Robotic transanal surgery for local excision of rectal neoplasia, transanal total mesorectal excision, and repair of complex fistulae: clinical experience with the first 18 cases at a single institution. Tech Coloproctol. 2015;19:401-410. [PMID: 25708682 DOI: 10.1007/s10151-015-1283-8]

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.

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.

Robotic Transanal Total Mesorectal Excision Compared to Laparoscopic Transanal Total Mesorectal Excision: Oncologic Results of the Past 5 Years

Colorectal cancer is one of the deadliest diseases on the planet. Rectal cancer (RC) is the 8 th most common type of cancer disease worldwide, accounting for over 300,000 fatalities in 2018. Total mesorectal excision (TME) is considered as the gold standard approach for surgical RC management. To alleviate technical problems associated with dissection of distal rectal, transanal procedure to mesorectum was developed. The robotic operating platforms’ development has brought about the most significant change. The robotic method, which was described first in the year 2001, is gaining popularity in colorectal surgery. A stable camera platform with three-dimensional imaging and tremor filtering, motion scaling, instruments with numerous degrees of freedom, 3 rd arm for fixed retraction, ambidextrous capability, superior ergonomics, and less fatigue, all these advantages have all influenced robotics implementation. However, there are certain disadvantages to robotic surgery, such as high expenses, lengthy time of operation, a bulky cart, and absence of haptic sense. Robotic transanal TME (R-TA TME) is unique method that integrates potential advantages of perineal dissection with precise control of distal margins, along with all robotic technology advantages with respect to dexterity and greater precision. This review goal is to evaluate the available literature critically regarding R-TA TME in comparison to laparoscopic TA TME (L-TA TME) using the most prevalent histopathological metrics, which are the circumferential resection margin, the distal rectal margin, recurrence rate, specimen quality, advantages, and disadvantages. Oncological results for the past 5 years were used. The resources were obtained from electronic sources such as Google Scholar and PubMed. The conclusion of this review revealed that R-TA TME is as safe as well as feasible as L-TA TME, is technically possible, and has comparable oncological results and short-term post-operative outcomes. However, further investigation is required to evaluate long-term oncological or functional results.

Robotic Surgery in Rectal Cancer: Potential, Challenges, and Opportunities

The current standard treatment for locally advanced rectal cancer is based on a multimodal comprehensive treatment combined with preoperative neoadjuvant chemoradiation and complete surgical resection of the entire mesorectal cancer. For ultra-low cases and cases with lateral lymph node metastasis, due to limitations in laparoscopic technology, the difficulties of operation and incidence of intraoperative complications are always difficult to overcome. Robotic surgery for the treatment of rectal cancer is an emerging technique that can overcome some of the technical drawbacks posed by conventional laparoscopic approaches, improving the scope and effect of radical operations. However, evidence from the literature regarding its oncological safety and clinical outcomes is still lacking. This brief review summarized the current status of robotic technology in rectal cancer therapy from the perspective of several mainstream surgical methods, including robotic total mesorectal excision (TME), robotic transanal TME, robotic lateral lymph node dissection, and artificial intelligence, focusing on the developmental direction of robotic approach in the field of minimally invasive surgery for rectal cancer in the future.

Robotic Transanal Surgery for Rectal Cancer

Robotic transanal surgery is the culmination of major developments in rectal cancer management and minimally invasive surgery. It is the result of continuous efforts to tackle the challenges inherent to rectal cancer surgery. This latest technology holds great promise and excitement for the care of the rectal cancer patient. In this article, we will describe the evolution of transanal rectal cancer surgery and describe how the convergence of transanal transabdominal, transanal endoscopic microsurgery, transanal minimally invasive surgery (TAMIS), transanal total mesorectal excision (taTME), and the different robotic platforms have culminated in the development of single port robotic transanal minimally invasive surgery (SP rTAMIS) and single port robotic transanal total mesorectal excision (SP rtaTME). We will describe the indications, technical aspects, outcomes, benefits, and limitations of the SP rTAMIS and SP rtaTME.

Robotic transanal total mesorectal excision: Is the future now?

Total mesorectal excision (TME) is the standard surgical treatment for the curative radical resection of rectal cancers. Minimally invasive TME has been gaining ground favored by the continuous technological advancements. New procedures, such as transanal TME (TaTME), have been introduced to overcome some technical limitations, especially in low rectal tumors, obese patients, and/or narrow pelvis. The earliest TaTME reports showed promising results when compared with the conventional laparoscopic TME. However, recent publications raised concerns regarding the high rates of anastomotic leaks or local recurrences observed in national series. Robotic TaTME (R-TaTME) has been proposed as a novel technique incorporating the potential benefits of a perineal dissection together with precise control of the distal margins, and also offers all those advantages provided by the robotic technology in terms of improved precision and dexterity. Encouraging short-term results have been reported for R-TaTME, but further studies are needed to assess the real role of the new technique in the long-term oncological or functional outcomes. The present review aims to provide a general overview of R-TaTME by analyzing the body of the available literature, with a special focus on the potential benefits, harms, and future perspectives for this novel approach.

First Clinical Experience With Single-Port Robotic Transanal Minimally Invasive Surgery: Phase II Trial of the Initial 26 Cases

BACKGROUND

Many transanal platforms have been developed to address the challenge of reach and vision when operating transanally. The single-port robot was specifically designed for narrow-aperture surgery and is a promising platform for minimally invasive transanal surgery.

OBJECTIVE

The purpose of this phase II trial is to evaluate the safety and feasibility of the initial clinical experience with single-port robot transanal minimally invasive surgery.

DESIGN

In a prospective phase II trial, patients with rectal neoplasms eligible for local excision were enrolled for single-port robotic transanal minimally invasive surgery.

SETTING

The study was conducted between October 2018 and March 2020 at a tertiary referral hospital.

PATIENTS/INTERVENTION

Twenty-six consecutive patients underwent single-port robotic transanal minimally invasive surgery resection of rectal lesions.

MAIN OUTCOME MEASURES

The primary end point of the study was the efficacy and safety of single-port robotic transanal minimally invasive surgery.

RESULTS

There were 13 men and 13 women, with an average lesion size of 2.9 cm (range, 1.0-6.0 cm) and average level of 4.8 cm from the anorectal ring (range, 0-30 cm). Ten patients had a preoperative diagnosis of adenocarcinoma, 7 of whom received neoadjuvant chemoradiation (range, 4500-5580 cGy with concurrent oral capecitabine). Eighty-eight percent of cases were completed by single-port robotic transanal minimally invasive surgery; 2 were converted to transanal endoscopic microsurgery, and 1 patient underwent a low anterior resection. There were no piecemeal extractions, and all margins were negative on final pathology. There were no mortalities, and the morbidity rate was 15.4%. There have been no local recurrences, with a mean follow-up of 5.8 months (range, 0-15.9 months).

LIMITATIONS

The study was limited by small sample size, short-term follow up, and a single-surgeon experience.

CONCLUSION

Single-port robotic transanal minimally invasive surgery procedures are safe and feasible in patients with select benign and malignant rectal lesions. Future trials will need to evaluate the long-term safety and efficacy of single-port robotic transanal minimally invasive surgery. See Video Abstract at http://links.lww.com/DCR/B605.

PRIMERA EXPERIENCIA CLNICA CON CIRUGA MNIMAMENTE INVASIVA TRANSANAL ROBTICA DE PUERTO NICO ENSAYO DE FASE II DE LOS CASOS INICIALES

ANTECEDENTES:Se han desarrollado muchas plataformas transanales para abordar el desafío del alcance y la visión cuando se opera de manera transanal. El robot de un solo puerto fue diseñado específicamente para la cirugía de apertura estrecha y es una plataforma prometedora para la cirugía transanal mínimamente invasiva.OBJETIVO:El propósito de este ensayo de fase II es evaluar la seguridad y viabilidad de la experiencia clínica inicial con la cirugía mínimamente invasiva transanal con robot de puerto único.DISEÑO:En un ensayo prospectivo de fase II, los pacientes con neoplasias rectales elegibles para la escisión local se inscribieron para la cirugía mínimamente invasiva transanal robótica de puerto único.AJUSTE:El estudio se realizó entre octubre de 2018 y marzo de 2020 en un hospital de referencia terciario.PACIENTES / INTERVENCIÓN:Veintiséis pacientes consecutivos fueron sometidos a cirugía mínimamente invasiva transanal robótica de puerto único para resección de lesiones rectales.PRINCIPALES MEDIDAS DE RESULTADO:El criterio de valoración principal del estudio fue la eficacia y seguridad de la cirugía mínimamente invasiva transanal robótica de puerto único.RESULTADOS:Hubo 13 hombres y 13 mujeres, con un tamaño de lesión promedio de 2.9 cm (rango 1.0-6.0 cm) y un nivel promedio de 4.8 cm del anillo anorrectal (rango 0-30 cm). Diez pacientes tenían un diagnóstico preoperatorio de adenocarcinoma, 7 de los cuales recibieron quimiorradiación neoadyuvante (rango 4500-5580 cGy con capecitabina oral concurrente). El 88% de los casos se completaron mediante cirugía mínimamente invasiva transanal robótica de puerto único; 2 se convirtieron a microcirugía endoscópica transanal y 1 se sometió a una resección anterior baja. No hubo extracciones parciales y todos los márgenes fueron negativos en la patología final. No hubo mortalidad y una tasa de morbilidad del 15,4%. No ha habido recidivas locales, con un seguimiento medio de 5,8 meses (rango 0-15,9 meses).LIMITACIONES:El estudio estuvo limitado por un tamaño de muestra pequeño, un seguimiento a corto plazo y la experiencia de un solo cirujano.CONCLUSIÓN:Los procedimientos de cirugía mínimamente invasiva transanal robótica de puerto único son seguros y factibles en pacientes con lesiones rectales benignas y malignas seleccionadas. Los ensayos futuros deberán evaluar la seguridad y eficacia a largo plazo de la cirugía mínimamente invasiva transanal robótica de puerto único. Consulte Video Resumen en http://links.lww.com/DCR/B605. (Traducción-Dr. Eduardo Londoño-Schimmer).

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 Transanal Total Mesorectal Excision (RTaTME): State of the Art

Total mesorectal excision (TME) is the gold standard technique for the surgical management of rectal cancer. The transanal approach to the mesorectum was introduced to overcome the technical difficulties related to the distal rectal dissection. Since its inception, interest in transanal mesorectal excision has grown exponentially and it appears that the benefits are maximal in patients with mid-low rectal cancer where anatomical and pathological features represent the greatest challenges. Current evidence demonstrates that this approach is safe and feasible, with oncological and functional outcome comparable to conventional approaches, but with specific complications related to the technique. Robotics might potentially simplify the technical steps of distal rectal dissection, with a shorter learning curve compared to the laparoscopic transanal approach, but with higher costs. The objective of this review is to critically analyze the available literature concerning robotic transanal TME in order to define its role in the management of rectal cancer and to depict future perspectives in this field of research.

Robotic-assisted transanal total mesorectal excision for rectal cancer: technique and results from a single institution

BACKGROUND

Total mesorectal excision (TME) has greatly reduced the local recurrence rate of rectal cancer after colorectal surgery. Transanal TME (TaTME) is potentially a suitable option for patients with mid and low rectal cancer. Robotic systems overcome the limitations of laparoscopic surgery. The aim of this study was to investigate the safety and feasibility of robotic-assisted transanal total mesorectal excision (RTaTME) in patients with rectal cancer.

METHODS

The clinical data of patients who underwent RTaTME for rectal cancer between May 2017 and January 2020 were reviewed. The perioperative data and short-term outcomes of all the patients were retrospectively analysed. Last follow-up was in May 2020.

RESULTS

A total of 13 patients had RTaTME during the 36-month study period. The median docking time was 18 (IQR 16-20) minutes, median transanal phase time was 95 (IQR 74-100) minutes, median total operation time was 240 (IQR 195-270) minutes, median estimated blood loss was 60 (IQR 50-100) ml, the median number of lymph nodes retrieved was 15 (IQR 13-16) and median length of postoperative hospital stay was 7 (IQR 6-10) days. There was no mortality. Three (23%) patients suffered a postoperative complication including one anastomotic leak and one prolonged ileus, none of them required any intervention. Patients were followed up for a median of 15 (IQR 11-18) months, and no local tumour recurrences, metastasis or deaths were reported.

CONCLUSIONS

Our preliminary results suggest that RTaTME for rectal cancer is feasible. This innovative approach may offer patients potential benefits-further studies are needed.

SP rTaTME: initial clinical experience with single-port robotic transanal total mesorectal excision (SP rTaTME)

BACKGROUND

The technical difficulty and steep learning curve of transanal total mesorectal excision (taTME) has limited widespread adoption. The single-port (SP) daVinci robot is designed to facilitate single-incision and natural-orifice transluminal endoscopic surgery (NOTES). This paper describes the first clinical experience of single-port robotic taTME (SP rTaTME).

METHODS

This was a prospective study on consecutive patients with rectal cancer who underwent SP rTaTME proctosigmoidectomy with handsewn coloanal anastomosis in December 2018 and January 2019. The primary outcome was technical feasibility of the procedure. The secondary outcomes include blood loss, intraoperative complications, length of hospital stay, quality of the TME specimen, short- and long-term morbidity and mortality, as well as short-term oncologic follow -up.

RESULTS

There were two patients, a 48-year-old male and a 38-year-old female. Both operations were completed successfully without complications or conversion. Estimated blood loss was 200 mL and 130 mL. In both cases the TME was completed transanally using the SP robot. In the first patient, the abdominal portion was completed through an abdominal single-incision; in the second patient the operation was entirely performed transanally as a pure NOTES procedure. In both cases, the final pathology report showed a complete TME with negative margins. Patients were discharged on postoperative day 3 and 4,respectively. There was no long-term morbidity or mortality.

CONCLUSIONS

SP rTaTME is feasible and can be safely performed. It provides excellent optics and dexterity to work in a limited space. Future studies are required to further define the safety profile and the ultimate utility of the SP robot for taTME.

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.

Future Directions

Transanal total mesorectal excision (taTME) is a novel technique that has evolved over the years to address the challenges of low rectal cancer surgery by applying the principles and benefits of laparoscopic surgery to more historic transanal techniques. It has been popularized through its use in rectal cancer, but the transanal approach is slowly being expanded to tackle different clinical scenarios including benign conditions such as inflammatory bowel disease and endometriosis. For all of these new indications, it is the desire to access and begin the dissection in native tissue beyond the pathology which makes this approach applicable to other diseases where anatomy can be challenging. Training pathways to safely introduce taTME in a standardized manner are being developed and implemented in a bid to ensure adequate training to all the surgeons using this technique and thus minimize complications and patient morbidity. The future directions of this promising technique include the use of image and optical technological enhancement to aid navigation, the use of pneumorectum stabilization, and perhaps the use of fluorescence as a safety improvement. Developments have come also from the field of robotics. After a demonstration of feasibility in cadaver models, a growing experience has been gathered in the robotic approach to taTME, covered in the last part of this chapter.

Robotic Transanal Minimally Invasive Surgery for Rectal Lesions

Background. Transanal minimally invasive surgery (TAMIS) was developed as a less aggressive alternative treatment for rectal lesions. The purpose of this study was to report the results of robotic TAMIS for such patients. Methods. Patients eligible for TAMIS were operated on using the da Vinci robotic surgical system and GelPOINT Path Transanal Access Platform. Patient demographics, lesion characteristics, perioperative data, complications, and follow-up of all patients were recorded retrospectively. Results. Between March 2015 and August 2018, 24 patients underwent robotic TAMIS by using the da Vinci Si or Xi. The median operative time was 129.6 minutes, and the estimated blood loss was minimal. The mean length of hospital stay was 4.6 days, with no operative complications and no 30-day mortality. There were no statistically significant differences in clinical results and pathological outcomes between the 2 generations of da Vinci systems. Conclusions. With the use of robotic technology, transanal local excision for rectal lesions can be performed with relative ease and safety and can be potentially decreasing the morbidity associated with more aggressive surgical techniques.

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.

Robotic Transanal Minimally Invasive Surgery for the Excision of Rectal Neoplasia: Clinical Experience With 58 Consecutive Patients

BACKGROUND

Given the significant perioperative risks and costs of total mesorectal excision, minimally invasive transanal surgical approaches have grown in popularity for early rectal cancer and rectal polyps. This article discusses a transanal robotic surgery technique to perform full-thickness resections of benign and malignant rectal neoplasms.

OBJECTIVE

The purpose of this study was to describe an initial experience with robotic transanal minimally invasive surgery.

DESIGN

This was a retrospective cohort study of consecutive patients who underwent robotic transanal minimally invasive surgery.

SETTINGS

The study was conducted at a high-volume colorectal surgery practice with a large health maintenance organization.

PATIENTS

Patients at Southern California Kaiser Permanente with early rectal cancer and rectal polyps amenable to transanal excision were included.

INTERVENTIONS

Transanal resection of rectal tumors were removed using robotic transanal minimally invasive surgery.

MAIN OUTCOME MEASURES

Local recurrence of rectal pathology was measured.

RESULTS

A total of 58 patients underwent robotic transanal minimally invasive surgery with full-thickness rectal resection by 4 surgeons for the following indications: rectal cancer (n = 28), rectal polyp (n = 18), rectal carcinoid (n = 11), and rectal GI stromal tumor (n = 1). Mean operative time was 66.2 minutes (range, 17-180 min). The mean tumor height from the anal verge was 8.8 cm (range, 4-14 cm), and the mean specimen size was 3.3 cm (range, 1.3-8.2 cm). A total of 57 (98.3%) of 58 specimens were intact, and 55 (94.8%) of 58 specimens had negative surgical margins. At a mean follow-up of 11.5 months (range, 0.3-33.3 mo), 3 patients (5.5%) developed local recurrences, and all underwent successful salvage surgery.

LIMITATIONS

The study was limited by being a retrospective, nonrandomized trial with short follow-up.

CONCLUSIONS

Robotic transanal minimally invasive surgery is a safe, oncologically effective surgical approach for rectal polyps and early rectal cancers. It offers the oncologic benefits and perioperative complication profile of other transanal minimally invasive surgical approaches but also enhances surgeon ergonomics and provides an efficient transanal rectal platform. See Video Abstract at http://links.lww.com/DCR/A759.

Robotic transanal microsurgery for high early rectal neoplasia (T0-T1, N0 lesions), case series of 10 patients

PURPOSE/BACKGROUND

In 2017, an estimated 39 910 people will receive a new diagnosis of rectal cancer. Current surgical guidelines limit transanal excision of early rectal neoplasia to 8 cm from the anal verge. We report that R0 resection of higher rectal cancers is possible using transanal robotic microsurgery.

METHODS/INTERVENTIONS

Ten cases of robotic assisted transanal surgery for early stage disease (T0-T1, N0) between 2013 and 2016 were reviewed.

RESULTS/OUTCOMES

All cases were diagnosed preoperatively with colonoscopy, and the average distance from the anal verge was 11.1 cm. The average operative time was 167 minutes, and the average blood loss was 37.5 cc. Four cases required intraoperative conversion; one conversion required robotic abdominal access to repair a proctotomy. All margins were histologically negative, and 6-month follow-up showed no recurrences.

CONCLUSION/DISCUSSION

Transanal robotic surgery may provide the colorectal surgeon a method to address rectal lesions farther from the anal verge.

Review and update: robotic transanal surgery (RTAS)

As the field of surgery advances, new approaches have allowed surgeons additional flexibility to perform further interventions with minimal or no external incisions. For many years, single site access (SSA) has been used for transanal procedures, and platforms allowing modified endoscopic approaches have been available. These platforms have limitations related to access, visualization, dexterity, camera control, and instrumentation. Recently, surgical robotics companies have developed and introduced new technologies and platforms, which may help address some of these limitations. Comprehensive internet, open access, and medical and industry conference reviews of robotic surgery platforms and technology available for use in SSA surgery were conducted and 30 articles were found using keywords "robotic surgery, transanal, single site, robotic transanal surgery". A PubMed, Medline, Journals @OVID and open access search for data related to these platforms and technologies was also performed yielding 11 articles. Abstracts were reviewed for those written in the English language, leaving 40 articles which were then filtered for those pertaining to robotic surgery, transanal. 58 abstracts were found, duplicates were eliminated, and the remaining 35 articles were read in their entirety by two reviewers. Several new and existing platforms are identified for use in SSA surgery for transanal surgery as well as abdominal and transoral surgery. These are reviewed, including brand, features, approved and suggested uses, and potential limitations. New robotic technologies serve to enhance the ability of surgeons to perform SSA surgery. This next generation of robotic surgery technology overcomes some of the limitations of preceding endoscopic SSA surgery technology and will enhance the advancement of robotic transanal surgery, but outcomes and performance data are still limited.

Robotic transanal minimally invasive surgery (TAMIS) for local excision of rectal lesions with the da Vinci Xi (dVXi): technical considerations and video vignette

Robotic transanal minimally invasive surgery (TAMIS) (RT) represents a compelling new alternative capable of overcoming the limitations of conventional TAMIS for the local excision of rectal lesions. We describe our RT technique using the dVXi™ (Intuitive Surgical, Sunnyvale, CA, USA) which we have used to efficiently and completely excise eight cases of rectal lesions which were not endoscopically resectable. We also include a video vignette of the procedure. With the patient in the prone jackknife position, we insert a GelPOINT™ Path Transanal Access Platform (Applied Medical, Rancho Santa Margarita, CA, USA) in combination with the dVXi and AirSeal™ insufflation system (Conmed, Niagara. Falls, ON, Canada). Our technique aims to be ergonomically efficient to minimise docking difficulties and to reduce instrument clash in the limited space, whilst maximising the capabilities of the dVXi for RT. At 3-month endoscopic follow-up, no evidence of recurrence was detected in any of the eight patients. RT is safe, feasible and has advantages over conventional laparoscopic TAMIS (LT). Our described technique addresses some of the long-standing challenges of LT and the novel RT. The immediate challenge to its widespread use remains the cost, expertise and availability.

Robotic Assisted Transanal Polypectomies: Is There Any Indication?

OBJECTIVES

Robotic assisted transanal polipectomy may have advantages compared with the conventional transanal minimally invasive surgery technique. We evaluate the safety, feasibility and advantages of this technique.

METHODS

Between February 2014 and October 2015, 9patients underwent robotic transanal polypectomy. We performed a retrospective study in which we analyse prospectively collected data regarding patient and tumor characteristics, perioperative outcomes, pathological report, morbidity and mortality.

RESULTS

A total of 5 male and 4 female patients underwent robotic TAMIS. Lesions were 6,22cm from the anal verge. Mean size was 15,8cm². All procedures were performed in the lithotomy position. Closure of the defect was performed in all cases. Mean blood loss was 39,8ml. Mean operative time was 71,9min. No severe postoperative complications or readmissions occured. Median hospital stay was 2,5 days.

CONCLUSIONS

Robotic TAMIS is useful to treat complex rectal lesions. Our transanal platform allowed a wider range of movements of the robotic arms and to perform all procedures in the lithotomy position.

Future of Minimally Invasive Colorectal Surgery

Minimally invasive surgery is slowly taking over as the preferred operative approach for colorectal diseases. However, many of the procedures remain technically difficult. This article will give an overview of the state of minimally invasive surgery and the many advances that have been made over the last two decades. Specifically, we discuss the introduction of the robotic platform and some of its benefits and limitations. We also describe some newer techniques related to robotics.

Rectourethral Fistula Management

Rectourethral fistula (RUF) is a rare condition that occurs, in most cases, as a consequence of prostate cancer treatments. Clinical suspicion and proper assessment prior to surgery are essential to adapt and successfully carry out an appropriate treatment plan. There are no randomized trials to guide clinical practice, and therefore, scientific evidence in this respect is limited. Expert recommendations seem to agree on the transperineal approach with flap interposition as the surgical treatment of choice in cases of complex fistulas, especially in those that have undergone prior radiation. Undoubtedly, the key to the successful treatment of the disease is the multidisciplinary and standardized management by physicians with experience in the field.

Transanal endoscopic surgery for complications of prior rectal surgery

BACKGROUND

Long-term complications of previous rectal surgery (e.g., enterovisceral fistula, anastomotic stricture, rectal stenosis) can be challenging problems for which transabdominal or transperineal surgery with or without definitive fecal diversion is often required. Transanal endoscopic surgery (TES) might allow for local treatment of these complications, thereby saving patients from otherwise major surgery.

PATIENTS AND METHODS

All patients undergoing TES in the IJsselland Hospital (NL) since 1996 were recorded in a prospective database, of which twenty patients were treated for complications after previous rectal surgery. Data on prior treatment, surgical techniques, outcomes, and need for additional surgery were collected.

RESULTS

Twenty patients were identified from the database (rectourinary fistula n = 3, rectovaginal fistula n = 5, anastomotic stricture n = 8, and rectal stenosis n = 4). One of the three (33 %) rectourinary fistulas and two of five (40 %) rectovaginal fistulas were successfully treated with TES. Anastomotic strictures were successfully treated in 5/8 (63 %) patients. Strictures after local excision of rectal tumors were successfully treated in 3/4 (75 %) patients. No minor complication and one major complication occurred (rectovaginal fistula after stenoplasty eventually requiring Hartmann's procedure).

CONCLUSIONS

Transanal treatment of anastomotic strictures, rectal stenosis, and fistula after prior rectal surgery is safe and effective in a large proportion of patients. TES should be considered as a first step in all patients presenting with these late complications after rectal surgery.

Transanal Approach to Rectal Polyps and Cancer

A transanal approach to rectal polyp and cancer excision is often an appropriate alternative to conventional rectal resection, and has a lower associated morbidity. There has been a steady evolution in the techniques of transanal surgery over the past 30 years. It started with traditional transanal excision and was revolutionized by introduction of transanal endoscopic microsurgery in early 1980s. Introduction of transanal minimally invasive surgery made it more accessible to surgeons around the world. Now robotic platforms are being tried in certain institutions. Concerns have been raised about recurrence rates of cancers with transanal approach and success of subsequent salvage operations.

Transanal total mesorectal excision: Towards standardization of technique

AIM: To describe the role of Transanal total mesorectal excision (TaTME) in minimally invasive rectal cancer surgery, to examine the differences in patient selection and in reported surgical techniques and their impacts on postoperative outcomes and to discuss the future of TaTME.

METHODS: MEDLINE (PubMed), EMBASE, and The Cochrane Library were systematically searched through the 1^st of March 2015 using a predefined search strategy.

RESULTS: A total of 20 studies with 323 patients were included. Most studies were single-arm prospective studies with fewer than 100 patients. Multiple transanal access platforms were used, and the laparoscopic approach was either multi- or single port. The procedure was initiated transanally or transabdominally. If a simultaneous approach with 2 operating surgeons was chosen, the operative time was significantly reduced.

CONCLUSION: TaTME was also associated with better TME specimens and a longer distal resection margin. TaTME is thus feasible in expert hands, but the learning curve and safety profile are not well defined. Long-term follow-up regarding anal function and oncological outcomes should be performed in the future.

Transanal total mesorectal excision: A valid option for rectal cancer?

Low anterior resection can be a challenging operation, especially in obese male patients and in particular after radiotherapy. Transanal total mesorectal excision (TaTME) might offer technical advantages over laparoscopic or open approaches particularly for tumors in the distal third of the rectum. The aim of this article is to review the current experience with TaTME. The limits and future developments are also explored. Although the experience with TaTME is still limited, it might be a promising alternative to laparoscopic TME, especially for difficult cases where laparoscopy is too demanding. The preliminary data on complications and short-term oncological outcomes are good, but also emphasize the importance of careful patient selection. Finally, there is a need for large-scale trials focusing on long-term outcomes and oncological safety before widespread adoption can be recommended.

Urogenital dysfunctions after treatment of rectal cancer

A significant part of rectal cancer survivors will experience urogenital dysfunction induced by the treatment. Significant progress has been made in order to improve the total mesorectal technique through different approaches (open, laparoscopic, robotic, transanal). Rectal cancer surgery is technically difficult notably deep in the pelvis, and therefore the most frequent cause of the postoperative dysfunction is the surgical nerve damage of the autonomic nerves at this level. The main objectives of these efforts were to obtain maximal oncological results and to achieve better functional outcomes including less postoperative urogenital dysfunctions. Our purpose was to build a comprehensive review of the existing literature data regarding this issue from past to present.