1. science
2. medicine
3. surgery

The best method for distal rectal
resection
Francis
Seow-Choen
Seow-Choen
Colorectal
Centre
Singapore
Rectal Cancer
• Rectal Cancer is a
surgical disease
• Surgical technique
is one of the most
important factor to
reduce local
recurrence.
• Meticulous
attention in
performing rectal
resection is of the
utmost importance
La muse
Real old methods
• William Allingham
claimed in 1882 that
much relief could be
obtained by tearing out
the rectum with his
fingers!
• By 1947, Synchronized
APR was in fashion
with operability at 86%
and operative mortality
at 8.2%
Granshaw L. St Mark’s Hospital,
London A social history of a specialist
Hospital
Open Surgery: The modern era:
Blunt methods
• Anterior resection often
removed by forceful
tearing away from the presacral fascia
• Results in excessive
bleeding and a substantial
local recurrence rates of up
to 55%
• However this technique
may still be useful in a very
small number of cases
even today.
New understanding: The Mesorectum
• First known description of
the mesorectum was by
the Romanian surgeon and
anatomist Thomas
Jonnesco.
• Jonnesco was the first to
observe that the rectum
was encapsulated within a
thin fibrous sheath, which
partitions it from the other
pelvic organs, and he also
described how proper
respect for this fibrous
sheath allowed the rectum
to be mobilized from the
sacrum without damage to
the presacral vessels.
The mesorectum and TME
• Heald gave TME
widespread attention
in 1979
• He emphasized direct
vision and sharp
dissection of the
mesorectum by
dividing between the
visceral and parietal
pelvic fascia during
rectal mobilization.
Open Surgery: Sharp disssection
• Heald, in fact, reported
the lowest recurrence
rates for rectal cancer at
that time, with his first
series of 112
patients showing a
cumulative 5-year local
recurrence rate of 2.7%
and an overall corrected
5-year survival of
87.5%.
•
Heald et al Lancet 1986:1:1479-82
Good indications for Open TME
Surgery
• Very large bulky
cancer in the low
rectum
• Lack of minimally
invasive facilities
or training
• Locally advanced
in a fat male
patient
The minimally invasive era:
Laparoscopic TME
• Three
randomized
controlled trials
evaluated
feasibility and
oncologic
safety of
laparoscopic
TME
Clasicc-5 year results
• No differences were found
between laparoscopically
assisted and open surgery in
terms of overall survival,
disease-free survival, and local
and distant recurrence at 5 yrs.
Wound/port-site recurrence
rates in the laparoscopic arm
remained stable at 2.4 per
cent.
• The use of laparoscopic surgery
to maximize short-term
outcomes does not
compromise the long-term
oncological results
•
Br J Surg. 2010 Nov;97(11):1638-45 Jayne et al Leeds
UK
Color II –Short term results
• 1103 patients were randomly
assigned to
the laparoscopic (n=739) and
open surgery groups (n=364),
and 1044 were eligible for
analyses (699 and 345,
respectively).
• Patients with rectal cancer
treated by skilled
surgeons, laparoscopic surgery
resulted in similar safety,
resection margins, and
completeness of resection to
that of open surgery, and
recovery was improved
after laparoscopic surgery.
Lancet Oncol. 2013 Mar;14(3):210-8. Laparoscopic versus open surgery for rectal cancer
(COLOR II): short-term outcomes of a randomised, phase 3 trial. van der Pas MH
Corean Trial
Open versus laparoscopic
surgery for mid or low REctal
cancer After Neoadjuvant
chemoradiotherapy
• 340 patients randomized
open surgery (n=170)
or laparoscopic
surgery (n=170). Both
groups with similar
outcomes for disease-free
survival as open resection,
thus justifying its use.
Lancet Oncol. 2014 Jun;15(7):767-74. Open versus
laparoscopic surgery for mid-rectal or low-rectal cancer
after neoadjuvant chemoradiotherapy (COREAN trial):
survival outcomes of an open-label, non-inferiority,
randomised controlled trial. Jeong SY
Good indications for Laparoscopic
Surgery
• Smaller rectal cancer
especially in a thin
female with wide
pelvis
• No evidence of
extensive pelvic
disease
• Experienced
laparoscopic surgeon
Robotic Rectal Resection
• Robotic surgery is an
emerging minimally invasive
technique. The optical
system provides a high
definition, threedimensional vision, and
surgical instruments are
provided for seven degrees
of freedom and for a range
of motion greater than the
human wrist; this enables
extremely fine and precise
manual dexterity.
Robotic-assisted versus laparoscopic colorectal surgery: a meta-analysis of
four randomized controlled trials
• 4 out of 71 studies were found to meet
the inclusion criteria .
• 110 patients underwent RCS, and 116
patients underwent LCS.
Benefits of RCS include a reduced
conversion rate, reduced blood loss and
reduced time to recovery of bowel
function. There were no significant
differences in operation time,
complication rate and LOS between the
two groups. However, RCS was associated
with a significant increase in total costs
relative to LCS
Liao et al: World Journal of Surgical
Oncology 2014, 12:122
•
•
•
•
Park JS, Choi GS, Park SY, Kim HJ, Ryuk JP: Randomized clinical trial of robot-assisted versus standard laparoscopic
right colectomy. Br J Surg 2012, 99:1219-1226.
Patriti A, Ceccarelli G, Bartoli A, Spaziani A, Biancafarina A, Casciola L: Short- and medium-term outcome of robotassisted and traditional laparoscopic rectal resection. JSLS 2009, 13:176-183.
Baik SH, Ko YT, Kang CM, Lee WJ, Kim NK, Sohn SK, Chi HS, Cho CH: Robotic tumor-specific mesorectal excision of
rectal cancer: short-term outcome of a pilot randomized trial. Surg Endosc 2008, 22:1601-1608.
Jimenez RR, Diaz PJ, de La Portilla DJF, Prendes SE, Hisnard CDJ, Padillo J: Prospective randomised study: roboticassisted versus conventional laparoscopic surgery in colorectal cancer resection. Cir Esp 2011, 89:432-438.
Good indications for robotic rectal
surgery
• Very low rectal
cancer
• Sexual function
important
• Male obese
patients
• Pre-operative
chemoradiation
• Large tumours
The next big thing
• From June 2012 until July 2013, 25
consecutive patients underwent
transanal TME.
• Within the transanal TME group,
96 % of the specimens had a
complete mesorectum, while in
the traditional laparoscopic group,
72 % was deemed complete
(p < 0.05). Other pathological
characteristics were comparable
between the two groups.
• Transanal TME appears associated
with a significant higher rate of
completeness of the mesorectum.
Surg Endosc. 2014 Jun 28. Transanal versus traditional laparoscopic
total mesorectal excision for rectal carcinoma. Velthuis S et al
Advantageous
• Twenty selected patients with
rectal cancer had transanal
NOTES and minilaparoscopy
technique.
• Thirty-five percent of tumors
were in the distal rectum, 50%
in midrectum, and 15% in
proximal rectum. There were
no procedure-related
complications. The mesorectal
fascia was intact in all the
specimens.
• Reverse TME may offer
advantages over pure
laparoscopic approaches for
visualizing and dissecting out
the distal mesorectum.
Surg Endosc. 2013 Sep;27(9):3165-72. Transanal natural
orifice transluminal endoscopic surgery (NOTES) rectal
resection: "down-to-up" total mesorectal excision (TME)-short-term outcomes in the first 20 cases. de Lacy AM
Data from Gerald Marks 2009
• Laparoscopic Rectal
Cancer Operations
• TATA N=106
• Surgical approach can
be confirmed before
surgery
• Local recurrence rate
2.6% (oncologic goal)
• Sphincter
preservation can be
achieved in >90% of
patients
Start with Laparoscopy
Then insert the TEO set
Insert the purse string
Reverse TME
Easy 1 man job
Connect to the Laparoscopic wound
Prolapse the rectum and cancer
Transect and insert stapler head
Insert the distal purse string
Anastomosis done!
Reverse TME wounds
Resected cancer
Why Reverse TME?
Minimally Invasive Technique maintained
Low Rectal Cancer in a difficult position
Distal margin assured at start of surgery
Perfect TME possible by combination
technique if required
• Decreased wound sites!
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Technologies and Techniques are getting
more advanced but the most important
question is not whether we are using latest
technology or technique!
The more important question is: are
we becoming better humans?