Open or Laparoscopic Total Mesorectal Excision for Rectal Cancer what is the Optimal Approach?

Abstract

Due to the different localizations, rectal cancer is a variable surgical entity. The laparoscopic resection of tumors located in rectosigmoid junction or upper rectum is technically easy to perform and the oncological outcome is similar to those of colon cancer. In contrast, the laparoscopic approach of mid and low rectum tumors is a technical challenge. Several studies demonstrated that the minimal invasive procedure is feasible and safe [2] However, most of these trials were small case series, were based on a retrospective setting, or did not include a proper control for open groups. To date, there exist no large, prospective, randomized trials comparing the laparoscopic TME for rectal cancer with the conventional open approach regarding the oncological long-term outcome. Taking this fact in consideration, every surgeon performing rectal surgery must ask himself: What is the optimal approach for TME? 48 studies, representing 4224 patients, comparing the laparoscopic TME with the open TME were analyzed by a Cochrane review in 2006 [3]. The majority of the included studies were non-randomized trials. The authors found no significant differences in terms of disease-free survival rate, local recurrence rate, mortality, morbidity, anastomotic leakage, resection margins, or recovered lymph nodes [3]. The laparoscopic TME seems to be associated with less blood loss, a quicker return to normal diet, less pain, less narcotic use and less immune response [3]. Moreover, other short-term advantages including less fatigue, better pulmonary function, decreased disability, and shorter hospitalization, have been proven by several other studies [4-7]. On the other hand, the laparoscopic TME is associated with a longer operative time and higher costs [3]. These higher costs may be at least partially charged off by lower follow-up cost due to reoperations for incisional hernia, as a fivefold lower incidence is reported after laparoscopic surgery in comparison with open TME (2.4 vs. 12.9%) [8].