Page 89 - Read Online

Page 2 of 8 Esen et al. Mini-invasive Surg 2018;2:29 I http://dx.doi.org/10.20517/2574-1225.2018.32

[3]
The first successful use of laparoscopy in colorectal surgery was by Jacobs et al. , published in 1991. Lapa-
roscopic surgery has numerous benefits, such as shorter length of hospitalization, reduced postoperative
[4-6]
pain, and improved recovery . Although many studies showed that the outcomes of laparoscopic and
open colon surgery were similar [6,7-10] , similar comparative outcomes have not been clearly demonstrated
in laparoscopic rectal surgery. Concerns regarding laparoscopic rectal surgery are port-site and abdominal
wall metastases and local oncological clearance [11-15] . In addition, laparoscopic rectal surgery has a chal-
[16]
lenging learning curve because of the deep and narrow pelvis and its assist-dependent procedure .
Current data comparing long-term oncological outcomes between open and laparoscopic rectal surgery are
insufficient; therefore, laparoscopy is not accepted as a gold standard in rectal surgery. This review aims to
summarize the oncological and physiological outcomes with laparoscopic and open rectal surgery based on
the results of recent studies.

Importance of TME
Significant improvements were observed in oncological outcomes with TME since its introduction by
[2]
Heald et al. in 1982 and subsequent standardization in rectal cancer surgery. With the TME technique,
the locoregional recurrence rate of 25% in the 1980s has been successfully reduced to 4% currently. Nag-
[17]
tegaal and van Krieken reported that the local recurrence rate of 36% with incomplete mesorectal exci-
[18]
sion was decreased to 20% with complete TME. Kapiteijn et al. compared the outcomes of conventional
rectal surgery and TME and found that both local control and survival were improved in the TME group.

TME should be routinely performed to improve oncological results in both laparoscopic and open rectal
surgery. Laparoscopic TME is a difficult technique to implement in the deep and narrow pelvis and has a
steep learning curve. Several studies reported that at least 50 laparoscopic TME should be performed to
achieve proficiency and consistent results [19-21] , and the conversion rate decreases between 151 and 200 cas-
[14]
es. Male sex and T staging of cancer are major risk factors affecting the learning curve . The most impor-
tant concerns regarding laparoscopic TME are postoperative morbidity and oncological outcomes. One of
the most important steps for the correct implementation of TME is dissection of the mesorectum from the
parietal and visceral fascia. Laparoscopy provides visualization of this plan and neurovascular structures
through a magnified and clean vision.

Short-term oncological outcomes
The use of TME for rectal cancer has led to many favorable results. Blunt dissection commonly performed
[22]
in the pelvis before the TME era often resulted in inadequate resection of the mesorectum. Quirke et al.
reported lateral surgical margin positivity in 14 of the 52 patients who achieved surgical cure and a local
[23]
recurrence of 85% in those with positive margins. In contrast, in 1998, Heald et al. reported 5- and 10-
year local recurrence rates of only 3% and 4%, respectively, among 405 patients who underwent curative
resection with TME; the 5- and 10-year disease-free survival rates were 80% and 78%, respectively, in this
[24]
cohort. In a recent study by Maurer et al. , where the patients were followed for a minimum of 7 years,
TME reduced rectal cancer recurrence from 20.8% to 5.9%.

Local recurrence is closely associated with several objectively measurable oncological parameters such as
completeness of TME, involvement of the circumferential surgical margin (CRM), and number of harvest-
ed lymph nodes (HLNs). Prospective randomized trials included Colorectal Cancer Laparoscopic or Open
Resection (COLOR) II trial, Conventional versus Laparoscopic-assisted Surgery in Patients with Colorectal
Cancer (MRC CLASICC) trial, Open versus laparoscopic surgery for mid-rectal or low-rectal cancer after
neoadjuvant chemoradiotherapy (COREAN) trial, ACOSOG Z6051 trial, Australian Laparoscopic Cancer
of the Rectum (ALaCaRT) trial; retrospective studies, and meta-analyses evaluated the oncological out-
comes of open and laparoscopic rectal surgery. In retrospective studies, laparoscopic rectal surgery was
reported to be a generally safe and feasible procedure [25,26] .