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Session: Ongoing Videos

VM3 - Robotic Transanal Minimally Invasive Surgery (TAMIS) for Resection of a Large Rectal Fungating Polyp with High Grade Dysplasia

ONGOING VIDEOS
Location: ASCRS Connect Lounge, Hall B1/B2, Ground Level

    Video Presentation(s)

  • Ahmad Abu Amr, MD (he/him/his)

    Resident
    USF Morsani
    Gotha, FL, United States

    All of the relevant financial relationships listed below have been mitigated.
    This individual has no financial relationships with ineligible companies.

    • Author(s)

  • JS

    Jamii St Julien, MD MPH, FACS,

    Physician-Surgical Oncology
    HCA Florida Surgical Specialists
    Trinity, Florida, United States

    Disclosure information not submitted.

All of the relevant financial relationships listed below have been mitigated.
Ahmad Abu Amr, MD: This individual has no financial relationships with ineligible companies.
Image or Table (Do Not add text here):

Purpose/Background: A large rectal polyp, especially one with high-grade dysplasia (HGD) or carcinoma in situ, presents a challenge in terms of complete resection with negative margins. Robotic Transanal Minimally Invasive Surgery (TAMIS) provides enhanced precision for complex resections, offering an alternative strategy for lesions that are difficult to remove endoscopically or with standard transanal techiques.
This case involves an 86-year-old female with a 4.3 cm fungating polyp on the anterior rectal wall, located 4–5 cm from the anal verge on colonoscopy. Biopsy revealed a tubulovillous adenoma with HGD. MRI of the pelvis showed a 4cm mass on the anterior rectal wall, staged T1/2 with no evidence of nodal disease.

Methods/Interventions: The patient was placed in the prone jackknife position. A digital rectal examination confirmed the lower margin of the polyp was palpable, but far enough from the verge to accommodate TAMIS. A GelPort was inserted and secured to the perianal skin with 2-0 nylon sutures. Three robotic trocars in a staggered fashion, and airseal was used for insufflation. The Xi Davinci robot was then docked.
A 0.5cm circumferential margin was marked on the mucosa with cautery. Dissection began distally by entering the submucosal plane using robotic scissors with cautery, progressing from caudad to cephalad. Care was taken to avoid full-thickness resection, as the proximal aspect of the tumor extended just above the peritoneal reflection on the MRI. Prior to complete detachment, a 2-0 silk orientation suture was placed at the left. The robot was undocked, the specimen removed and fully oriented for pathology, and then the robot was redocked. The mucosal defect was partially closed with a running 3-0 V-Loc suture proximally, leaving the distal portion open to avoid stenosis. Hemostasis was excellent.

Results/Outcomes: The procedure was completed without complications, and a total operative time of 67 minutes. Final pathology confirmed a 4.3 cm tubulovillous adenoma with high-grade dysplasia and a minute focus of possible intramucosal carcinoma. All resection margins were negative.

Conclusion/Discussion: Robotic TAMIS offers a safe and effective approach for the resection of large rectal polyps with high-grade dysplasia or early stage carcinoma, particularly when conventional methods are insufficient. This technique allows for precise dissection and closure, minimizing complications and ensuring clear margins, making it a valuable tool in managing complex rectal lesions.