal excision. Surg Endosc 2018;32:1091-103. [Crossref] [PubMed]
32. TAMIS Hands-On Course. European Society of Coloproctology. 2017. Available online: https://www.escp.eu.com/education
33. Popa C, Schlanger D, Prunoiu VM, et al. A novel step-by-step training program for transanal endoscopic surgery. BMC Med Educ 2023;23:327. [Crossref] [PubMed]
34. Stefanidis D, Korndorffer JR Jr, Markley S, et al. Closing the gap in operative performance between novices and experts: does harder mean better for laparoscopic simulator training? J Am Coll Surg 2007;205:307-13. [Crossref] [PubMed]
35. Bedetti B, Schnorr P, Schmidt J, et al. The role of wet lab in thoracic surgery. J Vis Surg 2017;3:61. [Crossref] [PubMed]
36. Haluck RS, Satava RM, Fried G, et al. Establishing a simulation center for surgical skills: what to do and how to do it. Surg Endosc 2007;21:1223-32. [Crossref] [PubMed]
37. Campbell ML, Vadas KJ, Rasheid SH, et al. A reproducible ex vivo model for transanal minimally invasive surgery. JSLS 2014;18:62-5. [Crossref] [PubMed]
38. Wynn GR, Austin RCT, Motson RW. Using cadaveric simulation to introduce the concept and skills required to start performing transanal total mesorectal excision. Colorectal Dis 2018;20:496-501. [Crossref] [PubMed]
39. Mann J, Rolinger J, Axt S, et al. Novel box trainer for taTME - prospective evaluation among medical students. Innov Surg Sci 2019;4:116-20. [Crossref] [PubMed]
40. Imai S, Ito M. A novel surgical training simulator for transanal total mesorectal excision. Tech Coloproctol 2020;24:1163-8. [Crossref] [PubMed]
41. Sinclair P, Fitzgerald JE, Hornby ST, et al. Mentorship in surgical training: current status and a needs assessment for future mentoring programs in surgery. World J Surg 2015;39:303-13; discussion 314. [Crossref] [PubMed]
42. Applied Medical. Education and Training Programs. Available online: https://www.appliedmedical.com/Education
43. Keller DS, de Lacy FB, Hompes R. Education and Training in Transanal Endoscopic Surgery and Transanal Total Mesorectal Excision. Clin Colon Rectal Surg 2021;34:163-71. [Crossref] [PubMed]
44. Knol J, Bonjer J, Houben B, et al. New Paradigm of Live Surgical Education: Synchronized Deferred Live Surgery. J Am Coll Surg 2018;227:467-73. [Crossref] [PubMed]
45. Andersen DK. How can educators use simulation applications to teach and assess surgical judgment? Acad Med 2012;87:934-41. [Crossref] [PubMed]
46. Atallah S, Brady RR. The iLappSurgery taTME app: a modern adjunct to the teaching of surgical techniques. Tech Coloproctol 2016;20:665-6. [Crossref] [PubMed]
47. Sugand K, Mawkin M, Gupte C. Validating Touch Surgery™: A cognitive task simulation and rehearsal app for intramedullary femoral nailing. Injury 2015;46:2212-6. [Crossref] [PubMed]
48. Lacy AM, Bravo R, Otero-Piñeiro AM, et al. 5G-assisted telementored surgery. Br J Surg 2019;106:1576-9. [Crossref] [PubMed]
49. Butt K, Jonas OS, Trichet LO, et al. Surgical telementoring as teaching tool in the operating room: trans-Nordic IDEAL stage 2a telementored series of a robotic ventral mesh rectopexy learning curve. Br J Surg 2024;111:znae123. [Crossref] [PubMed]
50. Zhu E, Hadadgar A, Masiello I, et al. Augmented reality in healthcare education: an integrative review. PeerJ 2014;2:e469. [Crossref] [PubMed]
51. Sheik-Ali S, Edgcombe H, Paton C. Next-generation Virtual and Augmented Reality in Surgical Education: A Narrative Review. Surg Technol Int 2019;35:27-35. [PubMed]
52. Stone NN, Wilson MP, Griffith SH, et al. Remote surgical education using synthetic models combined with an augmented reality headset. Surg Open Sci 2022;10:27-33. [Crossref] [PubMed]
53. Pellino G, García-Granero A, Fletcher-Sanfeliu D, et al. Preoperative surgical planning based on cadaver simulation and 3D imaging for a retrorectal tumour: description and video demonstration. Tech Coloproctol 2018;22:709-13. [Crossref] [PubMed]
54. Sahnan K, Adegbola SO, Tozer PJ, et al. Innovation in the imaging perianal fistula: a step towards personalised medicine. Therap Adv Gastroenterol 2018;11:1756284818775060. [Crossref] [PubMed]
55. Martin-Perez B, Bennis H, Lacy AM. Virtual reality simulation for surgery: from video games to transanal total mesorectal excision. Tech Coloproctol 2018;22:5-6. [Crossref] [PubMed]
56. Kitaguchi D, Takeshita N, Matsuzaki H, et al. Deep learning-based automatic surgical step recognition in intraoperative videos for transanal total mesorectal excision. Surg Endosc 2022;36:1143-51. [Crossref] [PubMed]
57. Quero G, Mascagni P, Kolbinger FR, et al. Artificial Intelligence in Colorectal Cancer Surgery: Present and Future Perspectives. Cancers (Basel) 2022;14:3803. [Crossref] [PubMed]
58. Hashimoto DA, Rosman G, Rus D, et al. Artificial Intelligence in Surgery: Promises and Perils. Ann Surg 2018;268:70-6. [Crossref] [PubMed]