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Special Issue
A bespoke approach to rectal cancer resec on and management
Guest Editor(s):
Gordon N Buchanan, MBBS, MD,
MSc, FRCS
The Lister Hospital, London, UK.
Special Issue Introduction
The platform or mode of resecting colorectal cancer, particularly in the rectum can
inuence outcome – it is not just the expertise of the primary surgeon, but also the mode of
resection (open vs. laparoscopic / robotic) that will not only predict the length of stay due
to recovery but also the pathological parameters; enhanced recovery programmes further
accelerate patient discharge. There are very important team factors too; the skill of
assistance is magnied in laparoscopic colorectal resection where not only does the
camera operator need to understand and predict steps to smooth the operation, but also a
second assistant particularly in left sided resection can retract during the case thus
facilitating easier dissection – however for rectal cancer resection recent trials using a non-
inferiority assessment for oncological parameters have shown that patients undergoing a
laparoscopic resection fared worse than those undergoing open surgery. The robotic
platform for rectal cancer allows a very detailed evaluation of pelvic anatomy due to its 3D
visualisation – in addition the wrist element afforded by the robot enables excellent
dissection of the TME plane, akin to the early descriptions popularised by Heald et al. but
with a more magnied view. It is within the connes of the pelvis that robotic resection is
likely to be of greatest benet, particularly for dissection of the mid and low rectum – the
extra robotic arm can be continuously placed in a similar fashion to a St Mark's pelvic
retractor in open surgery thus enabling accurate retraction without assistance fatigue or
movement as may occur in open or standard laparoscopic surgery. This should both reduce
conversion to open resection for low rectal cancer and improve oncological parameters,
either equivalent to, or superior to those of open resection. Lower conversion rates should
enhance earlier discharge and hospital recovery and reduce costs in the longer term. Whilst
some parts of the world have high rates of uptake for laparoscopic colorectal resection,
others lag far behind – the use of robotic surgery currently represents a small minority of
cases; going forward a tailored approach to colorectal cancer resection needs to
encompass and study these important factors to achieve the best clinical and oncological
outcomes for patients. In addition other modalities including transanal total mesorectal
excision (TaTME)to enable the inferior aspect of TME dissection and its place also need
detailed evaluation.
The evolution of therapies in rectal cancer continues to expand allowing a unique
approach through local excision, chemoradio - and contact therapy, watch and wait
along with endoscopic and extended resection. This special edition aims to focus on the
breadth of options available to clinicians and patients working in this arena.
Benets
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