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Robotic TAMIS

Jamie A Cannon, MD FACS, FASCRS

Associate Professor of Surgery

University of Alabama at Birmingham

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Disclosures

▪ Instructor for Intuitive Surgical

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Transanal Excision

▪ Tumors 8 cm from anal verge

▪ <= 3 cm in size

▪ <= 40% rectal circumference

▪ Polyps or favorable T1 lesions

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TEMS

▪ Introduced in the early 1980’s by Dr. Buess

▪ Large operating proctoscope

▪ Provides stable pneumorectum

▪ True 3D view

▪ Can access lesions up to the rectosigmoid junction

▪ Associated with lower rate of recurrence

▪ Difficult set-up; high learning curve; require of specialized equipment

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TAMIS

▪ Described in 2010 by Atallah

▪ Uses a transanal access port to establish pneumorectum

▪ Uses standard laparoscopic instruments

▪ Special patient positioning not required

▪ Lose the 3D view

▪ In both TEMS and TAMIS, long parallel instruments limit technical ability

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Why robotic TAMIS?

▪ Provides magnified, HD, 3D visualization

▪ Simpler set up than traditional TEMS

▪ Wristed instrumentation

▪ Helps overcome the challenges and frustrations of TEMS and laparoscopic TAMIS

▪ Simplifies suturing and closure of defects

▪ May allow for treatment of more complex lesions and varying pathologies

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Patient Positioning

Lithotomy vs Prone

Easy access to the anusMakes anesthesia happy

In either position, can access lesions in any location by rotating the camera

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Insertion of TAMIS port

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Insertion of trocars

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Insertion of trocars

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Docking

▪ Robot can be brought in from any position

▪ Laser lights centered over access device

▪ Rotate boom so robot arms are directed cephalad

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Tips and Tricks

▪ Before beginning operation, assess motion of instruments to make adjustments for maximum mobility

▪ Trocars can easily be burped and position adjusted as gel cap is malleable

▪ If difficulty reaching a certain area, bring the tissue to the instrument

▪ When internal collisions are encountered, withdrawing and reinserting camera and/or instruments can resolve

▪ Can change camera from 30 up to 30 down as needed

▪ Assistant uses suction- can use red rubber catheter on tip

▪ Be ambidextrous!

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Safety Considerations

▪ Advancement of instruments must be under direct visualization

▪ Can not use the “auto return” due to rectal valves

Robotic Transanal Resection

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Transanal Repair of Rectourethral Fistula

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Other Operating Systems

MedRobotics Davinci SP

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The Future

Fully robotic interventional bronchoscopes now entering the market, such as Monarch from Auris Health

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The Future

+

Now, imagine a fully robotic, stable colonoscope which can navigate the entire colon (or abdomen!) and has articulating arms…

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Summary

▪ Robotic TAMIS is feasible

▪ Offers advantages of excellent visualization and enhanced technical abilities due to wristed instrumentation

▪ Relieves some of the frustrations associated with TEMS/laparoscopic TAMIS

▪ May allow for resection of more advanced lesions and additional pathology

▪ The future is exciting!

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Thank you!

jacannon@uab.edu