Techniques in Coloproctology

, Volume 23, Issue 1, pp 53–63 | Cite as

Robotic-assisted stereotactic real-time navigation: initial clinical experience and feasibility for rectal cancer surgery

  • S. AtallahEmail author
  • E. Parra-Davila
  • A. G. F. Melani
  • L. G. Romagnolo
  • S. W. Larach
  • J. Marescaux
Multimedia Article



Real-time stereotactic navigation for transanal total mesorectal excision has been demonstrated to be feasible in small pilot series using laparoscopic techniques. The possibility of real-time stereotactic navigation coupled with robotics has not been previously explored in a clinical setting.


After pre-clinical assessment, and configuration of a robotic-assisted navigational system, two patients with locally advanced rectal cancer were selected for enrollment into a pilot study designed to assess the feasibility of navigation coupled with the robotic da Vinci Xi platform via TilePro interface. In one case, fluorescence-guided surgery was also used as an adjunct for structure localization, with local administration of indocyanine green into the ureters and at the tumor site.


Each operation was successfully completed with a robotic-assisted approach; image-guided navigation provided computed accuracy of ± 4.5 to 4.6 mm. The principle limitation encountered was navigation signal dropout due to temporary loss of direct line-of-sight with the navigational system’s infrared camera. Subjectively, the aid of navigation assisted the operating surgeon in identifying critical anatomical planes. The combination of fluorescence with image-guided surgery further augmented the surgeon’s perception of the operative field.


The combination of stereotactic navigation and robotic surgery is feasible, although some limitations and technical challenges were observed. For complex surgery, the addition of navigation to robotics can improve surgical precision. This will likely represent the next step in the evolution of robotics and in the development of digital surgery.


Digital surgery TaTME Rectal cancer Robotic colorectal Augmented reality Da Vinci navigation Stereotactic navigation Image-guided surgery Fluorescence-guided surgery 



The authors wish to thank Laura Galorneau, Zack Demetriou, Meraj Baig, Tina Langaee, Meghann Vizintos, Janelle Abravaya, Brian Solomon, and Lauren Skesavage for there assistance with this research.


No funding was received for this study.

Compliance with ethical standards

Conflict of interest

Dr. S. Atallah reports consultancy (such as consulting fees, honoraria) from Medtronic, Applied Medical, ConMed, Inc, and Medrobotics. Dr. S. Larach holds stock options with Applied Medical. Dr. J. Marescaux is president of both IRCAD and IHU Strasbourg, which are partly funded by Karl Storz, Medtronic, and Siemens Healthcare though he has no direct conflict of interest with content discussed in this manuscript. Dr. A.G.F. Melani receives remuneration (payment for services not otherwise identified as salary such as consulting fees, honoraria) from Medtronic, Ethicon, Intuitive Surgical, and Verb Surgical though he has no direct conflicts of interest with content discussed in this manuscript. Dr. E. Parra-Davila receives remuneration (payment for services not otherwise identified as salary such as consulting fees, honoraria) from Medtronic, Ethicon, Intuitive Surgical, and Verb Surgical though he has no direct conflicts of interest with content discussed in this manuscript. Dr. L. Romagnolo has received remuneration (honoraria) from Medtronic, Inc. and Johnson & Johnson.

Ethical approval

This research was performed in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained in accordance with the standards set forth by hospital regulations.

Supplementary material

Supplementary material 1 (MP4 14,66,599 kB)


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Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • S. Atallah
    • 1
    Email author
  • E. Parra-Davila
    • 2
  • A. G. F. Melani
    • 3
  • L. G. Romagnolo
    • 4
  • S. W. Larach
    • 1
  • J. Marescaux
    • 5
  1. 1.Department of Colorectal Surgery, EndoSurgical Center of FloridaFlorida HospitalOrlandoUSA
  2. 2.Department of SurgeryGood Samaritan HospitalWest Palm BeachUSA
  3. 3.Department of SurgeryIRCAD, Latin AmericaRio de JeneiroBrazil
  4. 4.Department of SurgeryIRCAD, Latin AmericaBarretosBrazil
  5. 5.Department of SurgeryIRCAD, FranceStrasbourgFrance

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