The endorectal incision level of transanal total mesorectal excision (taTME): An emphasis on the distance from the anterior vs. posterior mesorectal ends to the anal verge

•The anterior end of the mesorectum is quite far from the anal verge than the posterior end.•In certain individuals with significant distance difference, the endorectal incision level may not meet the mesorectal end during taTME.•Aligning the endorectal incision along with the levator hiatus may minimize the potential risk of missing mesorectal tissue posteriorly. There is no intraluminal guidance to ensure complete inclusion of the mesorectum in transanal total mesorectal excision (taTME). This study aimed to assess the distance difference between the anterior and posterior mesorectal terminal ends and the anal verge as a potential risk for residual mesorectum after resection. Forty-four surgical specimens of extra-levator abdominoperineal excision (ELAPE) and 28 mid-sagittal cadaveric specimens were included to this study. The distance between the mesorectum terminal end (T) and the endoluminal landmarks (dentate line (D)/anal verge (A)) was measured and compared between men and women. Furthermore, 66 MRI images from The Cancer Imaging Archive (TCIA) were used to validate the same concept in a non-Asian population. The mesorectal terminal end was found to be aligned along with the levator hiatus. From the midsagittal view, the ELAPE specimens showed that the distance between T and A anteriorly was significantly longer than the same distance posteriorly (34.74±7.79mm vs 23.74±4.24mm, P