Total mesorectal excision: Assessment of the laparoscopic approach

PURPOSE: Total mesorectal excision offers the lowest reported rates of loca l recurrence for rectal cancer; however, the ability to perform total mesor ectal excision laparoscopically remains unproven. The aim of this study was to assess the feasibility and adequacy of a totally laparoscopic total mes orectal excision for rectal cancer. METHODS: A prospective review of all pa tients undergoing laparoscopic-assisted surgery for rectal cancer by a sing le surgeon was undertaken. These were compared with a control group undergo ing open rectal resections by another colorectal consultant in the unit (n = 22). Comparison of total specimen length, longitudinal and radial excisio n margins, and lymph node yield was made between groups. RESULTS: Of 42 lap aroscopic-assisted rectal resections attempted, 14 (33 percent) were conver ted to open procedures and six had their dissection completed open. One res ection was considered noncurative. Twenty-one total mesorectal excisions (5 0 percent) were completed totally laparoscopically. No significant differen ce was detected between groups for specimen length, radial margin, or lymph node yield. Longitudinal margin of excision was longer in the laparoscopic group (4 (3.5-5) vs. 2.5 (1.05-3.5) cm; P = 0.02, Mann-Whitney). Operating time was significantly longer in the laparoscopic group (180 (168-218) vs. 125 (104-144) minutes; P = 0.003, Mann-Whitney). Data are medians (interqu artile ranges). Four patients in the laparoscopic-assisted group had clinic al anastomotic leakage vs, one in the open group (P = 0.329, Fisher's exact test). At median follow-up of 38 (range, 6-53) months, one local recurrenc e had occurred in each group and crude mortality rates were 29 and 23 perce nt in the laparoscopic-assisted and open groups, respectively (P = 0.736, F isher's exact test). CONCLUSION: Totally laparoscopic excision of the mesor ectum is feasible in 50 percent of patients and where possible yields histo logic parameters comparable to open surgery. Early survival and recurrence figures also appear to be comparable.