Robotic transanal minimally invasive surgery (TAMIS) with the newest robotic surgical platform: a multi-institutional North American experience

Influence of BMI on robotic rectal cancer surgery: a systematic review and meta-analysis

Obesity presents a significant public health challenge, known to escalate the risk of colorectal cancer twofold. The potential advantages of employing robotic technology in colorectal surgery for obese individuals remain mostly unexplored. A comprehensive search of articles retrieved from Scopus, PubMed, and the Cochrane Library for the duration of January 2014 to March 2024 was performed, without language limitations. Meta-analysis was conducted in accordance with PRISMA guidelines. The study compared results of robotic rectal cancer resections in obese patients (BMI ≥ 30 kg/m2) with those in non-obese counterparts. Out of 2410 full-text articles studied, 7 met the inclusion criteria and underwent final analysis. The study included 963 non-obese and 371 obese patients. Operative time produce significant variance in non-obese patients. However, DRM, CRM, HLN, length of hospital stays, conversion rate, and overall complications did not show any statistically significant differences. Robotic surgery for rectal cancer had no clinically significant influence in obese group patients, and postoperative complications are same as in non-obese group except duration of surgery.

Single-port robotic transanal minimally invasive surgery (SPR-TAMIS): another giant leap forward?

AIM

Minimally invasive transanal platforms are now the standard of care for select low-risk rectal tumours. However, existing platforms come with persistent technical challenges. The da Vinci SP Surgical System™ offers a new alternative designed to work effectively in narrow spaces. This technology has the potential to enhance the feasibility and proximal extent of complex transanal resections. This study aimed to describe the morbidity and technical success in patients undergoing single-port robotic transanal minimally invasive surgery (SPR-TAMIS). Secondary outcomes include rates of local recurrence.

METHODS

A retrospective analysis was conducted on all patients who underwent SPR-TAMIS at our institution between February 2019 and December 2023.

RESULTS

The study included 31 patients (19 men, 12 women) with a mean age of 61 ± 13.3 years. The average tumour distance from the anal verge was 10 cm. Thirty patients completed SPR-TAMIS, with one patient requiring conversion to robotic sigmoidectomy due to location in the mid-sigmoid colon. The mean operating time was 106 ± 42 min. Twenty-eight out of 30 patients underwent full-thickness excision and all but two were successfully closed. All specimens were resected intact, and margins were negative in 93.5% of cases. The average tumour size was 13 ± 34 cm2, with 13 lesions classified as adenomas and 16 as adenocarcinomas. All patients who did not undergo associated procedures were discharged on the day of surgery. Two patients experienced 30-day morbidity. At a mean follow-up of 18 months (± 13), no local or systemic recurrences were identified.

CONCLUSION

SPR-TAMIS for excision of low-risk rectal tumours is associated with high rates of technical success and low 30-day morbidity. Further research is needed to compare SPR-TAMIS with other techniques to determine potential advantages over current transanal platforms.

Initial case series experience with robotic-assisted transanal minimally invasive surgery performed with da Vinci single-port system for the excision of rectal cancer

BACKGROUND

Transanal minimally invasive surgery (TAMIS) is widely used for rectal lesion excision. Robot-assisted TA TAMIS (R-TAMIS) may improve surgical ergonomics. The introduction of the da Vinci Single-Port (SP) robot, designed for endoluminal surgery, has brought new possibilities. Our primary objective herein was to assess the technical and oncological feasibility and efficacy of Single-port robotic TAMIS (SPR-TAMIS) in rectal cancer excision. The secondary objective was to analyze the perioperative outcomes.

MATERIALS AND METHODS

We included 14 consecutive patients with rectal cancer who underwent SPR-TAMIS between April 2021 and February 2023. Patient data, surgical details, and clinical outcome data were collected to assess the safety and feasibility of SPR-TAMIS.

RESULTS

The median participant age was 72 years, and full-thickness excision was performed without specimen fragmentation in all cases. The median tumor diameter was 2.7 cm, positioned between 10 cm proximally and 7 cm distally from the anal verge. Negative margins were achieved in 93% of cases, with one case requiring further resection. The median operative time was 175 min, and the median hospital stay was 5 days. No intraoperative conversion from SPR-TAMIS to laparoscopic or conventional transanal excision was required. No mortalities or major postoperative complications occurred; however, one patient (7.1%) experienced minor morbidity manifesting as wound dehiscence (Clavien-Dindo grade I). No recurrence was observed during the 24-month follow-up.

CONCLUSIONS

In our early experience, SPR-TAMIS is a safe and feasible surgery for selected early stage rectal cancers, offering enhanced visualization and stable maneuverability transanally. This platform may have potential advantages for the excision of larger or more proximal lesions.

Robotic Transanal Minimally Invasive Surgery for Rectal Polyps

Transanal minimally invasive surgery (TAMIS) can be utilized to manage a wide variety of rectal lesions but can be technically demanding with traditional laparoscopic equipment. Robotic platforms such as the da Vinci Single Port system can reduce the technical barriers of TAMIS and allow more complicated lesions to be addressed. Robotic TAMIS with the SP system follows similar indications for local excision of benign and malignant lesions as conventional TAMIS or even transanal endoscopic microsurgery. We describe our initial experience using the SP system and provide technical suggestions for how to incorporate this technology. We also address innovations in flexible endoscopic robotic surgery that we anticipate will allow for increased use of organ preservation of the colon and rectum, as well as possibly expand the use of natural orifice surgery.

Comparing advanced platforms for local excision of rectal lesions

BACKGROUND

Transanal surgery facilitates organ preservation in select patients with benign and early malignant rectal lesions to avoid the functional consequences of radical surgery. The transanal endoscopic microsurgery (TEM) platform created a standard for local excision with lower margin positivity and recurrence rates than traditional transanal excision. The single-port robot (SP r) presents a promising alternative transanal platform. The goal of this study was to compare perioperative and pathologic outcomes of TEM and SP r for excision of rectal lesions.

METHODS

A review of consecutive patients who underwent local excision of rectal lesions at a tertiary referral center from 1/2001 to 5/2022 was performed. Cases were stratified into TEM or SP rTAMIS in a 1:1 propensity score-matched cohort, adjusting for all baseline characteristics. Clinical, tumor-specific, and perioperative outcomes were compared using χ2, and Mann-Whitney U-tests. The main outcomes were oncologic quality measures, complications, and operative time.

RESULTS

Matching resulted 50 patients in each cohort. Groups had similar age, gender, body mass index, comorbidity, diagnosis, lesion characteristics, and neoadjuvant chemoradiation rates. There were no intraoperative complications in either cohort. Three SP rTAMIS cases were converted intraoperatively; there were no conversions in TEM. SP rTAMIS had significantly shorter operative times than TEM (mean 104 vs. 245, p = 0.027). The rates of positive distal margins (2% TEM, 0% SP rTAMIS) and piecemeal resection (4% TEM, 0% SP rTAMIS) were similar. SP rTAMIS had significantly lower postoperative morbidity rates than TEM (9% vs. 20%, p = 0.031). There was no mortality in either cohort.

CONCLUSIONS

SP robotics provided high-quality outcomes similar to TEM for local excision of rectal lesions. SP robotics had faster operative time with comparable clinical and oncologic outcomes to TEM. These early data are promising for expanding use of SP robotic platforms.

Robotic transanal minimally invasive surgery (R-TAMIS): current evidence in the treatment of early rectal neoplasia

INTRODUCTION

Robotic transanal minimally invasive surgery (R-TAMIS) was introduced in 2012 for the excision of benign rectal polyps and low grade rectal cancer. Ergonomic improvements over traditional laparoscopic TAMIS (L-TAMIS) include increased dexterity within a small operative field, with possibility of better surgical precision. We aim to collate the existing data surrounding the use of R-TAMIS to treat rectal neoplasms from cohort studies and larger case series, providing a foundation for future, large-scale, comparative studies.

METHODS

Medline, EMBASE and Web of Science were searched as part of our review. Randomised controlled trials (RCTs), cohort studies or large case series (≥ 5 patients) investigating the use of R-TAMIS to resect rectal neoplasia (benign or malignant) were eligible for inclusion in our analysis. Quality assessment of included studies was performed via the Newcastle Ottawa Scale (NOS) risk of bias tool. Outcomes extracted included basic participant characteristics, operative details and histopathological/oncological outcomes.

RESULTS

Eighteen studies on 317 participants were included in our analysis. The quality of studies was generally satisfactory. Overall complication rate from R-TAMIS was 9.7%. Clear margins (R0) were reported in 96.2% of patients. Local recurrence (benign or malignant) occurred in 2.2% of patients during the specified follow-up periods.

CONCLUSION

Our review highlights the current evidence for R-TAMIS in the local excision of rectal lesions. While R-TAMIS appears to have complication, margin negativity and recurrence rates superior to those of published L-TAMIS series, comparative studies are needed.

Endorobotic submucosal dissection of rectal lesions using the single port robot DaVinci-SP: initial experience of the first 10 cases

BACKGROUND

Endoluminal surgery is increasingly recognized as a mode of treatment for colorectal neoplasms with the latest robotic single port platform Da Vinci-SP (Intuitive Surgical, Sunnyvale) facilitating submucosal dissection of benign rectal neoplasm.

METHOD

In this study, we present our initial experience with endorobotic submucosal dissection in the management of benign rectal neoplasms using the Da Vinci-SP (Intuitive Surgical, Sunnyvale) between 2020 and 2021. The primary endpoint was the successful completion of submucosal dissection.

RESULTS

During the study period, 10 patients underwent endorobotic submucosal dissection for benign rectal neoplasms. The median age of the patients was 68 (range: 59-78) years, and the mean BMI was 29.38 (range: 22.9-38.5). The mean size of the lesion was 42.3 mm (range: 20-65 mm) and was located 7.3 cm (mean) from the anal verge (range: 2-10 cm). The mean operative time was 91.3 minutes (range: 57-137 minutes). All 10 dissections were completed successfully en bloc. There were no intraoperative complications or mortality. All patients were discharged on the same day and commenced on a normal diet. Late bleeding was observed in one patient receiving anticoagulation, and one patient had urinary retention. Pathology revealed two adenocarcinomas, six tubulovillous adenomas, one tubular adenoma, and one sessile serrated adenoma. There was no recurrence in all other patients during the median follow-up of 6 months (range: 4-16 months).

CONCLUSIONS

Endorobotic submucosal dissection using a single-port robotic platform is safe and feasible for benign rectal mucosal neoplasms. The semiflexible platform offers an alternative to endoscopic submucosal dissection with favourable outcomes.

Robotic Transanal Minimally Invasive Surgery (rTAMIS): Large Tubulovillous Adenoma

Many transanal platforms have recently evolved to manage rectal pathologies. Transanal endoscopic microsurgery (TEM) and transanal laparoscopic minimally invasive surgery (TAMIS) have been developed to address the limitations of conventional transanal surgery. More recently, the addition of the robotic platform to the surgeon's armamentarium has made it possible to combine the dexterity of the robotic surgical system with the standard TAMIS single-port platform to treat complex rectal lesions. In this article, we present the case of a patient who underwent rTAMIS for the management of a large endoscopically unresectable rectal mass.

Robot-assisted TAMIS: a systematic review of feasibility and outcomes

BACKGROUND

In the advancement of transanal local excision, robot-assisted transanal minimal invasive surgery is the newest development. In the confined area of the rectum, robot-assisted surgery should, theoretically, be superior due to articulated utensils, video enhancement, and tremor reduction, however, this has not yet been investigated. The aim of this study was to review the evidence reported to-date on experience of using robot-assisted transanal minimal invasive surgery for treatment of rectal neoplasms.

METHODS

A comprehensive literature search of Embase and PubMed from May to August 2021were performed. Studies including patients diagnosed with rectal neoplasia or benign polyps who underwent robot-assisted transanal minimal invasive surgery were included. All studies were assessed for risk of bias through assessment tools. Main outcome measures were feasibility, excision quality, and complications.

RESULTS

Twenty-five studies with a total of 322 local excisions were included. The studies included were all retrospective, primarily case-reports, -series, and cohort studies. The median distance from the anal verge ranged from 3.5 to 10 cm and the median size was between 2.5 and 5.3 cm. Overall, 4.6% of the resections had a positive resection margin. The overall complication rate was at 9.5% with severe complications (Clavien-Dindo score III) at 0.9%.

CONCLUSION

Based on limited, retrospective data, with a high risk of bias, robot-assisted transanal minimal invasive surgery seems feasible and safe for local excisions in the rectum.

Clinical Robotic Surgery Association (India Chapter) and Indian rectal cancer expert group's practical consensus statements for surgical management of localized and locally advanced rectal cancer

INTRODUCTION

There are standard treatment guidelines for the surgical management of rectal cancer, that are advocated by recognized physician societies. But, owing to disparities in access and affordability of various treatment options, there remains an unmet need for personalizing these international guidelines to Indian settings.

METHODS

Clinical Robotic Surgery Association (CRSA) set up the Indian rectal cancer expert group, with a pre-defined selection criterion and comprised of the leading surgical oncologists and gastrointestinal surgeons managing rectal cancer in India. Following the constitution of the expert Group, members identified three areas of focus and 12 clinical questions. A thorough review of the literature was performed, and the evidence was graded as per the levels of evidence by Oxford Centre for Evidence-Based Medicine. The consensus was built using the modified Delphi methodology of consensus development. A consensus statement was accepted only if ≥75% of the experts were in agreement.

RESULTS

Using the results of the review of the literature and experts' opinions; the expert group members drafted and agreed on the final consensus statements, and these were classified as "strong or weak", based on the GRADE framework.

CONCLUSION

The expert group adapted international guidelines for the surgical management of localized and locally advanced rectal cancer to Indian settings. It will be vital to disseminate these to the wider surgical oncologists and gastrointestinal surgeons' community in India.

Comparison of advanced techniques for local excision of rectal lesions: a case series

Background

Robotic transanal minimally invasive surgery (R-TAMIS) is an appealing alternative to transanal minimally invasive surgery (TAMIS) and transanal endoscopic microsurgery (TEM) for benign and early malignant rectal lesions that are not amenable to traditional open transanal excision. However, no studies to our knowledge have directly compared the three techniques. This study sought to compare peri-operative and pathologic outcomes of the three approaches.

Methods

The records of 29 consecutive patients who underwent TEM, TAMIS, or R-TAMIS at a single academic center between 2016 and 2020 were reviewed. Intra-operative details, pathological diagnosis and margins, and post-operative outcomes were recorded. The three groups were compared using chi-square and Kruskal–Wallis tests.

Results

Overall, 16/29 patients were women and the median age was 57 (interquartile range (IQR): 28–81). Thirteen patients underwent TEM, six had TAMIS, and 10 had R-TAMIS. BMI was lower in the R-TAMIS patients (24.7; IQR 23.8–28.7), than in TEM (29.3; IQR 19.9–30.2), and TAMIS (30.4; IQR 26.6–32.9) patients. High grade dysplasia and/or invasive cancer was more common in TAMIS (80%) and R-TAMIS (66.7%) patients than in TEM patients (41.7%). The three groups did not differ significantly in tumor type or distance from the anal verge. No R-TAMIS patients had a positive surgical margin compared to 23.1% in the TEM group and 16.7% in the TAMIS group. Length of stay (median 1 day for TEM and R-TAMIS patients, 0 days for TAMIS patients) and 30-day readmission rates (7.7% of TEM, 0% of TAMIS, 10% of R-TAMIS patients) also did not differ among the groups. Median operative time was 110 min for TEM, 105 min for TAMIS, and 76 min for R-TAMIS patients.

Conclusions

R-TAMIS may have several advantages over other advanced techniques for transanal excisions. R-TAMIS tended to be faster and to more often result in negative surgical margins compared to the two other techniques.

Robotic transanal minimally invasive surgery: a single institutional experience

Robotic transanal minimally invasive surgery (R-TAMIS) is a novel and evolving technique with limited reported outcomes in the literature. Compared to the laparoscopic approach, R-TAMIS provides enhanced optics, increased degrees of motion, superior ergonomics, and easier maneuverability in the confines of the rectum. We report a single institution experience at a large quaternary referral academic medical center with R-TAMIS using the da Vinci Xi® platform. This is a retrospective review of electronic medical records at the Mayo Clinic from September 2017 to April 2020. It includes all available clinical documentations for patients undergoing R-TAMIS at our institution. Patient demographics, intraoperative data (procedure time, tumor size and distance), complications, and pathology reports were reviewed. A total of 28 patients underwent R-TAMIS. Median follow-up was 23.65 months. Sixteen patients underwent R-TAMIS for endoscopically unresectable rectal polyps, eight for rectal adenocarcinoma, two for rectal gastrointestinal stromal tumor, and two for rectal carcinoid tumor. The mean size of the lesions was 4.1 cm (range 0.2-13.8 cm). The mean location of lesions was 7.8 cm (range 0-16 cm) from the anal verge. The mean operative time was 132.5 ± 46.8 min. There was one 30-day complication, and no deaths. Twenty-three (82%) patients were discharged the day of surgery. R-TAMIS is a safe, feasible, and effective technique for the surgical treatment of a variety of rectal pathology. A hybrid technique can be used for the resecting tumors extending into the anal canal.

New Frontiers in Management of Early and Advanced Rectal Cancer

It is important to understand advances in treatment options for rectal cancer. We attempt to highlight advances in rectal cancer treatment in the form of a systematic review. Early-stage rectal cancer focuses on minimally invasive endoluminal surgery, with importance placed on patient selection as the driving factor for improved outcomes. To achieve a complete pathologic response, various neoadjuvant chemoradiation regimens have been employed. Short-course radiation therapy, total neoadjuvant chemotherapy, and others provide unique advantages with select patient populations best suited for each. With a clinical complete response, a "watch and wait" non-operative surveillance has been introduced with preliminary equivalency to radical resection. Various modalities for total mesorectal excision, such as robotic or transanal, have advantages and can be utilized in select patient populations. Tumors demonstrating solid organ or peritoneal spread, traditionally defined as unresectable lesions conveying a terminal diagnosis, have recently undergone advances in hepatic and pulmonary metastasectomy. Hepatic and pulmonary metastasectomy has demonstrated clear advantages in 5-year survival over standard chemotherapy. With the peritoneal spread of colorectal cancer, HIPEC with cytoreductive therapy has emerged as the preferred treatment. Understanding the various therapeutic interventions will pave the way for improved patient outcomes.

Envisioning the future of colorectal surgery: preclinical assessment and detailed description of an endoluminal robotic system (ColubrisMX ELS)

BACKGROUND

The EndoLuminal Surgical System (ELS) is an emerging non-linear robotic system specifically designed for transanal surgery that allows for excision of colorectal neoplasia and luminal defect closure.

METHODS

An evaluation of ELS was conducted by a single surgeon in a preclinical setting at the EndoSurgical Center of Florida in Orlando, between October 1st, 2020 and December 31st, 2020, using porcine colon as a model. Mock lesions measured 2.5 to 3.5 cm were excised partial-thickness. Specimen quality and excision time was assessed and evaluated.

RESULTS

Twenty consecutive robotic transanal minimally invasive surgery (TAMIS) operations utilizing the ELS system were successfully performed without fragmentation. The mean and standard deviation procedure time for all 20 cases was 18.41 ± 14.15 min. The latter 10 cases were completed in substantially less time, suggesting that ELS requires at least 10 preclinical cases for a surgeon to become familiar with the technology. A second task, namely suture closure of the partial-thickness defect, was performed in 9 of the 20 cases. Mean time and standard deviation for this task measured 27.89 ± 10.07 min. There were no adverse events.

CONCLUSIONS

ELS was successful in performing the tasks of partial-thickness disc excision and closure in a preclinical evaluation. Further study is necessary to determine its clinical applicability.

Robotic TAMIS: A Technical Note Comparing Si® versus Xi®

Transanal minimally invasive surgery (TAMIS) can be performed robotically assisted (R-TAMIS) for easier rectal defect suture closure particularly on the anterior rectal wall. The surgical technique described in this technical note emphasizes three safety points: 1) decreased likelihood for rectal injury when the ports are inserted into the GelPOINT® Path Transanal Access Platform (Applied Medical, Rancho Santa Margarita, California) on the back table rather than being inserted into the rectum; 2) decreased external collision between ports when using ports of different length; and 3) increased stabilization of pneumorectum when insufflating with an AirSeal™ port (Intelligent Flow System, ConMed, Utica, New York). Although R-TAMIS can be safely performed with the da Vinci® Si® or Xi® (Intuitive Surgical Inc., Sunnyvale, California) patient cart, the following differences are noteworthy: a) the Si® vertically-mounted arms design forces the patient in an uncomfortable position with asymmetrical hip flexion as opposed to the Xi® boom-mounted horizontal arm design; b) the 28cm circumference of each Si® patient cart arms operating between the patient's legs offer decreased maneuvering freedom as opposed to the 19cm circumference of the Xi® counterparts; and c) the abduction pattern of movement of the Si® arms potentially increases the risk of external collision with the patient's legs as opposed to the Xi® "jack-knife" pattern of movement.

The first robotic transanal minimally invasive surgery in Ireland: a case-based review

Transanal minimally invasive surgery (TAMIS) has gained worldwide acceptance as a means of local excision of early rectal cancers and benign rectal lesions. However, it is technically challenging due to the limitations of rigid laparoscopic instruments in the narrow rectal lumen. Robotic platforms offer improved ergonomics that are valuable in operative fields with limited space. Robotic TAMIS represents an exciting new development that may be more versatile than traditional TAMIS. In this review, we describe the first case of robotic TAMIS performed in our country and a review of current literature on the technique.

Transanal minimally invasive surgery vs endoscopic mucosal resection for rectal benign tumors and rectal carcinoids: A retrospective analysis

BACKGROUND

Transanal minimally invasive surgery (TAMIS) is a good choice for resection of rectal neoplasms. Endoscopic mucosal resection (EMR) is also widely used in the treatment of benign rectal tumors such as rectal polyps and rectal adenomas. However, no studies have compared the outcome of TAMIS and EMR.

AIM

To compare the short-term outcomes after TAMIS and EMR for rectal carcinoid and benign tumors (including rectal polyps and adenomas).

METHODS

From January 2014 to January 2019, 44 patients who received TAMIS and 53 patients who received EMR at The Fifth People’s Hospital of Shanghai were selected. Primary outcomes (surgical-related) were operating time, blood loss, length of postoperative hospital stay, rate of resection margin involvement and lesion fragmentation rate. The secondary outcomes were complications such as hemorrhage, urinary retention, postoperative infection and reoperation.

RESULTS

No significant differences were observed in terms of blood loss (12.48 ± 8.00 mL for TAMIS vs 11.45 ± 7.82 mL for EMR, P = 0.527) and length of postoperative hospital stay (3.50 ± 1.87 d for TAMIS vs 2.72 ± 1.98 d for EMR, P = 0.065) between the two groups. Operating time was significantly shorter for EMR compared with TAMIS (21.19 ± 9.49 min vs 49.95 ± 15.28 min, P = 0.001). The lesion fragmentation rate in the EMR group was 22.6% (12/53) and was significantly higher than that (0%, 0/44) in the TAMIS group (P = 0.001). TAMIS was associated with a higher urinary retention rate (13.6%, 6/44 vs 1.9%, 1/53 P = 0.026) and lower hemorrhage rate (0%, 0/44 vs 18.9%, 10/53 P = 0.002). A significantly higher reoperation rate was observed in the EMR group (9.4%, 5/53 vs 0%, 0/44 P = 0.036).

CONCLUSION

Compared with EMR, TAMIS can remove lesions more completely with effective hemostasis and lower postoperative hemorrhage and reoperation rates. TAMIS is a better choice for the treatment of rectal carcinoids.

Robotic transanal minimally invasive surgery - technical, oncological and patient outcomes from a single institution

AIM

Robotic transanal minimally invasive surgery (R-TAMIS) is gaining traction around the globe as an alternative to laparoscopic conventional TAMIS for local excision of benign and early malignant rectal lesions. The aim was to analyse patient and oncological outcomes of R-TAMIS for consecutive cases in a single centre.

METHODS

A prospective analysis of consecutive R-TAMIS procedures over a 12-month period was performed. Data were collated from hospital databases and theatre registers.

RESULTS

Eleven patients (six men, five women), mean age 69.81 years (51-92 years), underwent R-TAMIS over 12 months utilizing a da Vinci Xi platform. The mean lesion size was 36 mm (20-60 mm) with a mean distance from the anal verge of 7.5 cm (3-14 cm). Five lesions were posterior in anatomical location, four anterior, one right lateral and one left lateral. All procedures were performed in the lithotomy position using a GelPOINT Path Platform. Mean operative time was 64 min (40-100 min). Complete resection was achieved in 10/11 patients with two patients being upgraded to a diagnosis of adenocarcinoma. Nine patients were diagnosed with dysplastic lesions. Four patients had a false positive diagnosis of an invasive tumour on MRI. Six patients required suturing for full-thickness resections. One patient had a postoperative bleed requiring repeat endoscopy and clipping. One patient (full-thickness resection of T3 tumour) proceeded to a formal resection without difficulty with no residual disease (T0N0, 0/22). One patient with a fully resected T2 tumour is undergoing a surveillance protocol. The mean length of stay was 1 day with two patients having a length of stay of 2 days and one patient of 4 days.

CONCLUSION

R-TAMIS could potentially represent a safe novel approach for local resection of rectal lesions.

Single-port robotic transanal minimally invasive surgery (SPR-TAMIS) approach to local excision of rectal tumors

BACKGROUND

Trans-anal excision is the surgical treatment of choice for endoscopically unresectable rectal polyps, early rectal cancers, small carcinoid tumors, and other low-risk tumors. The single-port robotic (SPR) platform is the newest development in robotic surgery capable of performing trans-anal minimally invasive surgery (TAMIS). In theory, the single incision design would naturally lend itself to the size limitation of the anal canal, but in practice, this method has not been tested. Herein we describe the techniques and first reports of performing TAMIS using the SPR platform.

TECHNIQUE

We describe in detail how to perform the SPR-TAMIS technique using lessons and experience gained from performing this on five patients who had endoscopically unresectable rectal polyps or T1 rectal cancers. Each patient was followed for a minimum of 30 days and was seen in clinic post-operatively. A retrospective chart review was performed to obtain information on technical success, anatomic measurements, and reported complications.

RESULTS

The SPR TAMIS was successfully performed on all five patients without any reported complications. All underwent a non-piecemeal excision and had return of regular bowel function at 30-day follow-up. All patients were discharged from the hospital the same day as their operation.

CONCLUSIONS

SPR-TAMIS is a novel, safe, and feasible procedure capable of achieving non-piecemeal resections of low-risk rectal tumors. Further study needs to be conducted to determine complication rates, functional and oncologic outcomes, and ensure the long-term safety profile.

Hybrid Robotic Transanal Minimally Invasive Surgery Approach to Large and Low-Lying Rectal Polyps

BACKGROUND

Transanal excision is the surgical treatment of choice for low-risk rectal pathology such as endoscopically unresectable polyps, very select early rectal cancers, as well as other benign and low-risk tumors. Robotic transanal minimally invasive surgery enhances the surgeon's ability to work in the confined space of the rectum and helps overcome the limitations of other modalities for transanal excision. Large lesions that extend to the dentate line and cannot be excised transanally impart a particular challenge. Herein, we describe a hybrid robotic transanal minimally invasive surgery approach for excising large rectal lesions that extend to the dentate line and cannot be excised by utilizing traditional transanal techniques.

TECHNIQUE

With the use of a standard transanal approach, the distal margin of the lesion is marked and lifted off of the internal sphincter muscle. The dissection is continued until above the anorectal ring, and a 5.5-cm transanal platform is introduced transanally. Insufflation with an 8-mm trocar is initiated and the robotic platform is docked transanally. A 1-cm circumferential proximal margin is marked, and the excision is continued robotically until en bloc resection of the lesion is completed. The defect is closed in a transverse fashion using barbed suture. For rare cases of circumferential or nearly circumferential full-thickness defects, interrupted barbed sutures are placed equidistant, the robot is undocked, the transanal platform is removed, and a handsewn coloanal anastomosis is performed allowing complete closure of the defect.

RESULTS

A hybrid robotic transanal minimally invasive surgery approach to large and low-lying rectal lesions is feasible and safe, and it has advantages over standard transanal excision including enhanced ergonomics, dexterity, and optics, as well as reduced rates of specimen fragmentation.

CONCLUSION

A hybrid robotic transanal minimally invasive surgery approach allows for complete resection of very large polyps, which would otherwise be extremely challenging with standard transanal approaches. See Video at http://links.lww.com/DCR/B231.

The outcomes of two robotic platforms performing transanal minimally invasive surgery for rectal neoplasia: a case series of 21 patients

Colorectal cancer remains the third most common cancer effecting adults. Surgical guidelines recommend transanal excision of early rectal neoplasia up to 8 cm from the anal verge. A retrospective review of two novel approaches for transanal robotic local excision with R0 resections of rectal cancers which was, on average, higher than 8 cm. Twenty-one cases of robotic assisted transanal surgery for early stage disease (T0-T1, N0) were reviewed. The first 10 cases performed with the da Vinci^® Si robotic platform between 2013 and 2016, and the first 11 cases performed using the Flex^® Medrobotics platform between August 2017 and August 2018. The average distance from the anal verge was 11.1 cm and 9.5 cm for the da Vinci^® Si and Flex^® Colorectal Drive, respectively. The average operative time was 167.6 min for the da Vinci^® Si and 110.1 min for the Flex^® Colorectal Drive; the average EBL was 37.5 cc and 9.1 cc for the da Vinci^® Si and Flex^® Colorectal Drive. In the da Vinci^® series, four cases required intraoperative conversion. In the Flex^® series, one case was aborted due to unfavorable robotic positioning. All margins were histologically negative when surgically complete with no recurrences to date. Transanal robotic surgery may provide a method to address rectal lesions farther from the anal verge than previously described. The Flex^® Colorectal Drive platform may provide superior ability to navigate the nonlinear anatomy of the rectum and distal sigmoid colon.

Transanal TME: new standard or fad?

Transanal total mesorectal excision (taTME) has been developed to overcome the difficulty of laparoscopic dissection and transection in the deep pelvis. TaTME has several clinical benefits over laparoscopic surgery, such as better exposure of the distal rectum and direct determination of distal resection margin. Although evidence demonstrating the true benefits of taTME over laparoscopic TME (LapTME) is still insufficient, accumulating data have revealed that, as compared with LapTME, taTME is associated with shorter operative time and a lower conversion rate without jeopardizing other short-term outcomes. However, taTME is a technically demanding procedure with specific complications such as urethral injury, and so sufficient experience of LapTME and step-by-step acquisition of the skills needed for this procedure are requisite. The role of transanal endoscopic surgery is expected to change, along with the recent progress in the treatment of rectal cancer, such as robotic surgery and the watch-and-wait strategy. Optimization of treatment will be needed in the future in terms not only of oncological but also of functional outcomes.

Laparoscopic transanal minimally invasive surgery (L-TAMIS) versus robotic TAMIS (R-TAMIS): short-term outcomes and costs of a comparative study

BACKGROUND

Transanal minimally invasive surgery (TAMIS) has gained worldwide popularity as a method for the local excision of rectal neoplasms. However, it is technically demanding due to limited working space. Robotic TAMIS offers potential enhanced dexterity and ability while allowing for a more aggressive resection with a stable platform. The objective of this study was to review a single institution experience between laparoscopic (L-TAMIS) and robotic TAMIS (R-TAMIS) for treatment of rectal neoplasms and determine if there are significant differences on outcomes.

METHODS

Forty consecutive patients with rectal neoplasms underwent L-TAMIS or R-TAMIS by two colorectal surgeons from January 2012 to April 2017. We retrospectively reviewed a prospectively maintained database to analyze demographics, peri-operative data, pathology, post-operative complications, and cost.

RESULTS

There were no significant differences between L- and R-TAMIS on patient demographics. R-TAMIS showed a statically significant increase in cost of surgery by $880. Median direct cost of L-TAMIS was $3562 compared to $4440.92 for R-TAMIS (p = 0.04). Wider range of total duration for L-TAMIS is likely due to the variability of body habitus and location of rectal neoplasm, which can significantly limit L-TAMIS compare to R-TAMIS. There was a trend toward decreased blood loss in the R-TAMIS group. Mortality was 0% in both groups.

CONCLUSIONS

After reviewing our experience, we conclude there is no significant difference between L- and R-TAMIS other than total direct cost. We confirmed that both L- and R-TAMIS are safe and associated with low morbidity. The limitations of this study include its small sample size. In the future, we hope to show promising data on R-TAMIS with increased sample size and experience, which may allow for transanal resection not previously feasible. Studies with long-term follow-up assessing oncological and functional results will be mandatory.