RESUMO
This manuscript offers a detailed description of our successful tips for mastering transanal robotic surgery. It covers various aspects, including patient positioning, management of abdominal pressures to maintain a stable pneumorectum, platform positioning, camera alignment, trocar positioning to minimize collisions, instruments used, and approaches to tumor resection.
Assuntos
Posicionamento do Paciente , Procedimentos Cirúrgicos Robóticos , Cirurgia Endoscópica Transanal , Humanos , Procedimentos Cirúrgicos Robóticos/métodos , Procedimentos Cirúrgicos Robóticos/instrumentação , Cirurgia Endoscópica Transanal/métodos , Cirurgia Endoscópica Transanal/instrumentação , Posicionamento do Paciente/métodos , Neoplasias Retais/cirurgia , Canal Anal/cirurgiaRESUMO
BACKGROUND: Available platforms for local excision (LE) of early rectal cancer are rigid or flexible [transanal minimally invasive surgery (TAMIS)]. We systematically searched the literature to compare outcomes between platforms. METHODS: PRISMA-compliant search of PubMed and Scopus databases until September 2022 was undertaken in this random-effect meta-analysis. Statistical heterogeneity was assessed using I2 statistic. Studies comparing TAMIS versus rigid platforms for LE for early rectal cancer were included. Main outcome measures were intraoperative and short-term postoperative outcomes and specimen quality. RESULTS: 7 studies were published between 2015 and 2022, including 931 patients (423 females); 402 underwent TAMIS and 529 underwent LE with rigid platforms. Techniques were similar for operative time (WMD 11.1, 95%CI - 2.6 to 25, p = 0.11), percentage of defect closure (OR 0.7, 95%CI 0.06-8.22, p = 0.78), and peritoneal violation (OR 0.41, 95%CI 0.12-1.43, p = 0.16). Rigid platforms had higher rates of short-term complications (19.1% vs 14.2, OR 1.6, 95%CI 1.07-2.4, p = 0.02), although no significant differences were seen for major complications (OR 1.41, 95%CI 0.61-3.23, p = 0.41). Patients in the rigid platforms group were 3-times more likely to be re-admitted within 30 days compared to the TAMIS group (OR 3.1, 95%CI 1.07-9.4, p = 0.03). Rates of positive resection margins (rigid platforms: 7.6% vs TAMIS: 9.34%, OR 0.81, 95%CI 0.42-1.55, p = 0.53) and specimen fragmentation (rigid platforms: 3.3% vs TAMIS: 4.4%, OR 0.74, 95%CI 0.33-1.64, p = 0.46) were similar between the groups. Salvage surgery was required in 5.5% of rigid platform patients and 6.2% of TAMIS patients (OR 0.8, 95%CI 0.4-1.8, p = 0.7). CONCLUSION: TAMIS or rigid platforms for LE seem to have similar operative outcomes and specimen quality. The TAMIS group demonstrated lower readmission and overall complication rates but did not significantly differ for major complications. The choice of platform should be based on availability, cost, and surgeon's preference.
Assuntos
Neoplasias Retais , Cirurgia Endoscópica Transanal , Humanos , Neoplasias Retais/cirurgia , Neoplasias Retais/patologia , Cirurgia Endoscópica Transanal/métodos , Cirurgia Endoscópica Transanal/instrumentação , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Duração da Cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Margens de ExcisãoAssuntos
Neoplasias Retais , Procedimentos Cirúrgicos Robóticos , Cirurgia Endoscópica Transanal , Humanos , Procedimentos Cirúrgicos Robóticos/métodos , Neoplasias Retais/cirurgia , Cirurgia Endoscópica Transanal/métodos , Cirurgia Endoscópica Transanal/instrumentação , Adenocarcinoma in Situ/cirurgia , Adenocarcinoma in Situ/patologia , Masculino , Feminino , Adenocarcinoma/cirurgiaAssuntos
Canal Anal/cirurgia , Carcinoma , Complicações Pós-Operatórias/prevenção & controle , Protectomia , Neoplasias Retais , Cirurgia Endoscópica Transanal , Idoso , Carcinoma/patologia , Carcinoma/cirurgia , Humanos , Masculino , Margens de Excisão , Procedimentos Cirúrgicos Minimamente Invasivos/instrumentação , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Estadiamento de Neoplasias , Tratamentos com Preservação do Órgão/métodos , Protectomia/instrumentação , Protectomia/métodos , Neoplasias Retais/patologia , Neoplasias Retais/cirurgia , Reto/irrigação sanguínea , Reto/inervação , Reto/cirurgia , Cirurgia Endoscópica Transanal/instrumentação , Cirurgia Endoscópica Transanal/métodosRESUMO
OBJECTIVE: To evaluate the feasibility of transanal minimally invasive surgery (TAMIS) for submucosal rectal resection in large breed dogs. STUDY DESIGN: Cadaveric study. SAMPLE POPULATION: Canine cadavers (n = 6) weighing between 37.5 and 60 kg. METHODS: Dogs were positioned in sternal recumbency. After rectal cleansing, a transanal access platform was placed in the rectum, and a pneumorectum was established. An area of ventral rectal wall approximately 2 × 2 cm was resected in a submucosal plane by using laparoscopic instruments and submitted for histopathological evaluation. The rectal wall defect was closed with a single-layer continuous suture pattern with barbed suture. Postoperatively, the rectum was removed en bloc and evaluated for suture or surgical penetration of the serosal surface. RESULTS: Submucosal rectal resection was successfully completed by using TAMIS in all dogs. The median length of resected specimens after fixation was 24.5 mm (range 9.8-26.5). In two of six dogs, suture was macroscopically visible on the serosal surface, but no dogs had evidence of iatrogenic full-thickness surgical penetration of the rectum. The median distance from the aborad extent of the suture closure line to the anocutaneous junction was 35 mm (range, 35-105). CONCLUSION: Submucosal resection of the canine rectal wall was feasible in large breed dogs by using TAMIS. No evidence of full-thickness penetration of the rectal wall was seen in these cadaveric specimens. CLINICAL SIGNIFICANCE: Transanal minimally invasive surgery may provide an alternative minimally invasive approach for resection for benign adenomatous rectal polyps in large breed dogs that might otherwise require a rectal pull-through.
Assuntos
Doenças do Cão/cirurgia , Cães/cirurgia , Ressecção Endoscópica de Mucosa/veterinária , Neoplasias Retais/veterinária , Reto/cirurgia , Cirurgia Endoscópica Transanal/veterinária , Animais , Cadáver , Ressecção Endoscópica de Mucosa/instrumentação , Ressecção Endoscópica de Mucosa/métodos , Feminino , Laparoscopia/veterinária , Masculino , Neoplasias Retais/cirurgia , Cirurgia Endoscópica Transanal/instrumentação , Cirurgia Endoscópica Transanal/métodosRESUMO
According to the main features of transanal total mesorectal excision (taTME), we have designed a series of patented operating techniques, such as anal retractor, anal speculum and transanal port, to reduce the difficulty of transanal operation, shorten the surgeon's learning curve, and expand the indications of transanal surgery.
Assuntos
Canal Anal/cirurgia , Invenções , Neoplasias Retais/cirurgia , Cirurgia Endoscópica Transanal/instrumentação , Humanos , Mesentério/cirurgia , Reto/cirurgiaRESUMO
Robotic-assisted transanal total mesorectal excision (R-TaTME) has unique advantage in low rectal cancer. Single incision plus oneport (SIPOP) laparoscopic operation can synchronously cooperate with robotic-assisted transanal operation, in order to the difficulty of operation, improve the quality of operation and shorten the time of operation. A retrospective analysis was conducted on the clinical and pathological data of one patient who underwent SIPOP synchronously combined with R-TaTME + sigmoid-anal anastomosis + ileostomy at the Department of General Surgery, Army Characteristic Medical Center on September 11, 2019. This 71-year-old patient was male with body mass index of 24.08 kg/m(2) and received preoperative chemotherapy. Rectal adenocarcinoma was confirmed by colonoscopy biopsy, and distance from tumor lower edge to anal verge was 3 cm. MRI indicated T2N1 stage. The operation was completed successfully, and the transabdominal and robotic transanal surgery totaled 117 minutes, with 15 minutes for the robotic transanal preparation step. There was about 20 ml of intraoperative blood loss and no blood transfusion was performed. The patient was discharged 6 days after operation. No intraoperative or postoperative complications occurred. The postoperative TNM staging was stage I (pyT2N0cM0). No recurrence or metastasis was found at postoperative 7 month. It is a safe, effective and feasible technique for patients with low rectal cancer.
Assuntos
Adenocarcinoma/cirurgia , Neoplasias Retais/cirurgia , Procedimentos Cirúrgicos Robóticos/métodos , Cirurgia Endoscópica Transanal/métodos , Adenocarcinoma/tratamento farmacológico , Adenocarcinoma/patologia , Idoso , Canal Anal/cirurgia , Anastomose Cirúrgica , Antineoplásicos/administração & dosagem , Colo Sigmoide/cirurgia , Humanos , Ileostomia , Laparoscopia/métodos , Masculino , Mesentério/cirurgia , Terapia Neoadjuvante , Neoplasias Retais/tratamento farmacológico , Neoplasias Retais/patologia , Reto/cirurgia , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/instrumentação , Cirurgia Endoscópica Transanal/instrumentaçãoRESUMO
Colorectal cancer remains the third most common cancer effecting adults. Surgical guidelines recommend transanal excision of early rectal neoplasia up to 8 cm from the anal verge. A retrospective review of two novel approaches for transanal robotic local excision with R0 resections of rectal cancers which was, on average, higher than 8 cm. Twenty-one cases of robotic assisted transanal surgery for early stage disease (T0-T1, N0) were reviewed. The first 10 cases performed with the da Vinci® Si robotic platform between 2013 and 2016, and the first 11 cases performed using the Flex® Medrobotics platform between August 2017 and August 2018. The average distance from the anal verge was 11.1 cm and 9.5 cm for the da Vinci® Si and Flex® Colorectal Drive, respectively. The average operative time was 167.6 min for the da Vinci® Si and 110.1 min for the Flex® Colorectal Drive; the average EBL was 37.5 cc and 9.1 cc for the da Vinci® Si and Flex® Colorectal Drive. In the da Vinci® series, four cases required intraoperative conversion. In the Flex® series, one case was aborted due to unfavorable robotic positioning. All margins were histologically negative when surgically complete with no recurrences to date. Transanal robotic surgery may provide a method to address rectal lesions farther from the anal verge than previously described. The Flex® Colorectal Drive platform may provide superior ability to navigate the nonlinear anatomy of the rectum and distal sigmoid colon.
Assuntos
Canal Anal/cirurgia , Neoplasias Colorretais/cirurgia , Reto/cirurgia , Procedimentos Cirúrgicos Robóticos/instrumentação , Procedimentos Cirúrgicos Robóticos/métodos , Cirurgia Endoscópica Transanal/instrumentação , Cirurgia Endoscópica Transanal/métodos , Adulto , Idoso , Neoplasias Colorretais/patologia , Feminino , Humanos , Masculino , Margens de Excisão , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Duração da Cirurgia , Estudos RetrospectivosRESUMO
AIM: A new artificial anal sphincter placed into the intersphincteric space, SphinKeeper™, has recently been proposed to improve outcomes in the treatment of faecal incontinence (FI). We report our preliminary results with short-term follow-up, comparing preoperative and postoperative data after implant of SphinKeeper™ in patients suffering from FI. METHODS: All patients older than 18 years were included with FI of at least 6 months, incontinence episodes occurring more than once a week and resistance to other conservative treatments. Anorectal manometry, endoanal ultrasound, Cleveland Clinic FI Score, FI Quality of Life score and total number of episodes of FI per week were recorded preoperatively and at the end of the 6-month follow-up period. RESULTS: Thirteen consecutive patients were treated with SphinKeeper™. No intra-operative nor postoperative complications were reported. Two cases of prosthesis extrusion occurred, and in one case an anterior dislocation was detected. Maximum resting pressure, total number of episodes of FI per week and Cleveland Clinic FI Score were improved after 6 months (P < 0.05). CONCLUSIONS: SphinKeeper™ could be a minimally invasive procedure for FI with good postoperative outcomes. If these results are confirmed by studies with more patients and longer follow-up, it could be a first-line approach in FI.
Assuntos
Canal Anal/cirurgia , Incontinência Fecal/cirurgia , Implantação de Prótese/métodos , Cirurgia Endoscópica Transanal/instrumentação , Adulto , Endossonografia , Incontinência Fecal/diagnóstico por imagem , Feminino , Humanos , Masculino , Manometria , Pessoa de Meia-Idade , Período Pós-Operatório , Período Pré-Operatório , Qualidade de Vida , Índice de Gravidade de Doença , Resultado do TratamentoAssuntos
Humanos , História do Século XIX , História do Século XX , História do Século XXI , Equipamentos Cirúrgicos/história , Cirurgia Endoscópica por Orifício Natural/história , Procedimentos Cirúrgicos Robóticos/tendências , Cirurgia Endoscópica Transanal/história , Microcirurgia Endoscópica Transanal/história , Cirurgia Colorretal/história , Cirurgia Endoscópica por Orifício Natural/métodos , Cirurgia Endoscópica Transanal/instrumentação , Cirurgia Endoscópica Transanal/métodos , Microcirurgia Endoscópica Transanal/métodosAssuntos
Humanos , Neoplasias Retais/cirurgia , Cirurgia Endoscópica por Orifício Natural/métodos , Cirurgia Endoscópica Transanal/métodos , Protectomia/instrumentação , Protectomia/métodos , Cuidados Pré-Operatórios , Resultado do Tratamento , Posicionamento do Paciente , Cirurgia Endoscópica por Orifício Natural/instrumentação , Duração da Cirurgia , Cirurgia Endoscópica Transanal/instrumentaçãoRESUMO
BACKGROUND: Transanal total mesorectal excision (TaTME) is associated with a relatively long learning curve. Force, motion, and time parameters are increasingly used for objective assessment of skills to enhance laparoscopic training efficacy. The aim of this study was to identify relevant metrics for accurate skill assessment in more complex transanal purse-string suturing. METHODS: A box trainer was designed for TaTME and equipped with two custom made multi-DOF force/torque sensors. These sensors measured the applied forces in the axial direction of the instruments (Fz), instrument load orientation expressed in torque (Mx and My) on the entrance port, and the full tissue interaction force (Fft) at the intestine fixation point. In a construct validity study, novices for TaTME performed a purse-string suture to investigate which parameters can be used best to identify meaningful events during tissue manipulation and instrument handling. RESULTS: Significant differences exist between pre- and post-training assessment for the mean axial force at the entrance port Fz (p = 0.01), mean torque in the entrance port Mx (p = 0.03) and mean force on the intestine during suturing Fft (p = 0.05). Furthermore, force levels during suturing exceed safety threshold values, potentially leading to dangerous complications such as rupture of the rectum. CONCLUSIONS: Forces and torque measured at the entrance port, and the tissue interaction force signatures provide detailed insight into instrument handling, instrument loading, and tissue handling during purse-string suturing in a TaTME training setup. This newly developed training setup for single-port laparoscopy that enables objective feedback has the potential to enhance surgical training in TaTME.
Assuntos
Avaliação Educacional/métodos , Laparoscopia/educação , Protectomia/educação , Técnicas de Sutura/educação , Cirurgia Endoscópica Transanal/educação , Adulto , Competência Clínica , Feminino , Humanos , Laparoscopia/instrumentação , Curva de Aprendizado , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Protectomia/instrumentação , Técnicas de Sutura/instrumentação , Torque , Cirurgia Endoscópica Transanal/instrumentaçãoRESUMO
BACKGROUND: The aim of this study was to evaluate the feasibility of the Versius surgical robotic system for transanal total mesorectal excision (taTME) in a preclinical setting. METHODS: Dry laboratory and cadaveric sessions were first conducted for three experienced colorectal surgeons in order to gain familiarity with the modular surgical system and the robotic workstation. After introduction, the system was configured to allow for synchronous, totally robotic taTME in a cadaver. RESULTS: Using the modular robotic system, one surgeon performed the abdominal portion of the operation, including colonic mobilization and vascular pedicle ligation while simultaneously a second surgeon performed the transanal portion of the operation to the point of rendezvous at the peritoneal reflection, where the operation was completed cooperatively. The operation was successfully completed in 195 min demonstrating preclinical feasibility of this unique approach with an emerging robotic system. CONCLUSIONS: This is the first preclinical assessment of the Versius surgical robotic system for taTME. The ability to work simultaneously carries the theoretical advantage of reducing surgical time and thereby reducing overall operative costs. It may also allow surgeons to maintain focus on critical parts of the operation by halving the fatigue associated with long, complex cases such as taTME.
Assuntos
Procedimentos Cirúrgicos Robóticos/educação , Procedimentos Cirúrgicos Robóticos/instrumentação , Cirurgia Endoscópica Transanal/educação , Cirurgia Endoscópica Transanal/instrumentação , Cadáver , Competência Clínica , Desenho de Equipamento , HumanosRESUMO
BACKGROUND: Development of an anastomotic stricture following rectal cancer surgery is not uncommon. Such strictures are usually managed by manual or instrumental dilatation techniques that are often insufficiently effective, as evidenced by the high recurrence rate. Various surgical procedures using minimally invasive approaches have also been reported. One of these procedures, endoscopic radial incision and cutting (RIC), has been extensively reported. However, RIC by transanal minimally invasive surgery (TAMIS) is yet to be reported. We here report a novel application of TAMIS for performing RIC for anastomotic rectal stenosis. CASE PRESENTATION: A 67-year-old man had suffered from constipation for 6 years after undergoing low anterior resection for stage II rectal cancer 7 years ago. Colonoscopy showed a 1-cm diameter stricture in the lower rectum. Balloon dilatation was performed many times because of repeated recurrences. Thus, surgical management was considered and the stricture was successfully excised via a RIC method using a TAMIS approach. Postoperatively, the patient had minimal leakage that resolved with conservative treatment. CONCLUSIONS: A RIC method using a TAMIS approach is an effective minimally invasive means of managing anastomotic strictures following rectal cancer surgery.
Assuntos
Complicações Pós-Operatórias/cirurgia , Protectomia/efeitos adversos , Proctoscopia/métodos , Neoplasias Retais/cirurgia , Cirurgia Endoscópica Transanal/métodos , Idoso , Anastomose Cirúrgica/efeitos adversos , Constrição Patológica/diagnóstico por imagem , Constrição Patológica/etiologia , Constrição Patológica/cirurgia , Humanos , Masculino , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/etiologia , Proctoscopia/instrumentação , Reto/diagnóstico por imagem , Reto/patologia , Reto/cirurgia , Cirurgia Endoscópica Transanal/instrumentação , Resultado do TratamentoRESUMO
La morbilidad y alteración de la calidad de vida asociadas a la resección anterior del recto y amputación abdominoperineal determinaron un gran interés en el desarrollo del abordaje transanal. En los últimos años se ha visto un marcado desarrollo tecnológico en los dispositivos disponible para este abordaje. La cirugía por vía transanal ofrece ventajas en cuanto a sus resultados y complicaciones cuando se la compara a la cirugía por vía abdominal. La cirugía transanal mini-invasiva surge como una alternativa de abordaje videoendoscópico del recto. La resección local por cirugía endoscópica para los pólipos grandes de recto se ha convertido en un nuevo estándar de tratamiento en la mayoría de los centros, obteniendo piezas no fragmentadas con una alta tasa de márgenes negativos. En el presente estudio realizamos una revisión sobre la aplicación de TAMIS (TransAnal Minimally Invasive Surgery) al tratamiento de los pólipos de recto. (AU)
A great interest has developed in implementing trans anal minimally invasive surgery for the treatment of rectal adenomas and early rectal tumors. It present advantages when compare to radical surgery and peace meal endoscopic resections. TAMIS delivers non-fragmented specimens with clear resection margin in the majority of the cases. Such good technical results are mirrored with a low recurrence rate when evaluating rectal adenomas. This is a review of the application of TAMIS for the treatment of rectal adenomas. (AU)