Direct target NOTES: prospective applications for next generation robotic platforms

Robotics in interventional endoscopy-evolution and the way forward

The integration of robotics into gastrointestinal (GI) endoscopy represents a transformative advancement and bears the potential to bridge the gap between traditional limitations by offering unprecedented precision and control in diagnostic and therapeutic procedures. This review explores the historical progression, current applications and future potential of robotic platforms in GI endoscopy. Originally designed for surgical applications, robotic systems have expanded their reach into endoscopy, potentially enhancing procedural accuracy and reducing ergonomic strain on practitioners. Natural Orifice Transluminal Endoscopic Surgery (NOTES) emerged as a promising technique, leveraging natural orifices to perform minimally invasive surgeries. Despite its initial potential, several factors, including limitations of the available instrumentations and lack of reliable closure techniques, hindered its widespread adoption and progress. Conventional endoscopic tools often fall short in terms of triangulation, traction and degrees of freedom, necessitating the adoption of robotic interventions. Over recent decades, robotic endoscopy has significantly evolved, focusing on both diagnostic and complex therapeutic procedures such as endoscopic sub-mucosal dissection (ESD) and endoscopic full-thickness resection (EFTR). Various robotic platforms demonstrate enhanced safety and efficiency in GI procedures. As the field progresses, the emphasis on clinical validation, advanced training and the exploration of new applications remains crucial. Continuous innovation in robotic technology and endoscopic techniques promises to overcome existing limitations, further revolutionizing the management of GI diseases and improving patient outcomes.

Comparative outcomes between transvaginal endoscopic hysterectomy and total laparoscopic hysterectomy in patients with benign uterine disease: A single-center, retrospective, cohort, interrupted time-series study

OBJECTIVES

To compare the surgical outcomes of total laparoscopic hysterectomy (TLH) and transvaginal endoscopic hysterectomy (TVEH) for benign uterine diseases.

METHODS

This retrospective, cohort, interrupted time-series study included patients who underwent TLH between January 2013 and September 2016 and TVEH between October 2016 and June 2020. Median difference regression was used to compare the hospital length of stay (LOS) and operative time between the groups. Risk difference regression was used to analyze the proportion of patients who developed postoperative fever or vaginal stump infection.

RESULTS

Of the total 171 patients enrolled, 101 and 70 underwent TVEH and TLH, respectively. The mean ages of patients in the TVEH and TLH groups were 46.49 and 46.17 years, respectively. No conversion was observed. Ureteric injury occurred in one patient in the TVEH group, whereas there was no organ injury in any of the patients in the TLH group. Compared with those in the TLH group, patients in the TVEH group had a significantly shorter median operative time, shorter hospital LOS, lower morphine use, and lower postoperative febrile morbidity rates. However, no significant difference was observed in the rate of vaginal stump infection between the groups.

CONCLUSION

Given the shorter operative time, shorter hospital LOS, less febrile morbidity, and lower morphine use in patients with TVEH than in those with TLH, TVEH should be considered as an alternative hysterectomy procedure for benign uterine diseases.

Clinical relevance of vaginal natural orifice transluminal endoscopic surgery (vNOTES) in gynecology

This study reviews the progress and recent advances in vaginal natural orifice transluminal endoscopic surgery (vNOTES) as a minimally invasive gynecologic procedure. The proposed advantages of vaginal natural orifice transluminal surgery include enhanced cosmesis due to a scarless procedure, better exposure compared with the pure vaginal approach, tolerable pain scores, fewer perioperative complications, and a shorter hospital stay. Recent advances in surgical instrumentation and technology have improved the feasibility of vNOTES as an innovative treatment option for gynecological conditions. However, technical challenges and training issues must be overcome before its widespread use. As a promising surgical innovation, further randomized comparative studies are required to clarify the safety and effectiveness of vNOTES in gynecology.

Novel miniature transendoscopic telerobotic system for endoscopic submucosal dissection (with videos)

BACKGROUND AND AIMS

The lack of tissue traction and instrument dexterity to allow for adequate visualization and effective dissection were the main issues in performing endoscopic submucosal dissection (ESD). Robot-assisted systems may provide advantages. In this study we developed a novel transendoscopic telerobotic system and evaluated its performance in ESD.

METHODS

A miniature dual-arm robotic endoscopic assistant for minimally invasive surgery (DREAMS) was developed. The DREAMS system contained the current smallest robotic ESD instruments and was compatible with the commercially available dual-channel endoscope. After the system was established, a prospective randomized controlled study was conducted to validate the performance of the DREAMS-assisted ESD in terms of efficacy, safety, and workload by comparing it with the conventional technique.

RESULTS

Two robotic instruments can achieve safe collaboration and provide sufficient visualization and efficient dissection during ESD. Forty ESDs in the stomach and esophagus of 8 pigs were completed by DREAMS-assisted ESD or conventional ESD. Submucosal dissection time was comparable between the 2 techniques, but DREAMS-assisted ESD demonstrated a significantly lower muscular injury rate (15% vs 50%, P = .018) and workload scores (22.30 vs 32.45, P < .001). In the subgroup analysis of esophageal ESD, DREAMS-assisted ESD showed significantly improved submucosal dissection time (6.45 vs 16.37 minutes, P = .002), muscular injury rate (25% vs 87.5%, P = .041), and workload (21.13 vs 40.63, P = .001).

CONCLUSIONS

We developed a novel transendoscopic telerobotic system, named DREAMS. The safety profile and technical feasibility of ESD were significantly improved with the assistance of the DREAMS system, especially in the narrower esophageal lumen.

Feasibility and safety of hybrid transvaginal natural orifice transluminal endoscopic surgery for colon cancer: Protocol for a multicenter, single-arm, phase II trial (vNOTESCA)

INTRODUCTION

It has been a decade since the first patient with colon cancer underwent colectomy by hybrid transvaginal natural orifice transluminal endoscopic surgery (hvNOTES). However, the efficacy and safety of this procedure is not well established.

METHODS

This study is an open-label, multicenter, single-arm, phase 2 trial undertaken at six centers in China. Female patients aged over 18 years and below 80 years old with an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1, with pathologically proven, resectable, cT1-3N0-2M0 disease who have previously untreated colon cancer are eligible for inclusion. The primary endpoint is a composite of major intraoperative and postoperative complications (greater than grade III, the Common Terminology Criteria for Adverse Events [CTCAE], version 5.0). Secondary endpoints include conversion to laparoscopic or open surgery, postoperative concentration of C-Reactive Protein and procalcitonine, complete pathological assessment of complete mesocolic excision specimens, postoperative pain, amount of narcotic pain medication administered, time to first flatus after surgery, number of harvested lymph nodes, R0 resection rate, length of hospital stay, sexual function assessment, quality of recovery, satisfaction with surgical scars, quality of life, postoperative recurrence patterns, relapse-free survival, and overall survival.

ETHICS AND DISSEMINATION

The study was approved by the Research Ethics Committee, Renmin Hospital of Wuhan University, China, number: WDRY2022-K053. All patients will receive written information of the trial and provide informed consent before enrollment. The results of this trial will be disseminated in academic conferences and peer-reviewed medical journals.Trial registration number NCT04048421.

Endoscopic Transcecal Appendectomy (ETA): A Literature Review on Risks and Benefits

Different colorectal lesions have attracted different procedures in their management. One of the novel approaches that have been documented in recent times is endoscopic transcecal appendectomy (ETA). ETA is an endoscopic and less invasive approach to the excision of lesions within the appendix. The appendix is also completely resected in the process. The main aim of this paper is to establish some of the benefits and risks that come with ETA. The study was conducted from a systematic review perspective using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol, which governs the implementation of systematic reviews. Key considerations in the PRISMA framework used in this article include identifying the articles, screening them, and determining their eligibility and their final inclusion or exclusion based on the specified criteria. To arrive at relevant articles, some keywords were used in the various search engines of the databases that were consulted. Some of the keywords that were used included ETA, endoscopic mucosal resection (EMR), endoscopic full-thickness resection (EFTR), endoscopic submucosal dissection (ESD), adverse events, risks, safety, efficacy, and the appendiceal orifice. It was established that the key benefits of the ETA include the ability to avoid postoperative appendicitis and residual lesions in tissue. On the other hand, some risks that could come with ETA were found to include potential tumor seeding and postoperative bleeding. However, the key study limitation is that most of the referenced studies in this literature review are retrospective case series and case reports that are prone to selection bias. Furthermore, most ETA procedures in this literature review were performed by a few experienced and highly skilled endoscopists, making the ability to make such results generalizable to all endoscopists and patient populations a debatable issue. In the future, there is a need for more multicenter and large studies to be conducted with longer follow-up periods to ascertain the results obtained in this review. This will ensure a more informed decision-making process for or against ETA implementation in real-world clinical environments.

The Feasibility and Safety of vNOTES Hysterectomy and Uterosacral Ligament Suspension: A Case Series

The transvaginal natural orifice transluminal endoscopic surgery (vNOTES) is a recently introduced surgical approach that is even less invasive than conventional laparoscopy or robotic surgery. We conducted this study to report our experience in vNOTES hysterectomy and uterosacral ligament suspension and determine the feasibility and safety of this approach. Surgeries on 23 women were performed by a single surgeon in 1 tertiary medical center. Patient demographics, perioperative data, and follow-up details of 23 women were collected prospectively. Average age was 56.7 ± 8.9 years. Median parity was 3. Nine patients were smokers, and 4 patients had diabetes. Median stage of prolapse was 3. One patient had extensive adhesions, and after vNOTES hysterectomy was completed, decision was made to perform uterosacral suspension by conventional vaginal access. Another patient had intraoperative identification by cystoscopy of unilateral kinking of the ureter that was resolved after the most distal uterosacral stitch was released. Mean uterine weight was 271.9 ± 131.9 g. Average estimated blood loss was 85.22 ± 55.6 mL. Median length of stay in the hospital was 1 day. Only 1 patient had intermittent voiding postoperatively and required an indwelling catheter for 3 days. Hysterectomy and uterosacral ligament suspension when performed via vNOTES is a safe and feasible procedure. Large prospective trials are on the way to continue shedding light on this new surgical modality.

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.

Robotics in therapeutic endoscopy (with video)

Since its inception, endoscopy has evolved from a solely diagnostic procedure to an expanding therapeutic field within gastroenterology. The incorporation of robotics in gastroenterology initially addressed shortcomings of flexible endoscopes in natural orifice transluminal endoscopy. Developing therapeutic endoscopic robotic platforms now offer operators improved ergonomics, visualization, dexterity, precision, and control and the possibility of increasing proficiency and standardization of complex endoscopic procedures including endoscopic submucosal dissection, endoscopic full-thickness resection, and endoscopic suturing. The following review discusses the history, potential applications, and tools currently available and in development for robotics in therapeutic endoscopy.

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.

Robot-assisted Transvaginal Natural Orifice Transluminal Endoscopic Surgery for Management of Endometriosis: A Pilot Study of 33 Cases

STUDY OBJECTIVE

To describe the surgical techniques and short-term outcomes for 33 cases of robot-assisted transvaginal natural orifice transluminal endoscopic surgery (RvNOTES) to treat endometriosis.

DESIGN

Retrospective case series study.

SETTING

Academic tertiary care university hospital in Houston, TX.

PATIENTS

Patients who underwent RvNOTES resection of endometriosis between March 2020 and March 2021.

INTERVENTIONS

RvNOTES.

MEASUREMENTS AND MAIN RESULTS

A total of 33 cases of patients, with pathology-confirmed endometriosis, who underwent RvNOTES total hysterectomy with resection of endometriosis were included in the study. Thirty-two cases were completed successfully by RvNOTES, and 1 case was converted to robotic transumbilical single-incision laparoscopic surgery plus 1 additional port owing to an obliterated posterior cul-de-sac and upper abdominal wall endometriosis. The average operative time was 141.93 ± 40.22 (85-264) minutes, and the mean estimated blood loss was 52.25 ± 33.82 (25-150) mL. The mean preoperative pain score using the visual analog scale (VAS) score was 8.08 ± 2.39 (2-10). The mean VAS pain score 1 week after surgery was 6.73 ± 2.62 (0-10), which was significantly lower than the preoperative scores (p = .059). The mean VAS pain score in the second and third week after surgery was 4.81 ± 2.42 (0-9) and 2.63 ± 2.36 (0-7) respectively, which were both significantly lower than those before surgery (p = .001). There were 4 postoperative complications: urinary tract infection, pneumonia, headache requiring admission, and conversion disorder.

CONCLUSION

RvNOTES is a safe and feasible approach for the treatment of endometriosis, with promising short-term improvements in pain.

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.

Transanal endoscopic surgery with a 3D printed device

BACKGROUND

The aim of this study was to investigate the effectiveness of devices manufactured with 3D printing for performing transanal endoscopic procedures without pneumorectum.

METHODS

Functional devices were designed in the Polytechnic School of Engineering of Gijón from 2016 to 2018 using three-dimensional (3D) solid modelling software (Solid-Works®), that allows customization of the device (diameter and length). The devices were made in acrylonitrile butadiene styrene (ABS) by additive manufacturing using an HP Designjet 3D Printer, with fused deposition modelling (FDM) technology. Tests were carried out on mixed simulators (with viscera) and cadavers with a prototype in the form of an open cylindrical base ellipsoid spindle with two bars. In this paper, we present the information of the first series of patients in which this device has been used to perform a full-thikness endoscopic resection of the rectal wall without pneumorectum. The characteristics of the patients, size, and location of the lesion, the type of anesthesia used, the duration of the procedure, hospital stay, complications, and pathology were analyzed. An endoscopic follow-up was also carried out for at least 2 years.

RESULTS

Seven interventions were carried out in six patients. The lesions were located at a mean distance of 5 cm from the anal verge and an average area of 11.8 cm². Four of the procedures were performed with general anesthesia and 3 with spinal anesthesia. Histopathology examination identified 3 adenomas, 3 pT1 and 1 pT2 adenocarcinomas. All excisions were full thickness. En bloc excision was possible in all cases. In only one case of a benign polyp there was a positive lateral margin. As regards complications, there was one case of postoperative rectal bleeding without the need for transfusions. There were no readmissions and no postoperative mortality.

CONCLUSIONS

An innovative device made with a 3D printer can be used successfully in transanal endoscopic resections of the rectal wall, with spinal anaesthesia and avoiding the need for pneumorectum.

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.

Advances and Trends in Pediatric Minimally Invasive Surgery

As many meta-analyses comparing pediatric minimally invasive to open surgery can be found in the literature, the aim of this review is to summarize the current state of minimally invasive pediatric surgery and specifically focus on the trends and developments which we expect in the upcoming years. Print and electronic databases were systematically searched for specific keywords, and cross-link searches with references found in the literature were added. Full-text articles were obtained, and eligibility criteria were applied independently. Pediatric minimally invasive surgery is a wide field, ranging from minimally invasive fetal surgery over microlaparoscopy in newborns to robotic surgery in adolescents. New techniques and devices, like natural orifice transluminal endoscopic surgery (NOTES), single-incision and endoscopic surgery, as well as the artificial uterus as a backup for surgery in preterm fetuses, all contribute to the development of less invasive procedures for children. In spite of all promising technical developments which will definitely change the way pediatric surgeons will perform minimally invasive procedures in the upcoming years, one must bear in mind that only hard data of prospective randomized controlled and double-blind trials can validate whether these techniques and devices really improve the surgical outcome of our patients.

Surgical Robot for Intraluminal Access: An Ex Vivo Feasibility Study

Early-stage gastrointestinal cancer is often treated by endoscopic submucosal dissection (ESD) using a flexible endoscope. Compared with conventional percutaneous surgery, ESD is much less invasive and provides a high quality of life for the patient because it does not require a skin incision, and the organ is preserved. However, the operator must be highly skilled because ESD requires using a flexible endoscope with energy devices, which have limited degrees of freedom. To facilitate easier manipulation of these flexible devices, we developed a surgical robot comprising a flexible endoscope and two articulating instruments. The robotic system is based on a conventional flexible endoscope, and an extrapolated motor unit moves the endoscope in all its degrees of freedom. The instruments are thin enough to allow insertion of two instruments into the endoscope channel, and each instrument has a bending section that allows for up–down, right–left, and forward–backward motion. In this study, we performed an ex vivo feasibility evaluation using the proposed robotic system for ESD in a porcine stomach. The procedure was successfully performed by five novice operators without complications. Our findings demonstrated the feasibility of the proposed robotic system and, furthermore, suggest that even operators with limited experience can use this system to perform ESD.

Clinical adoption of robotics in endoscopy: Challenges and solutions

The endoscope was traditionally used as a diagnostic instrument. In past decades, it has increasingly been adapted for therapeutic intents. Subsequently, the master–slave robotic concept was introduced into the field of endoscopy to potentially reduce the difficulty and complication rates of endoscopic therapeutic procedures. As interest in robotic endoscopy intensified, progressively more robotic endoscopic platforms were developed, tested, and introduced. Nevertheless, the future of robotic endoscopy hinges on the ability to meet specific clinical needs of procedurists. Three aspects are vital in ensuring continued success and clinical adoption of the robotic endoscope—demonstration of clinical safety and cost‐efficacy of the device, widespread availability of directed training opportunities to enhance technical skills and clinical decision‐making capabilities of the procedurist, and continued identification of new clinical applications beyond the current uses of the device. This review provides a brief discussion of the historical development of robotic endoscopy, current robotic endoscopic platforms, use of robotic endoscopy in conventional therapeutic endoscopic procedures, and the future of robotic endoscopy.

Robotic transvaginal natural orifice transluminal endoscopic surgery for bilateral salpingo oophorectomy

Objectives

The vaginal surgical approach has not become the standard of care, despite its advantages. The Hominis™ Surgical System is a humanoid shaped robot-assisted system that was designed specifically for robotic vaginal natural orifice transluminal endoscopic surgery (RvNOTES). We aimed to present our experience with the first RvNOTES bilateral salpingo-oophorectomy (BSO) performed by the Hominis system.

Study design

A two-center prospective study of BSO by RvNOTES in women with nonmalignant indications conducted between August and December 2018. Women older than 18 years were offered to participate. Exclusion criteria included a history of abdominal malignancy, pelvic or abdominal irradiation, Crohn's disease, pelvic inflammatory disease, severe infections in the lower abdomen, active diverticulitis, deep infiltrating recto-vaginal endometriosis, and an active vaginal infection. The primary outcome of the study was the rate of conversion to open or laparoscopic approaches. Secondary outcomes included intra- and postoperative adverse events, operative time, estimated blood loss, length of hospital stay, and 6-week follow-up assessment.

Results

Eight women aged 50–70 years with BMI of 19–30 kg/m² were recruited. All the procedures were completed successfully without conversions to open surgery. No intraoperative complications were observed. Median blood loss was 10 mL (range: 10−50). The median duration of the procedure was 45 min (range: 38−91), and decreased over the study period. Surgeons’ usability assessment was very favorable, with a median of 5 on a 1–5 scale. The median visual analog scale (VAS) score was 1 (range: 1–3).

Conclusions

This is the first documentation of a surgery performed via the vagina using robotic instrumentation developed for this purpose. The disruptive technology of RvNOTES, with its fast learning curve, will make gynecological surgeries accessible to more women.

Evolution of surgery for rectal cancer: Transanal total mesorectal excision～new standard or fad?～

Transanal Total Mesorectal Excision (TaTME) has recently been developed to overcome the difficulties associated with conventional laparoscopic or robotic TME. TaTME has gained popularity and becomes the center of attention among colorectal surgeons globally. The present review aims to update the literature, clarify the current status and perspectives of TaTME. Complete TaTME specimens were obtained in 85-97.1% of the case; the reported circumferential resection margin (CRM) ranged from 1.5% to 8.1%, whereas and distal resection margin (DRM) positive rates ranged from 0% to 3.2%. The conversion rate of TaTME occurred from 0 to 15%, and there was no difference between TaTME and laparoscopic or robotic TME. Intraoperative complications occurred in 5-6% of the case, which compared favorably to laparoscopic TME. The most serious intraoperative complication with this approach was urethral injury, although only small numbers were reported, which was possibly due to under-reporting. Clavien-Dindo I or II postoperative complications occurred in 22-24% of the case, and III or IV in 10-11% of the case, which did not differ between TaTME and laparoscopic or robotic TME. TaTME may be technically easier and more beneficial than laparoscopic, robotic or open TME in male patients with a narrow pelvis; in obese patients with a bulky tumor. At present two randomized controlled trials, COLOR III and GRECCAR, and comparing TaTME with laparoscopic TME are being conducted and their outcomes are awaited. TaTME is a complex procedure, but proved to be feasible, oncologically safe, and effective in difficult cases. Before this new technique is adopted, proper training with Proctor/mentorship is strongly advised. Careful case selection and audit of data are mandatory.

Robot-assisted endoscopic submucosal dissection versus conventional ESD for colorectal lesions: outcomes of a randomized pilot study in endoscopists without prior ESD experience (with video)

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) is becoming the preferred method for certain early GI malignancies; however, very few U.S. physicians have adopted this technique. This is in part because of the technically challenging nature of the procedure and the long learning curve. Several endoscopic robots are under development to address these complexities.

METHODS

This is a randomized, controlled, pilot study comparing conventional ESD versus robotic-assisted ESD (RESD) in an ex vivo bovine colon model. Five endoscopists without prior ESD or RESD experience were randomized into 2 groups (group 1, RESD after ESD; group 2, RESD before ESD). A standard template was used to create colonic lesions. The primary outcome was completeness of en bloc resection. Secondary outcomes included differences in procedure time, perforation rate, muscle injury rate, and National Aeronautical and Space Administration Task Load Index (NASA-TLX) to assess physical and mental workload.

RESULTS

Five endoscopists each performed 4 tissue resections (2 RESD and 2 ESD), for a total of 20 procedures. Complete en bloc resection was achieved in all RESD and in 50% of ESD (P < .0001). The perforation rate was higher in the ESD group (60% vs 30%, P = .18). Total procedure time (34.1 vs 88.6 min, P = .001) and dissection time (27.8 vs 79.4 minutes, P = .002) were lower for RESD. The NASA-TLX also revealed better results for RESD (28.4 vs 47.4, P = .01).

CONCLUSIONS

RESD appears to be more effective in obtaining en bloc resection with shorter procedure times and a lower perforation rate compared with conventional ESD as performed by ESD novices. RESD is also associated with lower physical and mental workloads.

Assessment of the Versius surgical robotic system for dual-field synchronous transanal total mesorectal excision (taTME) in a preclinical model: will tomorrow's surgical robots promise newfound options?

BACKGROUND

The aim of this study was to evaluate the feasibility of the Versius surgical robotic system for transanal total mesorectal excision (taTME) in a preclinical setting.

METHODS

Dry laboratory and cadaveric sessions were first conducted for three experienced colorectal surgeons in order to gain familiarity with the modular surgical system and the robotic workstation. After introduction, the system was configured to allow for synchronous, totally robotic taTME in a cadaver.

RESULTS

Using the modular robotic system, one surgeon performed the abdominal portion of the operation, including colonic mobilization and vascular pedicle ligation while simultaneously a second surgeon performed the transanal portion of the operation to the point of rendezvous at the peritoneal reflection, where the operation was completed cooperatively. The operation was successfully completed in 195 min demonstrating preclinical feasibility of this unique approach with an emerging robotic system.

CONCLUSIONS

This is the first preclinical assessment of the Versius surgical robotic system for taTME. The ability to work simultaneously carries the theoretical advantage of reducing surgical time and thereby reducing overall operative costs. It may also allow surgeons to maintain focus on critical parts of the operation by halving the fatigue associated with long, complex cases such as taTME.

The current state of the transanal approach to the ileal pouch-anal anastomosis

BACKGROUND

The transanal approach to pelvic dissection has gained considerable traction and utilization continues to expand, fueled by the transanal total mesorectal excision (TaTME) for rectal cancer. The same principles and benefits of transanal pelvic dissection may apply to the transanal restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA)-the TaPouch procedure. Our goal was to review the literature to date on the development and current state of the TaPouch.

MATERIALS AND METHODS

We performed a PubMed database search for original articles on transanal pelvic dissections, IPAA, and the TaPouch procedure, with a manual search from relevant citations in the reference list. The main outcomes were the technical aspects of the TaPouch, clinical and functional outcomes, and potential advantages, drawbacks, and future direction for the procedure.

RESULTS

The conduct of the procedure has been defined, with the safety and feasibility demonstrated in small series. The reported rates of conversion and anastomotic leakage are low. There are no randomized trials or large-scale comparative studies available for comparative effectiveness compared to the traditional IPAA.

CONCLUSIONS

The transanal approach to ileal pouch-anal anastomosis is an exciting adaption of the transanal total mesorectal excision for refining the technical steps of a complex operation. Additional experience is needed for comparative outcomes and defining the ideal training and implementation pathways.

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.