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Jahansouz et al. Mini-invasive Surg 2021;5:1 I http://dx.doi.org/10.20517/2574-1225.2020.82 Page 5 of 13

system (Intuitive Surgical Inc., Sunnyvale, CA). Operations were performed with either the SILS port or
GelPOINT Path port. Indications for operation were benign rectal lesions not amenable to endoscopic
resection, namely low-grade neuroendocrine tumors £ 2 cm in diameter, node-negative cT1 rectal cancer
£ 3 cm in diameter, well-differentiated, and no lymphovascular invasion present. Palliative indications
included patients with more advanced cancer (cT2, cT3) or histologically unfavorable cT1 lesions who
were unwilling or unfit to undergo radical excision, and patients who exhibited endoscopic evidence of
complete clinical response following neoadjuvant therapy. Final surgical pathology revealed 90 benign
lesions and 110 malignant lesions. Notably, 11 of 110 patients with malignant lesions received neoadjuvant
therapy. Twenty patients had pT2-3 or ypT2-3 tumors and underwent subsequent radical resection,
received adjuvant treatment, or refused further treatment. Mean tumor size was 2.9 ± 1.5 cm, and distance
from anal verge was 7.2 cm (range 2-17 cm). Fourteen patients (7%) had positive margins, of which 9
patients had malignant lesions. Eight of these 9 patients with malignancy were pT2 or higher and radical
resection was recommended. Ninety-five percent of specimens were submitted without fragmentation.
Mean operative time was 69.5 ± 37.9 min. Defects were closed in 188 (94%) cases and were left open due to
the inability to obtain a tension-free closure. Peritoneal entry occurred in 8 (4%) cases, of which half were
amenable to closure by TAMIS while the other half required abdominal access. Intraoperative complication
rate was 8%. Morbidity was 11%, most commonly due to hemorrhage (9%), urinary retention (4%), and
scrotal or subcutaneous emphysema (3%). Three patients suffered major morbidity. One patient required
a diverting ileostomy for a symptomatic nonhealing rectal wound with fistula formation to the perineum.
One patient was readmitted on postoperative day 3 with significant perirectal inflammation which resolved
with medical management. One patient developed a rectovaginal fistula after a repeat TAMIS excision of a
local recurrence. This resolved with conservative management after two months. Most patients (76%) were
discharged following the procedure from the postanesthesia care unit. Mean follow-up for patients with benign
and malignant lesions undergoing TAMIS for curative intent was 13.6 ± 17.3 months and 14.4 ± 17.4 months,
respectively, with local recurrence rates of 3 and 6%, with distant metastases in 2%. Mean time to
recurrence following resection of both benign and malignant lesions was 17 months. Cumulative disease-
free survival for patients undergoing resection of benign neoplasms was 98, 94, and 94% and for malignant
neoplasms 96, 93, and 84% at 1-, 2-, and 3-year follow-up, respectively.

[21]
Keller et al. published their series of 75 consecutive patients undergoing 76 resections. Indications
followed NCCN guidelines for TAE, as well as patients unfit or unwilling to undergo radical resection
for more advanced pathology. Median lesion distance from anal verge was 10 cm (range 6 to 16 cm). The
GelPOINT PATH or SILS port was used for access. Mean operative time was 76 ± 36.1 min. Only 1 lesion
was fragmented. Inadvertent peritoneal entry occurred in 3 cases, with 2 of these 3 patients undergoing
creation of a protective loop ileostomy to assure healing. Postoperatively, there were 3 complications (4%);
one each of bleeding, rectovaginal fistula, and rectal stricture. One case was aborted after intraoperative
assessment deemed it unresectable by the transanal approach. Defects were closed in 69 cases, with
no complications noted in the 6 cases in which the defect was left open. There were no functional
complications noted following resection. Median length of stay was 1 day (range 0-6 days). Fifty-nine
resections were performed for benign disease, while 17 resections were performed for malignancy. Of
the malignant resections, final pathology yielded 4 pT2 lesions and 1 pT3 lesion, and all of these patients
underwent further treatment without apparent oncologic or technical compromise. There were 5 cases
of positive margins following resection, 3 of which were pT2 lesions, 1 pT1 lesion and 1 gastrointestinal
stromal tumor (GIST). Thus, an important point of emphasis in this study was the high rate of margin
positivity in T2 lesions, positive in 3 of 4 cases. Mean follow-up was 36.5 ± 14.8 months. In the 17
malignant cases in the patients who did not undergo immediate radical resection, there was 1 recurrence
(5.8%), occurring locally at 9 months after excision. No mortalities were recorded during the study follow-
up period.