Total Laparoscopic Approach for Rectal Cancer Resection—a Novel Technique and Review of the Literature

Abstract

The role of minimal invasive surgery is well established. As regards rectal cancers particularly low lying rectal cancer studies are still going on for safety, feasibility and duplicability. A large prospective single-institutional study aims to assess the effectiveness of our technique of laparoscopic resection of rectal cancer in terms of oncological safety, complications and long-term prognosis. Between July 2006 and June 2016, 582 patients underwent laparoscopic LAR for rectal adenocarcinoma at our centre. Routine preoperative workup was done. Patients were evaluated for complications, graded and managed as per Clavien-Dindo classification. Survival probability analysis rate calculated using Kaplan Meier method. Total number of patients included in the study were 582 (375 men and 207 women) with the average age of 65 years. Tumours located in upper, middle and lower rectum were 132, 258 and 192 patients, respectively. A total of 33 patients received chemoradiation preoperatively and 450 received chemo+/-radiation postoperatively. Laparoscopic TME was done in 381 patients. Six out of 381patients underwent low anterior resection with hand-sewn coloanal anastomosis (CAA). Average operating time, blood loss and hospital stay were 124 min, 70 ml and 5 days, respectively. Average number of lymph nodes removed was 25.4 Overall complication rate was 20.8%, i.e. 121 out of 582 patients had complications. No conversion to conventional surgery was required. The most common postoperative complication was the anastomotic leak (grade II, IIIB and IV acc. to Clavien-Dindo classification); we had 71 leaks (13.4%).After a mean follow-up of 46 months (1–128 months), tumour recurrence occurred in 39 patients of 582. Overall recurrence rate was 6.7%. Overall cancer-related survival rate was 99.3, 96.7, 90.7, 90.7 and 87.7% at 1st, 2nd, 3rd, 4th and5th year, respectively. Five-year survival rate was 100% for stage I, 94.4% for stage II, 66.6% for stage III and 44.6% for stage IV. Laparoscopic TME technique is feasible and safe. With the development of improved technique, devices and expertise, laparoscopic resection for rectal cancer should be a standard method. Our results when compared with the other similar studies on laparoscopic low anterior resection clearly demonstrate that laparoscopic rectal resection with our technique is not associated with higher morbidity or mortality. Oncological and surgical principles were respected, and long-term outcomes compared with the previous literature and open surgery were comparable.