COMMENTARY Robotically Assisted Transanal Total Mesorectal Excision: An Exciting New Trend in Rectal Cancer Surgery
read with great interest the Letter to the Editor published by Huscher et al1 in this issue of Annals of Surgery. The letter describes their experience with robotic transanal total mesorectal excision (taTME) with laparoscopic assistance. Their study included 7 patients with T2 and T3 node-negative low rectal cancer located an average of 2 cm from the anal verge. The study included 4 females and 3 males with a mean body mass index of 29.9 kg/m2 (range, 21.5–37.5 kg/m2 ), in whom robotic taTME was performed through a transanal endoscopic multiport platform. All cases were performed using laparoscopic assistance for inferior mesenteric vessel ligation, splenic flexure takedown, and ileostomy creation. A complete (6/7) or near-complete (1/7) mesorectum specimen was obtained with negative resection margins and a mean lymph node harvest of 14. One case was complicated by minor postoperative rectal bleeding, with no other complications at a mean follow-up of 2.5 months, and all 7 patients have undergone ileostomy closure. This report highlights one of the most exciting new trends in rectal cancer surgery since the adoption of laparoscopy. Proof of concept that complete rectal and mesorectal dissection can be achieved using a primary transanal endoscopic approach was demonstrated in animal and cadaveric models starting in 2007.2,3 The first published clinical report of laparoscopic-assisted taTME in 2010 highlighted the feasibility, preliminary safety, and potential impact of this approach in reducing the technical difficulty and improving the quality of TME specimens, particularly for low rectal tumors in the narrow male pelvis.4 Since this report, more than 14 series have been published outcomes in more than 100 patients undergoing either pure taTME or hybrid taTME procedures.5–8 These reports support the preliminary oncologic safety of taTME in carefully selected patients, as reflected by negative resection margins, grade I or II TME
specimen quality, and adequate lymph node harvest.5–8 Most recently, 3 case reports have described the use of the robotic platform to perform taTME in a total of 5 patients with locally advanced rectal cancers located an average 4.4 cm from the anal verge (range, 3–5 cm) and treated with neoadjuvant therapy (4/5) based on suspected node positivity.9–11 The robot was docked either on the patient’s left or right side, with operative time ranging from 205 to 420 minutes. The authors reported complete or nearcomplete TME specimens, negative margins, and a 40% overall incidence of postoperative complications.9–11 In their report, Huscher et al are to be congratulated not only for reporting the largest series published to date on robotic taTME with laparoscopic assistance but also for their excellent outcomes. Remarkably, the mean operative time of 165.7 minutes (range, 85–220 minutes) was substantially lower than that from prior robotic taTME reports, despite an average body mass index of 29.9 kg/m2 , and lower average rectal tumor location (range, 1–6.5 cm). The authors’ operative time is also lower than that reported in the majority of case series on laparoscopic-assisted taTME.8 It is possible that the shorter operative time reflected the authors’ fast learning curve and prior experience with laparoscopic-assisted taTME. From a technical standpoint, it is unclear whether docking of the robot along the patient’s right rather than left side, specific robotic arm configuration, and the use of combined abdominal and transanal operating teams may have impacted procedural time. In conclusion, this case series of 7 robotic taTME with laparoscopic assistance further demonstrates the feasibility and preliminary safety of taTME using a robotic platform in carefully selected patients. The results also suggest for the first time the potential for reducing operative time relative to taTME with laparoscopic assistance, which will have to be investigated in larger studies. Regardless of the specific approach to complete taTME, this reports highlights the prerequisite technical expertise and training required in minimally invasive techniques for rectal cancer resection, including transanal endoscopic and laparoscopic and/or robotic skills.
Patricia Sylla, MD Division of General and Gastrointestinal Surgery Department of Surgery Massachusetts General Hospital Boston, MA [email protected]
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Disclosure: The author declares no conflicts of interest. C 2015 Wolters Kluwer Health, Inc. All Copyright rights reserved. ISSN: 0003-4932/15/26105-e0122 DOI: 10.1097/SLA.0000000000001090
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Annals of Surgery r Volume 261, Number 5, May 2015
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