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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 11 of 15

Pubic symphysis

Vas deferens

Bladder

Left ureter

Rectum

Figure 9. Laparoscopic extended resection showing distal ureter where it arches below the vas deferens

resection in three patients with locally advanced rectal cancer. After abdominal part of laparoscopic surgery,
sacral resection (below S3/S4) was performed in prone position. Laparoscopic abdominosacral resection
provides short-term benefits of MIS approach with negative circumferential margin [76,77] . Uemura et al.
[78]
recently reported a complete laparoscopic abdominosacral resection using a Gigli wire saw for a locally
recurrent rectal cancer. The distance between the estimated line of resection (below the S4 vertebra) and
sacral promontory was measured by preoperative imaging. Intraoperatively, line of resection was marked and
Gigli wire was passed dorsal to sacral bone at the level of resection. Both the ends of wire were brought out
through lower abdominal ports and sacrum was cut by the linear reciprocating motion of the Gigli wire saw.

This review has several limitations. There were no randomized controlled trials or prospective studies
available in the current literature in context to this review. There was heterogeneity between the studies with
small sample size. There were no studies with long-term follow-up to evaluate oncological outcomes. Short-
term outcomes were variable due to patient selection bias and heterogeneity in the available studies.

CONCLUSIONS
The technological advances in instrumentation, advances in surgical techniques, increased surgeon
experience made MIS feasible with good perioperative outcomes in b-TME/e-TME in carefully selected
patients. Laparoscopic surgery has considerable learning curve and should be performed by experienced
surgical teams. Robotic surgery is feasible and beneficial in complex resection in pelvis. However, evidence
for long-term oncological outcomes of MIS in b-TME/e-TME is low and needs to be studied further by
randomized controlled trial once enough numbers are possible in institutes with high volume rate.

DECLARATIONS
Authors’ contributions
Concepts and definition of intellectual content: Kumar NAN, Saklani A
Literature search: Kumar NAN, Kammar P
Design, manuscript preparation, editing, and review: Kumar NAN, Kammar P, Saklani A

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.