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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 9 of 13

was the only difference in outcomes identified between the two procedures. At the Taiwan Medical Center
[37]
in Taipei, Huang et al. identified an approximate difference of $2000 in favor of laparoscopy due to their
current payment system. It has been proposed that robotic TAMIS may have a supplementary role in more
complex rectal lesions in which the gained dexterity of the platform would further support and justify its
[41]
utility .

FUNCTIONAL OUTCOMES
Overall, TAMIS is very well tolerated [28,29,45-47] . Studies published thus far have focused only on the
[28]
conventional platform. Schiphorst et al. examined 37 patients who underwent conventional TAMIS.
Patients were placed in lithotomy and the SILS port or the single-site laparoscopic access system (SSL,
Ethicon Endo-Surgery, Cincinnati, OH) were utilized for transanal access. Full thickness rectal excisions
were performed and defects, when closed, were done so using a V-loc absorbable suture. TAMIS was
completed in 36 patients. There were two cases of rectal perforation with peritoneal entry, with one patient
converted to laparoscopic anterior resection due to a large rectal defect and pneumoperitoneum. In 7 cases,
a hybrid approach with traditional transanal excision was required due to distal lesion location. Three (8%)
patients experienced postoperative complications which included hemorrhage (n = 2) and abscess (n = 1).
Long-term morbidity was also experienced in 3 (8%) patients, including local recurrence (n = 2) and rectal
stricture (n = 1). The rectal defect was closed in 27 (73%) patients [Table 2]. Functional outcomes were
assessed using the Fecal Incontinence Severity Index (FISI) Score, which takes into account leakage from
gas, mucus, liquid and solid stool, and ranges from 0 (total continence) to 61 (complete incontinence). Mean
FISI scores before and after surgery decreased from 10 to 5 (P = 0.01) at median follow-up of 11 months,
consistent with an overall significant improvement in anorectal function following TAMIS. The
[45]
same cohort was then evaluated again after a median follow-up of 3 years in 44 patients . Mean
preoperative FISI scores were 8.3 (range 0-35) vs. 5.4 (range 0-20) at one-year post-TAMIS (P = 0.5). At
3 years, mean FISI score increased to 10.1. This was not statistically significant relative to preoperative FISI.
Quality of life was not evaluated in the study.

[29]
Sumrien et al. described the Bristol conventional TAMIS series of 28 patients evaluating feasibility and
quality of life associated with incontinence. Either the GelPOINT Path or SILS port was used. Full thickness
defects were closed. All patients underwent endoscopic evaluation at 3 months along with evaluation of
quality of life with the International Consultation on Incontinence Modular Questionnaire (ICIQ). In all,
TAMIS was unable to be completed in 3 cases due to extent of tumor. Seventeen cases were performed for
benign neoplasia, with R0 resection achieved in 12 (71%). Eleven cases were for malignancy, of which 9
were palliative. In all of these cases, R0 resection was achieved, with one person experiencing recurrence
at 11 months. Two patients developed urinary retention and were sent home with a catheter, while 4
patients who developed urinary retention showed resolution prior to discharge. Notably, they modified
their practice in favor of a one-time in-out catheterization at the start of the procedure and then noticed a
reduction in the incidence of postoperative urinary retention. One patient was readmitted with bleeding
at 2 weeks following surgery and managed conservatively. One patient had full thickness perforation
amenable to closure by TAMIS. ICIQ was completed in 13 of 26 patients following surgery. Within the
questionnaire, the highest score is 60 and a higher score correlates with worsening severity of symptoms.
Median score was 15, and 11 of 13 patients scored under 30, while 2 scored higher. They concluded that
functional results were consistent with an acceptable quality of life.

[46]
Verseveld et al. evaluated quality of life and functional outcomes following TAMIS in 24 patients 6 months
following resection. Indications for resection were adenoma (n = 20) or low-risk T1 carcinomas (n = 4).
The SSL port was used for transanal access and patients were in lithotomy. Full thickness excisions were
performed and all defects were closed. Mean operative time was 32 (13-94) min and median length of stay
was 1 (1-3) day. There was one complication of hemorrhage requiring reoperation. Functional outcomes