title: Robotic transanal surgery for local excision of rectal neoplasia, transanal total mesorectal excision, and repair of complex fistulae: clinical experience with the first 18 cases at a single institution.
abstract: BACKGROUND
  Robotic transanal surgery represents a natural evolution of transanal minimally invasive surgery. This new approach to rectal surgery provides the ability to perform local excision of rectal neoplasia with precision. Robotic transanal surgery can also be used to perform more advanced procedures including repair of complex fistulae and transanal total mesorectal excision.
  
  
  METHODS
  Data from patients who underwent transanal robotic surgery over a 33-month period were retrospectively reviewed. Patients underwent three types of procedures using this approach: (a) local excision of rectal neoplasia, (b) transanal total mesorectal excision, and (c) closure of complex fistulae, such as rectourethral fistulae.
  
  
  RESULTS
  Eighteen patients underwent robotic transanal surgery during the 33-month study period. Of these, nine patients underwent local excision of rectal neoplasia; four patients underwent transanal total mesorectal excision; four patients underwent repair of rectourethral fistulae; and one patient underwent repair of an anastomotic fistula. Of the patients undergoing robotic transanal surgery for local excision, 6/9 were resections of benign neoplasia, while 3/9 were resections for invasive adenocarcinoma. There was no fragmentation (0/9) noted on any of the locally excised specimens, while one patient (1/9) had a positive lateral margin. During the mean follow-up of 11.4 months, no recurrence was detected. Four patients underwent robotic-assisted transanal total mesorectal excision for curative intent resection of rectal cancer confined to the distal rectum. Mesorectal quality was graded as complete or near complete, and an R0 resection was performed in all four cases. Other transanal robotic procedures performed were the repair of rectourethral fistulae (n = 3) and anastomotic fistula (n = 1). This approach was met with limited success, and only half of the rectourethral fistulae were closed.
  
  
  CONCLUSIONS
  Robotic transanal surgery for local excision, transanal total mesorectal excision, and repair of fistulae is feasible, although these new approaches represent a work-in-progress. Improvement in platform design will likely facilitate the ability to perform more complex procedures. Further research with robotic transanal approaches is necessary to determine whether or not this approach can provide patients with significant benefit.
authors.affiliation: Florida Hospital, Winter Park, FL, USA, atallah@post.harvard.edu.
authors.forename: S
authors.initials: S
authors.lastname: Atallah
authors.forename: B
authors.initials: B
authors.lastname: Martin-Perez
authors.forename: E
authors.initials: E
authors.lastname: Parra-Davila
authors.forename: T
authors.initials: T
authors.lastname: deBeche-Adams
authors.forename: G
authors.initials: G
authors.lastname: Nassif
authors.forename: M
authors.initials: M
authors.lastname: Albert
authors.forename: S
authors.initials: S
authors.lastname: Larach
mesh_terms: D000230:Adenocarcinoma / Q000601:surgery; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001003:Anal Canal / Q000601:surgery*; D001706:Biopsy; D013505:Digestive System Surgical Procedures / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures; D012003:Rectal Fistula / Q000601:surgery*; D012004:Rectal Neoplasms / Q000601:surgery*; D012007:Rectum / Q000473:pathology / Q000601:surgery*; D012189:Retrospective Studies; D065287:Robotic Surgical Procedures / Q000379:methods*; D016896:Treatment Outcome