Page 168 - Read Online

Genova et al. Mini-invasive Surg 2020;4:20 I http://dx.doi.org/10.20517/2574-1225.2019.47 Page 5 of 9

resection was performed and the wall defect was closed using a running barbed suture. However, already in
this first case report, the authors underlined the high direct cost of the procedure, $1500, and suggested the
use of (R-TAMIS) in complex cases where TEM or conventional TAMIS, often indicated as laparoscopic
[2]
TAMIS (L-TAMIS) , were not possible.
Since 2012, several studies reporting the outcomes of R-TAMIS were published, but they included many
[40]
case reports and small series of patients [2,35-41] . The largest series was published by Tommasi et al. in 2019
and included overall 58 patients. Surgery was performed using a Da Vinci Si system in 40 cases (69%) and
a Da Vinci Xi system in 18 cases (31%), whereas a GelPOINT platform was employed in all procedures. A
15-mmHg pneumorectum was created using conventional laparoscopic insufflation systems or an Airseal
system. Robotic operative arms were placed at 4 and 8 o’clock positions, with a 0° camera at 12 o’clock. A
full-thickness resection was performed for 28 cancers (48.3%), 18 adenomas (31%), 11 carcinoids (19%),
and 1 GIST (1.7%), and no conversion was reported. The mean console time was 66.2 min (range: 17-
180 min), with significantly shorter mean operative time for Xi robot (38.7 min vs. 78.5 min, P = 0.00003).
Complication rate was 10.3% and overall 52 patients (89.7%) were discharged the same day of surgery.
The mean specimen size was 3.3 cm (range: 1.3-8.2 cm). There was no specimen fragmentation in 57 cases
(98.3%) and negative resection margins in 55 (94.8%). R-TAMIS proved curative in 51 patients (88%), while
7 patients (12%) needed additional therapy. Finally, the authors generically concluded for the feasibility of
R-TAMIS and underlined satisfying oncologic results and better ergonomics.

Some useful data are also provided by the second largest series found about R-TAMIS, published by
[36]
Liu et al. in 2018 and including 34 patients. All cases reported were performed using a Da Vinci Xi
technology and a GelPOINT platform. Surgery was performed for benign lesions in 22 cases (64.7%)
and for malignant lesions in 11 cases (32.3%). In 94% of cases (n = 32), patients were placed in a lithotomy
position. The mean distance of rectal lesions from the dentate line was 8.6 cm (range: 2-15 cm), with a mean
maximum diameter of 2.6 cm (range: 0.5-4.5 cm). The overall operative time was 100 ± 70 min (mean ±
SD), including a docking time of 25 ± 14 min (mean ± SD) and a console time of 76 ± 67 min (mean ± SD).
No intraoperative complication and no conversion were reported. The postoperative complication rate
was 3% and the mean hospital stay was 1.18 (± 0.83) days. Full-thickness R0 resection was achieved in 97%
of patients (n = 33), three patients were upstaged to T2-stage and underwent anterior resection, and one
patient was staged T3. Moreover, the univariate analysis of operative time predictors showed that severe
obesity [body mass index (BMI) > 35] was a positive predictor of total operative time and console time,
probably because of a narrow space between the legs, whereas specimen size was a positive predictor of total
operative time. Finally, the authors concluded that R-TAMIS was safe for lesions located within up to 15 cm
from the dentate line and sizing up to 5.5 cm, and that a BMI > 35 was a significant predictor of a longer and
more challenging operation.

[41]
At least three further series with more than 10 patients were also published, one by Huang et al. in 2019
[39]
[37]
including 23 patients, one by Gómez Ruiz et al. in 2017 including patients, and one by Hompes et al.
in 2014 including 16 patients In the first study, robotic procedures were performed in a prone jackknife
position, whereas, in the latter two, all procedures were performed using a lithotomy position. Note that
[39]
Hompes et al. reported the use of a glove port, made up of a surgical glove positioned transanally with
ports inserted through the glove’s fingers.

[2]
Moreover, in 2019, Lee et al. published a study including 19 patients undergoing R-TAMIS and reported
that patients with anterior and lateral lesions (83.3% of overall included patients) were operated in a prone
position in order to reduce the conflict among robotic arms, whereas the lithotomy position was used only
for posterior lesions.