Skip to main content

Advertisement

SpringerLink
Log in

Feasibility of transanal total mesorectal excision (taTME) using the Medrobotics Flex® System

  • Dynamic Manuscript
  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

The use of transanal total mesorectal excision (taTME) for treatment of rectal cancer is growing, but anatomic constraints prevent access to the proximal rectum with rigid instruments. The articulated instrumentation of current surgical robots is promising in overcoming these limitations, but the bulky size of current platforms inhibits the proximal reach of dissection. Flexible robotic systems could overcome these constraints while maintaining a stable platform for dissection. The goal of this study was to evaluate feasibility of performing taTME using the semi-robotic Flex® System (Medrobotics Corp., Raynham, MA) in human cadavers.

Methods

taTME was performed by two surgeons in six fresh human cadaveric specimens using the Flex® System, with or without transabdominal laparoscopic assistance. Both mid- and low-rectal lesions were simulated. Metrics including quality of visualization, maintenance of pneumorectum, maneuverability of instruments, effectiveness of pursestring suture placement, and dissection in an anatomically correct plane were evaluated.

Results

The semi-robotic endoluminal platform allowed for excellent visualization, insufflation, and dissection during taTME. Adequate pursestring occlusion of the rectum was achieved in all six cases. In cadavers with simulated mid-rectal lesions (N = 4), dissection and anterior peritoneal entry was achieved in all cases, with abdominal assistance utilized in two of four cases. In cadavers with simulated low-rectal lesions (N = 2), dissection was incomplete and aborted due to difficulty maneuvering instruments in close proximity to the rigid transanal port.

Conclusions

Use of the Flex® system for taTME is feasible for mid-rectal dissection. Advantages over the traditional multi-armed robot include longer reach of instruments with the ability to dissect up to 17 cm from the anal verge, as well as tactile feedback. The current design of the flexible platform does not permit safe dissection in the distal rectum, although this constraint may be resolved with future adjustments to the equipment.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. MacFarlane JK, Ryall RD, Heald RJ (1993) Mesorectal excision for rectal cancer. Lancet 341:457–460

    Article  CAS  Google Scholar 

  2. Marijnen CA, Kapiteijn E, van de Velde CJ, Martijn H, Steup WH, Wiggers T, Kranenbarg EK, Leer JW, Cooperative Investigators of the Dutch Colorectal Cancer Group (2002) Acute side effects and complications after short-term preoperative radiotherapy combined with total mesorectal excision in primary rectal cancer: report of a multicenter randomized trial. J Clin Oncol 20:817–825

    Article  CAS  Google Scholar 

  3. Snijders H, Wouters M, van Leersum N, Kolfschoten N, Henneman D, de Vries A, Tollenaar R, Bonsing B (2012) Meta-analysis of the risk for anastomotic leakage, the postoperative mortality caused by leakage in relation to the overall postoperative mortality. Eur J Surg Oncol 38:1013–1019

    Article  CAS  Google Scholar 

  4. Jeong S, Park J, Nam B, Kim S, Kang S, Lim S, Choi H, Kim D, Chang H, Kim D, Jung K, Kim T, Kang G, Chie E, Kim S, Sohn D, Kim D, Kim J, Lee H, Kim J, Oh J (2014) Open versus laparoscopic surgery for mid-rectal or low-rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): survival outcomes of an open-label, non-inferiority, randomised controlled trial. Lancet Oncol 15:767–774

    Article  Google Scholar 

  5. Ohtani H, Tamamori Y, Azuma T, Mori Y, Nishiguchi Y, Maeda K, Hirakawa K (2011) A meta-analysis of the short- and long-term results of randomized controlled trials that compared laparoscopy-assisted and conventional open surgery for rectal cancer. J Gastrointest Surg 15:1375–1385

    Article  Google Scholar 

  6. Kang S, Park J, Jeong S, Nam B, Choi H, Kim D, Lim S, Lee T, Kim D, Kim J, Chang H, Lee H, Kim S, Jung K, Hong Y, Kim J, Sohn D, Kim D, Oh J (2010) 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 11:637–645

    Article  Google Scholar 

  7. Kang C, Halabi W, Luo R, Pigazzi A, Nguyen N, Stamos M (2012) Laparoscopic colorectal surgery: a better look into the latest trends. Arch Surg 147:724–731

    Article  Google Scholar 

  8. Guillou P, Quirke P, Thorpe H, Walker J, Jayne D, Smith A, Heath R, Brown J, MRC CLASICC trial group (2005) Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet 365:1718–1726

    Article  Google Scholar 

  9. van der Pas M, Haglind E, Cuesta M, Fürst A, Lacy A, Hop W, Bonjer H, COlorectal cancer Laparoscopic or Open Resection II (COLOR II) Study Group (2013) Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial. Lancet Oncol 14:210–218

    Article  Google Scholar 

  10. Green B, Marshall H, Collinson F, Quirke P, Guillou P, Jayne D, Brown J (2013) Long-term follow-up of the Medical Research Council CLASICC trial of conventional versus laparoscopically assisted resection in colorectal cancer. Br J Surg 100:75–82

    Article  CAS  Google Scholar 

  11. Fleshman J, Branda M, Sargent D, Boller A, George V, Abbas M, Peters W, Maun D, Chang G, Herline A, Fichera A, Mutch M, Wexner S, Whiteford M, Marks J, Birnbaum E, Margolin D, Larson D, Marcello P, Posner M, Read T, Monson J, Wren S, Pisters P, Nelson H (2015) Effect of laparoscopic-assisted resection vs open resection of stage II or III rectal cancer on pathologic outcomes: the ACOSOG Z6051 randomized clinical trial. JAMA 314:1356–1364

    Article  Google Scholar 

  12. Stevenson A, Solomon M, Lumley J, Hewett P, Clouston A, Gebski V, Davies L, Wilson K, Hague W, Simes J (2015) Effect of laparoscopic-assisted resection vs open resection on pathological outcomes in rectal cancer: the ALaCaRT randomized clinical trial. JAMA 314:1356–1363

    Article  CAS  Google Scholar 

  13. Collinson F, Jayne D, Pigazzi A, Tsang C, Barrie J, Edlin R, Garbett C, Guillou P, Holloway I, Howard H, Marshall H, McCabe C, Pavitt S, Quirke P, Rivers C, Brown J (2012) An international, multicentre, prospective, randomised, controlled, unblinded, parallel-group trial of robotic-assisted versus standard laparoscopic surgery for the curative treatment of rectal cancer. Int J Colorectal Dis 27:233–241

    Article  Google Scholar 

  14. Tyler J, Fox J, Desai M, Perry W, Glasgow S (2013) Outcomes and costs associated with robotic colectomy in the minimally invasive era. Dis Colon Rectum 56:458–466

    Article  Google Scholar 

  15. Jayne D, Pigazzi A, Marshall H, Croft J, Corrigan N, Copeland J, Quirke P, West N, Rautio T, Thomassen N, Tilney H, Gudgeon M, Bianchi P, Edlin R, Hulme C, Brown J (2017) Effect of robotic-assisted vs conventional laparoscopic surgery on risk of conversion to open laparotomy among patients undergoing resection for rectal cancer: the ROLARR Randomized Clinical Trial. JAMA 318:1569–1580

    Article  Google Scholar 

  16. Sylla P, Sohn D, Cizginer S, Konuk Y, Turner B, Gee D, Willingham F, Hsu M, Mino-Kenudson M, Brugge W, Rattner D (2010) Survival study of natural orifice translumenal endoscopic surgery for rectosigmoid resection using transanal endoscopic microsurgery with or without transgastric endoscopic assistance in a swine model. Surg Endosc 24:2022–2030

    Article  Google Scholar 

  17. Sylla P, Rattner D, Delgado S, Lacy A (2010) NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance. Surg Endosc 24:1205–1210

    Article  Google Scholar 

  18. Telem D, Han K, Kim M, Ajari I, Sohn D, Woods K, Kapur V, Sbeih M, Perretta S, Rattner D, Sylla P (2013) Transanal rectosigmoid resection via natural orifice translumenal endoscopic surgery (NOTES) with total mesorectal excision in a large human cadaver series. Surg Endosc 27:74–80

    Article  Google Scholar 

  19. Penna M, Hompes R, Arnold S, Wynn G, Austin R, Warusavitarne J, Moran B, Hanna G, Mortensen N, Tekkis P, Collaborative TR (2016) Transanal total mesorectal excision: international registry results of the first 720 cases. Ann Surg 266:111

    Article  Google Scholar 

  20. Penna M, Hompes R, Arnold S, Wynn G, Austin R, Warusavitarne J, Moran B, Hanna G, Mortensen N, Tekkis P (2018) Incidence and risk factors for anastomotic failure in 1594 patients treated by transanal total mesorectal excision: results from the international TaTME registry. Ann Surg. https://doi.org/10.1097/sla.0000000000002653

    Article  Google Scholar 

  21. Maykel J (2015) Laparoscopic transanal total mesorectal excision (taTME) for rectal cancer. J Gastrointest Surg 19:1880–1888

    Article  Google Scholar 

  22. Koedam T, Veltcamp Helbach M, Van de Ven P, Kryut P, van Heek N, Bonjer H, Tuynman J, Sietses C (2018) Transanal total mesorectal excision for rectal cancer: evaluation of the learning curve. Tech Coloproctol 22:279–287

    Article  CAS  Google Scholar 

  23. Lee L, Kelly J, Nassif G, DeBeche-Adams T, Albert M, Monson J (2018) Defining the learning curve for transanal total mesorectal excision for rectal adenocarcinoma. Surg Endosc. https://doi.org/10.1007/s00464-018-6360-4

    Article  PubMed  PubMed Central  Google Scholar 

  24. Atallah S, Parra-Davila E, DeBeche-Adams T, Albert M, Larach S (2012) Excision of a rectal neoplasm using robotic transanal surgery (RTS): a description of the technique. Tech Coloproctol 16:389–392

    Article  CAS  Google Scholar 

  25. Verheijen P, Consten E, Broeders I (2014) Robotic transanal total mesorectal excision for rectal cancer: experience with a first case. Int J Med Robot 10:423–426

    Article  CAS  Google Scholar 

  26. Gómez Ruiz M, Parra I, Palazuelos C, Martín J, Fernández C, Diego J, Fleitas M (2015) Robotic-assisted laparoscopic transanal total mesorectal excision for rectal cancer: a prospective pilot study. Dis Colon Rectum 58:145–153

    Article  Google Scholar 

  27. Atallah S, Martin-Perez B, Pinan J, Quinteros F, Schoonyoung H, Albert M, Larach S (2014) Robotic transanal total mesorectal excision: a pilot study. Tech Coloproctol 18:1047–1053

    Article  CAS  Google Scholar 

  28. Huscher C, Bretagnol F, Ponzano C (2015) Robotic-assisted transanal total mesorectal excision: the key against the Achilles’ heel of rectal cancer? Ann Surg 261:e120–121

    Article  Google Scholar 

  29. Kuo L, Ngu J, Tong Y, Chen C (2017) Combined robotic transanal total mesorectal excision (R-taTME) and single-site plus one-port (R-SSPO) technique for ultra-low rectal surgery-initial experience with a new operation approach. Int J Colorectal Dis 32:249–254

    Article  Google Scholar 

  30. Atallah S (2017) Assessment of a flexible robotic system for endoluminal applications and transanal total mesorectal excision (taTME): could this be the solution we have been searching for? Tech Coloproctol 21:809–814

    Article  CAS  Google Scholar 

  31. Johnson P, Rivera Serrano C, Castro M, Kuenzler R, Choset H, Tully S, Duvvuri U (2013) Demonstration of transoral surgery in cadaveric specimens with the medrobotics flex system. Laryngoscope 123:1168–1172

    Article  Google Scholar 

  32. Remacle M, Prasad MN, Lawson G, Plisson L, Bachy V, Van der Vorst S (2015) Transoral robotic surgery (TORS) with the Medrobotics Flex™ System: first surgical application on humans. Eur Arch Otorhinolaryngol 272:1451–1455

    Article  CAS  Google Scholar 

  33. Mandapathil M, Duvvuri U, Güldner C, Teymoortash A, Lawson G, Werner J (2015) Transoral surgery for oropharyngeal tumors using the Medrobotics(®) Flex(®) System—a case report. Int J Surg Case Rep 10:173–175

    Article  Google Scholar 

  34. Lang S, Mattheis S, Hasskamp P, Lawson G, Güldner C, Mandapathil M, Schuler P, Hoffmann T, Scheithauer M, Remacle M (2017) A european multicenter study evaluating the flex robotic system in transoral robotic surgery. Laryngoscope 127:391–395

    Article  Google Scholar 

  35. Jafari M, Carmichael J, Kopchok G, Pigazzi A (2017) A pilot study to evaluate a flexible robot for transanal surgery

  36. Friedrich D, Dürselen L, Mayer B, Hacker S, Schall F, Hahn J, Hoffmann T, Schuler P, Greve J (2018) Features of haptic and tactile feedback in TORS—a comparison of available surgical systems. J Robot Surg 12:103–108

    Article  Google Scholar 

Download references

Author information

Author notes

  1. Heather Carmichael and Anthony P. D’Andrea have contributed equally to this work and serve as co-first authors.

Authors and Affiliations

  1. Department of Surgery, University of Colorado, Denver, CO, USA

    Heather Carmichael

  2. Division of Colon and Rectal Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, Box 1259, New York, NY, 10029, USA

    Anthony P. D’Andrea & Patricia Sylla

  3. Department of General Surgery and Colorectal Surgery, George Washington University School of Medicine, Washington, DC, USA

    Matthew Skancke & Vincent Obias

Authors
  1. Heather Carmichael
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Anthony P. D’Andrea
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Matthew Skancke
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Vincent Obias
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Patricia Sylla
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Patricia Sylla.

Ethics declarations

Disclosures

Drs. Obias and Sylla are consultants for Medrobotics. Drs. Carmichael, D’Andrea, and Skancke have no conflicts of interest or financial ties to disclose.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (MP4 142060 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Carmichael, H., D’Andrea, A.P., Skancke, M. et al. Feasibility of transanal total mesorectal excision (taTME) using the Medrobotics Flex® System. Surg Endosc 34, 485–491 (2020). https://doi.org/10.1007/s00464-019-07019-y

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-019-07019-y

Keywords

Search

Navigation