Does ‘open’ surgery remain the gold standard in rectal cancer surgery?

Abstract

Department of GI Surgery, University College London Hospital, 235 Euston Road, London, UK *Author for correspondence: manish.chand@uclh.nhs.uk **Author for correspondence: alec.engledow@uclh.nhs.uk Let us start by defining the term ‘gold standard’. According to the Oxford Dictionaries’ definition, gold standard is defined as “a thing of superior quality which serves as a point of reference against which other things of its type may be compared.” In everyday parlance, this is fairly self-explanatory statement but in the context of scientific literature it takes on a more vague meaning. Commonly, the gold standard is used to validate new techniques which can be measured against a known reference. But in regard to surgery, the term becomes more fluid and only loosely associated with the original definition. The gold standard as relates to a surgical technique can be seen as the universally accepted technique but in many cases, one which has not been scientifically validated. This process of evolving the reference standard and the issue of validation can be demonstrated using cholecystectomy and hemorrhoidectomy as examples. In modern day practice, laparoscopic cholecysectomy has found itself as the gold standard for excision of the gallbladder for cases of cholelithiasis. This has been a transition from ‘open’ cholecystectomy which has occurred over the last 25 years due to a gradual accumulation of evidence in favor of laparoscopy. But to contrast, there are several ‘unvalidated’ but seemingly safe surgical techniques on offer to treat hemorrhoids with not one laying claim to the gold standard. So with that in mind, what is the current gold standard for rectal cancer surgery? There is little dispute that total mesorectal excision (TME) as popularized by Heald [1] is the accepted optimal, oncological surgical technique for rectal cancer excision. The modern surgical discussion revolves around approach rather than technique. Currently, there are four recognized approaches to TME – open, laparoscopic, robotic and transanal (taTME). The latter two are more novel and have yet to gain universal acceptance although taTME in