Minimally invasive techniques for an intersphincteric resection and lateral pelvic lymph node dissection in rectal cancer.

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A proper total mesorectal excision (TME) technique is paramount to the successful treatment of locally advanced rectal cancer irrespective of operative method, including open and minimally-invasive approaches. The use of minimally-invasive surgery is of growing interest for the treatment of rectal cancer. The results of a recent, multicenter, randomized COREAN trial and of the COlorectal cancer Laparoscopic or Open Resection (COLOR II) trial suggested that high-quality laparoscopic TME in rectal cancer could be safely achieved through proper patient selection when performed by a skilled surgeon [1, 2]. Moreover, robot-assisted rectal surgery has recently been introduced as a minimallyinvasive alternative. Several retrospective analyses have suggested that robotic surgery has several technical advantages and may lead to favorable patient outcomes, although it still has a few drawbacks, including a long operation time and high cost [3-5]. The potential benefits of laparoscopic colorectal surgery compared with open surgery include faster recovery, lower morbidity, less pain, and a shorter hospital stay, and these can be achieved without compromising oncologic outcomes [6]. Although a laparoscopic colorectal resection is now an established treatment for colorectal cancer, a belief exists that laparoscopic colorectal surgery is not suitable for tumors that have invaded adjacent organs or structures due to its having high morbidities, conversion rates, and questionable oncologic outcomes. Especially, an open resection for an intersphincteric resection (ISR) and a lateral pelvic lymph node dissection (LPND) in rectal cancer remains a very troublesome and demanding procedure; therefore, it would become even more difficult when performed laparoscopically. More recently, with advances in modern laparoscopic technology, a minimally-invasive laparoscopic resection for these circumstances has been reported. I previously suggested that a laparoscopic resection for colorectal cancer could be achieved with low rates of conversion and morbidity even in patients with a preoperativelysuspected T4 tumor, which is associated with the acceptable perioperative outcomes and the disease-free survival rates when compared with an open resection [7]. Moreover, I believe that patients with demanding conditions, such as duodenal or pancreatic invasion in right-sided colon cancer, complex pelvic irregularities or