Page 28 - Journal of World Association of Laparoscopic Surgeons

Comparative Analysis of Surgical and Pathological Outcomes
patients who underwent laparoscopic TME for rectal cancer. Pathological Assessment
Patients from laparoscopic groups were operated on by the exact All specimens were analyzed by the same experienced pathologist
same surgical personnel. Tumors situated within 17 cm of the anal who examined the involvement of the circumferential margin
verge were considered as: lower rectum (<7 cm from anal verge); (distance of 1 mm and or less from the tumor to the mesorectal
mid-rectum (7.1–12 cm from anal verge); higher rectum (>12 cm fascia), involvement of the distal margin (tumor approaching the
from anal verge). Patients with T3 and or T1 or T2 N1 tumors in distal portion), and the number of isolated lymph nodes.
the middle or lower third of the rectum underwent neoadjuvant
chemoradiation (50.4 Gy given over 5 weeks in combination with Statistical Analysis
5-fluorouracil or with oral capecitabine at a dosage of 1000–1500 The statistical analysis was performed employing the SPSS software
2
mg per m every day for the entire timeframe of radiotherapy- program version 22.0 (Chicago, IL, United States) and Windows.
based chemotherapy) and after that surgical procedures 6–8 Parametric variables were expressed as mean ± SD. The Student’s
weeks eventually. Preoperative planning was exactly the same t test was used to analyze variations between the LARS and ORS
in both categories. groups. The χ test (or Fisher’s exact test where appropriate) and
2
exact tests were performed to compare variables between the
Surgical Technique two groups. A p value less than 0.05 was considered statistically
Oncological concepts adopted were (1) ligation of the inferior significant.
mesenteric artery and the inferior mesenteric vein to offer sufficient
colon extent for a tension-free anastomosis, (2) sharp TME for
middle and lower rectal cancer, (3) preservation of the autonomic results
pelvic nerves, and (4) appropriate distal and radial surgical margins. A total of 58 patients participated in this study, including 34 in the
All patients were operated under general anesthesia. A 10-mm LARS (15 males and 19 females, mean age 52.41 years) and 24 in the
camera port was placed 0.5 cm above the umbilicus. Another ORS (15 males and 9 females, mean age 50.62 years) (Table 1). There
10 mm port was introduced one-third of the distance from the were no significant differences in baseline characteristics between
right anterior superior iliac spine to the navel. Two 5-mm trocars the two groups. 23 patients (67.6%) in the LARS and 18 patients
positioned at the level of umbilicus on either side, lateral to rectus (75%) in the ORS underwent neoadjuvant chemoradiotherapy
sheath, and an additional 5-mm port positioned in the left iliac before surgery. Majority of patients in both the groups had TNM
fossa. After inspecting for the presence of peritoneal diseases, the stage III disease (61.8% in LARS vs 70.8% in ORS). Surgery was not
peritoneum was incised from the level of the sacral promontory successfully completed by laparoscopy (converted to laparotomy) in
posterior to the rectum down to the summit of the coccyx. Anterior 5 of 34 (14.7%) patients. The most frequently performed procedure
dissection started in the retrovesical septum in males and in was APR (52.9%) in LARS group and LAR (45.38%) in ORS group. The
the rectovaginal space in females. The rectosacral ligament and ORS included 5 patients, 11 patients, and 4 patients underwent APR,
anococcygeal ligament were divided and incised at the level of the LAR, and anterior resection, respectively. 5.9% and 8.3% of patients
fourth sacral vertebra. The intact mesorectum was circumferentially underwent posterior pelvic exenteration in LARS and ORS groups,
mobilized. For tumors in the higher rectum, a higher TME or respectively (Table 2).
partial mesorectal excision was performed laparoscopically with Though statistically borderline significant, laparoscopic group

transection of the mesorectum 5-cm distal of the tumor, followed patients (LARS) had decreased length of hospital stay (p = 0.0511)

by a stapled anastomosis. For tumors situated in the mid and distal and decreased blood loss (p = 0.0491). Mean operating time was
rectum, a complete TME was done laparoscopically. The rectum was 16 minutes longer for laparoscopic than open surgery. Return to
transected with an endoscopic or traditional stapler with the use of oral diet was longer by a mean of 1.4 days in the open group. But
a Pfannenstiel incision. A coloanal anastomosis was performed if at these differences were not significant. Common procedure-related
least 1 cm from the dentate line often is spared with an adequate complications included anastomotic leakage, pelvic abscess, ileus,
oncological distal margin of 2 cm. Typical lateral-to-medial and urinary tract problems (Table 3).
mobilization was attempted of the sigmoid colon, descending The overall morbidity rate was 29.4% in the LARS as compared
colon, and the splenic flexure. After scoring the mesentery and with 45.8% in the ORS. However, this difference was not statistically

separating the mesenteric fat with small vessels by applying significant (p = 0.1999). Only one patient from the laparoscopic group
harmonic scalpel, the inferior mesenteric vessels were identified, had mortality within 30 days. 4.2% and 8.3% patients of open group
clipped, and transected with harmonic scalpel. A transverse had intestinal obstruction and wound dehiscence, respectively. 11.8%
incision of 3–4 cm was made to remove the specimen with the aid patients and 12.5% patients of LARS and ORS group had anastomotic
of a wound shield. Colorectal anastomoses were performed using leakage, respectively. The rate of wound infection and rate of delay in
circular staplers. Proximal and distal tissue donuts produced by the bladder emptying were more in ORS and LARS group, respectively.
circular stapler were checked for integrity. The distal donut was Regarding oncologic adequacy of resection, a total of 21.9%
sent for pathological assessment as the circumferential margin. (9/41) of patients showed a complete degree of response to NCRT;
Covering loop ileostomy or transverse colostomy was created for the proximal and distal resection margins did not differ significantly
diversion of feces. between the groups. A total of 2.9% of patients in the LARS group
showed circumferential resection margin (CRM) involvement;
Open TME however, none of the patients in the ORS group showed this
Open cases were performed through a midline incision. Open TME involvement, although the difference was not significant. The
was performed as outlined by earlier explained techniques. distribution of pathological tumor and nodal stages was similar
Conversions was defined as operating any procedure using an between the groups (Table 4).
open method, except the removal of the specimen or transection The mean numbers of lymph nodes harvested were 10.8 in the
of rectal cancer through the anus. LARS group (range: 8–13) and 12.6 (range: 8–19) in the ORS group.

20 World Journal of Laparoscopic Surgery, Volume 12 Issue 1 (January–April 2019)