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Year : 2014  |  Volume : 10  |  Issue : 2  |  Page : 68-71

Laparoscopic resection for middle and low rectal cancer

Department of Surgery, Kosin University College of Medicine, Busan, South Korea

Date of Submission16-Apr-2013
Date of Acceptance10-Jun-2013
Date of Web Publication7-Apr-2014

Correspondence Address:
Byung-Kwon Ahn
34 Amnam-dong, Seo-gu, Busan, 602-703
South Korea
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0972-9941.129951

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 ¤ Abstract 

Aims: The purpose of this study was to evaluate the technical feasibility, safety and oncological outcomes of laparoscopic resection for middle and low rectal cancers. Materials and Methods: From January 2004 to December 2011, review of prospectively collected database revealed a series of 97 laparoscopic resections for middle and low rectal cancer within 10 cm from the anal verge. Five patients with multiple primary cancers were excluded. Operation time, intra-operative blood loss, surgical complications, duration of hospital stay, retrieved lymph nodes, tumour, node, metastasis (TNM) stage and recurrence were retrospectively analysed. Results: Tumours were located within 5 cm of the anal verge in 28 patients (30.4%) and from 5 cm to 10 cm in 64 patients (69.6%). Abdominoperineal resection was performed in 12 patients (13%), and conversion to open surgery was necessary in four patients (4.3%). The mean operation time was 199.7 min (range 105-450 min) and the mean intra-operative blood loss was 169.9 mL (range 20-800 mL). The mean hospital stay was 11.8 days (range 5-45 days) and a mean of 12.2 lymph nodes were retrieved. The incidence of surgical complications was 11.9%, including anastomosis site leakage in five patients (5.4%). There were no mortalities resulting from laparoscopic surgery. The median follow-up period was 28.4 months (range 7-85 months). Recurrence occurred in eight patients (8.7%). Conclusions: Laparoscopic resection can be applied for middle and low rectal cancers with acceptable surgical and oncological outcomes.

Keywords: Anastomotic leakage, laparoscopic surgery, rectal cancer, recurrence

How to cite this article:
Park KK, Lee SH, Baek SU, Ahn BK. Laparoscopic resection for middle and low rectal cancer. J Min Access Surg 2014;10:68-71

How to cite this URL:
Park KK, Lee SH, Baek SU, Ahn BK. Laparoscopic resection for middle and low rectal cancer. J Min Access Surg [serial online] 2014 [cited 2022 Oct 7];10:68-71. Available from:

 ¤ Introduction Top

Since its use was first reported in 1991, [1] the laparoscopic approach has gained wide clinical acceptance in the treatment of patients with colorectal cancer. [2],[3] Compared to conventional open surgery, this minimally invasive approach offers decreased surgical trauma, fewer perioperative complications, and faster postoperative recovery with similar survival rates. Although laparoscopic colon resections have been shown to be both feasible and safe, uncertainty remains regarding the application of laparoscopic procedures for the treatment of rectal cancers. [3],[4] Due to the limited availability of data regarding long-term oncological outcomes, it remains unclear whether laparoscopic resection is feasible for the treatment of rectal cancers, particularly due to the difficulty in performing a proper mesorectal excision. [5],[6] However, during the last decade, data from multicenter studies and a meta-analysis have shown that rectal tumours may be laparoscopically removed without increasing the rate of morbidity or worsening oncological results. [7],[8],[9],[10] The aim of this study is to evaluate the technical feasibility, safety and oncological outcomes of laparoscopic resection for middle and low rectal cancers.

 ¤ Materials and Methods Top

From January 2004 to December 2011, 152 patients were identified who underwent laparoscopic resection for rectal cancers. Procedures performed included anterior resection, abdominoperineal resection and Hartmann's operation. After excluding 55 patients with upper rectal cancer (greater than 10 cm from the anal verge) and five patients with synchronous multiple primary cancers (e.g., thyroid cancer, gastric cancer, lymphoma, oropharyngeal cancer), the records of 92 patients with middle and low rectal cancer were retrospectively investigated. All tumours were treated with total mesorectal excision (TME). The decision to preserve the sphincters or complete an abdominoperineal resection or Hartmann's operation was based on the ability to achieve clear distal margins and functional outcomes.

The preoperative assessment included digital examination, colonoscopy with biopsy, rectal ultrasound, abdomino-pelvic computed tomography (CT), serum carcinoembryonic antigen (CEA), biochemical analyses, and a chest x-ray. Patients with a CT showing a locally advanced tumour (i.e., a tumour penetrating through the rectal wall (T3)), and/or a tumour with lymph node involvement without any evidence of distant metastasis were given the option of preoperative neoadjuvant chemoradiotherapy (two cycles of 5-Fluorouracil (5-FU) 450 mg/m 2 in continuous infusion and leucovorin 20 mg/m 2 for 5 days in the first and fifth weeks and radiotherapy 4,500 Gy in 25 fraction). The surgery was performed between 6 weeks and 8 weeks after completion of neoadjuvant treatment. All patients underwent mechanical bowel preparation.

Operative outcome was determined with respect to intra-operative blood loss, operation time, conversion to open surgery, the number of days until bowel function resumed, duration of hospital stay and surgical complications. Oncological outcome was assessed based on the number of retrieved lymph nodes, Tumour, Node, Metastasis (TNM) stage (7 th edition of the American Joint Committee on Cancer clinical tumor node metastasis (TNM) classification), [11] and recurrence rate.

 ¤ Results Top

Of the total 92 patients, 51 (55.4%) were male, and 41 (44.6%) were female. The mean age was 60.4 years. Regarding tumour site, 63 patients (68.5%) had tumours that were within 5-10 cm of the anal verge (middle rectal cancer) and 29 patients (31.5%) had a tumour located 5 cm from the anal verge (low rectal cancer). Sixteen patients (17.4%) with locally advanced rectal adenocarcinoma were enrolled in neoadjuvant chemo-radiotherapy. Low anterior resection was performed in 76 cases (82.6%), abdominoperineal resection in 10 (10.9%) and Hartmann's operation in two (2.2%). Protective ileostomy was done in 12 patients (13.0%). Conversion to open surgery occurred in four patients (4.3%) [Table 1].
Table 1: Patient characteristics

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The mean operation time was 199.71 ± 70.72 minutes and median blood loss was 166.89 ± 153.49 ml. The mean postoperative length of stay was 11.8 ± 6.51 days, and the mean number of days to toleration of clear fluids was 2.65 ± 1.58 days [Table 2]. The overall surgical complication rate was 9.8%, which included five anastomotic leakages (5.4%), one anal stricture (1.1%), one case of anastomotic fistula (1.1%) and two cases of urinary retention (2.2%) [Table 3]. There were no postoperative mortalities.
Table 2: Surgical outcome

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Table 3: Surgical complications

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The mean number of lymph nodes retrieved was 12.25 ± 8.14. The mean length of the distal resection margins was 2.22 ± 1.75 cm. Stage I tumours were present in 42 patients (41.3%), stage II in 20 patients (21.8%) and stage III in 30 patients (32.6%). No patients presented with stage IV disease [Table 4]. Mean follow-up period was 28.4 months (range 7-85 months). Recurrence occurred in a total of eight patients (8.7%). The most common site of recurrence was the lung (37.5%) [Table 5]. There were no port-site recurrences and all of the recurrences occurred in node-positive patients [Table 6].
Table 4: Disease stage distribution

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Table 5: Duration and sites of recurrence

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Table 6: Stage and recurrence

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 ¤ Discussion Top

Laparoscopy has emerged as a valuable means of surgical treatment for diseases of the colon and rectum. It offers a lower rate of wound complications, intraoperative blood loss, analgesic use, shorter time to bowel movement, earlier recovery, lower morbidity, shorter postoperative hospital stay, and better quality of life postoperatively. [12],[13] Laparoscopic resection of rectal cancer entered practice after the introduction of laparoscopic colon surgery in 1991. [1] But unlike colon cancer, treatment of rectal cancer does not comprise a single surgical entity. The type of resection depends mainly on the location of the tumour. Laparoscopic anterior resection of tumours in the recto-sigmoid and upper-rectum is technically easier to perform with oncological outcomes that are not different from those for colon cancer. However, with tumours in the middle and low rectum, the laparoscopic approach is a technical challenge, especially if sphincter preservation is required.

Laparoscopic rectal cancer surgery is technically more challenging compared with laparoscopic colon surgery because it involves TME in a limited pelvic cavity. This procedure regards the rectum and mesorectum as one lymphovascular structure and requires its excision within an intact fascia propria, [14] and TME has conclusively been shown to reduce the rate of local recurrence and increases the rate of survival. [15],[16] This approach has been reported to be feasible and safe while offering the advantages of laparoscopic surgery. [17],[18],[19] However, long-term outcomes including local recurrence, disease-free survival and overall survival have not yet been consistently studied.

Laparoscopic surgery for rectal cancer may be associated with relatively high morbidity and conversion rates. In this study, the morbidity rate was 9.8% without mortality. This is similar or lower to rates reported previously (21.9-27.0%). [8],[20] Also, the anastomotic leakage rate of 6.5% was lower than the rate reported in other studies (9.8-27%). [8],[10],[20],[21],[22] The 4.3% conversion rate in our study compares favourably with the results of laparoscopic resection of the rectum (1-33%). [3],[8],[9],[21] Major causes of conversion are a narrow pelvis and technical failure. Targarona et al., suggested that the local anatomy (lower pelvis diameter, sex, body mass index) and pathologic features (tumor size) directly affect surgical outcome in the laparoscopic approach to the rectum and should be taken into account when planning for this kind of procedure. [23] The rate of protective ileostomy was 13.0%.

In the present study, the mean hospital stay was 11.84 ± 6.51 (range 4-12), and the mean operation time was 199.71 ± 70.72 minutes (range 105-450), which is comparable to previously reported operation times ranging from 138 minutes to 250 minutes. [8],[9],[20],[22],[24] The mean amount of blood loss of 166.89 ± 153.49 cc (range 10-800 cc) in the present study is comparable to the amount previously reported. [20] The mean of 2.10 ± 1.34 days to gas out and the mean of 2.65 ± 1.58 days to intake of a liquid diet in the present study are both comparable to the values previously reported. [8],[20],[22],[24]

Examination of the oncologic adequacy of laparoscopic rectal resection in our study showed negative resection margins, including radial margins and the mean number of retrieved lymph nodes was 12.25 ± 8.15. The recurrence rate with laparoscopic resection in our study was 8.7% at a mean of 24.5 months of follow-up. These data are comparable to previously published laparoscopic results. [8],[25],[26]

In conclusion, laparoscopic resection for middle and low rectal cancer is feasible and can be performed safely with acceptable rates of overall morbidity and reoperation and low rates of specific complications, including anastomotic leakage. The limitations of this study include the relatively small sample size and the relatively short follow-up time, particularly for maintenance of oncologic issues. Planned randomised controlled trials addressing this issue with a larger sample size and long-term follow-up should be performed.

 ¤ References Top

1.Jacobs M, Verdeja JC, Goldstein HS. Minimally invasive colon resection (laparoscopic colectomy). Surg Laparosc Endosc 1991;1:144-50.  Back to cited text no. 1
2.Buchanan GN, Malik A, Parvaiz A, Sheffield JP, Kennedy RH. Laparoscopic resection for colorectal cancer. Br J Surg 2008;95:893-902.  Back to cited text no. 2
3.Neudecker J, Klein F, Bittner R, Carus T, Stroux A, Schwenk W. Short-term outcomes from a prospective randomized trial comparing laparoscopic and open surgery for colorectal cancer. Br J Surg 2009;96:1458-67.  Back to cited text no. 3
4.Laparoscopically assisted colectomy is as safe and effective as open colectomy in people with colon cancer Abstracted from: Nelson H, Sargent D, Wieand HS, et al; for the Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med 2004;350:2050-2059. Cancer Treat Rev 2004;30:707-9.  Back to cited text no. 4
5.Nagtegaal ID, Quirke P. What is the role for the circumferential margin in the modern treatment of rectal cancer? J Clin Oncol 2008;26:303-12.  Back to cited text no. 5
6.Winawer S, Fletcher R, Rex D, Bond J, Burt R, Ferrucci J, et al. Colorectal cancer screening and surveillance: Clinical guidelines and rationale-update based on new evidence. Gastroenterology 2003;124:544-60.  Back to cited text no. 6
7.Scheidbach H, Schneider C, Konradt J, Barlehner E, Kohler L, Wittekind C, et al. Laparoscopic abdominoperineal resection and anterior resection with curative intent for carcinoma of the rectum. Surg Endosc 2002;16:7-13.  Back to cited text no. 7
8.Leroy J, Jamali F, Forbes L, Smith M, Rubino F, Mutter D, et al. Laparoscopic total mesorectal excision (TME) for rectal cancer surgery: Long-term outcomes. Surg Endosc 2004;18:281-9.  Back to cited text no. 8
9.Anthuber M, Fuerst A, Elser F, Berger R, Jauch KW. Outcome of laparoscopic surgery for rectal cancer in 101 patients. Dis Colon Rectum 2003;46:1047-53.  Back to cited text no. 9
10.Laurent C, Leblanc F, Wutrich P, Scheffler M, Rullier E. Laparoscopic versus open surgery for rectal cancer: Long-term oncologic results. Ann Surg 2009;250:54-61.  Back to cited text no. 10
11.Edge SB, Compton CC. The American Joint Committee on Cancer: The 7 th edition of the AJCC cancer staging manual and the future of TNM. Ann Surg Oncol 2010;17:1471-4.  Back to cited text no. 11
12.Tjandra JJ, Chan MK. Systematic review on the short-term outcome of laparoscopic resection for colon and rectosigmoid cancer. Colorectal Dis 2006;8:375-88.  Back to cited text no. 12
13.Hewett PJ, Allardyce RA, Bagshaw PF, Frampton CM, Frizelle FA, Rieger NA, et al. Short-term outcomes of the Australasian randomized clinical study comparing laparoscopic and conventional open surgical treatments for colon cancer: The ALCCaS trial. Ann Surg 2008;248:728-38.  Back to cited text no. 13
14.Heald RJ. The 'Holy Plane' of rectal surgery. J R Soc Med 1988;81:503-8.  Back to cited text no. 14
15.Heald RJ, Ryall RD. Recurrence and survival after total mesorectal excision for rectal cancer. Lancet 1986;1:1479-82.  Back to cited text no. 15
16.Arbman G, Nilsson E, Hallbook O, Sjodahl R. Local recurrence following total mesorectal excision for rectal cancer. Br J Surg 1996;83:375-9.  Back to cited text no. 16
17.Castrini G, Toccaceli S. Cancer of the rectum - sphincter-saving operation. A new technique of coloanal anastomosis. Surg Clin North Am 1988;68:1383-90.  Back to cited text no. 17
18.Cavaliere F, Pemberton JH, Cosimelli M, Fazio VW, Beart RW Jr. Coloanal anastomosis for rectal cancer. Long-term results at the Mayo and Cleveland Clinics. Dis Colon Rectum 1995;38:807-12.  Back to cited text no. 18
19.Gamagami RA, Liagre A, Chiotasso P, Istvan G, Lazorthes F. Coloanal anastomosis for distal third rectal cancer: Prospective study of oncologic results. Dis Colon Rectum 1999;42:1272-5.  Back to cited text no. 19
20.Dulucq JL, Wintringer P, Stabilini C, Mahajna A. Laparoscopic rectal resection with anal sphincter preservation for rectal cancer: Long-term outcome. Surg Endosc 2005;19:1468-74.  Back to cited text no. 20
21.Hartley JE, Mehigan BJ, Qureshi AE, Duthie GS, Lee PW, Monson JR. Total mesorectal excision: Assessment of the laparoscopic approach. Dis Colon Rectum 2001;44:315-21.  Back to cited text no. 21
22.Morino M, Parini U, Giraudo G, Salval M, Brachet Contul R, Garrone C. Laparoscopic total mesorectal excision: A consecutive series of 100 patients. Ann Surg 2003;237:335-42.  Back to cited text no. 22
23.Targarona EM, Balague C, Pernas JC, Martinez C, Berindoague R, Gich I, et al. Can we predict immediate outcome after laparoscopic rectal surgery? Multivariate analysis of clinical, anatomic, and pathologic features after 3-dimensional reconstruction of the pelvic anatomy. Ann Surg 2008;247:642-9.  Back to cited text no. 23
24.Sample CB, Watson M, Okrainec A, Gupta R, Birch D, Anvari M. Long-term outcomes of laparoscopic surgery for colorectal cancer. Surg Endosc 2006;20:30-4.  Back to cited text no. 24
25.Fleshman JW, Wexner SD, Anvari M, LaTulippe JF, Birnbaum EH, Kodner IJ, et al. Laparoscopic vs. open abdominoperineal resection for cancer. Dis Colon Rectum 1999;42:930-9.  Back to cited text no. 25
26.Kapiteijn E, Putter H, van de Velde CJ. Impact of the introduction and training of total mesorectal excision on recurrence and survival in rectal cancer in The Netherlands. Br J Surg 2002;89:1142-9.  Back to cited text no. 26


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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