Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Review Article
  • Published:

Minimal access surgery for rectal cancer: an update

Nature Reviews Gastroenterology & Hepatology volume 11, pages 158–165 (2014)Cite this article

Subjects

Key Points

  • Laparoscopy for colon cancer resection is a widely practiced minimally invasive or minimal access surgery (MAS) technique

  • MAS techniques have been shown to be oncologically equivalent to open rectal cancer resection in terms of the number of harvested lymph nodes and margin negativity

  • Barriers such as a steep learning curve and the lack of long-term data on recurrence and survival preclude the widespread use of MAS approaches for rectal cancer

  • Several ongoing studies are evaluating the use of transanal endoscopic microsurgery for post-treatment rectal cancers that were initially staged at T2 or higher

  • Natural orifice transluminal endoscopic surgery remains an investigational approach for rectal cancer resection at this time

Abstract

Minimally invasive or minimal access surgery (MAS) for colon and rectal cancer was introduced in the early 1990s. Although laparoscopic colon surgery is now practiced worldwide, technical barriers, including a steep learning curve, preclude the widespread adoption of MAS techniques for rectal cancer. In addition, although randomized controlled trials have demonstrated that MAS techniques for colon cancer are oncologically equivalent to open surgery, similar confirmatory studies for rectal cancer have yet to be reported. In this Review, current evidence in support of laparoscopic and robotic total mesorectal excision for rectal cancer resection is presented. Other MAS approaches, such as transanal endoscopic microsurgery and natural orifice transluminal endoscopic surgery, are also discussed.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Figure 1: Trochar placement for robotic laparoscopic-assisted total mesorectal excision.

Similar content being viewed by others

References

  1. Lacy, A. M. et al. Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomised trial. Lancet 359, 2224–2229 (2002).

    Article  PubMed  Google Scholar 

  2. Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopically assisted and open colectomy for colon cancer. N. Engl. J. Med. 350, 2050–2059 (2004).

  3. Veldkamp, R. et al. Laparoscopic surgery versus open surgery for colon cancer: short-term outcomes of a randomised trial. Lancet Oncol. 6, 477–484 (2005).

    Article  Google Scholar 

  4. Guillou, P. J. et al. Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet 365, 1718–1726 (2005).

    Article  PubMed  Google Scholar 

  5. Kiran, R. P. et al. Laparoscopic approach significantly reduces surgical site infections after colorectal surgery: data from national surgical quality improvement program. J. Am. Coll. Surg. 211, 232–238 (2010).

    Article  PubMed  Google Scholar 

  6. Kang, S. B. et al. Open versus laparoscopic surgery for mid or low rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): short-term outcomes of an open-label randomised controlled trial. Lancet Oncol. 11, 637–645 (2010).

    Article  PubMed  Google Scholar 

  7. Color II Study Group et al. A randomized clinical trial comparing laparoscopic and open surgery for rectal cancer. Dan. Med. Bull. 56, 89–91 (2009).

  8. US National Library of Medicine. ClinicalTrials.gov[online], (2013).

  9. US National Library of Medicine. ClinicalTrials.gov[online], (2013).

  10. US National Library of Medicine. ClinicalTrials.gov[online], (2009).

  11. Kitano, S. et al. Randomized controlled trial to evaluate laparoscopic surgery for colorectal cancer: Japan Clinical Oncology Group Study JCOG 0404. Jpn J. Clin. Oncol. 35, 475–477 (2005).

    Article  PubMed  Google Scholar 

  12. Leung, K. L. et al. Laparoscopic resection of rectosigmoid carcinoma: prospective randomised trial. Lancet 363, 1187–1192 (2004).

    Article  PubMed  Google Scholar 

  13. Zhou, Z. G. et al. Laparoscopic versus open total mesorectal excision with anal sphincter preservation for low rectal cancer. Surg. Endosc. 18, 1211–1215 (2004).

    Article  PubMed  Google Scholar 

  14. Braga, M. et al. Laparoscopic resection in rectal cancer patients: outcome and cost–benefit analysis. Dis. Colon Rectum 50, 464–471 (2007).

    Article  PubMed  Google Scholar 

  15. Ng, S. S. et al. Laparoscopic-assisted versus open abdominoperineal resection for low rectal cancer: a prospective randomized trial. Ann. Surg. Oncol. 15, 2418–2425 (2008).

    Article  PubMed  Google Scholar 

  16. Lujan, J. et al. Randomized clinical trial comparing laparoscopic and open surgery in patients with rectal cancer. Br. J. Surg. 96, 982–989 (2009).

    Article  CAS  PubMed  Google Scholar 

  17. Ng, S. S. et al. Long-term morbidity and oncologic outcomes of laparoscopic-assisted anterior resection for upper rectal cancer: ten-year results of a prospective, randomized trial. Dis. Colon Rectum 52, 558–566 (2009).

    Article  PubMed  Google Scholar 

  18. Jayne, D. G. et al. Randomized trial of laparoscopic-assisted resection of colorectal carcinoma: 3-year results of the UK MRC CLASICC Trial Group. J. Clin. Oncol. 25, 3061–3068 (2007).

    Article  PubMed  Google Scholar 

  19. Jayne, D. G. et al. Five-year follow-up of the Medical Research Council CLASICC trial of laparoscopically assisted versus open surgery for colorectal cancer. Br. J. Surg. 97, 1638–1645 (2010).

    Article  CAS  PubMed  Google Scholar 

  20. van der Pas, M. H. et al. Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial. Lancet Oncol. 14, 210–218 (2013).

    Article  PubMed  Google Scholar 

  21. Leroy, J. et al. Laparoscopic total mesorectal excision (TME) for rectal cancer surgery: long-term outcomes. Surg. Endosc. 18, 281–289 (2004).

    Article  CAS  PubMed  Google Scholar 

  22. Heald, R. J. & Ryall, R. D. Recurrence and survival after total mesorectal excision for rectal cancer. Lancet 1, 1479–1482 (1986).

    Article  CAS  PubMed  Google Scholar 

  23. Morino, M. et al. Laparoscopic total mesorectal excision: a consecutive series of 100 patients. Ann. Surg. 237, 335–342 (2003).

    PubMed  PubMed Central  Google Scholar 

  24. Bretagnol, F. et al. The oncological safety of laparoscopic total mesorectal excision with sphincter preservation for rectal carcinoma. Surg. Endosc. 19, 892–896 (2005).

    Article  CAS  PubMed  Google Scholar 

  25. Strohlein, M. A. et al. Comparison of laparoscopic vs. open access surgery in patients with rectal cancer: a prospective analysis. Dis. Colon Rectum 51, 385–391 (2008).

    Article  PubMed  Google Scholar 

  26. Laurent, C. et al. Laparoscopic versus open surgery for rectal cancer: long-term oncologic results. Ann. Surg. 250, 54–61 (2009).

    Article  PubMed  Google Scholar 

  27. Ng, K. H. et al. Laparoscopic resection for rectal cancers: lessons learned from 579 cases. Ann. Surg. 249, 82–86 (2009).

    Article  PubMed  Google Scholar 

  28. Araujo, S. E. et al. Conventional approach x laparoscopic abdominoperineal resection for rectal cancer treatment after neoadjuvant chemoradiation: results of a prospective randomized trial. Rev. Hosp. Clin. Fac. Med. Sao Paulo 58, 133–140 (2003).

    Article  PubMed  Google Scholar 

  29. Wendling, P. Laparoscopic surgery safe for radical rectal cancer resection. American College of Surgeons Periodicals [online], (2011).

    Google Scholar 

  30. Aziz, O. et al. Laparoscopic versus open surgery for rectal cancer: a meta-analysis. Ann. Surg. Oncol. 13, 413–424 (2006).

    Article  PubMed  Google Scholar 

  31. Breukink, S., Pierie, J. & Wiggers, T. Laparoscopic versus open total mesorectal excision for rectal cancer. Cochrane Database Systematic Reviews 2006, Issue 4. Art. No.: CD005200 doi:10.1002/14651858.CD005200.pub2.

  32. Huang, M. J. et al. Laparoscopic-assisted versus open surgery for rectal cancer: a meta-analysis of randomized controlled trials on oncologic adequacy of resection and long-term oncologic outcomes. Int. J. Colorectal Dis. 26, 415–421 (2011).

    Article  PubMed  Google Scholar 

  33. Thorpe, H. et al. Patient factors influencing conversion from laparoscopically assisted to open surgery for colorectal cancer. Br. J. Surg. 95, 199–205 (2008).

    Article  CAS  PubMed  Google Scholar 

  34. Park, I. J. et al. Multidimensional analysis of the learning curve for laparoscopic resection in rectal cancer. J. Gastrointest. Surg. 13, 275–281 (2009).

    Article  PubMed  Google Scholar 

  35. Tjandra, J. J., Chan, M. K. & Yeh, C. H. Laparoscopic- vs. hand-assisted ultralow anterior resection: a prospective study. Dis. Colon Rectum 51, 26–31 (2008).

    Article  PubMed  Google Scholar 

  36. Mirnezami, A. H. et al. Robotic colorectal surgery: hype or new hope? A systematic review of robotics in colorectal surgery. Colorectal Dis. 12, 1084–1093 (2010).

    Article  CAS  PubMed  Google Scholar 

  37. Pigazzi, A. et al. Robotic-assisted laparoscopic low anterior resection with total mesorectal excision for rectal cancer. Surg. Endosc. 20, 1521–1525 (2006).

    Article  CAS  PubMed  Google Scholar 

  38. Park, J. S. et al. Robotic-assisted versus laparoscopic surgery for low rectal cancer: case-matched analysis of short-term outcomes. Ann. Surg. Oncol. 17, 3195–3202 (2010).

    Article  PubMed  Google Scholar 

  39. Bianchi, P. P. et al. Robotic versus laparoscopic total mesorectal excision for rectal cancer: a comparative analysis of oncological safety and short-term outcomes. Surg. Endosc. 24, 2888–2894 (2010).

    Article  CAS  PubMed  Google Scholar 

  40. Baek, J. H., Pastor, C. & Pigazzi, A. Robotic and laparoscopic total mesorectal excision for rectal cancer: a case-matched study. Surg. Endosc. 25, 521–525 (2011).

    Article  PubMed  Google Scholar 

  41. Kwak, J. M. et al. Robotic vs laparoscopic resection of rectal cancer: short-term outcomes of a case–control study. Dis. Colon Rectum 54, 151–156 (2011).

    Article  PubMed  Google Scholar 

  42. Lin, S. et al. Meta-analysis of robotic and laparoscopic surgery for treatment of rectal cancer. World J. Gastroenterol. 17, 5214–5220 (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  43. Memon, S. et al. Robotic versus laparoscopic proctectomy for rectal cancer: a meta-analysis. Ann. Surg. Oncol. 19, 2095–2101 (2012).

    Article  PubMed  Google Scholar 

  44. Yang, Y. et al. Robot-assisted versus conventional laparoscopic surgery for colorectal disease, focusing on rectal cancer: a meta-analysis. Ann. Surg. Oncol. 19, 3727–3736 (2012).

    Article  PubMed  Google Scholar 

  45. Trastulli, S. et al. Robotic resection compared with laparoscopic rectal resection for cancer: systematic review and meta-analysis of short-term outcome. Colorectal Dis. 14, e134–e156 (2012).

    Article  CAS  PubMed  Google Scholar 

  46. Patriti, A. et al. Short- and medium-term outcome of robot-assisted and traditional laparoscopic rectal resection. JSLS 13, 176–183 (2009).

    PubMed  PubMed Central  Google Scholar 

  47. Baek, J. H. et al. Oncologic outcomes of robotic-assisted total mesorectal excision for the treatment of rectal cancer. Ann. Surg. 251, 882–886 (2010).

    Article  PubMed  Google Scholar 

  48. Pigazzi, A. et al. Multicentric study on robotic tumor-specific mesorectal excision for the treatment of rectal cancer. Ann. Surg. Oncol. 17, 1614–1620 (2010).

    Article  PubMed  Google Scholar 

  49. Luca, F. et al. Impact of robotic surgery on sexual and urinary functions after fully robotic nerve-sparing total mesorectal excision for rectal cancer. Ann. Surg. 257, 672–678 (2013).

    Article  PubMed  Google Scholar 

  50. Park, J. S. et al. S052: a comparison of robot-assisted, laparoscopic, and open surgery in the treatment of rectal cancer. Surg. Endosc. 25, 240–248 (2011).

    Article  PubMed  Google Scholar 

  51. Kang, J. et al. The impact of robotic surgery for mid and low rectal cancer: a case-matched analysis of a 3-arm comparison—open, laparoscopic, and robotic surgery. Ann. Surg. 257, 95–101 (2013).

    Article  PubMed  Google Scholar 

  52. Baik, S. H. et al. Robotic tumor-specific mesorectal excision of rectal cancer: short-term outcome of a pilot randomized trial. Surg. Endosc. 22, 1601–1608 (2008).

    Article  CAS  PubMed  Google Scholar 

  53. Baik, S. H. et al. Robotic versus laparoscopic low anterior resection of rectal cancer: short-term outcome of a prospective comparative study. Ann. Surg. Oncol. 16, 1480–1487 (2009).

    Article  PubMed  Google Scholar 

  54. US National Library of Medicine. ClinicalTrials.gov[online], (2010).

  55. US National Library of Medicine. ClinicalTrials.gov[online], (2013).

  56. US National Library of Medicine. ClinicalTrials.gov[online], (2012).

  57. US National Library of Medicine. ClinicalTrials.gov[online], (2013).

  58. deSouza, A. L. et al. A comparison of open and robotic total mesorectal excision for rectal adenocarcinoma. Dis. Colon Rectum 54, 275–282 (2011).

    Article  PubMed  Google Scholar 

  59. Hellan, M. et al. Short-term outcomes after robotic-assisted total mesorectal excision for rectal cancer. Ann. Surg. Oncol. 14, 3168–3173 (2007).

    Article  PubMed  Google Scholar 

  60. Luca, F. et al. Full robotic left colon and rectal cancer resection: technique and early outcome. Ann. Surg. Oncol. 16, 1274–1278 (2009).

    Article  PubMed  Google Scholar 

  61. Bokhari, M. B. et al. Learning curve for robotic-assisted laparoscopic colorectal surgery. Surg. Endosc. 25, 855–860 (2011).

    Article  PubMed  Google Scholar 

  62. Kim, J. Y. et al. A comparative study of voiding and sexual function after total mesorectal excision with autonomic nerve preservation for rectal cancer: laparoscopic versus robotic surgery. Ann. Surg. Oncol. 19, 2485–2493 (2012).

    Article  PubMed  Google Scholar 

  63. Anderson, J. E. et al. The first national examination of outcomes and trends in robotic surgery in the United States. J. Am. Coll. Surg. 215, 107–114 (2012).

    Article  PubMed  Google Scholar 

  64. Turchetti, G. et al. Economic evaluation of da Vinci-assisted robotic surgery: a systematic review. Surg. Endosc. 26, 598–606 (2012).

    Article  PubMed  Google Scholar 

  65. Koh, D. C., Tsang, C. B. & Kim, S. H. A new application of the four-arm standard da Vinci® surgical system: totally robotic-assisted left-sided colon or rectal resection. Surg. Endosc. 25, 1945–1952 (2011).

    Article  PubMed  Google Scholar 

  66. Buess, G. et al. A system for a transanal endoscopic rectum operation [German]. Chirurg 55, 677–680 (1984).

    CAS  PubMed  Google Scholar 

  67. Steinhagen, E., Chang, G. & Guillem, J. G. Initial experience with transanal endoscopic microsurgery: the need for understanding the limitations. J. Gastrointest. Surg. 15, 958–962 (2011).

    Article  PubMed  Google Scholar 

  68. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Rectal Cancer [online], (2013).

  69. Lezoche, E. et al. Randomized clinical trial of endoluminal locoregional resection versus laparoscopic total mesorectal excision for T2 rectal cancer after neoadjuvant therapy. Br. J. Surg. 99, 1211–1218 (2012).

    Article  CAS  PubMed  Google Scholar 

  70. Garcia-Aguilar, J. et al. A phase II trial of neoadjuvant chemoradiation and local excision for T2N0 rectal cancer: preliminary results of the ACOSOG Z6041 trial. Ann. Surg. Oncol. 19, 384–391 (2012).

    Article  PubMed  Google Scholar 

  71. Langer, C. et al. Surgical cure for early rectal carcinoma and large adenoma: transanal endoscopic microsurgery (using ultrasound or electrosurgery) compared to conventional local and radical resection. Int. J. Colorectal Dis. 18, 222–229 (2003).

    CAS  PubMed  Google Scholar 

  72. Christoforidis, D. et al. Transanal endoscopic microsurgery versus conventional transanal excision for patients with early rectal cancer. Ann. Surg. 249, 776–782 (2009).

    Article  PubMed  Google Scholar 

  73. Moore, J. S. et al. Transanal endoscopic microsurgery is more effective than traditional transanal excision for resection of rectal masses. Dis. Colon Rectum 51, 1026–1030 (2008).

    Article  PubMed  Google Scholar 

  74. Palma, P. et al. Local excision of early rectal cancer: is transanal endoscopic microsurgery an alternative to radical surgery? Rev. Esp. Enferm. Dig. 101, 172–178 (2009).

    Article  CAS  PubMed  Google Scholar 

  75. Lebedyev, A. et al. Long-term results of local excision for T1 rectal carcinoma: the experience of two colorectal units. Tech. Coloproctol. 13, 231–236 (2009).

    Article  PubMed  Google Scholar 

  76. Winde, G. et al. Surgical cure for early rectal carcinomas (T1). Transanal endoscopic microsurgery vs. anterior resection. Dis. Colon Rectum 39, 969–976 (1996).

    Article  CAS  PubMed  Google Scholar 

  77. Heintz, A., Morschel, M. & Junginger, T. Comparison of results after transanal endoscopic microsurgery and radical resection for T1 carcinoma of the rectum. Surg. Endosc. 12, 1145–1148 (1998).

    Article  CAS  PubMed  Google Scholar 

  78. Lee, W. et al. Transanal endoscopic microsurgery and radical surgery for T1 and T2 rectal cancer. Surg. Endosc. 17, 1283–1287 (2003).

    Article  CAS  PubMed  Google Scholar 

  79. De Graaf, E. J. et al. Transanal endoscopic microsurgery versus total mesorectal excision of T1 rectal adenocarcinomas with curative intention. Eur. J. Surg. Oncol. 35, 1280–1285 (2009).

    Article  CAS  PubMed  Google Scholar 

  80. Allaix, M. E. et al. Long-term functional results and quality of life after transanal endoscopic microsurgery. Br. J. Surg. 98, 1635–1643 (2011).

    Article  CAS  PubMed  Google Scholar 

  81. US National Library of Medicine. ClinicalTrials.gov[online], (2011).

  82. US National Library of Medicine. ClinicalTrials.gov[online], (2012).

  83. US National Library of Medicine. ClinicalTrials.gov[online], (2011).

  84. Lezoche, G. et al. A prospective randomized study with a 5-year minimum follow-up evaluation of transanal endoscopic microsurgery versus laparoscopic total mesorectal excision after neoadjuvant therapy. Surg. Endosc. 22, 352–358 (2008).

    Article  CAS  PubMed  Google Scholar 

  85. Habr-Gama, A. et al. Operative versus nonoperative treatment for stage 0 distal rectal cancer following chemoradiation therapy: long-term results. Ann. Surg. 240, 711–717 (2004).

    PubMed  PubMed Central  Google Scholar 

  86. Maas, M. et al. Long-term outcome in patients with a pathological complete response after chemoradiation for rectal cancer: a pooled analysis of individual patient data. Lancet Oncol. 11, 835–844 (2010).

    Article  Google Scholar 

  87. Guillem, J. G. et al. Clinical examination following preoperative chemoradiation for rectal cancer is not a reliable surrogate end point. J. Clin. Oncol. 23, 3475–3479 (2005).

    Article  PubMed  Google Scholar 

  88. Guillem, J. G. et al. Neither FDG-PET nor CT is able to distinguish between a pathological complete response and an incomplete response after neoadjuvant chemoradiation in locally advanced rectal cancer: a prospective study. Ann. Surg. 55, 378–386 (2012).

    Google Scholar 

  89. Lambregts, D. M. et al. Diffusion-weighted MRI for selection of complete responders after chemoradiation for locally advanced rectal cancer: a multicenter study. Ann. Surg. Oncol. 18, 2224–2231 (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  90. Ghadimi, B. M. et al. Effectiveness of gene expression profiling for response prediction of rectal adenocarcinomas to preoperative chemoradiotherapy. J. Clin. Oncol. 23, 1826–1838 (2005).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  91. Garcia-Aguilar, J. et al. Identification of a biomarker profile associated with resistance to neoadjuvant chemoradiation therapy in rectal cancer. Ann. Surg. 254, 486–492 (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  92. Kalloo, A. N. et al. Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity. Gastrointest. Endosc. 60, 114–117 (2004).

    Article  PubMed  Google Scholar 

  93. Lacy, A. M. & Adelsdorfer, C. Totally transrectal endoscopic total mesorectal excision (TME). Colorectal Dis. 13 (Suppl. 7), 43–46 (2011).

    Article  PubMed  Google Scholar 

  94. Cho, Y. B. et al. Multimedia article. Natural orifice transluminal endoscopic surgery applied to sigmoidectomy in survival animal models: using paired magnetic intra-luminal device. Surg. Endosc. 25 (4), 1319–1324 (2011).

    Article  PubMed  Google Scholar 

  95. Whiteford, M. H., Denk, P. M. & Swanstrom, L. L. Feasibility of radical sigmoid colectomy performed as natural orifice translumenal endoscopic surgery (NOTES) using transanal endoscopic microsurgery. Surg. Endosc. 21, 1870–1874 (2007).

    Article  CAS  PubMed  Google Scholar 

  96. Bhat, Y. M. et al. Transluminal endosurgery: novel use of endoscopic tacks for the closure of access sites in natural orifice transluminal endoscopic surgery (with videos). Gastrointest. Endosc. 69, 1161–1166 (2009).

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Surgery, Colorectal Service, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, 10065, NY, USA

    Vanessa W. Hui & José G. Guillem

Authors
  1. Vanessa W. Hui
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. José G. Guillem
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

The authors contributed equally to all aspects of the production of this article.

Corresponding author

Correspondence to José G. Guillem.

Ethics declarations

Competing interests

The authors declare no competing financial interests.

PowerPoint slides

Rights and permissions

Reprints and permissions

About this article

Cite this article

Hui, V., Guillem, J. Minimal access surgery for rectal cancer: an update. Nat Rev Gastroenterol Hepatol 11, 158–165 (2014). https://doi.org/10.1038/nrgastro.2013.203

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/nrgastro.2013.203

This article is cited by

Search

Advanced search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing