Techniques in Coloproctology
Novel multi-image view for neuromapping meets the needs
of the robotic surgeon
Jonas F. Schiemer
· Lennart Zimniak
· Edin Hadzijusufovic
· Hauke Lang
· Werner Kneist
Received: 5 April 2018 / Accepted: 22 May 2018
© Springer International Publishing AG, part of Springer Nature 2018
Background Pelvic intraoperative neuromonitoring during nerve-sparing robot-assisted total mesorectal excision (RTME)
is feasible. However, visual separation of the neuromonitoring process from the surgeon console interrupts the workﬂow
and limits the usefulness of available information as the procedure progresses. Since the robotic surgical system provides
multi-image views in the surgeon console, the aim of this study was to integrate cystomanometry and internal anal sphincter
electromyography signals to aid the robotic surgeon in his/her nerve-sparing technique.
Methods We prospectively investigated 5 consecutive patients (1 male, 4 females) who underwent RTME for rectal cancer
at our institution in 2017. The robotic surgery was performed using the da Vinci Xi combined with pelvic intraoperative
neuromapping with real-time electromyography and cystomanometry signal transmission by multi-image view during RTME.
Results The adapted two-dimensional pelvic intraoperative neuromonitoring imaging successfully simulcasted to the surgeon
console view in all 5 cases. The technical note is complemented by an intraoperative video.
Conclusions This report demonstrates the technical feasibility of an improved neuromonitoring process during nerve-sparing
RTME. Robotic neuromapping can be fully visualized from the surgeon console.
Keywords Robotic surgical procedures · Rectal cancer · Neuromonitoring · Autonomic pathways
Nerve-sparing pelvic dissection with total mesorectal exci-
sion (TME) for rectal cancer includes identiﬁcation of auto-
nomic nerve ﬁbers such as pelvic splanchnic nerves, the
inferior hypogastric plexus (IHP), neurovascular bundles
and internal anal sphincter nerves [1, 2].
TME performed via a robotic platform may be advanta-
geous for functionally relevant pelvic autonomic nerve pres-
ervation . However, due to several intraoperative technical
challenges and patient-related factors , evidence for the
advantaage of a robotic approach is lacking.
Recently, Grade et al. demonstrated that neuromapping
can be used during robot-assisted TME (RTME) . How-
ever, this remote approach is cumbersome because it does
not include customized applications for translating neu-
romonitoring technology into the robotic platform. The inte-
gration of multiple views onto the surgeon console screen
has been shown to facilitate and simplify performance in
robotic surgery [6–8, 10].
The aim of this study was to integrate cystomanometry
and internal anal sphincter electromyography signals to
facilitate nerve-sparing during RTME. The image-guided
and computer-assisted neuromonitoring information was
implemented with the surgeon console viewer.
Materials and methods
To prove the feasibility of integrating neuromonitoring infor-
mation into the surgeon console display and vice versa, we
prospectively investigated ﬁve consecutive patients (1 male,
4 females) undergoing RTME for rectal cancer in 2017.
Electronic supplementary material The online version of this
article (https ://doi.org/10.1007/s1015 1-018-1804-3) contains
supplementary material, which is available to authorized users.
* Werner Kneist
Department of General, Visceral and Transplant Surgery,
University Medical Center of the Johannes Gutenberg-
University Mainz, Langenbeckstraße 1, 55131 Mainz,