THE INTERNATIONAL JOURNAL OF MEDICAL ROBOTICS AND COMPUTER ASSISTED SURGERY Int J Med Robotics Comput Assist Surg 2014; 10: 423–426. Published online 8 May 2014 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/rcs.1594
ORIGINAL ARTICLE
Robotic transanal total mesorectal excision for rectal cancer: experience with a first case P. M. Verheijen* E. C. J. Consten I. A. M. J. Broeders Department of General Surgery, Meander Medical Centre, Amersfoort, The Netherlands *Correspondence to: P. M. Verheijen, Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands. E-mail: [email protected]
Abstract Background A transanal approach for total mesorectal excision (TME) using a single incision port is feasible. The disadvantages are technical difficulties associated with limited manoeuvrability. Methods We present our first experience with robotic-assisted transanal total mesorectal excision. A 48 year-old woman with a tumour 8 cm from the anal verge was successfully operated using a transanal approach. A complete mesorectal excision was performed through a single incision port, using two robot arms. Results TME was performed successfully and the patient recovered quickly without any complications. The histological report showed a complete mesorectal excision with free distal and circumferential margins. A sigmoidoscopy showed an intact anastomosis and the patient was planned for reversal of her ileostomy. Conclusions Transanal total mesorectal excision using the robot is feasible. Robotics may help to overcome technical difficulties associated with the single incision port. Copyright © 2014 John Wiley & Sons, Ltd. Keywords
robotic; transanal; TME; rectum
Introduction
Accepted: 10 April 2014
Copyright © 2014 John Wiley & Sons, Ltd.
Total mesorectal excision (TME) is the standard treatment for rectal cancers. The common approach for TME is transabdominal, either laparoscopic or with open surgery. Contrary to laparoscopic colectomies, adoption rates of laparoscopic rectal resection have remained low, due to the challenges of low pelvic dissection (1–7). Whiteford et al. (8) have described the possibility of complete endoscopic mesorectal excision using transanal endoscopic microsurgery (TEM). Subsequent reports have demonstrated the feasibility and oncological safety of this transanal approach (9–13). All cases thus far reported have used TEM platforms or single incision ports for the transanal dissection. The advantages of this technique are better control of the level of transection of the rectum with a clear transanal view of the tumour and smaller abdominal incisions, possibly associated with less postoperative morbidity. The disadvantages are technical difficulties associated with the single-port transanal approach.
P. M. Verheijen et al.
424
Reports on transanal endoscopic microsurgery (TEM) have shown its technical difficulties and long learning curve. Manoeuvrability is seriously limited (14,15). Robotics has been developed to overcome the technical limits associated with classic laparoscopy. Several groups have reported their experience with robotic TEM, showing the feasibility of this technique (16–18). The use of robotics for transanal mesorectal excision might help to overcome the technical difficulties associated with TEM platforms or single-incision ports. One case has been presented thus far (19).
Materials and methods We present our initial experience with transanal TME using the Da Vinci® robot (Intuitive Surgery, Sunnyvale, CA, USA). A 48 year-old woman presented with rectal blood loss. Her medical history showed no previous illnesses. BMI of the patient was 23.6. Colonoscopy showed a circular rectal tumour 8 cm from the anal verge. Biopsies confirmed the diagnosis of rectal adenocarcinoma. CT scan of the pelvis, abdomen and thorax showed no metastases. MRI scan of the pelvis demonstrated a 3 cm T3 tumour with involvement of the mesorectal lymph nodes. Because of the suspicion of involvement of the lymph nodes and suggested anterior involvement of the mesorectal fascia, the patient was treated with preoperative chemoradiotherapy with 50.4 Gy and Capecitabine for 6 weeks. A preoperative MRI scan showed regression of the tumour, 6 weeks after finishing the long-course chemoradiotherapy. The patient received full bowel preparation and the rectum was washed using a povidone–iodine solution. Two attending surgeons with extensive laparoscopic colorectal experience performed the operation. The patient was operated placed in the lithotomy position. After general
anaesthesia, a Foley catheter was inserted. The operation was started with conventional laparoscopy, using four 5 mm ports. Trocars were inserted in the right lower quadrant, right upper quadrant, periumbilical region and left lower quadrant. A lateral-to-medial approach was used for mobilizing the left-sided colon. A full mobilization of the splenic flexure was obtained. The left ureter was identified and the TME plane was opened. The inferior mesenteric artery was divided using a 5 mm Thunderbeat laparoscopic sealer (Olympus, Center Valley, PA, USA). Pneumoperitoneum was maintained and the operation was continued transanally. The Gelpoint Path (Applied Medical, Rancho Santa Margarita, CA, USA) was introduced into the anus with three 8.5 mm robot ports and one 5 mm assistant port. The Gelpoint Path was secured to the perianal skin with two stitches. The robot was brought in over the left hip of the patient. Arms one and two of the robot were docked and a 8.5 mm camera was introduced after pneumorectum had been achieved. The robotic set-up is demonstrated in Figures 1, 2.
Figure 2. Port placement
Figure 1. Robotic set-up Copyright © 2014 John Wiley & Sons, Ltd.
Int J Med Robotics Comput Assist Surg 2014; 10: 423–426. DOI: 10.1002/rcs
Robotic transanal TME
The tumour was identified and 2 cm distal of the tumour a purse-string suture was applied to occlude the rectum below the tumour, using two needle drives. Then a cadiere forceps and a diathermy hook were introduced. The rectal wall was transected circumferentially with monopolar diathermy, starting just distal of the pursestring suture, followed by full-thickness rectal dissection. The TME plane was entered and further mobilized cranially. The rectovaginal plane was also fully mobilized until connection with the abdominal cavity was made. Subsequently, full circumferential rectal mobilization was completed. Now the rectum was grasped and the rectum and descending colon were extracted through the anus. Additional extracorporeal dissection of the mesocolon was performed and the descending colon was transected. The specimen was removed. A purse-string suture was applied to the proximal colon and the distal rectum and a circular anastomosis was made, using an EEA haemorrhoid and prolapse stapler (Covidien, Mansfield, MA, USA). A covering ileostomy was brought out under laparoscopic vision.
Results Total theatre time was 250 min, operating time was 205 min, robot console time was 65 min. Estimated blood loss was 50 cc. The single incision port turned out to be a stable and leak-free access point. The distance between the robotic ports was 2 cm and the distance from the robotic ports to the assistant port was 3 cm. No clashing of the arms or limitiations in manoeuvrability were experienced. The patient recovered quickly, without any complications, and left the hospital on day 3 after surgery. The histological report showed a complete mesorectal excision with free distal and circumferential margins. The mesorectal fascia was intact. No perforations were found. No metastases were found. The length of the specimen was 14 cm. The distal margin was 2.0 cm from a necrotic tumour with no vital tumour cells; the TNM classification was therefore pT0N0. Fig. 3 shows an anatomopathology picture of the tumour before radiation therapy. No pictures of the tumour after resection were possible, since there was complete regression. Six weeks after the resection, the patient was seen in the outpatient clinic and she had recovered very well. No postoperative complications had been noted. A sigmoidoscopy showed an intact anastomosis and the patient was planned for reversal of her ileostomy.
Discussion Laparoscopic TME is technically challenging and is associated with long operating times and a long learning curve, Copyright © 2014 John Wiley & Sons, Ltd.
425
Figure 3. Pathology of the tumour before chemoradiotherapy
especially in low rectal cancers (7,20). The main difficulties are the rectal dissection and pelvic exposure (1,4,7). A transanal approach helps to simplify the hardest part of the rectal resection. Most cases of transanal TME thus far presented have shown complete mesorectal resection with negative resection margins and adequate lymph node harvest, although Rouanet recently published his series of 30 cases with four positive circumferential margins (9–12,21,22). One of the main advantages of transanal endoscopic TME compared to laparoscopic TME is the accurate identification of the distal resection margin. Furthermore, no large abdominal incisions are needed to extract the specimen. Many of the laparoscopic difficulties are overcome with the tranasanal approach, especially difficulties with pelvic exposure, rectal dissection and distal stapling. However, the technical difficulties associated with TEM platforms and single ports may prevent the uptake of this new technique. The use of the robot helps to overcome most of these technical difficulties. In our early experience, the robot makes transanal mesorectal excision easier to perform. More experience in men with a narrow pelvis is needed before concluding on the true added value of the robot in this procedure. The limited manoeuvrability associated with TEM platforms and single incision ports was not experienced. In our first case operating time was 205 min, which is short compared to operating times in a series of transanal TMEs using conventional laparoscopic instruments (13). We assume that operating times can be even further decreased when more experience with the procedure is obtained. This patient was chosen for our first case because she was a woman with a wide pelvis, normal BMI and the tumour was in the mid-rectum. Although on first MRI the mesorectal fascia was dubiously involved, MRI after chemoradiotherapy showed almost complete regression Int J Med Robotics Comput Assist Surg 2014; 10: 423–426. DOI: 10.1002/rcs
426
of the tumour, making this, in our opinion, a very easy case and thus a perfect case to start with. We have shown the feasibility of robotic transanal rectal resection, although the major limitation of this study is the limited experience after one case. The possible advantages of the transanal approach make it an auspicious new technique with a promising role for the robot.
Conflict of interest The authors have stated explicity that there are no conflicts of interest in connection with this article.
Funding No specific funding.
References 1. Guillou PJ, Quirke P, Thorp H, et al. Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC Classic Trial): multicenter, randomized controlled trial. Lancet 2005; 365: 1718–1726. 2. Braga M, Frasson M, Vignali A, et al. Laparoscopic resection in rectal cancer patients: outcome and cost–benefit analysis. Dis Colon Rectum 2007; 50: 464–471. 3. Ng SS, Leung KL, Lee JF, et al. Laparoscopic-assisted versus open abdomino-perineal resection for low rectal cancer: a prospective randomized trial. Ann Surg Oncol 2008; 15: 2418–2425. 4. Ng SS, Leung KL, Lee JF, et al. Long- term morbidity and oncologic outcomes of laparoscopic-assisted anterior resection for upper rectal cancer: 10-year results of a prospective, randomized trial. Dis Colon Rectum 2009; 52: 558–566. 5. Lujan J, Valero G, Hernandez Q, et al. Randomized clinical trial comparing laparoscopic and open surgery in patients with rectal cancer. Br J Surg 2009; 96: 982–989. 6. Kang SB, Park JW, Jeong SY, et al. Open versus laparoscopic surgery for mid or low rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): short-term outcomes of an open-label randomised controlled trial. Lancet Oncol 2010; 11: 637–645.
Copyright © 2014 John Wiley & Sons, Ltd.
P. M. Verheijen et al. 7. Kang CY, Halabi WJ, Luo R, et al. Laparoscopic colorectal surgery: a better look into the latest trends. Arch Surg 2012; 147: 724–731. 8. Whiteford MH, Denk PM, Swanstrom LL. Feasibility of radical sigmoid colectomy performed as natural orifice translumenal endoscopic surgery (NOTES) using transanal endoscopic microsurgery. Surg Endosc 2007; 21: 1870–1874. 9. Chen YG, Hu M, Lei J, Chen JC, Li JY. NOTES transanal endoscopic total mesorectal excision for rectal cancer. Chin J Endosc 2010; 16: 1261–1265. 10. Tuech JJ, Bridoux V, Kianifard B, et al. Natural orifice total mesorectal excision using transanal port and laparoscopic assistance. Eur J Surg Oncol 2011; 37: 334–335. 11. Zorron R, Phillips HN, Coelho D, et al. Perirectal NOTES access: ‘down-to-up’ total meso-rectal excision for rectal cancer. Surg Innov 2012; 19: 11–19. 12. Lacy AM, Adelsdorfer C, Delgado S, et al. Minilaparoscopyassisted transrectal low anterior resection (LAR): a preliminary study. Surg Endosc 2013; 27(1): 339–346. 13. Sylla P, Bordeianou LG, Berger D, et al. A pilot study of natural orifice transanal endoscopic total mesorectal excision with laparoscopic assistance for rectal cancer. Surg Endosc 2013; 27: 3396–3405. 14. Koebrugge B, Bosscha K, Ernst MF. Transanal endoscopic microsurgery for local excision of rectal lesions: is there a learning curve? Dig Surg 2009; 26: 372–377. 15. Bardakcioglu O. Robotic transanal access surgery. Surg Endosc 2013; 27: 1407–1409. 16. Hompes R, Rauh SM, Hagen ME, et al. Preclinical cadaveric study of transanal endoscopic da Vinci® surgery. Br J Surg 2012; 99: 1144–1148. 17. Atallah SB, Albert MR, de Beche-Adams TH, et al. Robotic transanal minimally invasive surgery in a cadaveric model. Tech Coloproctol 2011; 15: 461–464. 18. Buchs NC, Pugin FP, Volonte F, et al. Robotic transanal endoscopic microsurgery: technical details for the lateral approach. Dis Colon Rectum 2013; 56: 1194–1198. 19. Atallah S, Nassif G, Polavarapu H, et al. Robotic-assisted transanal surgery for total mesorectal excision (RATS–TME): a description of a novel surgical approach with video demonstration. Tech Coloproctol 2013; 17(4): 441–447. 20. The Surgical Care and Outcomes Assessment Program (SCOAP) Collaborative, Kwon S, Billingham R, Farrokhi E, et al. Adoption of laparoscopy for elective colorectal resection: a report from the Surgical Care and Outcomes Assessment Program. J Am Coll Surg 2012; 214: 909–918: e1. 21. Sylla P, Rattner DW, Delgado S, et al. NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance. Surg Endosc 2010; 24: 1205–1210. 22. Rouanet P, Mourregot A, Azar CC, et al. Transanal endoscopic proctectomy: an innovative procedure for difficult resection of rectal tumors in men with narrow pelvis. Dis Colon Rectum 2013; 56(4): 408–415.
Int J Med Robotics Comput Assist Surg 2014; 10: 423–426. DOI: 10.1002/rcs
ORIGINAL ARTICLE
Robotic transanal total mesorectal excision for rectal cancer: experience with a first case P. M. Verheijen* E. C. J. Consten I. A. M. J. Broeders Department of General Surgery, Meander Medical Centre, Amersfoort, The Netherlands *Correspondence to: P. M. Verheijen, Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands. E-mail: [email protected]
Abstract Background A transanal approach for total mesorectal excision (TME) using a single incision port is feasible. The disadvantages are technical difficulties associated with limited manoeuvrability. Methods We present our first experience with robotic-assisted transanal total mesorectal excision. A 48 year-old woman with a tumour 8 cm from the anal verge was successfully operated using a transanal approach. A complete mesorectal excision was performed through a single incision port, using two robot arms. Results TME was performed successfully and the patient recovered quickly without any complications. The histological report showed a complete mesorectal excision with free distal and circumferential margins. A sigmoidoscopy showed an intact anastomosis and the patient was planned for reversal of her ileostomy. Conclusions Transanal total mesorectal excision using the robot is feasible. Robotics may help to overcome technical difficulties associated with the single incision port. Copyright © 2014 John Wiley & Sons, Ltd. Keywords
robotic; transanal; TME; rectum
Introduction
Accepted: 10 April 2014
Copyright © 2014 John Wiley & Sons, Ltd.
Total mesorectal excision (TME) is the standard treatment for rectal cancers. The common approach for TME is transabdominal, either laparoscopic or with open surgery. Contrary to laparoscopic colectomies, adoption rates of laparoscopic rectal resection have remained low, due to the challenges of low pelvic dissection (1–7). Whiteford et al. (8) have described the possibility of complete endoscopic mesorectal excision using transanal endoscopic microsurgery (TEM). Subsequent reports have demonstrated the feasibility and oncological safety of this transanal approach (9–13). All cases thus far reported have used TEM platforms or single incision ports for the transanal dissection. The advantages of this technique are better control of the level of transection of the rectum with a clear transanal view of the tumour and smaller abdominal incisions, possibly associated with less postoperative morbidity. The disadvantages are technical difficulties associated with the single-port transanal approach.
P. M. Verheijen et al.
424
Reports on transanal endoscopic microsurgery (TEM) have shown its technical difficulties and long learning curve. Manoeuvrability is seriously limited (14,15). Robotics has been developed to overcome the technical limits associated with classic laparoscopy. Several groups have reported their experience with robotic TEM, showing the feasibility of this technique (16–18). The use of robotics for transanal mesorectal excision might help to overcome the technical difficulties associated with TEM platforms or single-incision ports. One case has been presented thus far (19).
Materials and methods We present our initial experience with transanal TME using the Da Vinci® robot (Intuitive Surgery, Sunnyvale, CA, USA). A 48 year-old woman presented with rectal blood loss. Her medical history showed no previous illnesses. BMI of the patient was 23.6. Colonoscopy showed a circular rectal tumour 8 cm from the anal verge. Biopsies confirmed the diagnosis of rectal adenocarcinoma. CT scan of the pelvis, abdomen and thorax showed no metastases. MRI scan of the pelvis demonstrated a 3 cm T3 tumour with involvement of the mesorectal lymph nodes. Because of the suspicion of involvement of the lymph nodes and suggested anterior involvement of the mesorectal fascia, the patient was treated with preoperative chemoradiotherapy with 50.4 Gy and Capecitabine for 6 weeks. A preoperative MRI scan showed regression of the tumour, 6 weeks after finishing the long-course chemoradiotherapy. The patient received full bowel preparation and the rectum was washed using a povidone–iodine solution. Two attending surgeons with extensive laparoscopic colorectal experience performed the operation. The patient was operated placed in the lithotomy position. After general
anaesthesia, a Foley catheter was inserted. The operation was started with conventional laparoscopy, using four 5 mm ports. Trocars were inserted in the right lower quadrant, right upper quadrant, periumbilical region and left lower quadrant. A lateral-to-medial approach was used for mobilizing the left-sided colon. A full mobilization of the splenic flexure was obtained. The left ureter was identified and the TME plane was opened. The inferior mesenteric artery was divided using a 5 mm Thunderbeat laparoscopic sealer (Olympus, Center Valley, PA, USA). Pneumoperitoneum was maintained and the operation was continued transanally. The Gelpoint Path (Applied Medical, Rancho Santa Margarita, CA, USA) was introduced into the anus with three 8.5 mm robot ports and one 5 mm assistant port. The Gelpoint Path was secured to the perianal skin with two stitches. The robot was brought in over the left hip of the patient. Arms one and two of the robot were docked and a 8.5 mm camera was introduced after pneumorectum had been achieved. The robotic set-up is demonstrated in Figures 1, 2.
Figure 2. Port placement
Figure 1. Robotic set-up Copyright © 2014 John Wiley & Sons, Ltd.
Int J Med Robotics Comput Assist Surg 2014; 10: 423–426. DOI: 10.1002/rcs
Robotic transanal TME
The tumour was identified and 2 cm distal of the tumour a purse-string suture was applied to occlude the rectum below the tumour, using two needle drives. Then a cadiere forceps and a diathermy hook were introduced. The rectal wall was transected circumferentially with monopolar diathermy, starting just distal of the pursestring suture, followed by full-thickness rectal dissection. The TME plane was entered and further mobilized cranially. The rectovaginal plane was also fully mobilized until connection with the abdominal cavity was made. Subsequently, full circumferential rectal mobilization was completed. Now the rectum was grasped and the rectum and descending colon were extracted through the anus. Additional extracorporeal dissection of the mesocolon was performed and the descending colon was transected. The specimen was removed. A purse-string suture was applied to the proximal colon and the distal rectum and a circular anastomosis was made, using an EEA haemorrhoid and prolapse stapler (Covidien, Mansfield, MA, USA). A covering ileostomy was brought out under laparoscopic vision.
Results Total theatre time was 250 min, operating time was 205 min, robot console time was 65 min. Estimated blood loss was 50 cc. The single incision port turned out to be a stable and leak-free access point. The distance between the robotic ports was 2 cm and the distance from the robotic ports to the assistant port was 3 cm. No clashing of the arms or limitiations in manoeuvrability were experienced. The patient recovered quickly, without any complications, and left the hospital on day 3 after surgery. The histological report showed a complete mesorectal excision with free distal and circumferential margins. The mesorectal fascia was intact. No perforations were found. No metastases were found. The length of the specimen was 14 cm. The distal margin was 2.0 cm from a necrotic tumour with no vital tumour cells; the TNM classification was therefore pT0N0. Fig. 3 shows an anatomopathology picture of the tumour before radiation therapy. No pictures of the tumour after resection were possible, since there was complete regression. Six weeks after the resection, the patient was seen in the outpatient clinic and she had recovered very well. No postoperative complications had been noted. A sigmoidoscopy showed an intact anastomosis and the patient was planned for reversal of her ileostomy.
Discussion Laparoscopic TME is technically challenging and is associated with long operating times and a long learning curve, Copyright © 2014 John Wiley & Sons, Ltd.
425
Figure 3. Pathology of the tumour before chemoradiotherapy
especially in low rectal cancers (7,20). The main difficulties are the rectal dissection and pelvic exposure (1,4,7). A transanal approach helps to simplify the hardest part of the rectal resection. Most cases of transanal TME thus far presented have shown complete mesorectal resection with negative resection margins and adequate lymph node harvest, although Rouanet recently published his series of 30 cases with four positive circumferential margins (9–12,21,22). One of the main advantages of transanal endoscopic TME compared to laparoscopic TME is the accurate identification of the distal resection margin. Furthermore, no large abdominal incisions are needed to extract the specimen. Many of the laparoscopic difficulties are overcome with the tranasanal approach, especially difficulties with pelvic exposure, rectal dissection and distal stapling. However, the technical difficulties associated with TEM platforms and single ports may prevent the uptake of this new technique. The use of the robot helps to overcome most of these technical difficulties. In our early experience, the robot makes transanal mesorectal excision easier to perform. More experience in men with a narrow pelvis is needed before concluding on the true added value of the robot in this procedure. The limited manoeuvrability associated with TEM platforms and single incision ports was not experienced. In our first case operating time was 205 min, which is short compared to operating times in a series of transanal TMEs using conventional laparoscopic instruments (13). We assume that operating times can be even further decreased when more experience with the procedure is obtained. This patient was chosen for our first case because she was a woman with a wide pelvis, normal BMI and the tumour was in the mid-rectum. Although on first MRI the mesorectal fascia was dubiously involved, MRI after chemoradiotherapy showed almost complete regression Int J Med Robotics Comput Assist Surg 2014; 10: 423–426. DOI: 10.1002/rcs
426
of the tumour, making this, in our opinion, a very easy case and thus a perfect case to start with. We have shown the feasibility of robotic transanal rectal resection, although the major limitation of this study is the limited experience after one case. The possible advantages of the transanal approach make it an auspicious new technique with a promising role for the robot.
Conflict of interest The authors have stated explicity that there are no conflicts of interest in connection with this article.
Funding No specific funding.
References 1. Guillou PJ, Quirke P, Thorp H, et al. Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC Classic Trial): multicenter, randomized controlled trial. Lancet 2005; 365: 1718–1726. 2. Braga M, Frasson M, Vignali A, et al. Laparoscopic resection in rectal cancer patients: outcome and cost–benefit analysis. Dis Colon Rectum 2007; 50: 464–471. 3. Ng SS, Leung KL, Lee JF, et al. Laparoscopic-assisted versus open abdomino-perineal resection for low rectal cancer: a prospective randomized trial. Ann Surg Oncol 2008; 15: 2418–2425. 4. Ng SS, Leung KL, Lee JF, et al. Long- term morbidity and oncologic outcomes of laparoscopic-assisted anterior resection for upper rectal cancer: 10-year results of a prospective, randomized trial. Dis Colon Rectum 2009; 52: 558–566. 5. Lujan J, Valero G, Hernandez Q, et al. Randomized clinical trial comparing laparoscopic and open surgery in patients with rectal cancer. Br J Surg 2009; 96: 982–989. 6. Kang SB, Park JW, Jeong SY, et al. Open versus laparoscopic surgery for mid or low rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): short-term outcomes of an open-label randomised controlled trial. Lancet Oncol 2010; 11: 637–645.
Copyright © 2014 John Wiley & Sons, Ltd.
P. M. Verheijen et al. 7. Kang CY, Halabi WJ, Luo R, et al. Laparoscopic colorectal surgery: a better look into the latest trends. Arch Surg 2012; 147: 724–731. 8. Whiteford MH, Denk PM, Swanstrom LL. Feasibility of radical sigmoid colectomy performed as natural orifice translumenal endoscopic surgery (NOTES) using transanal endoscopic microsurgery. Surg Endosc 2007; 21: 1870–1874. 9. Chen YG, Hu M, Lei J, Chen JC, Li JY. NOTES transanal endoscopic total mesorectal excision for rectal cancer. Chin J Endosc 2010; 16: 1261–1265. 10. Tuech JJ, Bridoux V, Kianifard B, et al. Natural orifice total mesorectal excision using transanal port and laparoscopic assistance. Eur J Surg Oncol 2011; 37: 334–335. 11. Zorron R, Phillips HN, Coelho D, et al. Perirectal NOTES access: ‘down-to-up’ total meso-rectal excision for rectal cancer. Surg Innov 2012; 19: 11–19. 12. Lacy AM, Adelsdorfer C, Delgado S, et al. Minilaparoscopyassisted transrectal low anterior resection (LAR): a preliminary study. Surg Endosc 2013; 27(1): 339–346. 13. Sylla P, Bordeianou LG, Berger D, et al. A pilot study of natural orifice transanal endoscopic total mesorectal excision with laparoscopic assistance for rectal cancer. Surg Endosc 2013; 27: 3396–3405. 14. Koebrugge B, Bosscha K, Ernst MF. Transanal endoscopic microsurgery for local excision of rectal lesions: is there a learning curve? Dig Surg 2009; 26: 372–377. 15. Bardakcioglu O. Robotic transanal access surgery. Surg Endosc 2013; 27: 1407–1409. 16. Hompes R, Rauh SM, Hagen ME, et al. Preclinical cadaveric study of transanal endoscopic da Vinci® surgery. Br J Surg 2012; 99: 1144–1148. 17. Atallah SB, Albert MR, de Beche-Adams TH, et al. Robotic transanal minimally invasive surgery in a cadaveric model. Tech Coloproctol 2011; 15: 461–464. 18. Buchs NC, Pugin FP, Volonte F, et al. Robotic transanal endoscopic microsurgery: technical details for the lateral approach. Dis Colon Rectum 2013; 56: 1194–1198. 19. Atallah S, Nassif G, Polavarapu H, et al. Robotic-assisted transanal surgery for total mesorectal excision (RATS–TME): a description of a novel surgical approach with video demonstration. Tech Coloproctol 2013; 17(4): 441–447. 20. The Surgical Care and Outcomes Assessment Program (SCOAP) Collaborative, Kwon S, Billingham R, Farrokhi E, et al. Adoption of laparoscopy for elective colorectal resection: a report from the Surgical Care and Outcomes Assessment Program. J Am Coll Surg 2012; 214: 909–918: e1. 21. Sylla P, Rattner DW, Delgado S, et al. NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance. Surg Endosc 2010; 24: 1205–1210. 22. Rouanet P, Mourregot A, Azar CC, et al. Transanal endoscopic proctectomy: an innovative procedure for difficult resection of rectal tumors in men with narrow pelvis. Dis Colon Rectum 2013; 56(4): 408–415.
Int J Med Robotics Comput Assist Surg 2014; 10: 423–426. DOI: 10.1002/rcs
