Low Hartmann's (LH) procedure for rectal cancer is indicated for frail patients with a high risk of anastomotic fistulas or poor functional outcomes. While transanal total mesorectal excision (TaTME) offers potential technical advantages over transabdominal laparoscopy, its clinical benefits are lacking. We aimed to evaluate whether TaTME improves short-term outcomes of the LH procedure compared with transabdominal laparoscopy.

We retrospectively evaluated all patients who underwent laparoscopic LH procedures for mid or low rectal cancer at our center from 2010 to 2023. The primary endpoint was 90-day morbidity. The secondary endpoints included conversion rate, pelvic abscess rate, length of hospital stay (LHS), and oncological quality of resection.

The baseline characteristics of the patients were comparable between the laparoscopic (Lap; n = 44) and TaTME ( n = 31) groups. Severe morbidity was significantly lower in the TaTME group (3.2% vs. 23%; P = 0.04), with a lower pelvic abscess rate (9.6% vs. 25%, P = 0.04). Operative time was comparable, but conversion rate and blood loss were significantly lower in the TaTME group. LHS was shorter in the TaTME group (12.3 vs. 16.9 days; P = 0.03), with a comparable readmission rate. Pathologic outcomes, including resection margins and mesorectal quality, were comparable between the groups. Among patients with 3-year follow-up data, local recurrence occurred in 3 (7.6%) and 2 (7.7%) patients in the Lap and TaTME groups, respectively ( P = 1).

The TaTME approach for the LH procedure can be a valuable option for rectal cancer management, as it reduces severe morbidity and hospital stay, without compromising oncologic outcomes.