Sa2062 TRANSANAL ENDOSCOPIC SUBMUCOSAL DISSECTION USING THE FLEX® ROBOTIC SYSTEM (MEDROBOTICS) BY A GASTROENTEROLOGIST: A CASE SERIES

Abstract

Precancerous rectal lesions not amenable to standard mucosal resection and early T1a cancers are effectively treated with endoscopic submucosal dissection. Recently, a robotic endoscope with potential to expand and improve efficiency of transanal procedures has been approved by the FDA for transanal use. This scope provides access for two accessories capable of multiple freedoms of movement allowing effective dissection of tissue. The endoscopic surgeon uses both his hands, divorced from the scope controls for the dissection. We present the first case series of a gastroenterologist using the Flex® Robotic System for endoscopic submucosal resection of advanced rectal lesions. A retrospective review of patients was approved by the Institutional Review Board at Penn State Hershey Medical Center. Clinical data for the 7 consecutive patients was collected including length of the procedure, length of stay, location of mass, size of mass, and details of the procedure. Data on patient demographics including BMI, age, and ASA score were also collected. Procedural notes from prior to the robotic resection, the robotic resection itself, and follow-up endoscopic evaluation after robotic resection were all reviewed. Of the 7 patients listed for procedure, 2 cases were abandoned; one due to evidence of T2 cancer and another due to anal stenosis. Among the rest, 3 used the robotic device alone while 2 of the cases used traditional ESD in addition to the robotic device. Reasons for needing to use conventional methods included equipment issues with suctioning using the robotic device and need for improved visualization of a bleed occurring in a difficult location. Average age of the patients was 62, BMI was 30, and ASA score was 3. Average size of the lesions resected was 4.4cm x 5.0cm. Final pathology included one tubulovillous adenoma, one tubular adenoma with high grade dysplasia, one tubulovillous adenoma with high grade dysplasia, and two with adenocarcinoma. The robotic scope represents a true advancement in the endoscopic surgical platform. Advantages of the robotic system include the ability to use traction and counter-traction which allow for precise control and ease of dissection as well as stabilization of the resection field, allowing for faster dissection with seemingly less bleeding. In addition, the 3D vision of the robotic system allows for excellent sense of tissue planes, even without the use of submucosal elevation. Disadvantages include the need for anal dilation and general anesthesia. The current robot lacks suction and submucosal injection capabilities. Additional weaknesses include limited length reached within the rectum and maneuverability of the device. With improvement of technique and technology, endoscopists skilled in both conventional and robotic ESD could minimize the need for proctectomy.Figue 2Endoscopic robotic suturing after dissection of the rectal mass lesionView Large Image Figure ViewerDownload Hi-res image Download (PPT)