What is the role of laparoscopic resection in the treatment of rectal cancer?

Updated: Apr 06, 2021
  • Author: Burt Cagir, MD, FACS; Chief Editor: N Joseph Espat, MD, MS, FACS  more...
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Answer

The first laparoscopic colectomy study was published in 1991 by Jacobs et al. It included 20 cases, mostly right and sigmoid colectomies but only one low anterior rectal resection and one abdominal perineal resection. [58] In the succeeding decades, minimally invasive rectal procedures, including radical proctectomy, became a well-accepted practice for rectal cancers. Compared with open resection, laparoscopic proctectomy is associated with earlier return of bowel function and faster overall recovery. However, operating room time, and laparoscopic resections should be performed by experienced surgeons.

In 2012, Trastulli et al compared open and laparoscopic rectal resection for cancer in a meta-analysis of nine randomized clinical trials that included1544 patients. In the study, patients who underwent laparoscopic rectal resection experienced shorter hospital stay; earlier return of bowel function; reduced intraoperative blood loss; and less postoperative bleeding, late intestinal adhesion obstruction, and late morbidity. Intra-operative and late oncological outcomes were similar in the two groups. [59]  

The COLOR-II trial, a European multi-center, randomized phase III noninferiority study, concluded that in the hands of skilled surgeons, the safety, resection margins, and completeness of rectal resection are similar with laparoscopic and open proctectomy. In both the laparoscopic group (n=739) and the open proctectomy group (n=364), 10% of patients had positive circumferential margins (< 2 mm). Morbidity and mortality within 20 days after surgery were similar in both groups. The laparoscopic surgery group had less blood loss, earlier return of bowel function, and shorter duration of hospital stay, but laparoscopic surgeries took longer. [60]  

However, another multi-center randomized trial (ACOSOG Z6051), conducted in patients with stage II and III rectal cancer in the United States and Canada, failed to support the noninferiority of laparoscopic resection for rectal cancer. A successful rectal resection—defined as a tumor-free circumferential radial margin larger than 1 mm and complete total mesorectal resection—was identified in 81.7% of 220 laparoscopic rectal resection cases and 86.9% of 222 open resection cases, which did not meet the study's criterion for noninferiority. Conversion from laparoscopic resection to open rectal resection occurred in 11% of the patients. Operative time was significantly longer for laparoscopic procedures than for open proctectomy. [61]


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