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Page 8 of 13 Jahansouz et al. Mini-invasive Surg 2021;5:1 I http://dx.doi.org/10.20517/2574-1225.2020.82

significantly longer total operative time, requiring on average twice the operative and robotic console time.
Average hospital stay was 1.18 ± 0.83 days, and all patients remained disease-free and alive at follow-up
(mean follow-up 188 days), with the exception of the lone patient who underwent palliative resection for
[36]
bleeding .
[8]
Tomassi et al. published their experience with robotic TAMIS in 58 consecutive patients. The first 40
patients were completed with the da Vinci Si platform, and the last 18 with the Xi platform. Patients were
most commonly placed in the lateral decubitus hockey stick position (n = 45), as opposed to lithotomy (n
= 5) or prone (n = 8), allowing the legs to be moved away from the operative field enabling more range of
motion for the robotic arms. While excision was performed as previously described, the proctotomy was
closed in a transverse fashion with running 3-0 V-lock Maxon sutures (Medtronic, Minneapolis, MN).
Floseal Hemostatic Matrix (Baxter International, Deerfield, IL) was selectively injected below the rectal wall
of larger or previously radiated defects. Indications for TAMIS varied widely and included uT1N0 rectal
cancer (41.4%), uT2N0 (3.4%), stage III rectal cancer with complete clinical response following neoadjuvant
therapy (3.4%), rectal polyps (31%), carcinoid (19%), and GIST (1.7%). Tumor distance from anal verge
ranged from 4 to 14 cm and mean operative time on robot was 66 (range 17-180) min. No cases required
conversion. Ninety percent of patients were discharged home the same day following surgery, and the
remaining patients were discharged on postoperative day 1. Complications included two patients unable
to void in recovery and one patient with nausea in a case combined with laparoscopic cholecystectomy.
Three patients presented with delayed complications: two patients with lower gastrointestinal bleeding
required further endoscopic intervention, and one patient with mucus drainage and tenesmus from suture
line dehiscence was treated with antibiotics. Final pathology confirmed preoperative staging in 79.3%
of patients, with appropriate oncologic treatment in 88%. Seven patients required further treatment due
to upstaging or high-risk features. Fifty-three patients underwent surveillance for a mean follow-up of
[8]
11.5 months with 3 local recurrences (5.5%). Overall, 54 (93.1%) have not required radical resection .

HEAD-TO-HEAD COMPARISONS
[23]
A single institution head-to-head comparison of conventional and robotic TAMIS was published by Lee et al. .
The study was a retrospective analysis of a prospectively collected database of 40 consecutive patients
undergoing TAMIS. For conventional resection (n = 21), patients were positioned such that the lesion was
in the dependent position to allow for laparoscopic suturing. Patients undergoing robotic-assisted resection
(n = 19) were either in lithotomy or prone depending on tumor location. Platform was selected based on
robot availability and surgeon preference. The GelPOINT Path port was utilized for both platforms. Median
times for resection were similar between the two platforms, as were for distance of neoplasms from anal
verge, R0 resection rate, and indications for resection (with the most common reason being adenoma).
Perioperative morbidity was similar as well, with one patient in each group experiencing urinary retention
requiring catheterization, and one patient in the conventional group requiring laparoscopic abdominal
assistance in repairing a defect with inadvertent peritoneal entry. There were no readmissions or mortalities
in either group.

COST
While perioperative and postoperative outcomes appear largely similar, cost appears to consistently favor
the use of laparoscopic instruments. The primary cost is the transanal port; the cost of the GelPOINT Path
is approximately $600-800 and the SILS port is $500 [11,17] . The addition of the robotic platform adds to the
cost due to the additional instrumentation.

[35]
Hompes et al. identified an additional cost of €837 in comparison to conventional TAMIS. In their head-
to-head study, Lee et al. demonstrated an average of $880 (conventional-$3563 vs. robotic-$4440.92). This
[23]