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Eventually large randomised trials such as COST (Clinical Outcomes of Surgical Therapy) Study group,
COLOR (Colon cancer Laparoscopic or Open Resection) trial, ALCCaS (Australian laparoscopic colon
cancer study) trial, and the MRC CLASICC (Conventional versus laparoscopic-assisted surgery in patients
with colorectal cancer) have shown the safety and efficacy of laparoscopic colonic surgery [26-28] . This same
journey seems to parallel that of for laparoscopic rectal surgery. Currently the main criticism is that the
short term oncological outcome of the resected specimen is not reaching noninferiority of the same speci-
mens resected via open surgery. However, the long-term survival data that is emerging, is supporting equiva-
lent outcomes regarding long term disease free survival, overall survival and locoregional recurrence.

COMPLEXITIES OF LAPAROSCOPIC RECTAL SURGERY
Laparoscopic rectal surgery can be divided into an abdominal component and a pelvic component. For the
operation to be considered laparoscopic both components need to be completed laparoscopically. Regard-
ing the traditional open operations this could be achieved by either the conventional laparotomy or via a
hybrid procedure where the abdominal component is accomplished by laparoscopy (therefore taking ad-
vantage of the known benefits of laparoscopic colonic surgery). The pelvic component is then completed via
a pfannensteil incision which allows direct vision of the rectum and surrounding mesorectal envelope [17,29] .

There are several theoretical advantages to completing the operation completely laparoscopically as com-
pared to open. The first of which is an intensely magnified view of the pelvis, which could allow improved
preservation of the autonomic nerves. Furthermore, this magnification could lead to better visualisation
of the TME plane and theoretically allow a more precise dissection. In addition to this, there has been evi-
dence to support less blood loss, earlier feeding, early return of bowel function and decreased length of stay
[29]
in hospital following laparoscopic procedures .
However, the learning curve of laparoscopic TME dissection is significant and requires time to master;
more so than that of the curve for laparoscopic colonic resections. It is particularly challenging working
within the narrow, confined space of the bony pelvis which creates issues with tissue retraction and dis-
[29]
section of the mesorectum . Furthermore, the technical issues with laparoscopic equipment, particularly
with laparoscopic stapling devices and the linear energy devices can be quite difficult to use inside the
[29]
rigid, narrow pelvis, therefore requiring a high level of surgical expertise .

EVIDENCE FROM MULTICENTRE RANDOMISED CONTROL TRIALS (SHORT TERM ONCOLOGI-
CAL DATA)
To date there have been several studies comparing the short term oncological outcomes of laparoscopic
rectal surgery to that of open surgery. The landmark multicentre RCTs include the early UK-based MRC
[27]
CLASICC (Conventional vs. Laparoscopic-Assisted Surgery in Colorectal Cancer) trial , the North
[18]
American COLOR (Colon Cancer Laparoscopic or Open Resection) II trial , the South Korean based
COREAN (Comparison of Open Versus Laparoscopic Surgery for mid or low Rectal Cancer After Neoad-
[20]
juvant Chemoradiotherapy) trial , the Australian based ALaCaRT (Australian Laparoscopic Cancer of
[17]
[10]
the Rectum Trial) trial and the US based ACOSOG Z6051 .
Some of the earliest data published came from the MRC CLASICC trial which was published in the Lancet
in 2005. This was a multicentre trial that compared laparoscopic colon and rectal surgery to the conven-
tional open modalities. Overall, the trial recruited 794 patients of which 242 had rectal cancer between
1996 and 2002. The relatively concerning results reported, likely reflected the challenges of laparoscopic
rectal surgery and its early utilization. Thirty-four percent of patients required conversion, there was a 5%
mortality rate and there was a high positive circumferential resection margin (CRM) rate of 12% for the