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Adegbola et al. Mini-invasive Surg 2018;2:40 I http://dx.doi.org/10.20517/2574-1225.2018.55 Page 5 of 9

ROBOTIC TAMIS
Robotic transanal surgery is one of the developments which have arisen from the natural evolution of TA-
[48]
MIS. It was initially described in a cadaveric model by Atallah and colleagues and was proposed at the
time as a potential tool to counteract some of the limitations of using standard laparoscopic instruments
and approaches via a TAMIS platform. In particular, limitation of operative navigation in the confined
rectal lumen, and the resultant restriction in instrument working angles vs. camera angle can make trans-
anal surgery challenging. Proposed advantages of combining robotic technique with the TAMIS platform
include greater precision for dissection and ease of intraluminal suturing of the surgical defect compared
[49]
[5]
to standard TAMIS . Atallah et al. subsequently demonstrated the option of using the da Vinci surgi-
cal robot to perform TAMIS as an option for local excision of rectal lesions, later going on to perform a
[49]
pilot study for transanal TME using the robotic-TAMIS platform . The feasibility and safety of these ap-
proaches have been confirmed in other cohort series from various groups in Europe and America, demon-
strating its feasibility and safety in both local excision and taTME [7,49-54] . The pioneers of this technique also
describe its use in the repair of complex fistula, specifically in the repair of three rectourethral fistulae and
1 anastomotic fistula, using the robotic TAMIS platform for suture closure of the fistula and flap construc-
[53]
tion of the rectal wall . The robotic TAMIS use is still very much in its infancy, and studies are currently
experimental, demonstrate feasibility with anecdotal reports of advantages in ergonomics, tremor elimina-
[55]
tion, motion scaling and instruments with multiple degrees of freedom . However, the financial implica-
tions as well as the increased set up time of robotic techniques may well serve as a significant counteraction
to widespread use. As this modality evolves with technology, further studies will be required to determine
whether it offers significant patient benefit.

DISCUSSION
There has been a rapid explosion in the TAMIS platform, with widening use for intraluminal and ex-
traluminal pelvic surgery. The reported ease of access to the rectum and pelvis lends use to various ad-
ditional applications as described. Furthermore, the rapid development of compatible instruments, ports,
and equipment is allowing further refinement to improve the technical approach to this complex area of
colorectal surgery. The cost savings, potentially shorter learning curve for trained colorectal surgeons and
[56]
increased incorporation into surgical training in comparison to TEM , are likely to stimulate an increase
in procedures being performed using the TAMIS modality. Comparative studies will however be required
to address benefit between these two techniques as none currently exist.

[10]
Martin-Perez et al. described TEM surgery (equipment by Richard Wolf GMBH, Knittlingen, Germany)
as being born out of the need to improve on conventional transanal excision with a Park’s retractor. TEM
was soon followed with reports of TEO (equipment by Karl Storz GmbH, Tutlingen, Germany), which
similarly uses a rigid rectoscope, but employs a 2-D high definition camera compared with TEM’s 3-D and
thus obviating the need for specially designed instrumentation and equipment as is required with TEM.
When compared with TEM, TEO has been reported to offer similar results in terms of quality of surgical
resections and surgical difficulty, however, there is limited published evidence on its use [57-60] . TAMIS was
born out the need to make transanal surgery more accessible to all, cost-effective and with a more translat-
able learning-curve. The spectrum of pathology that can be managed with TAMIS has already broadened
[43]
from excision of intraluminal small rectal lesions to a full TME . Short-term outcomes for TaTME show
shorter operative times, lower readmission rates, and acceptable morbidity and mortality with satisfac-
tory oncological resection quality [5,28,61] . As with most pathology a nuanced approach is necessitated and
TAMIS offers that for low lying rectal lesions and has particular benefit in complex cases such as in obese
male patients. Here TAMIS offers visibility and technical advantage for a presumed narrow pelvis and is
[5]
advantageous where exposure to the distal rectum from the abdominal approach can be challenging . The
improved transanal visibility and exposure as well as proposed technical advantage has led to a breadth of