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Page 6 of 13 Jahansouz et al. Mini-invasive Surg 2021;5:1 I http://dx.doi.org/10.20517/2574-1225.2020.82

ROBOTIC TAMIS [TABLE 2]
Following the utilization of standard and advanced laparoscopic tools for transanal surgery came the
application of the robotic platform to transanal surgery [8,23,31-37] . By utilizing the robotic platform, one can
take advantage of its three-dimensional imaging and multidegree movement which may be limited in
the narrow working space of the rectum. Tasks such as full thickness dissection and closure of rectal wall
defects that may otherwise be technically and ergonomically challenging laparoscopically might be more
easily performed. Robotic TAMIS allows the working surgeon to be seated and ergonomically optimized,
[23]
enabling greater ease of suturing . It has also been suggested that the robotic platform permits better
[23]
visualization and maneuverability, which may allow for more aggressive resection .
Preclinical cadaveric studies began in 2010 and confirmed the feasibility of applying the da Vinci system and
illustrated the possibility of side or parallel approach to docking the da Vinci robotic cart [38,39] . Hompes et al. [39,40]
applied a glove port, which they had previously described for TAMIS, for use with the robot. Creatively
designed, the port consisted of a circular anal dilator, a standard wound retractor, and a surgical glove
allowing for greater working room which minimized arm collisions [39,40] . The first human study was
[41]
published by Atallah et al. , which described the resection of a 3-cm tubulovillous adenoma 7 cm from
the anal verge in a 58-year-old female. The patient was in modified lithotomy, and the GelPOINT port was
utilized, along with three arms of the da Vinci robot via 8-mm trocars placed in the port cannulas. The
robot was docked over the patient’s right shoulder. The defect was closed with a V-Loc 180 Absorbable
Wound Closure Device (Covidien, Mansfield, MA). Operative time was 105 min and there were no
complications. Initial publications following these initial experiences were primarily case reports, but since
then larger series have been published [42-44] .

[35]
Hompes et al. described their initial experience in 16 patients among three sites. One case required
conversion to TAMIS due to problems with the glove port. The da Vinci Si platform was utilized. Mean
docking and operative duration were 36 (18-75) and 108 (40-180) min, respectively. Patients were
positioned prone or left lateral depending on tumor location. Problems included tearing of the glove
in four procedures, which required replacement and subsequent completion. There were no cases of
peritoneal entry reported, and one patient developed pneumoperitoneum managed conservatively. One
patient developed urinary retention requiring catheterization. Median hospital stay was 1.3 days (0-4 days).
Positive margins were identified in 2 patients who were found to have more advanced lesions and
underwent further resection. No other complications occurred.

[36]
Liu et al. described the application of the newest robotic platform, the da Vinci Xi platform (Intuitive
Surgical Inc., Sunnyvale, CA), in 34 patients. Lesions were located from 2 to 15 cm from the dentate line
and up to 5.5 cm in diameter, average operative time was 100 ± 70 min, and robotic console time was 76 ±
67 min, with a docking time of 25 ± 14 min. Most patients (n = 32) were positioned lithotomy versus prone
(n = 2). There were no intraoperative complications or operative conversions, and the only postoperative
complication was a case of Clostridium difficile infection in one patient managed medically. Preoperative
evaluation consisted of colonoscopy and imaging with use of either endorectal ultrasound or pelvic
Magnetic Resonance Imaging (MRI) for local staging. Patients with early-stage rectal neoplasms (uTis or
uT1N0M0) and low-risk histology (no lymphovascular invasion) were considered candidates. Patients also
included were those with T1 carcinoid tumors, incomplete endoscopically resected rectal polyps, and one
[36]
case of partial resection for palliative control of bleeding in the setting of metastatic disease . No patients
had received neoadjuvant therapy. The GelPOINT Path port was utilized, and the robotic cart was docked
from the side of the patient. A 30° 8-mm robotic camera was placed in the middle trocar and two robotic
instruments were used along with an additional assistant trocar. Final pathology yielded 22 (65%) patients
with adenoma, 7 (21%) with carcinoma, and 4 (12%) with carcinoid tumors. Three patients were identified
as T2 and underwent formal low anterior resection. Notably, severe obesity (BMI > 35) was a predictor of