Robotic Transanal Minimally Invasive Surgery (TAMIS)
Minimally invasive excision of low rectal tumors has led to the development of robotic transanal minimally invasive surgery. In this technique, robotic instruments are placed through the anus to perform full-thickness intraluminal resection of tumors with
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Shanglei Liu and Samuel Eisenstein
Introduction In this chapter, we will discuss the techniques for robotic transanal minimally invasive surgery (R-TAMIS) for the purpose of excising rectal lesions. This procedure is the newest evolution from a variety of natural orifice operations described in the past including transanal endoscopic microsurgery (TEM) and laparoscopic transanal minimally invasive surgery (TAMIS). R-TAMIS is considered a natural orifice approach to full-thickness resection of anorectal diseases that are locally contained. It is great option for patients with small to moderate sized lesions of low malignant potential. The robotic platform adapts very well to the limited operative space in the anus and rectum without significantly compromising operative dexterity. Many investigators are expanding the utilization of R-TAMIS beyond simple excision (such as transanal total mesorectal excision). But as these procedures remain largely investigational, this chapter will limit itself to the simple excision and closure technique.
Background In the early 1980s, Buess et al. first reported on TEM as a minimally invasive procedure to remove rectal polyps and early rectal cancers through the anus [1–3]. This approach achieved full-thickness resections with acceptable margins
S. Liu Department of General Surgery, University of California San Diego, San Diego, CA, USA e-mail: [email protected] S. Eisenstein (*) Department of Surgery, UC San Diego, La Jolla, CA, USA e-mail: [email protected]
for lesions from 5 to 20 cm from the anal verge [3]. In long- term follow-up, TEM had favorable oncologic outcome as well as low morbidity and mortality [4–8]. However, general adoption of TEM has been limited in clinical practice. One of the biggest reasons for this was the difficult learning curve associated with the technical challenges of this operation. Training was often only available at selective centers across the nation. Additionally, the operation required specialized instruments not widely available. And finally, the TEM approach may be unsuitable for lesions closer to the anal verge [8–10]. To solve these problems, transanal minimally invasive surgery (TAMIS) was introduced in 2009. This approach used traditionally laparoscopic instruments placed through the anus to perform local excision. Previous studies have shown that TAMIS provides high-quality local excision, comparable to TEM [11–14]. TAMIS has the additional benefit of utilizing conventional laparoscopic instruments that are nearly ubiquitously available in all hospitals. Yet, using laparoscopic tools in TAMIS to replace TEM equipment was not without its shortcomings. While the original TEM instruments were angled to facilitate rotational maneuvers within the rectum, laparoscopic instruments were limited by their rigid design and inability to fully articulate their working tip. This loss of degree of freedom was a great drawback to operating with laparoscopic instruments, especially in small spaces or through single port techniques [15]. This dec
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