Robotic transanal endoscopic microsurgery : technical details for the lateral approach

Nicolas C Buchs, MD, Francois Pugin, MD, Francesco Volonte, MD, Philippe Morel, MD, Frederic Ris, MD

University Hospitals of Geneva

Background :
Transanal endoscopic microsurgery (TEM) is a minimally invasive approach reserved for the resection of benign and low risk T1 rectal tumors. However, this approach is technically demanding and is associated with a long learning curve. Robotic technology may overcome limitations of this approach thanks to its stable and highly maneuverable platform. Yet, the robotic system can be difficult to be docked, especially in lithotomy position. A lateral approach can be more easily obtained. The study aim is thus to report the technical details of robotic TEM using a lateral approach.

Patients underwent a routine mechanical bowel preparation and were place in left or right lateral position according to the tumor location. A circular anal dilatator (CAD) was used together with the glove port technique. The da Vinci Si Surgical System (Intuitive Surgical Inc, Sunnyvale, CA) was then docked over the hip. A 30° optic and 2 articulated instruments were used with an additional 5 or 10mm trocar for the assistant alternatively for the retraction and suction-irrigation. The protocol was approved by our local Ethics committee.

Three patients underwent a robotic TEM using the lateral approach. The CAD with the glove port technique allows to protect the anal sphincter and to avoid air leak during surgery. The pneumorectum was easily established and stable allowing a clear visualization of the entire rectum. The tumor excision was realized with an atraumatic gasper and an articulated cautery hook and the defect was closed with V-Lock continuous stiches in each cases. The margins were negative in all the cases.

Robotic TEM using the lateral approach is feasible and may facilitate local resection of small tumor of the mid and low rectum, with a short learning curve. It might take an important place in function preserving surgery, particularly in case of downstaging or complete response after neoadjuvant radiochemotherapy for rectal cancer.

Session: Poster Presentation

Program Number: P046

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