**9. Robotic transanal total mesorectal excision (TaTME)**

To improve the oncological and functional outcomes of the patients with rectal cancer new surgical techniques have been developed. It is known that the laparoscopic approach to rectal cancer with medium or lower location is a challenge due to the anatomy of a narrow pelvis and thus increases the risk of incomplete resection of the mesorectum with the possibility of an increased rate of local recurrences.

The introduction of single-port transanal surgery led to the development of the technique of complete excision of the transanal mesorectum [40, 41]. The first studies published by laparoscopic approach were published in 2010 [42]. The promoters of this approach claim that TaTME emphasize a number of benefits, namely a better quality of the specimen with a lower rate of circumferential resection involved, with a lower morbidity related to the extraction of the specimen and a much more sphincter saving procedures without compromising the oncological results.

The help of the robotic system is certain. Stable position, more ergonomic, the possibility of superior maneuverability in narrow spaces, with articulated instruments [43]. The first part of the intervention is performed normally with mesorectal dissection up to the level of the pelvic peritoneal fold. It then passes to the pelvic stage. Only three arms of the robot are used, and the use of AirSeal for smoke absorption is essential (**Figure 13**). It starts with a circular suture of the rectum about 1–2 cm below the tumor. The circular rectal wall is sectioned and after we reach the mesorectum plane, the complete dissection of the mesorectum

**Figure 13.** *Operative set-up for TaTME.*

**Figure 14.** *Step 1 – transanal circular suture.*

begins. The upper part will reach the peritoneal cavity, where the previously dissected mesorectal area will meet. The whole piece is extracted transanal and after the colorectal resection, the anvil of the stapler is mounted in the remaining colon, after which it is reintroduced in the peritoneal cavity. A circular bursa is performed at the level of the remaining anal canal and the stapler is inserted, performing a low or very low colorectal anastomosis (**Figure 14**).
