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Page 2 of 8 Ishida et al. Mini-invasive Surg 2018;2:31 I http://dx.doi.org/10.20517/2574-1225.2018.53

operating time, higher theater costs, and a steep learning curve. However, the long-term recurrence rate
was similar and no significant difference was found in the disease-free survival (DFS) or overall survival
[4]
(OS) rate . Therefore, laparoscopic surgery is now considered to be an acceptable approach for colon
cancer.

However, some controversy surrounds the non-inferiority of laparoscopic surgery to open surgery for
rectal cancer in terms of long-term outcomes. Two previous large randomized controlled trials (RCTs),
the Colorectal Cancer Laparoscopic or Open Resection (COLOR) II and Comparison of Open versus
laparoscopic surgery for mid or low Rectal cancer After Neoadjuvant chemoradiotherapy (COREAN)
trials, and several meta-analyses showed similar pathological and oncological outcomes of laparoscopic
and open approaches for rectal cancer, and the laparoscopic approach is now a standard alternative to the
open approach [5,10-13] . However, two more recent RCTs, the ALaCaRT and ACOSOG Z6051 trials, yielded
contradictory results, and failed to show the non-inferiority of laparoscopic to open rectal resection [14,15] .
The most recent meta-analysis showed that the risk of a positive circumferential resection margin in rectal
[16]
cancer was significantly greater for laparoscopic than for open surgery . Although laparoscopic surgery
might be useful for the treatment of rectal cancer in selected patients, the evaluation of long-term outcomes
is needed to determine whether the poor pathological outcomes have adverse effects on DFS or OS.

Laparoscopic procedures are becoming less invasive. Conventional multiport laparoscopic surgery (CMLS)
for colorectal cancer (CRC) requires four or five abdominal incisions for trocars, and each incision could be
[17]
associated with wound complications and pain . Single-incision laparoscopic surgery (SILS) would reduce
the incidence of such wound-related complications and achieve better cosmetic outcomes relative to CMLS.
The potential advantages of SILS over CMLS are less pain and early recovery. Indeed, SILS reportedly has
more acceptable short-term outcomes compared with CMLS [18-21] . In addition, it has been reported that
SILS performed by experienced laparoscopic surgeons for selected patients can be an oncologically safe
option [22-24] . However, SILS is a highly demanding procedure with several technical challenges, such as the
handling of conventional laparoscopic instruments through small incisions, which could decrease the
range of motion, and the potential for collisions between instruments and the camera. As a result, SILS
also has disadvantages, such as a longer operation time, increased surgeon fatigue, and a steep learning
curve. Reduced-port laparoscopic surgery (RPS), which is single-port surgery with one additional port,
may overcome the limitations of SILS while retaining its advantages.

Here, we review the present situation, challenges, and future prospects of the use of RPS for CRC.

A comprehensive literature search was performed following an electronic search of PubMed@. Articles
published in the English language between January 2013 and June 2018 were evaluated using the key terms
“RPS, CRC” or “SILS, CRC”. Case reports or small case series ( < 20 cases) were excluded.

CMLS, SILS, AND RPS PROCEDURES FOR RECTAL CANCER CMLS
CMLS for CRC is usually performed via the five-port method, with an umbilical camera port, two operator
[25]
ports, and two assistant ports [Figure 1A]. The left colon is initially mobilized laterally to medially to the
extent required for identification of the left ureter and left hypogastric nerve plexus. Mobilization of splenic
flexure is performed if necessary. After intracorporeal high ligation of the inferior mesenteric vessels,
mobilization of the rectum and mesorectum is performed. After mobilization of the rectum, a 3-4 cm
abdominal-wall incision is made to extract the specimen. Bowel anastomosis is performed intracorporeally
for anterior resection using a double-stapling technique.

SILS and RPS
A vertical 3 cm incision is made in the umbilicus and a multiple-instrument access port (MIAP) is placed