A pelvic‐first approach to total mesorectal excision following total neoadjuvant therapy—A video vignette

Over the past four decades, surgical treatment for rectal cancer has steadily evolved, with total neoadjuvant therapy (TNT) increasingly adopted to enhance both local control and long-term outcomes [1-3]. However, TNT can complicate total mesorectal excision (TME) by altering tissue quality and obscuring dissection planes, as reported in a national survey of Austrian rectal surgeons [4]. We herein introduce a strategic sequence termed the ‘Pelvic-First Approach to TME’, which prioritizes rectal dissection and transection before vascular ligation or colonic mobilization. This approach enables rectal transection to be completed while the operative field remains dry, before the onset of interstitial edema and exudative oozing, which typically worsen with prolonged operative time and fluid shifts [5, 6]. Furthermore, it facilitates a wide, unobstructed view of the upper abdomen, allowing for safe vascular ligation and colonic mobilization. This video illustrates the advantages of the pelvic-first technique for rectal cancer following TNT. It includes postoperatively analysed footage using a Japanese-developed artificial intelligence (AI) surgical navigation system (Eureka; Anaut, Inc., Tokyo, Japan), which highlights loose connective tissue and autonomic nerves to enhance anatomical understanding [7] (Video 1). We believe that in the era of TNT—where preoperative treatment increases the technical complexity of TME—the pelvic-first approach offers an effective strategy that maximizes the synergistic benefits of combining Ta-TME with multi-articulated robotic systems. Shunjin Ryu: Conceptualization; investigation; methodology; validation; funding acquisition; visualization; software; formal analysis; project administration; data curation; supervision; resources; writing – original draft; writing – review and editing. Yuta Imaizumi: Resources; investigation. Shunsuke Nakashima: Investigation; resources. Hyuga Kawakubo: Resources; investigation. Daiki Suzuki: Resources; investigation. Ryusuke Ito: Supervision. The authors would like to express thanks to the operating room staff of the Kawaguchi Municipal Medical Center. Finally, the authors give special thanks to Yukio Nakabayashi. The authors have nothing to report. Shunjin Ryu receives funds for a collaborative research project from Anaut, Inc. Yuta Imaizumi, Shunsuke Nakashima, Hyuga Kawakubo, Daiki Suzuki and Ryusuke Ito have no conflicts of interest or financial ties to disclose. This study was approved by the institutional ethics committee (approval number: 2022-27). Written informed consent was obtained from the patient for publication of this study. The data that support the findings of this study are available from the corresponding author upon request.