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Ishida et al. Mini-invasive Surg 2018;2:31 I http://dx.doi.org/10.20517/2574-1225.2018.53 Page 3 of 8

Figure 1. Trocars placement in conventional (A), reduced port (B) and single incision (C) laparoscopic surgery for rectal cancer

[26]
[27]
at the site . SILS is performed entirely through this access port . For RPS, an additional port is inserted
on the operator’s dominant-hand side [Figure 1A and C]. The assistant uses one channel of the MIAP to
create a working view, and a 5 mm flexible-tip laparoscope is inserted through the other MIAP channel. A
flexible laparoscope is useful for preventing interference from the hand instruments. After mobilization of
the rectum, the transumbilical site is used to extract the specimen, and bowel anastomosis is performed in
the same manner as in CMLS.

SILS compared with CMLS
Although no RCT on the subject has been performed, the most recent systematic review showed that
[17]
colorectal SILS is at least as feasible and safe as CMLS in selected patients with rectal cancer . SILS
had outcomes comparable to those of CMLS in terms of operating time, conversion rate, reoperation
rate, postoperative complication rate, and mortality rate. The oncological results of SILS for CRC were
satisfactory, as demonstrated by similar average lymph-node retrieval and adequate resection margins
relative to those obtained with CMLS. Nevertheless, long-term follow-up data on survival and local
recurrence rates are lacking. In addition, colorectal SILS is technically limited because of instrument
crowding, in-line viewing, and insufficient countertraction [24,28] . In particular, cutting of the distal rectum
[29]
from the umbilicus using a linear stapler is technically difficult . Therefore, the authors of the systemic
[17]
review concluded that they could not recommend the use of SILS instead of CMLS for CRC .
RPS compared with CMLS
RPS has become more feasible due to the accumulation of experience and improvement of laparoscopic
tools, such as energy devices and specific forceps. Although they included relatively few patients with rectal
cancer, four retrospective studies have compared RPS with CMLS for the treatment of this disease [27,30-32] .
The advantages of RPS over CMLS are summarized in Table 1. No RCT, systematic review, or meta-
analysis has compared the outcomes of RPS and CMLS. An RCT of the short-term surgical and long-term
[33]
oncological safety of RPS compared with CMLS for rectosigmoid colon cancer is underway .

[27]
One study evaluated long-term oncological outcomes after RPS for rectosigmoid cancer. Liu et al.
reported that the 3-year DFS and OS rates were comparable between the RPS and CMLS groups.

Regarding short-term outcomes, the operation time is shorter for RPS than for CMLS [27,30,31] , possibly due to
selection bias [30,31] or a decreased time to wound closure as a result of the fewer and smaller wounds created
[30]
during RPS .
RPS is less invasive than CMLS and results in shorter times to flatus passage, liquid diet consumption, and