Robotic Transanal Surgery for Rectal Cancer

Robotic transanal surgery is the culmination of major developments in rectal cancer management and minimally invasive surgery. It is the result of continuous efforts to tackle the challenges inherent to rectal cancer surgery. This latest technology holds great promise and excitement for the care of the rectal cancer patient. In this article, we will describe the evolution of transanal rectal cancer surgery and describe how the convergence of transanal transabdominal, transanal endoscopic microsurgery, transanal minimally invasive surgery (TAMIS), transanal total mesorectal excision (taTME), and the different robotic platforms have culminated in the development of single port robotic transanal minimally invasive surgery (SP rTAMIS) and single port robotic transanal total mesorectal excision (SP rtaTME). We will describe the indications, technical aspects, outcomes, benefits, and limitations of the SP rTAMIS and SP rtaTME.

Robotic Transanal Surgery. Initial Experience in a Developing Country

Background Transanal minimally invasive surgery (TAMIS) is a surgical technique used for the excision of rectal neoplasia that gained popularity during the last decade.Due to the technical difficulty (non-articulated instruments, reduced workspace) and the long learning curve associated with this technique, the use of robotic platforms to improve resection results has been suggested and reported, at the same time that the learning curve decreases and the procedure is facilitated Materials and Methods From March 2017 to December 2019, all patients with rectal lesions eligible for TAMIS were offered the possibility to receive a robotic TAMIS (R-TAMIS). We used a transanal GelPoint Path (Applied Medical Inc., Santa Margarita, CA, USA) in the anal canal to be able to do the Da Vinci Si (Intuitive Surgical, Sunnyvale, CA, USA) robotic platform docking, which we used to perform the excision of the rectal lesion as well as the resection site defect. Results Five patients between 34 and 79 years of age underwent R-TAMIS. The mean distance to the anal verge was 8.8 cm. There were no conversions. The mean surgery time was 85 minutes, and the mean docking time was 6.6 minutes. Conclusions Robotic TAMIS is a feasible alternative to TAMIS, with a faster learning curve for experienced surgeons in transanal surgery and better ergonomics. Further studies are needed to assess the cost-benefit relationship.

Current Challenges for Education and Training in Transanal Surgery

Transanal endoscopic microsurgery (TEM) is a technique that was introduced in the 1980s for improved exposure to upper rectal polyps. This technique, though initially difficult to master due to new skill acquisition for surgeons, has spared many patients proctectomy. There are many benign indications for transanal endoscopic surgery which has led to in vivo operating room training with fewer undesirable effects to the patient. With the explosion of laparoscopic technology this transanal technique is no longer limited to intraluminal pathology, but is now being used to remove the entire rectum. In transanal total mesorectal excision (taTME), benign indications are less common, translating to potentially more severe oncologic patient consequences during the early phase of adoption. For this reason, strict training criteria consensus guidelines have been developed by the experts in taTME. The current consensus statements agree that training surgeons should have performed a minimum of 10 laparoscopic TME procedures and should have some experience with transanal surgery. Surgeons need to attend a formal training course and should start clinically on benign or early malignant pathology without threated circumferential resection margins. Surgeons also need to have their first cases proctored until deemed proficient by the proctor and monitor their morbidity, oncologic, and functional outcomes prospectively.

O83: COMPASS – MANAGEMENT OF COMPLICATED INTRA-ABDOMINAL COLLECTIONS AFTER COLORECTAL SURGERY, A EUROSURG COLLABORATIVE INTERNATIONAL STUDY

Presenting Author Email: [email protected] Research question To explore current practices on the use of prophylactic postoperative drains in colorectal surgery and whether it influences 30-day postoperative outcomes. Background and aim Traditionally, postoperative drains have been used in colorectal surgery for the prevention or early detection of intraabdominal collections. However, current evidence suggests there is no clear clinical benefit to prophylactic drain placement following colorectal surgery, and Enhanced Recovery After Surgery (ERAS) guidelines recommend against their routine use. Nevertheless, a previous international audit by Eurosurg (Ileus Management International) found more than a third of participating centres routinely placed a drain in more than half of their patients. Therefore, this study aims to audit compliance to ERAS guidelines regarding the use of postoperative drains in colorectal surgery. Design Patients Adult patients undergoing elective and emergency colorectal surgery will be included. Procedures under any surgical approach including any formation of colostomy or ileostomy, resection of large bowel, or reversal of stoma will be eligible. Patients undergoing appendicectomy, transanal surgery, primarily urological, gynaecological or vascular procedure, surgery involving multivisceral resection, diagnostic laparotomy or laparoscopy or hernia surgery without colorectal resection, will be excluded. Comparator Group of patients receiving a prophylactic drain after surgery. Main explanatory variable will be intrabdominal collections rate including anastomotic leak. Outcomes The primary outcome measure will be the adherence to selected ERAS guidelines regarding rate of routine prophylactic drain insertion in colorectal surgery. As Secondary outcome measures we will assess: • Rate of intra-abdominal postoperative collections, defined as collections which alter the normal postoperative course (e.g. requiring either medical, radiological, endoscopic or surgical intervention). • Time-to-diagnosis (days) of intra-abdominal postoperative collections defined as collections which alter the normal postoperative course. • Rate of drain-related complications defined as: surgical site infection by Centers for Disease Control and Prevention definition; cutaneous irritation at the drain insertion site; small bowel evisceration and herniation of omentum, bowel injury (defined as intraoperative identification of or CT-proven drain-related iatrogenic bowel perforation); time (measured in whole days) until drain removal and drain output (quantity and contents) on day of removal; and overall 30-day adverse event rate as defined by the Clavien-Dindo scale of postoperative complications and length of stay (days). Study design This is a prospective, multicentre, audit that will be conducted through the student- and trainee-led EuroSurg collaborative network across Europe, South Africa and Australasia. Data will be collected on consecutive 14-day periods, from 3rd February to 26th April 2020, with 30-day follow-up on included patients. Data will be collected online on REDCap database based on Birmingham University. Team and infrastructure The study will be run by the European Student Research Collaborative. EuroSurg is a pan-European student- and trainee-led surgical which also counts with international collaboration from Australia, New Zealand and South Africa. The study will be coordinated by the International Study Management Group and at each participating country, there will be a core of national leads or national collaborative in charge of organising the study locally. Each hospital will count with a Local Lead who will coordinate the mini-teams based at their centre and will be in contact with its corresponding National Leads. A mini-team will be composed by three collaborators collecting data and a supervising consultant per centre. As infrastructure for leading the project, we will use social media for study diffusion including Twitter, Facebook, Instagram and LinkedIn, and emails through Gmail official account and Mailchimp. Management group communications will be held through WhatsApp, Slack and Skype.