ROBOTIC TRANSANAL MINIMALLY INVASIVE SURGERY (TAMIS): LARGE TUBULOVILLOUS ADENOMA

Objectives:

Introduction: The Transanal Minimally Invasive Surgery (TAMIS) technique addressed most of the limitations of the conventional transanal surgical approach for rectal pathologies. However, persistent inherent limitations still exist, including retraction, exposure, suturing, assistant positioning, range of motion restriction by straight laparoscopic instruments, ergonomics, and steep learning curve resulting in limited adoption of these techniques. Robotics was introduced as a potential solution to the many obstacles encountered in laparoscopic surgery. The proposed advantages of robotics as applied to transanal surgery include superior 3D view, increased instrument degrees of freedom, improved ergonomics, and more precise surgery compared to traditional TAMIS.

Case presentation: We present a case of a 48-year-old female with a large symptomatic rectal polyp. The polyp was discovered during a colonoscopy performed after several episodes of rectal bleeding. The mass on colonoscopy was described as large, fungating, and partially obstructing, located at 6 cm proximal to the anal verge. Biopsies were consistent with tubulovillous adenoma without evidence of dysplasia or malignancy. Due to inability to completely remove the polyp endoscopically, the patient was scheduled for excisional robotic TAMIS.

The patient was placed in a prone jackknife position. A digital rectal examination confirmed the location and distance from the anal verge. The TAMIS platform was inserted into the anal canal and sutured in place. Three TAMIS platform ports and an AirSeal® access port were used. Pneumorectum was created up to a pressure of 20 mm Hg with the AirSeal® system. The robotic trocars were placed through the TAMIS ports, and the robotic camera was inserted. The DaVinci Xi® robot was docked in standard fashion.

The normally appearing mucosa surrounding the polyp was scored using monopolar scissors and fenestrated bipolar instruments. A submucosal dissection was performed on the lateral and distal sides first. Then, a residual stalk was transected after the removal of the TAMIS platform cap, and the mass was fully excised (Figure 1). The pneumorectum was restored, and hemostasis was confirmed. The residual defect was then closed using a running 2-0 absorbable barbed suture. The patient was discharged home on the day of the procedure, and there were no post-operative complications.

Conclusion: The reported experience using the DaVinci Xi surgical system® for transanal surgery has been limited. The versatility of the robotic platform may allow lesions that would be considered unsuitable for laparoscopic TAMIS to be managed by local excision.

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