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Kumar et al. Mini-invasive Surg 2018;2:19 I http://dx.doi.org/10.20517/2574-1225.2018.26 Page 3 of 15

and feasibility of laparoscopic and robotic surgery in b-TME and e-TME are not well established, and there
are very few studies in the world literature. This review summarizes current evidence for MIS approach for
b-TME/extended resections in rectal cancer.

METHODS
A systematic search was carried out in PubMed. Studies available in English related to MIS approach in
b-TME/e-TME in rectal cancers were identified and evaluated. Keywords used were “MIS, laparoscopic
surgery, robotic surgery, b-TME, e-TME, locally advanced rectal cancer, pelvic exenteration, extended
resection, lateral pelvic lymph node dissection, abdominosacral resection”. The perioperative outcomes such
as duration of surgery, blood loss, conversion rate, overall morbidity, hospital stay, R0 status, and long-term
outcomes such as local recurrence rate, disease-free survival, and overall survival (OS) were studied.

PELVIC EXENTERATION
Local control and long-term survival in locally advanced and locally recurrent rectal cancer mainly depend
on R0 resection . Complete en bloc resection of the tumor along with adjacent structures depending on the
[1]
location and depth of invasion is important to achieve R0 status . Pelvic exenteration by open approach is
[27]
a standard of care for locally advanced and locally recurrent rectal cancer. MIS for pelvic exenteration is not
well established. Only few studies have been described and have confirmed the feasibility and short-term
outcomes. Whenever feasible and appropriate, MIS can be performed.

The locally advanced and locally recurrent rectal cancers with invasion limited to the anterior pelvic organ
are good candidates for laparoscopic pelvic exenteration as a free circumferential margin can be achieved
easily . The b-TME Collaborative has generated a consensus guideline suggesting certain contraindications
[28]
for these resections , which holds true for MIS also. Absolute contraindications are poor performance
[7]
status/medically unfit patients, bilateral sciatic nerve involvement, and circumferential bone involvement.
Relative contraindications include extension of tumor through the sciatic notch, encasement of external iliac
vessels - requiring en bloc resection and/or reconstruction of external iliac vessels, high sacral involvement
(above S2/S3), and predicted R2 resection. Patients who underwent multiple laparotomies and predicted to
have severe small bowel adhesion are precluded from having MIS .
[29]

Initial experience in laparoscopic pelvic exenteration was reported in few case reports and video vignette [28,30] .
Akiyoshi et al. demonstrated an laparoscopic pelvic exenteration for locally recurrent rectal cancer and
[31]
suggested that laparoscopic pelvic exenteration was a technically challenging procedure that requires a long
operative time with benefits of a very clear view of the operative field, allowing precise dissection, less blood
loss, and a smaller abdominal wound.

One of the initial experiences of laparoscopic pelvic exenteration come from Uehara et al. . They
[29]
discussed the technical points of laparoscopic pelvic exenteration and compared the short-term results
of laparoscopic pelvic exenteration with those of conventional open pelvic exenteration. The surgeon
performed posterior and lateral pelvic wall dissection in the initial part of surgery and anterior dissection
in the last phase to avoid suspension of urinary bladder. Dissection along internal iliac vessels and
identification and transection of small branches are important to avoid intraoperative bleeding . The
[29]
dorsal vein complex was clipped and divided using bipolar soft-coagulation of a VIO system. Investigators
observed that laparoscopic-guided perineal approach avoided much blood loss by helping proper dissection.
Intraoperative blood loss was significantly lower in laparoscopic pelvic exenteration group (830 vs. 2769 mL,
P = 0.003), and operative time and rate of R0 resection were similar in both groups. The authors concluded
that laparoscopic pelvic exenteration performed by an experienced pelvic surgeon was safe and efficient in
carefully selected patients.