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Page 2 of 15 Kumar et al. Mini-invasive Surg 2018;2:19 I http://dx.doi.org/10.20517/2574-1225.2018.26

total mesorectum along with en bloc resection of involved pelvic structures often required to achieve R0
status . Magnetic resonance imaging (MRI) of pelvis is accurate in staging of locally advanced and locally
[1]
recurrent rectal cancer . On the basis of the involvement of fascial boundaries and the anatomic planes
[2,3]
of dissection between intra-pelvic organs in the MRI, pelvis was divided into seven compartments, namely
the central, peritoneal reflection, anterior above and below the peritoneal reflection, posterior, lateral, and
inferior compartments . The locally advanced and locally recurrent rectal cancers were classified depending
[4]
on the MRI findings of tumor invasion within seven intra-pelvic compartments .
[2]
The extended-TME (e-TME) is defined as partial resection of adjacent organ(s) of the rectum such as posterior
wall of the prostate or the vagina, the uterus, the seminal vesicles, the hypogastric plexuses, the ureter, and
bladder en bloc with the TME with curative intent, to achieve a R0 resection . The beyond-TME (b-TME)
[5,6]
includes posterior pelvic exenteration, total pelvic exenteration, extralevator abdomino-perineal resection
for inferior compartment involvement, and sacral resection for posterior compartment involvement .
[5,7]
Lateral pelvic lymph node dissection is considered for subgroup of patients with clinically suspected lateral
pelvic lymph node metastasis, even after neo-adjuvant chemo-radiotherapy .
[8,9]

Only few specialized multidisciplinary units across the world perform these aggressive resections as the
morbidity and mortality associated with these surgeries is very high . Refinement and standardization of
[10]
these techniques forge the way forward in improving outcomes. Multidisciplinary team approach, advances
in surgical technique, perioperative care, interventional radiology, and better patient selection have
contributed to the decrease in complication rates, making it feasible for an increasing number of surgical
units to adopt these aggressive surgical techniques.

Minimal invasive surgery (MIS) is an accepted modality of treatment for rectal cancer. Laparoscopic resection
improves perioperative outcomes, including decrease in intraoperative blood loss, postoperative pain, ileus,
and duration of hospital stay. Randomized trials such as the CLASICC (Conventional vs. Laparoscopic-
Assisted Surgery in Colorectal) trial, COREAN (Comparison of Open vs. Laparoscopic Surgery for Mid
or Low Rectal Cancer after Neoadjuvant Chemoradiotherapy) trial, and COLOR II (Colorectal Cancer
Laparoscopic or Open Resection II) trials have confirmed the feasibility and oncological safety of laparoscopic
surgery in TME [11-13] . Despite the advantages, laparoscopic surgery has some limitations, such as unstable,
two-dimensional view, limitations in the freedom degrees of the surgical instruments, the amplification of
the physiological tremor and the “fulcrum” effect, and poor ergonomics [14,15] . The robotic surgery overcomes
these disadvantages and improves the ergonomics of the surgeon . The robotic surgery helps reduce hospital
[16]
stay and conversion rates and similar oncological outcomes in TME [17-19] . But recently, ROLARR (RObotic vs.
LAparoscopic Resection for Rectal Cancer) trial revealed that robotic-assisted laparoscopic surgery do not
confer an advantage over laparoscopic surgery in rectal cancer resection for TME . However this trial did
[20]
not address the e-TME/b-TME.

The aforementioned randomized trials have excluded cT4 lesions. Bretagnol et al. assessed feasibility and
[21]
oncological outcomes of laparoscopic surgery for cT4 colorectal cancer and suggested that locally advanced
rectal cancer cannot be considered as absolute contraindication. A multicenter propensity score-matched
analysis of laparoscopic surgery vs. open surgery for T4 rectal cancer by de’Angelis et al. suggested that
[22]
laparoscopic surgery can achieve good pathological and oncological outcomes similar to open surgery with
faster recovery and shorter hospital stay, despite the risk of conversion. The indications for MIS have gradually
been extended to locally advanced and locally recurrent rectal cancer as a result of technological advances
in instrumentation, advances in surgical techniques, increased surgeon experience, and high volume center,
which suggested laparoscopic surgery is feasible with good perioperative outcomes [23-25] . Kim et al. reported
[26]
that laparoscopic multivisceral resection seems to be a feasible and effective treatment option for colorectal
cancer for carefully selected patients without any adverse long-term oncological outcomes. However, safety