Fig. 23.1
The robotic trocar is introduced into the GelPOINT Path TAMIS port via three cannulas. The cannulas are placed into the TAMIS port gelatinous lid which is then placed and secured onto its sheath (not shown)
Fig. 23.2
The setup for RTS. The robotic cart is docked over the left (or right) shoulder with the patient positioned modified lithotomy in Allen stirrups. A bedside assistant operates a suction irrigator device to assist with smoke evacuation. The robotic arms are configured using either an 8-mm or 15-mm lens with 8-mm working arms
Fig. 23.3
A T1 well-differentiated adenocarcinoma arising from a tubulovillous adenoma measure 3 cm is shown being removed during RTS for local excision
Fig. 23.4
The robot is now docked transanally. The console surgeon performs the excision, assisted only by the need for periodic smoke evacuation. A 5-mm laparoscopic smoke evacuator can be operated by a bedside assistant
Fig. 23.5
The tumor is now visible and a hook cautery and Maryland grasper are all that are needed to complete the RTS local excision of rectal neoplasm
To retrieve the resected specimen, the robot must be dismounted from the GelPOINT path interface. The lesion can be retrieved with a 5-mm grasper, the lid to the port simply removed allowing for specimen extraction.
The next step is closure of the full-thickness rectal wall defect, which is always recommended. To do this, the hook cautery and Maryland grasper are exchanged with two robotic needle drivers. Robotic intraluminal suturing is then carried out using a V-Loc 180 Absorbable Wound Closure Device (Covidien, Mansfield, MA). This allowed for suturing without the need for intraluminal knot tying, since the unidirectional barbs on the suture self-lock as they pass through the rectal wall. The defect can be closed with a single running V-Loc stitch, thereby completing the operation (Fig. 23.6).
Fig. 23.6
Once local excision has been completed, the full-thickness defect is closed using needle drivers and a V-Loc suture, obviating the need for knot tying
Discussion
RTS illustrates a novel approach to the resection of well-selected and appropriately staged rectal neoplasia. A key advantage of RTS over TAMIS or TEM is that the console surgeon is able to perform intricate surgery more easily within the narrow, cylindrical lumen. The EndoWrist movement allows for greater intraluminal dexterity. This, together with magnified 3D optics, enhances the surgeon’s ability to perform transanal local excision with improved precision. This also improves the ability to successfully complete complex tasks, such as intraluminal suturing. RTS is a new approach to transanal access, and its ability to accomplish intricate tasks with ease makes this method suitable for complex cases, where local excision or other advanced transanal procedures (such as transanal repair of rectourethral fistulae) may prove difficult with TAMIS or TEM.
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