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Page 2 of 8 O’Donohue et al. Mini-invasive Surg 2018;2:24 I http://dx.doi.org/10.20517/2574-1225.2018.34

[1]
lymph nodes, within an intact mesorectum . TME, in addition to neoadjuvant and adjuvant treatments
have led to a reduction in locoregional recurrence to less than 10% and 5-year survivals of more than
[7,8]
70% . The removal of the rectum and its mesorectum allows for potentially curative resection, pathologi-
[9]
cal staging, prognosis and aids in further treatment decisions . The quality of this resection is associated
with improved outcomes in terms of survival and locoregional recurrence, thus the push for standardised
good quality surgery [10,11] .

Over the last 30 years there has been a drive towards minimally invasive techniques. Advances in lapa-
roscopic surgery was thought to further revolutionise the surgical treatment of rectal cancer. Current
evidence supports the concept of laparoscopic colonic resection over the traditional open modalities with
known improvements in short-term outcomes, in addition to equivalent long-term results, when com-
pared to open surgery [12,13] . In the short-term patients were noted to have faster recoveries, earlier feeding,
decreased overall morbidity, earlier return of bowel function and decreased amounts of intraoperative
blood loss [14,15] . In the intermediate term there was an earlier return to work. More importantly though the
long term oncological outcomes regarding local recurrence, disease free survival and overall survival were
[16]
shown to be improved .
Unfortunately to date the promise of similar results in laparoscopic rectal surgery has not yet been de-
livered. Several studies have shown laparoscopic rectal surgery has failed to reach noninferiority when
compared to open resection in terms of short term pathological outcomes [10,17] . However, early reports from
some of the major trials are suggesting that laparoscopic rectal surgery and open resection are equivalent
regarding long-term disease-free survival, overall survival and local recurrence [18-20] .

This review article aims to answer the question “is laparoscopic rectal surgery really is non-inferior to open
surgery?” Is there too much focus on the short term pathological outcomes or should we be more patient
and wait for the long-term survival data before we answer this question?

This article will outline the evidence to date, discuss the evolution of laparoscopic colonic surgery and its
applicability to rectal surgery and finally discuss the current evidence for long term oncological outcomes
and the evidence that is yet to be published. It is our belief that laparoscopic rectal surgery is not non-
inferior to open surgical techniques in experienced hands.

EVOLUTION OF LAPAROSCOPIC COLONIC SURGERY
Laparoscopic colonic surgery had a relatively slow progression into accepted surgical practise. It was noted
to have a steep learning curve, there was limited evidence regarding randomised control trials (RCTs),
concerns were raised regarding its lymph node harvests, oncological outcomes and reports of port site
[21]
metastasis . Eventually over time, these concerns were laid to rest with robust, quality evidence. Laparo-
scopic colectomies have proven to be not only cost effective but have shown to have improved short-term
[21]
outcomes with equivalent long-term oncological outcomes .
[22]
In 1991, Jacobs et al. published their first case series of 20 patients who had received laparoscopic assisted
[23]
colectomies. Lacy published the first RCT which was a single institution study comparing 219 patients.
This study revealed significant short-term benefits for the laparoscopic patient group regarding reduced
[23]
blood loss, early return of intestinal function and overall decreased morbidity . However, concerns were
raised over the low lymph node harvests in both groups (average yield of 13 lymph nodes) and the low
number of patients receiving adjuvant chemotherapy [21,23] . Furthermore, there were initial concerns raised
[24]
about port site metastasises with reported incidences of 1%-21% . Ultimately this was disproven, with an
[19]
accepted incidence of 1% . The accepted incidence of cutaneous metastasis after open resection is 1%-
[25]
1.5% .