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Page 4 of 7 Kunkel et al. Mini-invasive Surg 2020;4:27 I http://dx.doi.org/10.20517/2574-1225.2020.05

Figure 3. Transanal minimally invasive surgery platform inserted transanally

outlining the critical views for pure NOTES proctosigmoidectomy via TAMIS. While these advancements
highlight what can be achieved transanally by highly experienced surgeons with single port laparoscopy, the
ergonomics and technical challenges of these approaches resulted in limited adoption of these techniques.

As robotic surgery emerged, Atallah et al. [15,16] described the first robotic TAMIS in 2011 using the da Vinci
Si robot on a cadaveric model and later performed the first local excision of rectal cancer on a live patient
in 2012. Subsequent to this, several institutions have reported on their experience with robotic TAMIS. The
advantages reported are superior 3D view, wristed instruments, better ergonomics, and superior precision.
Despite these benefits, the multi-arm robot was found to be ill-suited for single port surgery. External arm
clashes and internal conflicts have relegated this approach to an interesting novelty.

With the clinical introduction of the da Vinci Single Port (SP) robot, many of these hurdles of robotic single
port surgery have been addressed, employing this technology in the next generation of robotic TAMIS
(rTAMIS). The da Vinci SP platform is a single arm single port system that is ideal for rectal procedures
[Figure 4]. The SP system includes three 6-mm jointed and wristed instruments and the first da Vinci
jointed 3D camera [Figures 5 and 6]. This facilitates viewing and operating on all quadrants of the rectum
without repositioning the patient. The hologram of instrument position seen on the SP screen allows the
surgeon to better avoid instrument collision and permits superior retraction. Current instruments available
for the SP robotic system include: needle driver, cadiere forceps, round tooth retractor, clip applier,
monopolar scissors, monopolar hook and spatula tip cautery, and both Maryland and fenestrated bipolar
forceps. To date, there is no SP vessel sealer, suction, or stapler. These represent significant drawbacks that
will likely be addended in the near future.

In a cadaveric feasibility study, the SP robot was shown to be a realistic platform for the future of
[17]
endoluminal surgery. As reported in a manuscript published in 2017, Marks et al. performed 12 local
excision procedures (SPr TAMIS) with no fragmentation of the specimen and negative margins. In January
2020, the first clinical experience performing a single-port left colectomy using the SP robot (SPr SILS left
[18]
colectomy) was described . Relative ease and comfort were noted with this novel operative platform with
minimal physical or mental fatigue to the surgeon. In an FDA regulated feasibility study, the use of the SP
robot was expanded to perform transanal TME dissections. Building on prior laparoscopic transanal total
mesorectal excision experiences, Dr. Marks began utilizing the SP robot in total transanal TME procedures,
including transanal splenic flexure release and high ligation of the IMA. The results of these experiences
have yet to be published. With these advances, the SP robot demonstrates significant surgical milestones