A new era in surgical robotics has centered on alternative access to anatomic targets and next generation designs include flexible, single-port systems which follow circuitous rather than straight pathways. Such systems maintain a small footprint and could be utilized for specialized operations based on direct organ target natural orifice transluminal endoscopic surgery (NOTES), of which transanal total mesorectal excision (taTME) is an important derivative.
During two sessions, four direct target NOTES operations were conducted on a cadaveric model using a flexible robotic system to demonstrate proof-of-concept of the application of a next generation robotic system to specific types of NOTES operations, all of which required removal of a direct target organ through natural orifice access. These four operations were (a) robotic taTME, (b) robotic transvaginal hysterectomy in conjunction with (c) robotic transvaginal salpingo-oophorectomy, and in an ex vivo model, (d) trans-cecal appendectomy.
Feasibility was demonstrated in all cases using the Flex® Robotic System with Colorectal Drive. During taTME, the platform excursion was 17 cm along a non-linear path; operative time was 57 min for the transanal portion of the dissection. Robotic transvaginal hysterectomy was successfully completed in 78 min with transvaginal extraction of the uterus, although laparoscopic assistance was required. Robotic transvaginal unilateral salpingo-oophorectomy with transvaginal extraction of the ovary and fallopian tube was performed without laparoscopic assistance in 13.5 min. In an ex vivo model, a robotic trans-cecal appendectomy was also successfully performed for the purpose of demonstrating proof-of-concept only; this was completed in 24 min.
A flexible robotic system has the potential to access anatomy along circuitous paths, making it a suitable platform for direct target NOTES. The conceptual operations posed could be considered suitable for next generation robotics once the technology is optimized, and after further preclinical validation.
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Rao P, Reddy N (2004) Per oral transgastric endoscopic appendectomy in human. In: Proceedings of the 45th annual conference of the society of gastrointestinal endoscopy of India, Jaipur 28–29
Rattner D, Kalloo A, ASGE/SAGES Working Group (2005) ASGE/SAGES working group on natural ori ce translumenal endoscopic surgery. Surg Endosc 20:329–333
Rattner D (2006) Introduction to NOTES White Paper. Surg Endosc 20:185
McGee MF, Rosen MJ, Marks J et al (2006) A primer on natural orifice transluminal endoscopic surgery: building a new paradigm. Surg Inno 13(2):86–93
Rattner DW, Hawes R, Schwaitzberg S, Kochman M, Swanstrom L (2011) The second SAGES/ASGE white paper on natural orifice transluminal endoscopic surgery: 5 years of progress. Surg Endosc 1 25(8):2441–2448
Atallah S, Martin-Perez B, Keller D, Burke J, Hunter L (2015) Natural-orifice transluminal endoscopic surgery. Br J Surg 102(2):e73–92. https://doi.org/10.1002/bjs.9710
Arezzo A, Zornig C, Mod H et al (2013) The EURO-NOTES clinical registry for natural orifice transluminal endoscopic surgery: a 2-year activity report. Surg Endosc 27:3073–3084
Zorron R, Palanivelu C, Galvão Neto MP et al (2010) International multicenter trial on clinical natural orifice surgery—NOTES IMTN study: preliminary results of 362 patients. Surg Innov 17:142–158
Lang S, Mattheis S, Hasskamp P et al (2017) A European multicenter study evaluating the flex robotic system in transoral robotic surgery. Laryngoscope 127(2):391–395. https://doi.org/10.1002/lary.26358
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(10):809–814. https://doi.org/10.1007/s10151-017-1697-6
Penna M, Hompes R, Arnold S et al (2017) Transanal total mesorectal excision: international registry results of the first 720 cases. Ann Surg 266(1):111–117
Arroyave MC, DeLacy FB, Lacy AM (2017) Transanal total mesorectal excision (TaTME) for rectal cancer: step by step description of the surgical technique for a two-teams approach. Eur J Surg Oncol 43(2):502–505
Atallah S, Albert M, Nassif G, Polavarapu H, Larach S (2013) Transanal minimally invasive surgery for total mesorectal excision (TAMIS–TME): a stepwise description of the surgical technique with video demonstration. Tech Coloproctol 17(3):321–325
Marks JH, Lopez-Acevedo N, Krishnan B, Johnson MN, Montenegro GA, Marks GJ (2016) True NOTES TME resection with splenic flexure release, high ligation of IMA, and side-to-end hand-sewn coloanal anastomosis. Surg Endosc 30(10):4626–4631
Leroy J, Barry BD, Melani A, Mutter D, Marescaux J (2013) No-scar transanal total mesorectal excision: the last step to pure NOTES for colorectal surgery. JAMA Surg 148(3):226–230
Chouillard E, Chahine E, Khoury G,et al (2014) NOTES total mesorectal excision (TME) for patients with rectal neoplasia: a preliminary experience. Surg Endosc 28(11):3150–3157
Zhang H, Zhang YS, Jin XW, Li MZ, Fan JS, Yang ZH (2013) Transanal single-port laparoscopic total mesorectal excision in the treatment of rectal cancer. Tech Coloproctol 17(1):117–123
Leão P, Goulart A, Veiga C et al (2015) Transanal total mesorectal excision: a pure NOTES approach for selected patients. Tech Coloproctol 19(9):541–549
Geller EJ (2014) Vaginal hysterectomy: the original minimally invasive surgery. Minerva Ginecol 66:23–33
Atallah S, Albert M, Larach S (2010) Transanal minimally invasive surgery: a giant leap forward. Surg Endosc 24(9):2200–2205
Atallah S, Martin-Perez B, Schoonyoung H et al (2014) Vaginal access minimally invasive surgery: a new approach to hysterectomy. J Minim Invasive Gynecol 21(6):S116
Atallah S, Martin-Perez B, Albert M,et al (2015) Vaginal access minimally invasive surgery (VAMIS): a new approach to hysterectomy. Surg Innov 22(4):344–347. https://doi.org/10.1177/1553350614560273
Atallah S, Dubose A, Larach S (2017) Vaginal access minimally invasive surgery for repair of a postanastomotic rectovaginal fistula: a video description of a novel method. Dis Colon Rectum 60(1):126–127
Baekelandt J, Cavens D (2016) GelPOINT (Applied Medical) is a suitable port for transvaginal NOTES procedures. J Gynecol Surg 32(5):257–262
Baekelandt J (2015) Total vaginal NOTES hysterectomy: a new approach to hysterectomy. J Minim Invasive Gynecol 22(6):1088–1094
Rassweiler JJ, Autorino R, Klein J, Mottrie A, Goezen AS, Stolzenburg JU, Rha KH, Schurr M, Kaouk J, Patel V, Dasgupta P, Liatsikos E (2017) Future of robotic surgery in urology. BJU Int. https://doi.org/10.1111/bju.13851
Palanivelu C, Rajan PS, Rangarajan M, Parthasarathi R, Senthilnathan P, Prasad M (2008) Transvaginal endoscopic appendectomy in humans: a unique approach to NOTES—world’s first report. Surg Endosc 22(5):1343–1347
Velthuis S, Veltcamp Helbach M et al (2015) Intra-abdominal bacterial contamination in TAMIS total mesorectal excision for rectal carcinoma: a prospective study. Surg Endosc 29(11):3319–3323. https://doi.org/10.1007/s00464-015-4089-x (Epub 2015 Feb 11)
Marks JH, Frenkel JL, Greenleaf CE, D’Andrea AP (2014) Transanal endoscopic microsurgery with entrance into the peritoneal cavity: is it safe? Dis Colon Rectum 57(10):1176–1182
Gavagan JA, Whiteford MH, Swanstrom LL (2004) Full-thickness intraperitoneal excision by transanal endoscopic microsurgery does not increase short-term complications. Am J Surg 187(5):630–634
Trastulli S, Coratti A, Guarino S et al (2015) Robotic right colectomy with intracorporeal anastomosis compared with laparoscopic right colectomy with extracorporeal and intracorporeal anastomosis: a retrospective multicentre study. Surg Endosc 29(6):1512–1521. https://doi.org/10.1007/s00464-014-3835-9
Milone M, Elmore U, Di Salvo E et al (2015) Intracorporeal versus extracorporeal anastomosis. Results from a multicentre comparative study on 512 right-sided colorectal cancers. Surg Endosc 29(8):2314–2320. https://doi.org/10.1007/s00464-014-3950-7
Schmidt A, Bauerfeind P, Gubler C, Damm M, Bauder M, Caca K (2015) Endoscopic full-thickness resection in the colorectum with a novel over-the-scope device: first experience. Endoscopy 47(08):719–725
Schurr MO, Baur F, Ho CN, Anhoeck G, Kratt T, Gottwald T (2011) Endoluminal full-thickness resection of GI lesions: a new device and technique. Minim Invasive Ther Allied Technol 20(3):189–192. https://doi.org/10.3109/13645706.2011.582119
Schurr MO, Baur FE, Krautwald M,et al (2015) Endoscopic full-thickness resection and clip defect closure in the colon with the new FTRD system: experimental study. Surg Endosc 29(8):2434–2441
Schmidt A, Beyna T, Schumacher B et al (2017) Colonoscopic full-thickness resection using an over-the-scope device: a prospective multicentre study in various indications. Gut. https://doi.org/10.1136/gutjnl-2016-313677
Kantsevoy SV, Bitner M, Davis JM, Hajiyeva G, Thuluvath PJ, Gushchin V (2015) Endoscopic suturing closure of large iatrogenic colonic perforation. Gastrointest Endosc 82(4):754–755. https://doi.org/10.1016/j.gie.2015.05.031
Kantsevoy SV, Bitner M, Mitrakov AA, Thuluvath PJ (2014) Endoscopic suturing closure of large mucosal defects after endoscopic submucosal dissection is technically feasible, fast, and eliminates the need for hospitalization (with videos). Gastrointest Endosc 79(3):503–507. https://doi.org/10.1016/j.gie.2013.10.051
Atallah S, Albert M, DeBeche-Adams T, Nassif G, Polavarapu H, Larach S (2013) Transanal minimally invasive surgery for total mesorectal excision (TAMIS-TME): a stepwise description of the surgical technique with video demonstration. Tech Coloproctol 17(3):321–325. https://doi.org/10.1007/s10151-012-0971-x
Sylla P, Rattner DW, Delgado S, Lacy AM (2010) NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance. Surg Endosc 24(5):1205–1210
Araujo SE, Crawshaw B, Mendes CR, Delaney CP (2015) Transanal total mesorectal excision: a systematic review of the experimental and clinical evidence. Tech Coloproctol 19(2):69–82. https://doi.org/10.1007/s10151-014-1233-x (Epub 2014 Nov 9)
Atallah S, Martin-Perez B, Pinan J et al (2014) Robotic transanal total mesorectal excision: a pilot study. Tech Coloproctol 18:1047–1053
Gómez Ruiz M, Parra IM, Palazuelos CM,et al (2015) Robotic-assisted laparoscopic transanal total mesorectal excision for rectal cancer: a prospective pilot study. Dis Colon Rectum 58(1):145–153
Kuo LJ, Nqu JC, Tong YS, Chen CC (2017) Combined robotic transanal total esorectal excision (R-taTME) and single-site plus one-port (R-SSPO) technique for uotra-low rectal surgery-initial experience with a new operation approach. Int J Colorectal Dis 32(2):249–254
Huscher CG, Bretagnol F, Ponzano C (2015) Robotic-assisted transanal total mesorectal excision: the key against the Achilles’ heel of rectal cancer? Ann Surg 261(5):e120–e121
Marks J, Ng S, Mak T (2017) Robotic transanal surgery (RTAS) with utilization of a next-generation single-port system: a cadaveric feasibility study. Tech Coloproctol 21(7):541–545. https://doi.org/10.1007/s10151-017-1655-3
Peters BS, Armijo PR, Krause C, Choudhury SA, Oleynikov D (2018) Review of emerging surgical robotic technology. Surg Endosc 32(4):1636–1655. https://doi.org/10.1007/s00464-018-6079-2 (Epub 2018 Feb 13)
Ballantyne GH, Moll F (2003) The da Vinci telerobotic surgical system: the virtual operative field and telepresence surgery. Surg Clin 83(6):1293–1304
Ballantyne GH (2002) Robotic surgery, telerobotic surgery, telepresence, and telementoring. Surg Endosc Other Intervent Techn 16(10):1389–1402
Rawlings AL, Woodland JH, Vegunta RK, Crawford DL (2007) Robotic versus laparoscopic colectomy. Surg Endosc 21(10):1701–1708
Baik SH, Kwon HY, Kim JS,et al (2009) Robotic versus laparoscopic low anterior resection of rectal cancer: short-term outcome of a prospective comparative study. Ann Surg Onc 16(6):1480–1487
Conflict of interest
S. Atallah is a paid consultant for ConMed, Inc, Applied Medical, Inc, THD, America, and has an ongoing consultant relationship with Medicaroid Robotics and MedRobotics, Inc. This research was supported by MedRobotics, division of Colorectal Surgery, Research and Development. The other authors declare that they have no conflict of interest.
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 was not applicable as the work represented herein did not involve human subjects. Cadaveric research was conducted in accordance with the standards set forth by ethics and scientific laboratory regulations.
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Atallah, S., Hodges, A. & Larach, S.W. Direct target NOTES: prospective applications for next generation robotic platforms. Tech Coloproctol 22, 363–371 (2018) doi:10.1007/s10151-018-1788-z
- Minimally Invasive Surgical Procedures
- Surgical Procedures, Robotic
- Natural Orifice Endoscopic Surgery
- Hysterectomy, Vaginal