Single-port Robotic Transanal Minimally Invasive Surgery Using a Novel Access Port: Initial Prospective Consecutive Case Series from the UK

Single-port Robotic Transanal Minimally Invasive Surgery Using a Novel Access Port: Initial Prospective Consecutive Case Series from the UK | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Single-port Robotic Transanal Minimally Invasive Surgery Using a Novel Access Port: Initial Prospective Consecutive Case Series from the UK Shakil Ahmed, Ali Murtada, Sara Martin, Muneeb Ul Haq, Muhammad Ahsan Javed This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9382827/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background: Transanal minimally invasive surgery (TAMIS) is widely used for the management of benign and early rectal neoplasia; however, technical limitations persist, particularly in confined pelvic anatomy. The da Vinci single-port (SP) platform, combined with a dedicated access port, has been developed to improve instrument articulation and distal access. This study reports early experience and feasibility of this approach. Methods: A prospectively maintained database was reviewed for consecutive patients undergoing SP robotic TAMIS (R-TAMIS) at a single tertiary center in the United Kingdom. All cases were discussed at a specialist early rectal cancer multidisciplinary team and underwent triple assessment with endoscopy, endoscopic rectal ultrasound, and MRI rectum. Primary endpoints were technical success (completion without conversion) and perioperative morbidity. Results: Eighteen patients underwent SP R-TAMIS for benign (n = 10) and malignant (n = 8) rectal lesions. Tumour height ranged from 1 to 20 cm from the anal verge. All procedures were completed without conversion. En bloc resection was achieved in 16/18 (88%) cases, with clear (R0) margins in all malignant lesions (resected en bloc). Median operative time was 55 (35–90) minutes with minimal blood loss (< 10 mL). All patients were discharged within 24 hours. One patient required readmission for delayed bleeding, managed conservatively. No major functional impairment was observed at early follow-up Conclusions: SP R-TAMIS using a dedicated access platform is a feasible and safe approach for transanal management of rectal lesions, enabling precise excision across a wide anatomical range with low morbidity and favourable early functional outcomes. Further studies are required to assess long-term oncological and functional outcomes. Transanal minimally invasive surgery (TAMIS) single-port robotic surgery local excision perioperative care functional outcomes 1. INTRODUCTION Transanal local excision remains an important organ-preserving strategy for the management of selected benign and early malignant rectal lesions. It aims to preserve anorectal function while avoiding radical resection where appropriate ( 1 ). Historically, this has been achieved using techniques such as transanal excision (TART), transanal endoscopic microsurgery (TEMS), and transanal endoscopic operation (TEO). The introduction of transanal minimally invasive surgery (TAMIS) has expanded the applicability of local excision by enabling improved access throughout the rectum using flexible and widely available platforms ( 2 ). However, despite these advances, conventional approaches remain technically challenging, particularly within the confined anatomical space of the pelvis. Robotic assistance has been increasingly utilised to overcome these limitations. Multiport robotic systems, such as the da Vinci Si and Xi platforms, provide enhanced dexterity, stability and visualisation, particularly during suturing and closure of resection defects. However, the utility of these platforms in transanal surgery is constrained by external arm collisions, complex docking, instrument crowding, and challenges achieving a reliable airseal in a confined anatomical space. The da Vinci single-port (SP) platform was developed to address these challenges, enabling deployment of a flexible 3D camera and multi-jointed instruments through a single cannula. This improves manoeuvrability in narrow spaces, and has demonstrated early utility in transanal procedures ( 1 ). Despite these advances, a key limitation persists; conventional transanal access platforms require a minimum deployment distance to full deployment and articulation of SP instruments. This restricts access to distal lesions near the anal verge and can limit procedural feasibility ( 1 ). A novel dedicated single-port access system, incorporating a flexible wound retractor and balloon-based interface, has recently been introduced to facilitate instrument deployment within a confined space prior to advancement towards the target lesion. Additionally, it also provides channels for assistant instrumentation ( 3 , 4 ). Early reports suggest that this may overcome limitations associated with distal access, although experience remains limited. To address these gaps, this study aims to report the initial experience, with SP R-TAMIS using this novel access platform, as a prospective consecutive case series, focusing on safety, technical feasibility and early clinical outcomes. To the best of our knowledge, this is the first reported series of SP R-TAMIS in the United Kingdom and Europe. In addition to reporting technical and oncological outcomes, this paper also assesses early postoperative bowel function using the Low Anterior Resection Syndrome (LARS) score ( 5 ). Lastly, it describes a standardised operative approach performed entirely in the lithotomy position, irrespective of tumour location. 2. METHODS 2.1 Study design This study was conducted as a single-centre prospective consecutive case series representing early experience with a novel technique; TAMIS using the da Vinci single-port (SP) platform in combination with a dedicated access port. Data were collected prospectively and the study has been reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines ( 6 ). Patients were identified from a prospectively maintained database. All procedures were performed at a single tertiary centre by an experienced colorectal surgeon, with expertise in robotic as well as transanal endoscopic microsurgery (TEMS). Institutional approval for the introduction and clinical use of this technique and device was obtained from the New Device and Technique Committee. In accordance with institutional governance policies, this study was classified as a service evaluation and did not require formal Research Ethics Committee approval. All patients provided written informed consent for the procedure and data collection. Procedures were video recorded following patient consent. The primary aim was to describe the technical application and short-term clinical outcomes of this approach during its early adoption phase. 2.2 Patient Selection Between September 2025 and March 2026, all consecutive patients undergoing single-port robotic transanal minimally invasive surgery (SP R-TAMIS) at Liverpool University Hospitals NHS Foundation Trust were included in this study. All patients were discussed at the Regional Small Early Rectal Cancer (SERC) multidisciplinary team (MDT), comprising colorectal surgeons with expertise in TEMS, gastroenterologists specialising in advanced endoscopic techniques (EMR, ESD, and FTR), specialist SERC radiologists, histopathologists, oncologists, and a dedicated clinical nurse specialist. In accordance with SERC MDT protocol, all patients underwent triple assessment consisting of endoscopic evaluation by an experienced SERC endoscopist, endoscopic ultrasound (EUS) of rectal lesion, and rectal magnetic resonance imaging (MRI). Patients with lesions suspicious for malignancy underwent computed tomography (CT) for staging, with additional liver MRI performed where indicated. All treatment options were considered prior to referral for SP R-TAMIS. To minimise selection bias, all consecutive patients deemed suitable for SP R-TAMIS during the study period were included. Patients were included if they presented with benign or early malignant rectal lesions and were deemed suitable for transanal local excision and fit for surgery under general anaesthesia following MDT review. Patients were excluded if they had locally advanced disease requiring radical resection, evidence of nodal or metastatic disease on staging imaging, or were otherwise unsuitable for transanal surgery. 2.3 Operative technique All procedures were performed under general anaesthesia with patients positioned in lithotomy, irrespective of tumour location. All patients received prophylactic intravenous antibiotics at the time of induction. An intraoperative urinary catheter was placed in all patients and removed at the end of the procedure. A 5–10° Trendelenburg tilt was applied. Rectal insufflation was maintained using the AirSeal® system (LAWMED, UK) via a 7-mm trocar inserted through the assistant channel, maintaining a constant pressure of 20 mmHg. A bedside assistant facilitated smoke evacuation, suction, and irrigation using extended laparoscopic suction as required. A dedicated flexible access platform incorporating a wound retractor and balloon interface was used to facilitate access. In all cases, a single-port robotic system was docked parallel to the patient’s right hip. The central remote centre and instrument limits were established prior to the procedure commenced to ensure optimal instrument range and ergonomics. Excision was performed using SP-compatible instruments, including scissors with monopolar diathermy, a fenestrated bipolar grasper with bipolar diathermy, and Cadier forceps, allowing both submucosal and full-thickness dissection as indicated. A needle holder was used for suturing when required. A three-instrument approach was used in all cases, with the third robotic arm equipped with a grasping device to optimise exposure and facilitate dissection. A circumferential margin was marked using monopolar diathermy prior to excision, aiming for approximately 5 mm for benign lesions and 10 mm for malignant lesions. Histopathological margin status for malignant lesions was defined as R0 (no tumour at the resection margin) or R1 (microscopic tumour involvement at the margin). Defect closure was performed in most cases but was selectively omitted in cases of large defects or lesions involving the dentate line, at the discretion of the operating surgeon. In total, three defects were left open (two large defects > 6 cm and one lesion at the dentate line). Both submucosal and full-thickness defects ≤ 8 cm were routinely closed using a running barbed absorbable suture (3 − 0 V-Loc PDS; Medtronic, Watford, UK). 2.4 Data collection and outcome measures Baseline demographic variables included age, sex and preoperative status assessed using American Society of Anesthesiologists (ASA) score. The primary outcomes were technical success (defined as completion of the procedure using the SP platform without conversion to an alternative transanal or abdominal approach) and perioperative morbidity. Secondary outcomes included operative time (including total operating time, perineal setup time, robot docking time, and console time), estimated blood loss, intraoperative complications, need for blood transfusion, resection type (submucosal vs full thickness), specimen fragmentation (en bloc vs piecemeal), and histopathological outcomes including margin status. Perioperative morbidity was defined as any complication occurring within 30 days of surgery. Endoscopic variables included lesion size, distance from the anal verge, lesion size, pit pattern, and JNET classification. EUS assessments captured lesion size, distance from the anal verge, lesion position, layer of origin, and depth of invasion. Imaging variables from MRI included tumour stage, extramural depth of invasion, circumferential resection margin status, and nodal involvement. Imaging was performed and reported according to established rectal cancer guidelines and standardised institutional protocols to ensure uniform evaluation across the cohort. Additional variables comprised histopathological diagnosis and resection margin status. 2.4 Patient follow-up All patients were followed for a minimum of 30 days postoperatively to assess short-term outcomes, including 30-day morbidity and mortality. Recurrence was assessed clinically and radiologically. Functional outcomes were assessed using the LARS questionnaire at 6 weeks and 3 months postoperatively. Baseline (preoperative) LARS scores were recorded for all patients and were zero in all cases. Questionnaires were administered during routine follow-up (in-person or virtual clinic). Complete 6-week data were available for all patients, while 3-month follow-up was available for 14/18 patients. Missing data were due to incomplete follow-up at the time of analysis and were not imputed. 3 RESULTS A total of 18 patients underwent SP R-TAMIS following discussion at the SERC MDT. Patient demographics and lesion characteristics are summarised in Table 1 . Patients were aged 53–81 years, with a male predominance (12/18). All patients were ASA grade 2 or 3. Lesions were located between 1 and 20 cm from the anal verge (median 6 cm) and measured 1–8.5 cm in size (median 4 cm). Lesion distribution was anterior in 9 (50%), posterior in 7 (38%), and lateral in 2 (11%) cases. Triple assessment was performed in the majority of patients; endoscopic evaluation was completed in all cases, while EUS and MRI were omitted in selected cases due to lesion characteristics or prior treatment. EUS was omitted in two cases due to lesion proximity to the dentate line or prior polypectomy, and MRI was omitted in two patients with recurrent benign polyps. Table 1 Patient Demographics and Lesion Characteristics Characteristic Value [N (%)] Patients 18 Age [median (range)] (years) 67 (53–81) Gender Male 12 (67%) Female 6 (33%) ASA grade Grade II 9 (50%) Grade III 9 (50%) Histology LGD 3 (17%) HGD 10 (56%) Adenocarcinoma 4 (22%) Neuroendocrine 1 (6%) Lesion Size [median (range)] (cm) 4 (1–8.5) Preoperative assessment Endoscopy 18 (100%) EUS 15 (83%) MRI 16 (88%) Distance from Anal Verge [median (range)] (cm) 6 (1–20) Lesion Position Anterior 9 (50%) Posterior 7 (39%) Lateral 2 (11%) LGD, low-grade dysplasia; HGD, high-grade dysplasia; ASA, American Society of Anesthesiologists; EUS, endoscopic ultrasound; MRI, magnetic resonance imaging. All procedures were completed using the SP robotic platform without conversion to alternative techniques. Two lesions involving the dentate line were approached using a hybrid approach combining open transanal mobilisation with SP R-TAMIS. Two proximal lesions above the peritoneal reflection were excised using a full-thickness approach with defect closure. Defect closure was performed in 15/18 (83%) cases per surgeon preference. The post operative outcomes are summarised in Table 2 . Median operative time (including docking and console time) was 55 minutes (range 35–90), with minimal blood loss (median 5 mL). A local perineal block (20–30 mL) with 20 mls of 0.5% Bupivicaine was administered in all patients. Table 2 Post-operative outcomes Characteristic Value [N (%)] Operating Time ( Docking and console Time) [median (range)] 55 (35–90) min Estimated blood loss [median (range)] 5 (0–10) mL Final Histopathology Malignant T1 7 (39%) Sm1 0 Sm2 4 (57%) Sm3 3 (43%) T2 0 T3 0 Neuroendocrine tumour (Tis) 1 (6%) Benign LGD 3 (17%) HGD 5 (28%) Scar 2 (11%) Margins (Malignant Lesion) R0 8 (100%) R1 0 Length of Stay (Days) 0* Resection Type Full thickness 14 (78%) Hybrid (combined submucosal and full-thickness dissection) 4 (22%) Specimen En-bloc 16 (89%) Piecemeal 2 (11%) Conversion to alternative technique TEMS/TAMIS 0 TART 0 Postoperative complications Overall morbidity (30 days) 1 (6%) Return to Theatre 0 Transfusion 0 Readmission 1 (6%) Bleeding (before discharge) 0 * Discharged within 23 hours. TEMS, transanal endoscopic microsurgery; TAMIS, transanal minimally invasive surgery; TART, transanal robotic surgery; LGD, low-grade dysplasia; HGD, high-grade dysplasia; Sm, Submucosal invasion level Final histopathology demonstrated 8 malignant lesions (adenocarcinoma 7, neuroendocrine tumour 1), 5 high-grade dysplasia, 3 low-grade dysplasia, and 2 cases with no residual lesion following prior endoscopic resection ESD (presumed benign). Clear (R0) resection margins were achieved in all malignant cases. A planned circumferential margin of approximately 5 mm (benign) and 10 mm (malignant) was targeted in all patients. Full-thickness excision was performed in 14 patients, with a hybrid approach in 4. En bloc resection was achieved in 16/18 (88%) cases. All patients were discharged within 23 hours of surgery. One patient required readmission on postoperative day 7 for bleeding, which was managed conservatively. No patients required reoperation, transfusion, or experienced bleeding prior to discharge. Baseline LARS scores were zero in all patients. At six weeks, LARS assessment demonstrated no symptoms in 16 patients, with two reporting minor symptoms. At 3 months, follow-up data were available for 14/18 patients; of these, 13 reported no LARS and 1 reported minor symptoms. No patients developed major LARS during follow-up. The reduced sample at 3 months reflects incomplete follow-up rather than attrition due to adverse outcomes. 3.1 Published SP R-TAMIS series Published single-centre series of SP R-TAMIS are summarised in Table 3 . Across studies, technical success rates ranged from 93% to 100%, with R0 resection rates between 93% and 100%. Reported complication rates ranged from 0% to 11.8%, and length of hospital stay varied from same-day discharge to a median of 5 days. Follow-up duration ranged from short-term (30 days) to a median of 24 months ( 1 , 7 – 10 ). Table 3 Summary of published single-centre series of single-port robotic transanal minimally invasive surgery (SP R-TAMIS) Study Location Patients and Demographics Key Outcomes Follow-up Ferrari et al. (2024) ( 10 ) Mayo Clinic, Minnesota, USA n = 31 (19M, 12F); Mean age 61 ± 13.3; Mean BMI 30.0 Technical success: 96.8%; Conversion: 3.2%; Negative margins: 93.5%; 30-day morbidity: 6.5%; LOS: Same-day discharge Mean 18.3 months; Recurrence 0% Kim et al. (2024) ( 9 ) Seoul St Mary’s Hospital, Korea n = 9 (5M, 4F); Age 30–72 years Technical success: 100%; Negative margins: 100%; Intraoperative complications: 0%; LOS: mean 1.67 days 10.5–21.1 months; Recurrence 0% Friedman et al. (2025) ( 7 ) Mountain View Hospital, Nevada, USA n = 17 (13M, 4F); Mean age 63.9 years Technical success: 100%; Negative margins: 100%; Postoperative complications: 11.8%; LOS: 0 days (Same-day) Short-term (30-day); No recurrence observed Woo et al. (2024) ( 8 ) Ulsan University Hospital, Korea n = 14 (11M, 3F); Median age 72; Median BMI 22.6 Technical success: 100%; Negative margins: 93%; Complications: 7.1%; LOS: Median 5 days Median 24 months (range 12–34); Recurrence 0% Liu et al. (2021) ( 1 ) Mayo Clinic, Minnesota, USA n = 5 (3M, 2F); Age 50–66 years Technical success: 100%; Negative margins: 100%; Postoperative complications: 1 readmission (bleeding); LOS: Same-day discharge Minimum 30 days; Normal bowel function at 2 weeks Abbreviations: SP R-TAMIS, single-port robotic transanal minimally invasive surgery; BMI, body mass index; LOS, length of stay; M, male; F, female. 4 DISCUSSION This study represents the first reported series of SP R-TAMIS in the United Kingdom and Europe. As a prospective case series, it describes technical implementation and short-term outcomes rather than comparative effectiveness of this technique. Our findings demonstrate that SP R-TAMIS is feasible and safe, with all procedures completed without conversion and performed entirely in the lithotomy position irrespective of lesion location. This standardised positioning simplifies operative workflow and avoids intraoperative repositioning reported in other series (10). Robotic-assisted TAMIS using multiport platforms improves dexterity and visualisation compared with conventional TEMS and laparoscopic TAMIS (3, 4), but adoption is limited by external arm collisions, instrument crowding, and ergonomic constraints within the confined pelvic space (11). The single-port platform addresses these limitations by enabling deployment of a flexible 3D camera and multi-jointed instruments through a single access point, improving maneuverability. In our series, all malignant lesions were resected en bloc, and no conversions were required, suggesting acceptable short-term resection quality. A key technical advancement in our series is the use of a dedicated flexible access platform incorporating a balloon-based interface and wound retractor (7). Conventional platforms, such as GelPOINT or glove-port systems (1, 8, 9), require a minimum deployment distance (7–10 cm) for effective articulation (1, 7), limiting access to lesions above peritoneal reflection. The platform used in our series allows instrument deployment within a confined space, enabling safe resection of lesions as low as 1 cm from the anal verge while maintaining access to more proximal lesions, thereby expanding the applicability of the technique. Oncological outcomes were favourable, with R0 resection in all malignant cases and an en bloc resection rate of 88%. These findings are consistent with reported SP R-TAMIS series (93–100% R0) (1, 7-10). Compared with laparoscopic TAMIS, which has reported higher margin positivity (up to 8.6% or 15%) and specimen fragmentation (5%) (8, 10), the SP system offers better visualisation. The ability to visualise around the lesion facilitates more accurate identification of tumour boundaries although further validation in larger studies is required. The ability to approach lesions up to 20 cm from the anal verge, including above the peritoneal reflection, highlights the versatility of this technique. Although proximal resections carry a risk of peritoneal entry, enhanced visualisation and articulation of SP approach allows safe identification and transanal closure of defects (8). In our cohort, lesions above the peritoneal reflection were managed with full-thickness excision and secure closure. However, this was not formally evaluated. A learning curve was observed, particularly in early cases due to adjustments in docking, port positioning. (to achieve adequate seal), and defect closure. Proficiency improved rapidly, and the technique was transferable under supervision, suggesting that structured training may facilitate wider adoption. Functional outcomes following TAMIS are generally favourable, with most patients reporting minimal bowel dysfunction (5). consistent with studies indicting approximately 70–75% of patients experience no LARS at 6 months, with minor symptoms in 15–20% and major LARS in less than 10% (12, 13). In this series, no patients developed major LARS at early follow-up. This may relate to reduced sphincter stretch with a single access port compared with multi-instrument approaches (1, 10). Although findings are consistent with prior TAMIS cohorts, interpretation of early functional is limited by short follow-up and incomplete 3-month data (14). Consecutive case inclusion minimised selection bias. All patients were managed as day cases, supported by perineal block, early virtual follow-up, and low morbidity, with one readmission managed conservatively. Looking forward, the platform may have wider applications, including as an alternative to ESD for larger lesions or complex resections requiring combined full-thickness and submucosal dissection. Structured training and proctoring remain essential for safe adoption of this approach. Shared access across specialties, as seen in our institution, may improve utilisation. 4.1 Characteristics and outcomes of published SP R-TAMIS series Compared with published SP R-TAMIS series, our cohort demonstrated comparable technical and oncological outcomes, with 100% technical success and R0 resection in all malignant lesions. Despite some piecemeal resections, margin status remained negative, suggesting appropriate case selection and precise dissection. All patients were discharged within 23 hours, comparing favourably with published cohorts reporting same-day discharge to a mean of approximately 2 days (9) and median of 5 days (8). While variation likely reflects differences in institutional pathways and case complexity, this suggests SP R-TAMIS can be integrated into short-stay pathways without compromising resection quality. In our series, postoperative morbidity was low, with one delayed bleeding episode managed conservatively, consistent with published reports where bleeding is a common complication (1, 7). Additionally, this study reported on the structured assessment of early postoperative bowel function. One SP R-TAMIS series reported LARS outcomes beyond very early follow-up at 2 weeks (1). Although longer-term follow-up data are required, these findings support the short-term safety and favourable early functional profile of the technique in appropriately selected patients. 4.2 Limitations This study represents a small, single-centre, single-surgeon case series, which may limit generalisability and could potentially introduce operator-dependent bias. The absence of a comparative control group limits conclusions regarding relative oncological or functional superiority. Although data were prospectively collected, the observational design and limited sample size restrict statistical power. Follow-up was short, and while no early recurrence was observed, long-term oncological outcomes could not be assessed. In addition, perioperative recovery metrics were not routinely recorded, and cost analysis was not performed, both of which are important considerations for wider adoption. 5 CONCLUSIONS In conclusion, SP R-TAMIS using a dedicated access platform is a feasible and safe technique that allows precise excision of rectal lesions across a wide anatomical range with low morbidity and favourable early functional outcomes. The ability to standardise operative positioning and address technical limitations associated with distal access represents a key advantage. Further studies with larger cohorts and longer follow-up are required to establish long-term oncological and functional outcomes. Declarations DISCLOSURE ChatGPT: AI-assisted language editing. OpenAI, San Francisco, CA. Version GPT-5, September 2025 URL https://chat.openai.com/ was utilised to assist with English language editing, grammar, punctuation, and improvements to clarity of expression in this manuscript. No AI tools were used for study design, data analysis, interpretation of results, or the generation of tables, figures, references, or citations. All scientific content, analyses, and conclusions are the responsibility of the authors. CONFLICT OF INTEREST The authors declare no competing interests. FUNDING This research has received no external funding Author Contribution Conceptualization: SA; data curation: AM, MH; methodology: MAJ, SA, SM; formal analysis: SM, SA; writing—original draft: AM, SM; writing—review and editing: MH, MAJ; supervision: MAJ Acknowledgement We would like to acknowledge the clinical staff at LUHFT, including the surgeons, trainees, and nursing teams, for their continuous support in patient care and data collection. Data Availability The datasets generated and analysed during this study are available from the corresponding author on reasonable request. References Liu S, Kelley SR, Behm KT. Single-port robotic transanal minimally invasive surgery (SPR-TAMIS) approach to local excision of rectal tumors. Techniques in coloproctology. 2021;25(2):229–34. Martin-Perez B, Andrade-Ribeiro GD, Hunter L, Atallah S. A systematic review of transanal minimally invasive surgery (TAMIS) from 2010 to 2013. Techniques in coloproctology. 2014;18(9):775–88. O’Sullivan NJ, Temperley HC, Larkin J, McCormick JJ, Rausa E, McCormick P, et al. Robotic transanal minimally invasive surgery (R-TAMIS): current evidence in the treatment of early rectal neoplasia. International journal of colorectal disease. 2024;39(1):71. Coco D, Leanza S. Robotic Transanal minimally invasive surgery for rectal neoplasms: A systematic review of outcomes and innovations. Langenbeck's archives of surgery. 2026;411(1):83. Duggan WP, Sugrue DD, Shannon N, Murphy B, Burke JP. A prospective evaluation of the effect of transanal minimally invasive surgery (TAMIS) on low anterior resection syndrome. Surgical endoscopy. 2023;37(7):5241–5. Cuschieri S. The STROBE guidelines. Saudi journal of anaesthesia. 2019;13(5):31–4. Friedman G, Specht K. Robotic Transanal Minimally Invasive Surgery With da Vinci Single-Port Platform and Single-Port Access Port. Diseases of the colon & rectum. 2025;68(9):e1783-e7. Woo JS, Cho MJ, Park IK, Im YC, Kim GY, Park DJ, et al. Initial case series experience with robotic-assisted transanal minimally invasive surgery performed with da Vinci single-port system for the excision of rectal cancer. Surgical endoscopy. 2024;38(11):6762–70. Kim IK, Bae JH, Lee YS, Lee IK. Clinical Feasibility and Technical Aspects of Single Port Robotic TransAnal Minimally Invasive Surgery (SP–rTAMIS) for Rectal Neoplasm. The international journal of medical robotics + computer assisted surgery. 2025;21(1):e70026 -n/a . Ferrari D, Peponis T, Violante T, Cheng JN, Perry WR, Larson DW, et al. Single-port robotic transanal minimally invasive surgery (SPR‐TAMIS): another giant leap forward? Colorectal disease. 2025;27(1): n/a . Ho JCE, Yong CJC, Goel AR, Rafaih AB, Shaikh I, Iqbal MR. Robotic surgery (R-TAMIS): a systematic review. Journal of robotic surgery. 2026;20(1):276. Sun R, Dai Z, Zhang Y, Lu J, Zhang Y, Xiao Y. The incidence and risk factors of low anterior resection syndrome (LARS) after sphincter-preserving surgery of rectal cancer: a systematic review and meta-analysis. Supportive care in cancer. 2021;29(12):7249–58. Pieniowski EHA, Nordenvall C, Palmer G, Johar A, Tumlin Ekelund S, Lagergren P, et al. Prevalence of low anterior resection syndrome and impact on quality of life after rectal cancer surgery: population-based study. BJS open. 2020;4(5):935–42. Goldenshluger M, Gutman Y, Katz A, Schtrechman G, Westrich G, Nissan A, et al. Long-Term Bowel Function after Transanal Minimally Invasive Surgery (TAMIS). The Israel Medical Association journal. 2020;22(7):426. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 26 Apr, 2026 Reviews received at journal 24 Apr, 2026 Reviewers agreed at journal 24 Apr, 2026 Reviewers agreed at journal 24 Apr, 2026 Reviewers invited by journal 23 Apr, 2026 Editor assigned by journal 16 Apr, 2026 Submission checks completed at journal 11 Apr, 2026 First submitted to journal 10 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9382827","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":631667448,"identity":"3090a2b7-9c18-4b17-9c83-3c828f3ef3a1","order_by":0,"name":"Shakil Ahmed","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABM0lEQVRIie2QPUvDQBiA3yB0Os0mF07av/CWg1ix0r9yIRCXQwOCZOoiZKq6RvonAk5uloJT7VyIQ8U/EBCkg4NvmorSxI9R8J7hcnfcwz0XAIPhL8JhA1QIgMU8D/lqO2zSwIqZqlewVJwE3xWU/FsFVopgCD8rreHZE84RWrvb41HWxY53Ke5H8xyxD+J8nFtxsK7gw51UFNa+GQb+vkbuXV0c+e0EKXFnGnAr1hWFK3lLipVm2hWkSJwwlwpfOXDtghVHlbDk8LlQeml2/CI6pPRKBQtF5jUKzPQyzKNbGoIubSL7ULA2bKZPUCH30yyQewNS+GRr+RYnpjCuppXnU9i1s4i6B2nmP84WUZ/Zg036YxHadhGWn/qVsBL+ecHKT6MY1BfCGux3xwwGg+Hf8AasHF7bUa2NnAAAAABJRU5ErkJggg==","orcid":"","institution":"University Hospitals of Liverpool Group","correspondingAuthor":true,"prefix":"","firstName":"Shakil","middleName":"","lastName":"Ahmed","suffix":""},{"id":631667449,"identity":"808750ba-a911-460b-ab98-4acce6ab8984","order_by":1,"name":"Ali Murtada","email":"","orcid":"","institution":"University Hospitals of Liverpool Group","correspondingAuthor":false,"prefix":"","firstName":"Ali","middleName":"","lastName":"Murtada","suffix":""},{"id":631667450,"identity":"331cf2ab-97da-4a18-9877-f39d463e313c","order_by":2,"name":"Sara Martin","email":"","orcid":"","institution":"University Hospitals of Liverpool Group","correspondingAuthor":false,"prefix":"","firstName":"Sara","middleName":"","lastName":"Martin","suffix":""},{"id":631667451,"identity":"28fde3db-e455-4be7-bdb9-35a057aaa8e8","order_by":3,"name":"Muneeb Ul Haq","email":"","orcid":"","institution":"University Hospitals of Liverpool Group","correspondingAuthor":false,"prefix":"","firstName":"Muneeb","middleName":"Ul","lastName":"Haq","suffix":""},{"id":631667452,"identity":"30cbfe53-90e6-4bcc-b0c7-e63ca3fda38d","order_by":4,"name":"Muhammad Ahsan Javed","email":"","orcid":"","institution":"University Hospitals of Liverpool Group","correspondingAuthor":false,"prefix":"","firstName":"Muhammad","middleName":"Ahsan","lastName":"Javed","suffix":""}],"badges":[],"createdAt":"2026-04-10 20:08:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9382827/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9382827/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108493615,"identity":"751390bf-6b93-48a0-9666-b0a47787ceea","added_by":"auto","created_at":"2026-05-05 10:01:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":273966,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9382827/v1/6a577238-0d19-4687-89f8-9dd11700b6e5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Single-port Robotic Transanal Minimally Invasive Surgery Using a Novel Access Port: Initial Prospective Consecutive Case Series from the UK","fulltext":[{"header":"1. INTRODUCTION","content":"\u003cp\u003eTransanal local excision remains an important organ-preserving strategy for the management of selected benign and early malignant rectal lesions. It aims to preserve anorectal function while avoiding radical resection where appropriate (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Historically, this has been achieved using techniques such as transanal excision (TART), transanal endoscopic microsurgery (TEMS), and transanal endoscopic operation (TEO). The introduction of transanal minimally invasive surgery (TAMIS) has expanded the applicability of local excision by enabling improved access throughout the rectum using flexible and widely available platforms (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). However, despite these advances, conventional approaches remain technically challenging, particularly within the confined anatomical space of the pelvis.\u003c/p\u003e \u003cp\u003eRobotic assistance has been increasingly utilised to overcome these limitations. Multiport robotic systems, such as the da Vinci Si and Xi platforms, provide enhanced dexterity, stability and visualisation, particularly during suturing and closure of resection defects. However, the utility of these platforms in transanal surgery is constrained by external arm collisions, complex docking, instrument crowding, and challenges achieving a reliable airseal in a confined anatomical space.\u003c/p\u003e \u003cp\u003eThe da Vinci single-port (SP) platform was developed to address these challenges, enabling deployment of a flexible 3D camera and multi-jointed instruments through a single cannula. This improves manoeuvrability in narrow spaces, and has demonstrated early utility in transanal procedures (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Despite these advances, a key limitation persists; conventional transanal access platforms require a minimum deployment distance to full deployment and articulation of SP instruments. This restricts access to distal lesions near the anal verge and can limit procedural feasibility (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA novel dedicated single-port access system, incorporating a flexible wound retractor and balloon-based interface, has recently been introduced to facilitate instrument deployment within a confined space prior to advancement towards the target lesion. Additionally, it also provides channels for assistant instrumentation (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Early reports suggest that this may overcome limitations associated with distal access, although experience remains limited.\u003c/p\u003e \u003cp\u003eTo address these gaps, this study aims to report the initial experience, with SP R-TAMIS using this novel access platform, as a prospective consecutive case series, focusing on safety, technical feasibility and early clinical outcomes. To the best of our knowledge, this is the first reported series of SP R-TAMIS in the United Kingdom and Europe. In addition to reporting technical and oncological outcomes, this paper also assesses early postoperative bowel function using the Low Anterior Resection Syndrome (LARS) score (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Lastly, it describes a standardised operative approach performed entirely in the lithotomy position, irrespective of tumour location.\u003c/p\u003e"},{"header":"2. METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study design\u003c/h2\u003e \u003cp\u003eThis study was conducted as a single-centre prospective consecutive case series representing early experience with a novel technique; TAMIS using the da Vinci single-port (SP) platform in combination with a dedicated access port. Data were collected prospectively and the study has been reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Patients were identified from a prospectively maintained database. All procedures were performed at a single tertiary centre by an experienced colorectal surgeon, with expertise in robotic as well as transanal endoscopic microsurgery (TEMS).\u003c/p\u003e \u003cp\u003e Institutional approval for the introduction and clinical use of this technique and device was obtained from the New Device and Technique Committee. In accordance with institutional governance policies, this study was classified as a service evaluation and did not require formal Research Ethics Committee approval. All patients provided written informed consent for the procedure and data collection. Procedures were video recorded following patient consent. The primary aim was to describe the technical application and short-term clinical outcomes of this approach during its early adoption phase.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Patient Selection\u003c/h2\u003e \u003cp\u003eBetween September 2025 and March 2026, all consecutive patients undergoing single-port robotic transanal minimally invasive surgery (SP R-TAMIS) at Liverpool University Hospitals NHS Foundation Trust were included in this study. All patients were discussed at the Regional Small Early Rectal Cancer (SERC) multidisciplinary team (MDT), comprising colorectal surgeons with expertise in TEMS, gastroenterologists specialising in advanced endoscopic techniques (EMR, ESD, and FTR), specialist SERC radiologists, histopathologists, oncologists, and a dedicated clinical nurse specialist.\u003c/p\u003e \u003cp\u003eIn accordance with SERC MDT protocol, all patients underwent triple assessment consisting of endoscopic evaluation by an experienced SERC endoscopist, endoscopic ultrasound (EUS) of rectal lesion, and rectal magnetic resonance imaging (MRI). Patients with lesions suspicious for malignancy underwent computed tomography (CT) for staging, with additional liver MRI performed where indicated. All treatment options were considered prior to referral for SP R-TAMIS. To minimise selection bias, all consecutive patients deemed suitable for SP R-TAMIS during the study period were included.\u003c/p\u003e \u003cp\u003ePatients were included if they presented with benign or early malignant rectal lesions and were deemed suitable for transanal local excision and fit for surgery under general anaesthesia following MDT review. Patients were excluded if they had locally advanced disease requiring radical resection, evidence of nodal or metastatic disease on staging imaging, or were otherwise unsuitable for transanal surgery.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Operative technique\u003c/h2\u003e \u003cp\u003eAll procedures were performed under general anaesthesia with patients positioned in lithotomy, irrespective of tumour location. All patients received prophylactic intravenous antibiotics at the time of induction. An intraoperative urinary catheter was placed in all patients and removed at the end of the procedure. A 5\u0026ndash;10\u0026deg; Trendelenburg tilt was applied. Rectal insufflation was maintained using the AirSeal\u0026reg; system (LAWMED, UK) via a 7-mm trocar inserted through the assistant channel, maintaining a constant pressure of 20 mmHg. A bedside assistant facilitated smoke evacuation, suction, and irrigation using extended laparoscopic suction as required.\u003c/p\u003e \u003cp\u003eA dedicated flexible access platform incorporating a wound retractor and balloon interface was used to facilitate access. In all cases, a single-port robotic system was docked parallel to the patient\u0026rsquo;s right hip. The central remote centre and instrument limits were established prior to the procedure commenced to ensure optimal instrument range and ergonomics.\u003c/p\u003e \u003cp\u003eExcision was performed using SP-compatible instruments, including scissors with monopolar diathermy, a fenestrated bipolar grasper with bipolar diathermy, and Cadier forceps, allowing both submucosal and full-thickness dissection as indicated. A needle holder was used for suturing when required. A three-instrument approach was used in all cases, with the third robotic arm equipped with a grasping device to optimise exposure and facilitate dissection.\u003c/p\u003e \u003cp\u003eA circumferential margin was marked using monopolar diathermy prior to excision, aiming for approximately 5 mm for benign lesions and 10 mm for malignant lesions. Histopathological margin status for malignant lesions was defined as R0 (no tumour at the resection margin) or R1 (microscopic tumour involvement at the margin).\u003c/p\u003e \u003cp\u003eDefect closure was performed in most cases but was selectively omitted in cases of large defects or lesions involving the dentate line, at the discretion of the operating surgeon. In total, three defects were left open (two large defects\u0026thinsp;\u0026gt;\u0026thinsp;6 cm and one lesion at the dentate line). Both submucosal and full-thickness defects\u0026thinsp;\u0026le;\u0026thinsp;8 cm were routinely closed using a running barbed absorbable suture (3\u0026thinsp;\u0026minus;\u0026thinsp;0 V-Loc PDS; Medtronic, Watford, UK).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Data collection and outcome measures\u003c/h2\u003e \u003cp\u003eBaseline demographic variables included age, sex and preoperative status assessed using American Society of Anesthesiologists (ASA) score. The primary outcomes were technical success (defined as completion of the procedure using the SP platform without conversion to an alternative transanal or abdominal approach) and perioperative morbidity. Secondary outcomes included operative time (including total operating time, perineal setup time, robot docking time, and console time), estimated blood loss, intraoperative complications, need for blood transfusion, resection type (submucosal vs full thickness), specimen fragmentation (en bloc vs piecemeal), and histopathological outcomes including margin status. Perioperative morbidity was defined as any complication occurring within 30 days of surgery.\u003c/p\u003e \u003cp\u003eEndoscopic variables included lesion size, distance from the anal verge, lesion size, pit pattern, and JNET classification. EUS assessments captured lesion size, distance from the anal verge, lesion position, layer of origin, and depth of invasion. Imaging variables from MRI included tumour stage, extramural depth of invasion, circumferential resection margin status, and nodal involvement. Imaging was performed and reported according to established rectal cancer guidelines and standardised institutional protocols to ensure uniform evaluation across the cohort. Additional variables comprised histopathological diagnosis and resection margin status.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Patient follow-up\u003c/h2\u003e \u003cp\u003eAll patients were followed for a minimum of 30 days postoperatively to assess short-term outcomes, including 30-day morbidity and mortality. Recurrence was assessed clinically and radiologically. Functional outcomes were assessed using the LARS questionnaire at 6 weeks and 3 months postoperatively. Baseline (preoperative) LARS scores were recorded for all patients and were zero in all cases. Questionnaires were administered during routine follow-up (in-person or virtual clinic). Complete 6-week data were available for all patients, while 3-month follow-up was available for 14/18 patients. Missing data were due to incomplete follow-up at the time of analysis and were not imputed.\u003c/p\u003e \u003c/div\u003e"},{"header":"3 RESULTS","content":"\u003cp\u003eA total of 18 patients underwent SP R-TAMIS following discussion at the SERC MDT. Patient demographics and lesion characteristics are summarised in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Patients were aged 53\u0026ndash;81 years, with a male predominance (12/18). All patients were ASA grade 2 or 3. Lesions were located between 1 and 20 cm from the anal verge (median 6 cm) and measured 1\u0026ndash;8.5 cm in size (median 4 cm). Lesion distribution was anterior in 9 (50%), posterior in 7 (38%), and lateral in 2 (11%) cases. Triple assessment was performed in the majority of patients; endoscopic evaluation was completed in all cases, while EUS and MRI were omitted in selected cases due to lesion characteristics or prior treatment. EUS was omitted in two cases due to lesion proximity to the dentate line or prior polypectomy, and MRI was omitted in two patients with recurrent benign polyps.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient Demographics and Lesion Characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue [N (%)]\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge [median (range)] (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67 (53\u0026ndash;81)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (67%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (33%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eASA grade\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (50%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (50%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eHistology\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLGD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (17%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHGD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (56%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdenocarcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (22%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeuroendocrine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLesion Size [median (range)] (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (1\u0026ndash;8.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003ePreoperative assessment\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEndoscopy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEUS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (83%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMRI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (88%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistance from Anal Verge [median (range)] (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (1\u0026ndash;20)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eLesion Position\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnterior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (50%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePosterior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (39%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (11%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eLGD, low-grade dysplasia; HGD, high-grade dysplasia; ASA, American Society of Anesthesiologists; EUS, endoscopic ultrasound; MRI, magnetic resonance imaging.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eAll procedures were completed using the SP robotic platform without conversion to alternative techniques. Two lesions involving the dentate line were approached using a hybrid approach combining open transanal mobilisation with SP R-TAMIS. Two proximal lesions above the peritoneal reflection were excised using a full-thickness approach with defect closure. Defect closure was performed in 15/18 (83%) cases per surgeon preference. The post operative outcomes are summarised in Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Median operative time (including docking and console time) was 55 minutes (range 35\u0026ndash;90), with minimal blood loss (median 5 mL). A local perineal block (20\u0026ndash;30 mL) with 20 mls of 0.5% Bupivicaine was administered in all patients.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePost-operative outcomes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue [N (%)]\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOperating Time (\u003c/b\u003eDocking and console Time) [median (range)]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55 (35\u0026ndash;90) min\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEstimated blood loss\u003c/b\u003e [median (range)]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (0\u0026ndash;10) mL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFinal Histopathology\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMalignant\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eT1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (39%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSm1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSm2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (57%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSm3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (43%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eT2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eT3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeuroendocrine tumour (Tis)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBenign\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLGD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (17%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHGD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (28%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (11%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMargins\u003c/b\u003e (Malignant Lesion)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eR0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eR1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLength of Stay\u003c/b\u003e (Days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResection Type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFull thickness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (78%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHybrid (combined submucosal and full-thickness dissection)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (22%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSpecimen\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEn-bloc\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (89%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePiecemeal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (11%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eConversion to alternative technique\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTEMS/TAMIS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTART\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePostoperative complications\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOverall morbidity (30 days)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReturn to Theatre\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTransfusion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReadmission\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBleeding (before discharge)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003e*\u003c/b\u003e \u003cem\u003eDischarged within 23 hours.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eTEMS, transanal endoscopic microsurgery; TAMIS, transanal minimally invasive surgery; TART, transanal robotic surgery; LGD, low-grade dysplasia; HGD, high-grade dysplasia; Sm, Submucosal invasion level\u003c/em\u003e \u003c/p\u003e \u003cp\u003eFinal histopathology demonstrated 8 malignant lesions (adenocarcinoma 7, neuroendocrine tumour 1), 5 high-grade dysplasia, 3 low-grade dysplasia, and 2 cases with no residual lesion following prior endoscopic resection ESD (presumed benign). Clear (R0) resection margins were achieved in all malignant cases. A planned circumferential margin of approximately 5 mm (benign) and 10 mm (malignant) was targeted in all patients. Full-thickness excision was performed in 14 patients, with a hybrid approach in 4. En bloc resection was achieved in 16/18 (88%) cases. All patients were discharged within 23 hours of surgery. One patient required readmission on postoperative day 7 for bleeding, which was managed conservatively. No patients required reoperation, transfusion, or experienced bleeding prior to discharge.\u003c/p\u003e \u003cp\u003eBaseline LARS scores were zero in all patients. At six weeks, LARS assessment demonstrated no symptoms in 16 patients, with two reporting minor symptoms. At 3 months, follow-up data were available for 14/18 patients; of these, 13 reported no LARS and 1 reported minor symptoms. No patients developed major LARS during follow-up. The reduced sample at 3 months reflects incomplete follow-up rather than attrition due to adverse outcomes.\u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Published SP R-TAMIS series\u003c/h2\u003e \u003cp\u003ePublished single-centre series of SP R-TAMIS are summarised in Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Across studies, technical success rates ranged from 93% to 100%, with R0 resection rates between 93% and 100%. Reported complication rates ranged from 0% to 11.8%, and length of hospital stay varied from same-day discharge to a median of 5 days. Follow-up duration ranged from short-term (30 days) to a median of 24 months (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of published single-centre series of single-port robotic transanal minimally invasive surgery (SP R-TAMIS)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLocation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients and Demographics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKey Outcomes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFollow-up\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFerrari et al. (2024)\u003c/em\u003e(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMayo Clinic, Minnesota, USA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;31 (19M, 12F); Mean age 61\u0026thinsp;\u0026plusmn;\u0026thinsp;13.3; Mean BMI 30.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTechnical success: 96.8%; Conversion: 3.2%; Negative margins: 93.5%; 30-day morbidity: 6.5%; LOS: Same-day discharge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMean 18.3 months; Recurrence 0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eKim et al. (2024)\u003c/em\u003e(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSeoul St Mary\u0026rsquo;s Hospital, Korea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;9 (5M, 4F); Age 30\u0026ndash;72 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTechnical success: 100%; Negative margins: 100%; Intraoperative complications: 0%; LOS: mean 1.67 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.5\u0026ndash;21.1 months; Recurrence 0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFriedman et al. (2025)\u003c/em\u003e(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMountain View Hospital, Nevada, USA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;17 (13M, 4F); Mean age 63.9 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTechnical success: 100%; Negative margins: 100%; Postoperative complications: 11.8%; LOS: 0 days (Same-day)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eShort-term (30-day); No recurrence observed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eWoo et al. (2024)\u003c/em\u003e(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUlsan University Hospital, Korea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;14 (11M, 3F); Median age 72; Median BMI 22.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTechnical success: 100%; Negative margins: 93%; Complications: 7.1%; LOS: Median 5 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMedian 24 months (range 12\u0026ndash;34); Recurrence 0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eLiu et al. (2021)\u003c/em\u003e(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMayo Clinic, Minnesota, USA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;5 (3M, 2F); Age 50\u0026ndash;66 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTechnical success: 100%; Negative margins: 100%; Postoperative complications: 1 readmission (bleeding); LOS: Same-day discharge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMinimum 30 days; Normal bowel function at 2 weeks\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cb\u003eAbbreviations: SP R-TAMIS, single-port robotic transanal minimally invasive surgery; BMI, body mass index; LOS, length of stay; M, male; F, female.\u003c/b\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"4\tDISCUSSION","content":"\u003cp\u003eThis study represents the first reported series of SP R-TAMIS in the United Kingdom and Europe. As a prospective case series, it describes technical implementation and short-term outcomes rather than comparative effectiveness of this technique. Our findings demonstrate that SP R-TAMIS is feasible and safe, with all procedures completed without conversion and performed entirely in the lithotomy position irrespective of lesion location. This standardised positioning simplifies operative workflow and avoids intraoperative repositioning reported in other series (10).\u003c/p\u003e\n\u003cp\u003eRobotic-assisted TAMIS using multiport platforms improves dexterity and visualisation compared with conventional TEMS and laparoscopic TAMIS (3, 4), but adoption is limited by external arm collisions, instrument crowding, and ergonomic constraints within the confined pelvic space (11). The single-port platform addresses these limitations by enabling deployment of a flexible 3D camera and multi-jointed instruments through a single access point, improving maneuverability. In our series, all malignant lesions were resected en bloc, and no conversions were required, suggesting acceptable short-term resection quality.\u003c/p\u003e\n\u003cp\u003eA key technical advancement in our series is the use of a dedicated flexible access platform incorporating a balloon-based interface and wound retractor (7). Conventional platforms, such as GelPOINT or glove-port systems (1, 8, 9), require a minimum deployment distance (7\u0026ndash;10 cm) for effective articulation (1, 7), limiting access to lesions above peritoneal reflection. The platform used in our series allows instrument deployment within a confined space, enabling safe resection of lesions as low as 1 cm from the anal verge while maintaining access to more proximal lesions, thereby expanding the applicability of the technique.\u003c/p\u003e\n\u003cp\u003eOncological outcomes were favourable, with R0 resection in all malignant cases and an en bloc resection rate of 88%. These findings are consistent with reported SP R-TAMIS series (93\u0026ndash;100% R0)\u0026nbsp;(1, 7-10). Compared with laparoscopic TAMIS, which has reported higher margin positivity\u0026nbsp;(up to 8.6% or 15%)\u0026nbsp;and specimen fragmentation\u0026nbsp;(5%) (8, 10),\u0026nbsp;the SP system offers better visualisation. The ability to visualise around the lesion facilitates more accurate identification of tumour boundaries although further validation in larger studies is required.\u003c/p\u003e\n\u003cp\u003eThe ability to approach lesions up to 20 cm from the anal verge, including above the peritoneal reflection, highlights the versatility of this technique. Although proximal resections carry a risk of peritoneal entry, enhanced visualisation and articulation of SP approach allows safe identification and transanal closure of defects (8). In our cohort, lesions above the peritoneal reflection were managed with full-thickness excision and secure closure. However, this was not formally evaluated.\u003c/p\u003e\n\u003cp\u003eA learning curve was observed, particularly in early cases due to adjustments in docking, port positioning. (to achieve adequate seal), and defect closure. Proficiency improved rapidly, and the technique was transferable under supervision, suggesting that structured training may facilitate wider adoption.\u003c/p\u003e\n\u003cp\u003eFunctional outcomes following TAMIS are generally favourable, with most patients reporting minimal bowel dysfunction (5). consistent with studies indicting approximately 70\u0026ndash;75% of patients experience no LARS at 6 months, with minor symptoms in 15\u0026ndash;20% and major LARS in less than 10% (12, 13). \u0026nbsp;In this series, no patients developed major LARS at early follow-up. This may relate to reduced sphincter stretch with a single access port compared with multi-instrument approaches (1, 10). Although findings are consistent with prior TAMIS cohorts, interpretation of early functional is limited by short follow-up and incomplete 3-month data (14).\u003c/p\u003e\n\u003cp\u003eConsecutive case inclusion minimised selection bias. All patients were managed as day cases, supported by perineal block, early virtual follow-up, and low morbidity, with one readmission managed conservatively.\u003c/p\u003e\n\u003cp\u003eLooking forward, the platform may have wider applications, including as an alternative to ESD for larger lesions or complex resections requiring combined full-thickness and submucosal dissection. Structured training and proctoring remain essential for safe adoption of this approach. Shared access across specialties, as seen in our institution, may improve utilisation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.1 Characteristics and outcomes of published SP R-TAMIS series\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCompared with published SP R-TAMIS series, our cohort demonstrated comparable technical and oncological outcomes, with 100% technical success and R0 resection in all malignant lesions. Despite some piecemeal resections, margin status remained negative, suggesting appropriate case selection and precise dissection.\u003c/p\u003e\n\u003cp\u003eAll patients were discharged within 23 hours, comparing favourably with published cohorts reporting same-day discharge to a mean of approximately 2 days (9) and median of 5 days (8). While variation likely reflects differences in institutional pathways and case complexity, this suggests SP R-TAMIS can be integrated into short-stay pathways without compromising resection quality.\u003c/p\u003e\n\u003cp\u003eIn our series, postoperative morbidity was low, with one delayed bleeding episode managed conservatively, consistent with published reports where bleeding is a common complication (1, 7). Additionally, this study reported on the structured assessment of early postoperative bowel function. One SP R-TAMIS series reported LARS outcomes beyond very early follow-up at 2 weeks (1). Although longer-term follow-up data are required, these findings support the short-term safety and favourable early functional profile of the technique in appropriately selected patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.2 Limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study represents a small, single-centre, single-surgeon case series, which may limit generalisability and could potentially introduce operator-dependent bias. The absence of a comparative control group limits conclusions regarding relative oncological or functional superiority. Although data were prospectively collected, the observational design and limited sample size restrict statistical power. Follow-up was short, and while no early recurrence was observed, long-term oncological outcomes could not be assessed. In addition, perioperative recovery metrics were not routinely recorded, and cost analysis was not performed, both of which are important considerations for wider adoption.\u003c/p\u003e"},{"header":"5\tCONCLUSIONS","content":"\u003cp\u003eIn conclusion, SP R-TAMIS using a dedicated access platform is a feasible and safe technique that allows precise excision of rectal lesions across a wide anatomical range with low morbidity and favourable early functional outcomes. The ability to standardise operative positioning and address technical limitations associated with distal access represents a key advantage. Further studies with larger cohorts and longer follow-up are required to establish long-term oncological and functional outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eDISCLOSURE\u003c/h2\u003e \u003cp\u003eChatGPT: AI-assisted language editing. OpenAI, San Francisco, CA. Version GPT-5, September 2025 \u003cem\u003eURL\u003c/em\u003e \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://chat.openai.com/\u003c/span\u003e\u003cspan address=\"https://chat.openai.com/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e was utilised to assist with English language editing, grammar, punctuation, and improvements to clarity of expression in this manuscript. No AI tools were used for study design, data analysis, interpretation of results, or the generation of tables, figures, references, or citations. All scientific content, analyses, and conclusions are the responsibility of the authors.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCONFLICT OF INTEREST\u003c/h2\u003e \u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\u003ch2\u003eFUNDING\u003c/h2\u003e \u003cp\u003eThis research has received no external funding\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConceptualization: SA; data curation: AM, MH; methodology: MAJ, SA, SM; formal analysis: SM, SA; writing\u0026mdash;original draft: AM, SM; writing\u0026mdash;review and editing: MH, MAJ; supervision: MAJ\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe would like to acknowledge the clinical staff at LUHFT, including the surgeons, trainees, and nursing teams, for their continuous support in patient care and data collection.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and analysed during this study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLiu S, Kelley SR, Behm KT. Single-port robotic transanal minimally invasive surgery (SPR-TAMIS) approach to local excision of rectal tumors. Techniques in coloproctology. 2021;25(2):229\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMartin-Perez B, Andrade-Ribeiro GD, Hunter L, Atallah S. A systematic review of transanal minimally invasive surgery (TAMIS) from 2010 to 2013. Techniques in coloproctology. 2014;18(9):775\u0026ndash;88.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO\u0026rsquo;Sullivan NJ, Temperley HC, Larkin J, McCormick JJ, Rausa E, McCormick P, et al. Robotic transanal minimally invasive surgery (R-TAMIS): current evidence in the treatment of early rectal neoplasia. International journal of colorectal disease. 2024;39(1):71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCoco D, Leanza S. Robotic Transanal minimally invasive surgery for rectal neoplasms: A systematic review of outcomes and innovations. Langenbeck's archives of surgery. 2026;411(1):83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDuggan WP, Sugrue DD, Shannon N, Murphy B, Burke JP. A prospective evaluation of the effect of transanal minimally invasive surgery (TAMIS) on low anterior resection syndrome. Surgical endoscopy. 2023;37(7):5241\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCuschieri S. The STROBE guidelines. Saudi journal of anaesthesia. 2019;13(5):31\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFriedman G, Specht K. Robotic Transanal Minimally Invasive Surgery With da Vinci Single-Port Platform and Single-Port Access Port. Diseases of the colon \u0026amp; rectum. 2025;68(9):e1783-e7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWoo JS, Cho MJ, Park IK, Im YC, Kim GY, Park DJ, et al. Initial case series experience with robotic-assisted transanal minimally invasive surgery performed with da Vinci single-port system for the excision of rectal cancer. Surgical endoscopy. 2024;38(11):6762\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim IK, Bae JH, Lee YS, Lee IK. Clinical Feasibility and Technical Aspects of Single Port Robotic TransAnal Minimally Invasive Surgery (SP\u0026ndash;rTAMIS) for Rectal Neoplasm. The international journal of medical robotics\u0026thinsp;+\u0026thinsp;computer assisted surgery. 2025;21(1):e70026\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e-n/a\u003c/span\u003e\u003cspan address=\"http://-n/a\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFerrari D, Peponis T, Violante T, Cheng JN, Perry WR, Larson DW, et al. Single-port robotic transanal minimally invasive surgery (SPR‐TAMIS): another giant leap forward? Colorectal disease. 2025;27(1):\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003en/a\u003c/span\u003e\u003cspan address=\"http://n/a\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHo JCE, Yong CJC, Goel AR, Rafaih AB, Shaikh I, Iqbal MR. Robotic surgery (R-TAMIS): a systematic review. Journal of robotic surgery. 2026;20(1):276.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSun R, Dai Z, Zhang Y, Lu J, Zhang Y, Xiao Y. The incidence and risk factors of low anterior resection syndrome (LARS) after sphincter-preserving surgery of rectal cancer: a systematic review and meta-analysis. Supportive care in cancer. 2021;29(12):7249\u0026ndash;58.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePieniowski EHA, Nordenvall C, Palmer G, Johar A, Tumlin Ekelund S, Lagergren P, et al. Prevalence of low anterior resection syndrome and impact on quality of life after rectal cancer surgery: population-based study. BJS open. 2020;4(5):935\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoldenshluger M, Gutman Y, Katz A, Schtrechman G, Westrich G, Nissan A, et al. Long-Term Bowel Function after Transanal Minimally Invasive Surgery (TAMIS). The Israel Medical Association journal. 2020;22(7):426.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"techniques-in-coloproctology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tcol","sideBox":"Learn more about [Techniques in Coloproctology](http://link.springer.com/journal/10151)","snPcode":"10151","submissionUrl":"https://submission.nature.com/new-submission/10151/3","title":"Techniques in Coloproctology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Transanal minimally invasive surgery (TAMIS), single-port robotic surgery, local excision, perioperative care, functional outcomes","lastPublishedDoi":"10.21203/rs.3.rs-9382827/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9382827/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eTransanal minimally invasive surgery (TAMIS) is widely used for the management of benign and early rectal neoplasia; however, technical limitations persist, particularly in confined pelvic anatomy. The da Vinci single-port (SP) platform, combined with a dedicated access port, has been developed to improve instrument articulation and distal access. This study reports early experience and feasibility of this approach.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eA prospectively maintained database was reviewed for consecutive patients undergoing SP robotic TAMIS (R-TAMIS) at a single tertiary center in the United Kingdom. All cases were discussed at a specialist early rectal cancer multidisciplinary team and underwent triple assessment with endoscopy, endoscopic rectal ultrasound, and MRI rectum. Primary endpoints were technical success (completion without conversion) and perioperative morbidity.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eEighteen patients underwent SP R-TAMIS for benign (n\u0026thinsp;=\u0026thinsp;10) and malignant (n\u0026thinsp;=\u0026thinsp;8) rectal lesions. Tumour height ranged from 1 to 20 cm from the anal verge. All procedures were completed without conversion. En bloc resection was achieved in 16/18 (88%) cases, with clear (R0) margins in all malignant lesions (resected en bloc). Median operative time was 55 (35\u0026ndash;90) minutes with minimal blood loss (\u0026lt;\u0026thinsp;10 mL). All patients were discharged within 24 hours. One patient required readmission for delayed bleeding, managed conservatively. No major functional impairment was observed at early follow-up\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e \u003cp\u003eSP R-TAMIS using a dedicated access platform is a feasible and safe approach for transanal management of rectal lesions, enabling precise excision across a wide anatomical range with low morbidity and favourable early functional outcomes. Further studies are required to assess long-term oncological and functional outcomes.\u003c/p\u003e","manuscriptTitle":"Single-port Robotic Transanal Minimally Invasive Surgery Using a Novel Access Port: Initial Prospective Consecutive Case Series from the UK","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-04 13:02:51","doi":"10.21203/rs.3.rs-9382827/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"171058199323499223702167881207969958442","date":"2026-04-26T17:42:50+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-24T08:05:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"3163723635547057937824979167794534442","date":"2026-04-24T07:58:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"202858510840391109474010587128623273224","date":"2026-04-24T07:24:58+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-23T13:07:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-16T21:25:06+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-11T07:29:11+00:00","index":"","fulltext":""},{"type":"submitted","content":"Techniques in Coloproctology","date":"2026-04-10T20:01:23+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"techniques-in-coloproctology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tcol","sideBox":"Learn more about [Techniques in Coloproctology](http://link.springer.com/journal/10151)","snPcode":"10151","submissionUrl":"https://submission.nature.com/new-submission/10151/3","title":"Techniques in Coloproctology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"8667b44c-3e45-475c-bda9-6aee5e37ed16","owner":[],"postedDate":"May 4th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T13:02:51+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-04 13:02:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9382827","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9382827","identity":"rs-9382827","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}