title: Robotic transanal endoscopic microsurgery: technical details for the lateral approach.
abstract: BACKGROUND
  Transanal endoscopic microsurgery is a minimally invasive approach reserved for the resection of selected rectal tumors. However, this approach is technically demanding. Although robotic technology may overcome the limitations of this approach, the system can be difficult to dock, especially in the lithotomy position.
  
  
  OBJECTIVE
  The study aim is thus to report the technical details of robotic transanal endoscopic microsurgery with the use of a lateral approach.
  
  
  METHODS
  This study is a prospective evaluation of robotic transanal endoscopic microsurgery in a single tertiary institution, under a protocol approved by our local ethics committee.
  
  
  METHODS
  Patients underwent a routine mechanical bowel preparation and were placed in the left or right lateral position according to the tumor location. A circular anal dilatator was used together with the glove port technique. The robotic system was then docked over the hip. A 30° optic and 2 articulated instruments were used with an additional assistant trocar. The tumor excision was realized with an atraumatic grasper and an articulated cautery hook, and the defect was closed with barbed continuous stiches in each case.
  
  
  METHODS
  The primary outcome was the safety and feasibility of the procedure.
  
  
  RESULTS
  Three patients underwent a robotic transanal endoscopic microsurgery with the use of the lateral approach. Mean operative time was 110 minutes, including 20 minutes for the docking of the robot. There was 1 intraoperative complication (a pneumoperitoneum without intraabdominal lesion) and no postoperative complications. Mean hospital stay was 3 days. Margins were negative in all the cases.
  
  
  CONCLUSIONS
  The study was limited by the small number of patients.
  
  
  CONCLUSIONS
  Robotic transanal endoscopic microsurgery with use of the lateral approach is feasible and may facilitate the local resection of small lesions of the mid and lower rectum. It might assume an important place in sphincter-preserving surgery, especially for selected and early rectal cancer (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A114).
authors.affiliation: Clinic for Visceral and Transplantation Surgery, Department of Surgery, University Hospital of Geneva, Geneva, Switzerland.
authors.forename: Nicolas C
authors.initials: NC
authors.lastname: Buchs
authors.forename: François
authors.initials: F
authors.lastname: Pugin
authors.forename: Francesco
authors.initials: F
authors.lastname: Volonte
authors.forename: Monika E
authors.initials: ME
authors.lastname: Hagen
authors.forename: Philippe
authors.initials: P
authors.lastname: Morel
authors.forename: Frederic
authors.initials: F
authors.lastname: Ris
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001003:Anal Canal; D006801:Humans; D007431:Intraoperative Complications; D007902:Length of Stay; D008297:Male; D008866:Microsurgery / Q000009:adverse effects / Q000379:methods*; D008875:Middle Aged; D061646:Operative Time; D011027:Pneumoperitoneum / Q000209:etiology; D011351:Proctoscopy / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D012004:Rectal Neoplasms / Q000601:surgery*; D012371:Robotics