Rectal cancer should not be resected laparoscopically: the rationale and the data

Is taTME delivering?

“…In fact, a matched comparison of the first 20 robotic cases by the same surgeon showed that the width of the CRM was significantly improved (open 8 mm vs. laparoscopic 4 mm vs. robotic 10.5 mm; p = 0.02) despite the learning curve [6]. A reasonable explanation seems to be that laparoscopic proctectomy may decrease the width of the CRM as a result of its restricted range of motion leading to a coning effect, which would be minimized by the improved ergonomics of the robotic wristed instruments [5]. The study by Barnajian et al also concluded that the lack of tactile feedback did not adversely impact the quality of TME in the robotic cases [6].…”

“…In fact, two other RCTs (COLOR 2 and COREAN) concluded that laparoscopic resection is non-inferior to open surgery based on survival rates, which as known are influenced by multiple factors (gene mutations, chemoradiation, etc.) and do not necessarily reflects the quality of surgery [4,5]. As it is unlikely that the results of the ACOSOG Z6051 and the ALaCart trials will bring us back to open surgery, one could speculate that the same results may indirectly turn the light onto robotic-assisted resection.…”

“…Although the literature in the English language does not provide evidence to back up the abovementioned concern for suboptimal oncologic metrics in MOL, the study by Targarona et al [3] brought to everybody's attention how the promontory-subsacrum angle of an android pelvis can affect oncological metrics when the resection is carried out laparoscopically. In fact, the shortcomings of a laparoscopic access to pelvic dissection for rectal cancer have been confirmed by two recent randomized control trials (RCT) (ACOSOG Z6051 and ALaCart), which concluded that laparoscopic resection is inferior to open surgery [4,5]. The main reason to trust these two RCTs has much more to do with the choice of histopathology endpoints (circumferential resection margin (CRM) and complete quality of TME) than with their random order design.…”

Medium-term adoption trends for laparoscopic, robotic and transanal total mesorectal excision (TaTME) techniques

“…Despite this, the debate on oncologic outcomes when compared with open surgery is still ongoing [1][2][3]. The benefits of one minimally invasive approach over the others form the subject of further debate, and as much of this is driven by proponents of an individual technique, choosing the most appropriate technique can be difficult [1,2]. Despite the enthusiasm of the proponents, many other factors play a part in the choice of technique and these can be broadly described as those related to the patient, surgeon and individual hospital or a country.…”

Nearly complete TME quality conundrum

“…Previous enthusiasm for a laparoscopic approach has been recently counterbalanced by the increased rates of circumferential resection margin involvement secondary to the impaired ergonomics of non-articulating laparoscopic instruments in the confined space of the pelvis [2].…”