Transanal total mesorectal excision with real-time, image-guided stereotaxy

Sam B Atallah, MD, George Nassif, DO, Beatriz Martin-Perez, MD, Sergio W Larach, MD. Florida Hospital.

Real-time stereotactic navigation can be used to help facilitate transanal total mesorectal excision (TME) using a frameless navigation system. This is demonstrated in video format. A  67 year-old male has undergone neoadjuvant treatment for a distal, locally advanced rectal cancer. After an eight-week resting period he is prepared for curative intent resection, transanal TME is performed using Transanal Minimally Invasive Surgery  (TAMIS). So that transanal TME can be performed with real-time navigation, a CT scan is obtained intra-operatively using a special protocol which includes placement of skin-fixed fiducials. The fiducials are used for software registration, and the scan is then used to calibrate a virtual wand and also a dissecting instrument, such as the tip of an electocuatery device. Once calibrated, any point of interest during dissection can be correlated to the CT-scan in real-time.  This allows the operating surgeon to augment the information gained from the camera image obtained during TAMIS-TME making real-time image guided navigation feasible with accuracy to within 4 mm.  This approach is a derivative of the navigational methods used in neurological surgery.  This represents the first application of this technology to facilitate pelvic surgery, thus opening the application of stereotactic navigation towards other fixed pelvic and abdominal organs. 

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