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16 The Evolution ofRobotic TAMIS
Fig. 16.4 2012: The rst
robotic transanal excision
of a neoplasm in a human.
The da Vinci Si platform
was used in conjunction
with the GelPOINT Path
Transanal Access
Platform, the lesions were
completely excised, and
the defect reapproximated
robotically using barbed
absorbable suture. Note
the patient’s modied
Lloyd-Davies position and
the docking of the cart
over the right shoulder
Table 16.1 Chronological publications on robotic TAMIS
Author Date Country Interface Model n Remarks
Atallah [27] September
Atallah [36] May 2012 USA GelPOINT Human 1 1st robotic TAMIS in a human
Hompes [33] May 2012 UK Glove Cadaver 2 1st report of glove as interface for
Bardakcioglu
[37]
Atallah [47] June 2013 USA GelPOINT Human 1 1st robotic taTME in a human
Valls [42] August
Buchs [38] August
Hompes [40] April 2014 UK Glove Human 16
Atallah [48] June 2014 USA GelPOINT Human 3 1st pilot series on robotic taTME
Gómez-Ruiz
[49]
Atallah [41] February
Atallah [50] May 2015 USA GelPOINT
Kuo [51] October
Gómez-Ruiz
[46]
Erenler [45] April 2017 Turkey GelPOINT Human 1 1st published case using Xi
Marks [35] July 2017 USA GelPOINT Cadaver 12 1st preclinical series with da Vinci
Atallah [50] October
2011
December
2012
2013
2013
January
2015
2015
2016
December
2017
2017
USA GelPOINT Cadaver 2 1st experiment with robotic
USA GelPOINT Human 1 2nd robotic TAMIS in a human to
Spain Glove Human 1
Switzerland Glove Human 3 1st description of the lateral
Spain Custom Human 5 Totally robotic (above and below)
USA GelPOINT Human 18 Includes local excision, stula
LoneStar
Taiwan GelPOINT Human 15 Single port+1 combined with
Spain Custom Human 9 da Vinci Si utilizing specialized
USA Flex robot
port
Human 1 1st report of robotic taTME with
Cadaver 2 1st preclinical report utilizing
TAMIS
transanal robotic access
be reported
approach
taTME
repair, taTME
robotic ISR
robotic taTME
hybrid port
platform
SP
exible robotic system for TAMIS
and taTME
157
158
Fig. 16.5 Local excision via robotic TAMIS. 8 mm
wristed, instrumented, and stereoscopic magnied optics
are among the perceived advantages of the robotic platform. Here, rectal neoplasm boarders have been delineated with cautery marks, and a full-thickness excision is
in progress. A Maryland grasper and hook cautery are the
only instruments required to complete the excision
S. Atallah et al.
TAMIS remains limited, with mostly singlesurgeon retrospective series reported in the literature [39].
Docking andConguration
Today, docking of the multi-arm da Vinci robotic
cart can be performed in various methods and is
often predicated by surgeon preference, as well
as the specic platform’s design and interface.
For S and Si platforms, with the patient in dorsal
lithotomy, cart docking can be parallel and ush
against the operating table (Fig.16.6) or tangentially with the robotic arms delivered over the
shoulder. In general, the Xi® system with its long
Fig. 16.6 Docking and patient conguration is often
dependent on the specic robotic platform, the type of
TAMIS port or glove port, and sometimes the position of
the lesion. Surgeons who perform robotic TAMIS may
also have a specic preference; although for robotic
TAMIS (as compared to conventional TAMIS), there is
more likely to be position and docking variability.
Notwithstanding, one of the most common congurations
of the da Vinci Si systems with GelPOINT Path Transanal
Access Platform is shown. Note that the robotic cart is
docked ush with the operating table and working arms
one and two are delivered over the thigh to prevent
encroachment and collision during robotic TAMIS. The
patient is typically positioned in steep Trendelenburg
16 The Evolution ofRobotic TAMIS
Fig. 16.7 The Xi® system
has been docked
orthogonally to the
operating table, and the
patient’s steep
Trendelenburg, LloydDavies position is evident.
The low-prole arms and
large wingspan of the Xi
system allow for improved
transanal access with less
collision. Compared to the
Si, however, 5mm
effector arm instrumentation is not (currently)
available representing a
potential limitation since,
in general, it is advantageous to have small
diameter instruments so as
not to restrict workspace
®
arm span and low-prole conguration, provides
more leeway in cart-to-patient arrangement.
Common approaches using the Xi® system
include perpendicular docking relative to the
side of the operating table (Fig.16.7), but other
options are valid.
While TAMIS is almost always performed
with the patient in dorsal lithotomy, robotic
TAMIS may or may not require the patient to
be positioned in this fashion. Indeed, other
patient positioning may be desirable. For
example, anterior lesions are best approached
with the patient positioned prone jack-knife.
The advantage here is that the lower extremities do not collide with the working arms during the process of dissection, leaving the
effector arms with less likelihood for collision
(Fig.16.8).
In the spring of 2014, the da Vinci Xi
®
was
introduced, providing signicant advantages for
the operator, especially regarding versatility
with docking. The rst robotic TAMIS utilizing
the Xi® platform was believed to have been performed on July 28, 2015 by S.Atallah (Fig.16.9).
The rst published report using the Xi® was
reported in a video vignette by Erenler etal. in
2017 [45]. The Xi® platform allows for various
options in docking, and some experts prefer the
prone jack-knife position with orthogonal cart
159
Fig. 16.8 Common conguration for robotic TAMIS
using the Xi
pneumatics. Here, an anterior distal rectal lesion is targeted for local excision. Two working arms and a 30°
8 mm lens are mated to the TAMIS port. Note that the
GelPOINT Path Transanal Access Platform (TAMIS port)
is suspended by the hooks of the Lone Star Retractor,
which allows the access channel sleeve to be only partly
admitted into the anal canal. This allows for improved distal access for low-lying lesions
®
system is adapted with 5mm AirSeal for
160
S. Atallah et al.
Fig. 16.9 July 28, 2015: The rst robotic TAMIS using
®
the Xi
system was performed by S.Atallah in Orlando,
FL, USA. The lesion was a 2.8 cm adenoma and was
excised with negative margins. Note the conguration of
the working arms with a 30° downward lens placed superiorly and equidistant to two 8mm working arms. An additional 5mm AirSeal port (ConMed, Inc., Utica, NY, USA)
was used to provide stable pneumorectum. This fourth port
allows for access of 5mm instruments (such as a suction
irrigator) which can be operated by a bedside assistant
positioning for anterior rectal wall pathology.
Another option is the lateral approach, which
when combined with a glove port results in
improved robotic arm excursion, as demonstrated by N.Buchs in 2013 with the Si system
[38]. Furthermore, Gómez-Ruiz et al. have
described the use of a specialized interface in
which the platform is part rigid and bedrail
mounted and part reusable. The rigid portion is
similar to a 40mm dia. TEM scope, but the faceplate utilizes an 80 mm GelPOINT membrane
that is twice the diameter of the standard TAMIS
port (Fig.16.10). This likely allows for improved
instrument maneuverability, decreased arm collisions, and a simplication of the port-to-robot
rendezvous.
Fig. 16.10 A custom- made port, developed by Marcos
Gómez-Ruiz, MD, is a hybrid cross between a TEM scope
and a TAMIS port. The rigid reusable portion of the device
is secured to the bedrail with a mount to hold it in position. The faceplate (disposable) is an 80mm GelPOINT
(Applied Medical, Inc.). The conguration improves
ergonomics and decreases collisions between working
arms
Applications ofRobotics Beyond
Local Excision
In 2013, just 3years after the rst reported human
case of taTME by P.Sylla and A.Lacy, robotic
taTME was successfully performed on a human
for the rst time [54]. The patient was an obese
female with familial adenomatous polyposis
(FAP) syndrome and synchronous hepatic exure
and rectal cancers. The abdominal resection was
performed laparoscopically, and the taTME was
performed by docking the da Vinci Si transanally
with GelPOINT Path Access Platform as an interface. While there were limitations of reach, the
robotic taTME was successfully completed in
87 min; the mesorectal envelop contained one
16 The Evolution ofRobotic TAMIS
161
defect measuring 1.5 cm and therefore was
graded as a Quirke II (near complete); all margins were negative [54].
While limited to expert centers, small series
and pilot studies on robotic taTME have been published in both the preclinical and clinical settings
[47–49, 51, 55, 56], each series concluding that
high-quality excision is feasible with the robotic
platform (Fig. 16.11). Although most robotic
approaches to taTME have applied the platform
transanally in conjunction with laparoscopy for
the abdominal portion of the operation, Marcos
Gómez-Ruiz has used a totally robotic approach
by double docking abdominally and then subsequently transanally [49]. This technique utilizes a
specialized platform that is a hybrid between TEM
and TAMIS with some components reusable and
others disposable, as described previously.
There has been an accelerated advancement in
minimally invasive approaches to transanal surgery over recent years (Fig. 16.12). Robotic
approaches are continuing to evolve with several
new venders rapidly lling the space with creative systems that, instead of mimicking laparoscopy, are being designed with computerized,
remodeled mechanics that provide improved
exibility and thus an ability to access anatomic
targets not previously believed possible [50, 57].
Today, much of the focus on robotic transanal
surgery is toward the development of taTME,
with the objective of improving the operative
approach and reducing the challenges of conventional instrumentation [58–60]. Image-guided
surgery in conjunction with robotics for complex
surgical procedures, such as taTME, is also an
area actively being investigated. Robotic taTME
is discussed further in Chap. 44.
Fig. 16.11 Robotic taTME represents the next step in the
evolution of advanced, robotic transanal access. Here the
da Vinci Si platform with a 5mm hook monopolar cautery
and 5mm grasper is used to initiate the posterior TME
dissection. The theoretical advantage of the robotics in a
conned space is the potential to improve resection quality by providing a platform with superior optics, magnication, and surgeon control
2012 : First Glove Port
for Robotics TAMIS
2011 : First Robotic
TAMIS Cadaveric
Experimentation
2013: First
Robotic taTME
2012: First
Robotic TAMIS
in a human
2017 : First
Cadaveric Report
using SP System
2015: First Xi
System for
robotic TAMIS
2017: First
Robotic TAMIS
and taTME
(Cadaveric)
With Flexible
Roboitc System
®
1984: TEM
Developed
2001: First Robotic
Prostatectomy
2001: Transcontinental
Robotic Surgery
~1999: Sugical
Robotics Introduced
2002: First
Robotic
Colectomy
2009 : First
TAMIS
2009 : First
Abdominal Robotic
Single Port Surgery
2010: First
Robotic Transanal
Surgery Dry Lab
Experiments
Fig. 16.12 Timeline delineating the milestones in robotics in colorectal surgery including transanal approaches
162
S. Atallah et al.
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eCollection 2016.
Transanal Robotic Surgery
andFuture Directions
KevinM.Izquierdo, ThushySiva, JeanSalem,
BrigitteAnderson, andJohnMarks
Abbreviations
MIS Minimally invasive surgery
NOTES Natural orice transluminal
endoscopic surgery
RATS-TME Robotic transanal total mesorec-
tal excision; robotic taTME
RTAS Robotic transanal surgery
SILS Single incision laparoscopic surgery
TAMIS Transanal minimally invasive
surgery
TATA Transanal transabdominal
proctosigmoidectomy
taTME Transanal total mesorectal excision
TEM Transanal endoscopic
microsurgery
K. M. Izquierdo (*) · J. Salem
Lankenau Medical Center, Division of Colorectal
Surgery, Wynnewood, PA, USA
e-mail: salemj@mlhs.org
T. Siva
Easton Hospital, Department of Surgery,
Easton, PA, USA
B. Anderson · J. Marks
Colon and Rectal Surgery, Lankenau Medical Center,
Marks Colorectal Surgical Associates, Wynnewood,
PA, USA
e-mail: crresearch@mlhs.org; marksj@mlhs.org
17
Introduction
The challenges inherent to rectal cancer surgery
have inspired ideological innovations in the eld.
Driven by high recurrence rates and high morbidity seen with the earliest rectal cancer operations,
and by the technical difculty of operating in the
deep and narrow connes of the pelvis, the surgical treatment of rectal cancer has continued to
evolve. The total mesorectal excision (TME) as
described by Dr. Bill Heald [1] and the transanal
transabdominal proctosigmoidectomy (TATA) as
described by Dr. Gerald Marks [2], which ensures
a clear distal margin in the rectum pre-treated
with radiation, have both become core oncologic
tenets of rectal cancer surgery. Furthermore, the
TATA allows sphincter preservation, even for
patients with low rectal cancers, without sacricing the quality of oncologic outcomes [3].
Combined with TEM, these concepts have given
rise to the transanal total mesorectal excision
(taTME).
Benets and advances in minimally invasive
surgery (MIS) have been applied successfully to
rectal cancer surgery. Prior to the 1980s, transanal excision of rectal neoplasms was restricted
by limited reach and exposure. In 1983, Dr.
Gerhard Buess invented transanal endoscopic
microsurgery (TEM) [4], setting the stage for a
long technological evolution in rectal surgery.
Building off of Dr. Buess’ TEM technique, the
© Springer Nature Switzerland AG 2019
S. Atallah (ed.), Transanal Minimally Invasive Surgery (TAMIS) and Transanal Total Mesorectal
Excision (taTME), https://doi.org/10.1007/978-3-030-11572-2_17
165
166
K. M. Izquierdo et al.
applications of transanal surgery have been
extended by Atallah, Albert, and Larach using
single-port transanal laparoscopy, today known
as transanal minimally invasive surgery (TAMIS);
and most recently, robotic surgical technology is
applied transanally (Robotic TAMIS). By
addressing many of the technical challenges that
have hindered wider adoption of TEM, TAMIS,
and taTME, robotic transanal surgery promises to
increase surgeon access to these techniques so
that more patients can benet. Future directions
of transanal robotic surgery will undoubtedly
lead to a new era of pure natural orice transluminal endoscopic surgery (NOTES), the ultimate
in minimally invasive surgery.
Evolution ofTransanal Surgery
Dr. Gerhard Buess’ transanal endoscopic microsurgery (TEM) platform in 1983 represented a
disruptive change in surgical approach and technology. TEM predates laparoscopy – the rst
demonstration of the laparoscopic cholecystectomy was presented in 1989 at the Surgical
Association of Gastrointestinal and Endoscopic
Surgeons (SAGES) conference by Drs. Perissat
and Mouiel [5, 6]. In 1983, open surgery was the
only approach in the surgical treatment of rectal
cancer. The original application of TEM was in
the removal of rectal polyps and was later
expanded to treating malignant lesions with local
excision. Although unpublished, it is believed
that in 2008 Dr. John Marks performed the rst
transanal total mesorectal excision (taTME)
using the TEM platform.
Key technological features of TEM are binocular stereotactic optics, improved access to
more proximal lesions, and incisionless natural
orice surgery via the anus. As applications of
TEM expanded to T1 cancers, the technical
advantages became evident with signicantly
lower recurrence rates as compared to open transanal approaches. Experiences at the University of
Minnesota and the Cleveland Clinic reported
local recurrence rates of 4.2–9% with TEM compared to 25–33% with conventional transanal
excision for T1 rectal cancers [7, 8]. This disruptive transanal minimally invasive approach set
the stage for the rapid evolution of technology in
colorectal surgery over the next three decades.
However, the steep learning curve and signicant
cost were major barriers to its universal
adoption.
Transanal minimally invasive surgery
(TAMIS), rst described in 2009 by Drs. Atallah,
Albert, and Larach, is a cost-effective alternative
to TEM [9]. Building upon TEM concepts,
TAMIS uses a exible single incision laparoscopic surgery (SILS) port transanally rather than
the rigid proctoscope used in TEM. Cost is
decreased by avoiding the large start-up cost of
TEM equipment and through the use of laparoscopic instrumentation readily available in
modern- day operating rooms. Atallah etal. published their experience with TAMIS in the excision of both malignant and benign lesions of the
rectum, and early data suggests that oncologic
outcomes are comparable to TEM [10].
From a technical standpoint, TAMIS, allows
access to the full 360 degrees of the lumen,
whereas with TEM, the workspace is limited to
the lower 180 degrees of the visualized operative
eld. Furthermore, the exible platform allows
better access to more proximal structures, allowing its application to expand to complete transanal total mesorectal excision. However, TAMIS
initially suffered from the lack of a stable pneumatic platform that TEM provides. Drs. Lacy,
Rattner, and Sylla published a systematic study
of the transanal total mesorectal excision using
the TAMIS platform [11]. In doing so, they successfully melded the core principles of TATA,
hybrid NOTES, and TAMIS.
Pushing the limits of transanal surgery using
the TAMIS technique, Dr. Leroy pioneered
“pure” NOTES proctosigmoidectomy with transanal completion of the TME dissection, release
of the splenic exure, transection of the inferior
mesenteric vessels, and coloanal anastomosis. He
coined the procedure perirectal oncologic gateway for retroperitoneal endoscopic single site
surgery (PROGRESSS) [12]. Select centers have
further pioneered pure NOTES taTME [13, 14].
As it was with TEM for local excision of rectal lesions, a steep learning curve is the primary
obstacle to wider adoption of pure NOTES for
rectal cancer as it requires the highest level of