VM16 - Robotic TAMIS for Rectal Cancer

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Purpose/Background: Developed in 2009, transanal minimally invasive surgery (TAMIS) was introduced as a method to excise benign and early-stage rectal cancers. Compared to transanal endoscopic microsurgery (TEM,) TAMIS requires a shorter learning curve and utilizes conventional laparoscopic instruments which has led to a broader adoption. Additionally, TAMIS has been shown to be effective in treating early-stage rectal cancers, with low recurrence rates while avoiding the morbidity of a radical resection. Robotic approaches to TAMIS were described shortly thereafter, initially with cadaveric models before clinical application. Advantages of robotic TAMIS include improved precision along with the utilization of wristed instruments, which can help with larger or more difficult to access rectal lesions. Furthermore, robotic TAMIS facilitates suturing within the rectum. We present this didactic video of a patient with early-stage rectal cancer that was treated with robotic TAMIS, outlining the setup and steps of the procedure.

Methods/Interventions: This patient is an 81-year-old male who was diagnosed with a rectal cancer on screening colonoscopy. MRI revealed a flat 2 cm anterior rectal cancer, T1/T2N0, 8 cm from the anal verge. CT scans did not reveal any evidence of metastatic disease. Discussion was held at multidisciplinary tumor board and decision was made to proceed with local excision.
The patient was consented for a robotic TAMIS excision. As this was an anterior tumor, the patient was placed in a prone jackknife position. The access channel was placed and secured to the perianal skin. Once pneumorectum was established with the insufflation port, two additional robotic trocars were placed through the sleeves. To minimize collisions, the ports may be staggered where one port is a longer, bariatric length port. Additionally, moving the camera and two working instruments together helps avoid collisions.
Once the tumor was identified laparoscopically, the robot was docked. The tumor margins were marked circumferentially with cautery. Full-thickness excision was then carried out using monopolar curved scissors. Rather than having to redock the robot, the specimen was kept in the rectum until the procedure was complete. It is important to keep the specimen in view to prevent proximal migration. The defect was then closed with a running, absorbable barbed suture from right to left. The robot was undocked, and the specimen was retrieved and pinned prior to submitting it to pathology.

Results/Outcomes: The patient tolerated the procedure well and was discharged home the following day. Pathology revealed a 2x1.4 cm moderately-differentiated adenocarcinoma invading into the submucosa (T1,) without lymphovascular invasion and with uninvolved margins.

Conclusion/Discussion: The robotic TAMIS procedure is a feasible option for treating benign rectal lesions and early-stage rectal cancers. While having increased costs, advantages of robotic TAMIS compared to traditional TAMIS include improved vision, ergonomics, the ability to excise harder to reach lesions and facilitating suturing within the rectum.