Drainoscopy: a doorway to the abdomen in the post-surgical patient.

The ability to optically visualize the abdominal cavity in the post-surgical patient can prove to be invaluable, particularly when imaging studies and exam findings can be difficult to interpret. Post-surgical drains are often used and provide a window into the abdominal cavity. In this proof-of-concept study, it is demonstrated that an ordinary drain can be used as a point of access and hence a doorway into the abdominal cavity. This technique has been termed drainoscopy, and the approach is demonstrated with video supplement.

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.

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.

Transanal minimally invasive surgery for total mesorectal excision (TAMIS-TME): results and experience with the first 20 patients undergoing curative-intent rectal cancer surgery at a single institution.

BACKGROUND: Transanal TME is a new approach to performing minimally invasive rectal resection. It is particularly well suited for patients with locally advanced distal rectal cancer and obesity, where the abdominal approach is challenging. Transanal TME can be performed with either TAMIS or TEM. Here, we report our initial experience with transanal TME using TAMIS (TAMIS-TME). METHODS: Patients were selected to undergo transanal TME using the TAMIS platform (TAMIS-TME) primarily for malignant disease, but also for select cases of benign disease. Transanal TME defines a "bottom-up" approach to en bloc rectal cancer resection. Transanal TME requires abdominal access for proximal colonic mobilization and is often done in conjunction with a laparoscopic approach. RESULTS: During a 32-month period, 20 patients underwent TAMIS-TME with curative intent. The primary indication for transanal TME was distal, locally advanced rectal cancer. The median age of rectal cancer patients at the time of surgery was 57 years (range 36-73 years) with 30% (6) female and 70% (14) male. The median body mass index (BMI) measured was 24 kg/m(2) (range 18-41 kg/m(2)); this included six patients (30%) with obesity (BMI ≥ 30 kg/m(2)). Mean operating time was 243 min (range 140-495 min) with blood loss averaging 153 ml. Postoperative length of stay averaged 4.5 days (range 3-24 days). There was no 30-day postoperative mortality. Surgical complications included wound infection (n = 2), pelvic abscess (n = 4), and prolonged ileus (n = 4). The anastomotic leak rate was 6.7% (1/15). Of the 20 patients who underwent resection, 90% (18/20) had negative margins. Pathologic grading of the TME specimen revealed that 85% (17/20) of transanal TME specimens were found to have "completely" or "near-completely" intact mesorectal envelopes. Data collected during the 6-month median follow-up period revealed that only one patient had developed distant metastasis. There was no locoregional recurrence in any of the patients. CONCLUSIONS: Transanal TME is a feasible method for oncologic resection of locally advanced mid- and distal-rectal cancer with curative intent. It has special application for patients with obesity and anatomic constraints such as a narrow male pelvis.

Robotic-assisted transanal surgery for total mesorectal excision (RATS-TME): a description of a novel surgical approach with video demonstration.

A new era has emerged in rectal cancer surgery--transanal total mesorectal excision (TME). Various platforms have been used to facilitate this novel approach, including transanal minimally invasive surgery (TAMIS) and transanal endoscopic microsurgery. We have previously reported the use of TAMIS-TME. This is a report of the first human case of robotic-assisted transanal surgery for TME.

Transanal minimally invasive surgery for total mesorectal excision (TAMIS-TME): a stepwise description of the surgical technique with video demonstration.

Transanal minimally invasive surgery (TAMIS), which can provide high-quality local excision for rectal neoplasia, has emerged as an important alternative to transanal endoscopic microsurgery. The role of TAMIS beyond local excision has also been explored, and it has been shown that this platform can be used for complete rectal resection with total mesorectal excision (TME). The stepwise approach to TAMIS for TME is described and illustrated in video format.

Transanal minimally invasive surgery (TAMIS): applications beyond local excision.

Transanal minimally invasive surgery (TAMIS) is a new technique for the local excision of rectal neoplasia. This platform employs ordinary laparoscopic instruments to achieve high-quality local excision. The TAMIS platform, however, is quite versatile. Described here are applications of TAMIS beyond local excision, ranging from repair of a rectourethral fistula to reverse proctectomy.

The technical approach to laparoscopic colectomy in patients who have undergone prior abdominoplasty.

BACKGROUND: For those patients undergoing laparoscopic colorectal surgery who have had prior abdominoplasty, cosmetic outcome is important and the technical considerations for laparoscopy in post-abdominoplasty patients have not been previously addressed. The aim of the present study was to define the technical approach to the post-abdominoplasty patient undergoing laparoscopic colorectal surgery after abdominoplasty. METHODS: Utilizing the technical approach described, eleven patients underwent laparoscopy after prior abdominoplasty over a 7-year period. RESULTS: The majority of patients (10/11) felt their laparoscopic colorectal resection had no adverse effect on the aesthetics of their prior abdominoplasty. From a surgeon's standpoint, the only significant challenge was due to the loss of abdominal wall compliance. CONCLUSIONS: The surgical approach to laparoscopic colectomy in the post-abdominoplasty patient requires careful planning. Cosmetic outcome is a particularly important consideration for this subset of patients, and this should be appreciated by the operating surgeon.

Excision of a rectal neoplasm using robotic transanal surgery (RTS): a description of the technique.

The approach to local excision of benign and early-stage, well-selected neoplasms of the rectum continues to evolve. We demonstrate here that local excision of a rectal neoplasm using the da Vinci Robotic Surgical System can be successfully performed. To our knowledge, this is the first time robotic transanal surgery (RTS) has been used in this manner.

The Altemeier procedure using biologic mesh.

Transperineal rectosigmoidectomy is a relatively safe operation for the treatment of rectal prolapse; however, it carries a high rate of recurrence. The use of biologic mesh to buttress the repair and support the pelvic floor muscles may decrease the rate of recurrence. The technique for performing an Altemeier procedure with biologic mesh is described.

Robotic TransAnal Minimally Invasive Surgery in a cadaveric model.

The technique of TransAnal Minimally Invasive Surgery (TAMIS) was pioneered in 2009 as a hybrid approach to endoluminal resections of appropriately selected rectal lesions. There are, however, limitations to performing this type of resection. Robotic TAMIS is a novel, experimental technique and in this study was performed in a cadaveric model at a surgical education center. Various tasks were carried out using robotic TAMIS, including full-thickness sharp and cautery excision of rectal wall, as well as intra-luminal suturing of the surgical defect. It was found that for the da Vinci-trained surgeon, these tasks were simple to perform and accomplished with greater precision when compared to standard TAMIS. Our initial results indicate that robotic TAMIS overcomes the limitations of standard TAMIS and that it is a feasible platform for transanal surgery. The cost, however, of performing robotic TAMIS may limit its application to special cases in which standard TAMIS or transanal endoscopic microsurgery resections may prove difficult. Further study is necessary to validate these preliminary findings before robotic TAMIS is performed on live patients.