Current status of laparoscopy for the treatment of rectal cancer

Abstract

Surgery for rectal cancer in complex and entails many challenges. While the laparoscopic approach in general and specific to colon cancer has been long proven to have short term benefits and to be oncologically safe, it is still a debatable topic for rectal cancer. The attempt to benefit rectal cancer patients with the known advantages of the laparoscopic approach while not compromising their oncologic outcome has led to the conduction of many studies during the past decade. Herein we describe our technique for laparoscopic proctectomy and assess the current literature dealing with short term outcomes, immediate oncologic measures (such as lymph node yield and specimen quality) and long term oncologic outcomes of laparoscopic rectal cancer surgery. We also briefly evaluate the evolving issues of robotic assisted rectal cancer surgery and the current innovations and trends in the minimally invasive approach to rectal cancer surgery.

Keywords: Laparoscopy; Minimally invasive surgery; Oncological outcomes; Rectal cancer; Short term benefits.

Figure 1

Schematic illustration of port placement for laparoscopic proctectomy. Hasson cannula is placed first via a vertical infra-umbilical incision. The left lower quadrant port is not always used and is reserved for cases in which it is needed to facilitate splenic flexure mobilization and retraction at the time of pelvic dissection. It is usually needed in obese patients and in women with an enlarged uterus.

Figure 2

View of the pelvic dissection at the time of laparoscopic proctectomy. Total mesorectal excision was carried out to the level of the levator muscles and the mesorectum is reflected superiorly. This quality of exposure is rarely seen in open total mesorectal excision.

Figure 3

Cosmetic outcome after a laparoscopic assisted low anterior resection with a diverting loop ileostomy for rectal cancer, followed by a takedown of ileostomy. The specimen was extracted through a periumbilical incision which, especially in thin persons, can be very limited.

Figure 4

Laparoscopic assisted low anterior resection can be safely performed in morbid obese patients. This is a 49 year old gentleman with a body mass index of 41 kg/m². The picture was taken at the same hospital stay in which the patient underwent surgery.

Figure 5

Specimen resected in a laparoscopic proctectomy. Notice the high ligation of the inferior mesenteric artery and the shiny surface of the mesorectum, which reflects its intactness. The laparoscopic approach facilitates visualization and hence precise dissection and achievement of an intact mesorectum.