Laparoscopic TME in rectal cancer--electronic supplementary: op-video

Minimally Invasive Rectal Surgery: Current Status and Future Perspectives in the Era of Digital Surgery

Over the past two decades, minimally invasive approaches in rectal surgery have changed the landscape of surgical interventions, impacting both malignant and benign pathologies. The dynamic nature of rectal cancer treatment owes much to innovations in surgical techniques, reflected in the expanding literature on available treatment modalities. Local excision, facilitated by minimally invasive surgery, offers curative potential for patients with early T1 rectal cancers and favorable pathologic features. For more complex cases, laparoscopic and robotic surgery have demonstrated significant efficacy and provided precise, durable outcomes while reducing perioperative morbidity and enhancing postoperative recovery. Additionally, advancements in imaging, surgical instrumentation, and enhanced recovery protocols have further optimized patient care. The integration of multidisciplinary care has also emerged as a cornerstone of treatment, emphasizing collaboration among surgeons, oncologists, and radiologists to deliver personalized, evidence-based care. This narrative review aims to elucidate current minimally invasive surgical techniques and approaches for rectal pathologies, spanning benign and malignant conditions, while also exploring future directions in the field, including the potential role of artificial intelligence and next-generation robotic platforms.

A nationwide comparison of short-term outcomes after transanal, open, laparoscopic, and robot-assisted total mesorectal excision

AIM

Laparoscopic rectal cancer surgery has several limitations. Transanal total mesorectal excision (TaTME) can potentially overcome these limitations. The aim of this study was to compare the rates of non-radical surgery and anastomotic leakage after TaTME, open TME (OpTME), laparoscopic TME (LaTME) and robotic TME (RoTME) procedures in a nationwide cohort.

METHODS

We extracted the demographic, perioperative and pathological data of patients who underwent a curative OpTME, LaTME, RoTME or TaTME procedure between January 2014 and December 2018 from the national database of the Danish Colorectal Cancer Group (DCCG). We conducted multiple group-comparisons, uni- and multivariate analyses to determine the factors associated with positive resection margin (+RM) and anastomotic leakage.

RESULTS

We included 2393 patients (OpTME = 205, LaTME = 1163, RoTME = 713 and TaTME = 312). The rate of +RM was 5.7% after TaTME. The lowest rate of +RM was achieved after RoTME (8.2%, 4.7%, 2.52%, and 5.7%, after OpTME, LaTME, RoTME and TaTME respectively, p < 0.001). In multivariate analysis, having a T4 tumour and intraoperative bowel perforation were associated with the risk of +RM (p < 0.001, p < 0.001, respectively). The factors associated with anastomotic leakage in multivariate analysis were male gender, high BMI and intraoperative bowel perforation (p < 0.001, p = 0.049, p = 0.002, respectively). TaTME was associated with the highest rate of sphincter-saving procedures (79.8%, p < 0.001), the lowest rate of bowel perforation (2.9%, p = 0.028) and the lowest rate of conversion to open surgery (1.3%, p < 0.001).

CONCLUSIONS

In a nationwide audit of TME approaches, the rate of +RM was lowest after RoTME. No differences were found between the four approaches regarding the risk of anastomotic leakage. TaTME offered advantages related to sphincter-saving, perforation and conversion.

Transanal vs laparoscopic total mesorectal excision for rectal cancer: initial experience from Denmark

AIM

Laparoscopic total mesorectal excision (LaTME) has improved short-term outcomes of rectal cancer surgery with comparable oncological results to open approach. LaTME can be difficult in the lowermost part of the rectum, leading potentially to higher rates of complications, conversion to open surgery and probably suboptimal oncological quality. Transanal TME (TaTME) can potentially solve these problems. The aim of this study was to compare the short-term results after TaTME with those after LaTME.

METHOD

A prospectively collected database of consecutive patients who underwent TaTME was maintained. Results were compared with those who underwent LaTME in the preceding period. Patients who underwent low anterior resection or intersphincteric abdominoperineal excision were included. Primary end-points were radical resection and specimen quality. Secondary end-points were complications, rates of conversion, operating time and hospital stay.

RESULTS

In total, 50 patients were included (TaTME = 25, LaTME = 25). The groups were comparative in demographic data and tumour characteristics. Circumferential resection margin was positive in one patient in the TaTME group vs four patients in the LaTME group (P = 0.349). All patients in the TaTME group had either complete or nearly complete specimen quality, while four patients in the LaTME group had incomplete specimen quality (P = 0.113). Less blood loss, shorter operating time and shorter hospital stay were found in the TaTME group (P values 0.016, 0.002 and 0.020 respectively). Intra-operative complications were comparable (P = 0.286).

CONCLUSION

The TaTME procedure had comparable pathological results and acceptable short-term postoperative outcomes compared to LaTME.

Transanal versus traditional laparoscopic total mesorectal excision for rectal carcinoma

BACKGROUND

After total mesorectal excision (TME) surgery, patients with an incomplete mesorectum have an increased risk of local and overall recurrence. With the introduction of laparoscopic TME, an improved quality of the specimen was expected. However, the quality-related results were comparable to the results after traditional open surgery. Transanal TME is a new technique in which the rectum is mobilised by using a single-port and endoscopic instruments through the so called 'down to up' procedure. This new technique potentially leads to an improved specimen quality. This study was designed to investigate the pathological quality of specimens after transanal (TME) and to compare these with specimens after traditional laparoscopic TME.

METHODS

This matched case control study compared the specimens of a cohort of consecutive patients who underwent transanal TME with the specimens after traditional laparoscopic TME. The pathological quality of the mesorectum was determined by the definitions of Quirke as 'complete', 'nearly complete', or 'incomplete'.

RESULTS

From June 2012 until July 2013, 25 consecutive patients underwent transanal TME because of a rectum carcinoma. 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, such as the circumferential resection margin, were comparable between the two groups.

CONCLUSIONS

Transanal TME appears associated with a significant higher rate of completeness of the mesorectum. Further studies are necessary to evaluate this novel technique.

Long-term oncologic outcome after laparoscopic surgery for rectal cancer

BACKGROUND

Recent studies demonstrated favorable short- and mid-term results after laparoscopic surgery for rectal cancer. However, long-term results from large series are lacking. The present study analyses long-term results of laparoscopic rectal cancer surgery from a large-volume center.

METHODS

From January 1998 until March 2005, 225 patients underwent laparoscopic rectal resection due to carcinoma at the Medical Centre of the University of Regensburg. From 224 patients, a follow-up over 10 years was performed using the data of the Tumour Centre of the University of Regensburg. The data were analysed using oncological data (tumour recurrence) as well as overall survival. In addition, the effect of conversion to open resection on overall survival was analysed.

RESULTS

With a median of 10 years at follow-up, the overall and disease-free survival was 50.5 and 50.1 %, respectively. Local recurrence of all patients was 5.8 % and none of the converted patients was within this group. The median time interval for the development of local recurrence was 30 months. Six of the 13 patients with local recurrence (46.1 %) had received neoadjuvant radiochemotherapy before surgery. Patients with a conversion to open surgery had primarily a significantly worse outcome than patients resected completely laparoscopically (p = 0.003). However, this difference was no longer apparent using a multivariant analysis (hazard ratio 1.221; p = 0.478).

CONCLUSIONS

Overall survival and local recurrence rate of patients undergoing laparoscopic resection of rectal cancer are comparable to open surgery. However, in our analysis, patients undergoing laparoscopic anterior resection had a higher survival rate compared with patients with abdominoperineal resection.

Nerve-oriented mesorectal excision (NOME): autonomic nerves as landmarks for laparoscopic rectal resection

PURPOSE

We have developed nerve-oriented mesorectal excision (NOME) as a novel concept in rectal cancer surgery by which autonomic pelvic nerves serve as landmarks for a standardized navigation along fascial planes. This article describes the technique step by step and presents our results from 2008 to 2012.

MATERIAL AND METHODS

The key steps are: preparation of the splanchnic nerves at the mid-posterior sidewall, the hypogastric nerves at the upper sidewall, and the urogenital nerve branches (Walsh) at the caudal-anterior sidewall. The dissection of the lateral ligament is strictly performed as the last step. NOME was applied in 274 consecutive mesorectal excisions (partial 20.4%, total 79.6%); a subgroup of 42 male patients underwent a questionnaire-based interview on sexual activity.

RESULTS

The conversion rate was 0.7%. High (complete) specimen quality and circumferential margin negativity were achieved in 90.1% and 95.3%, respectively. Anastomotic leaks occurred in 13 (4.7%) patients. Mortality was 1.8%. The frequency of prolonged urinary catheter was 1.8%. Of 22 sexually active males interviewed, 18 (81.8%) maintained activity postoperatively.

CONCLUSIONS

NOME achieves high-quality mesorectal specimens and a high rate of preservation of autonomic nerve function. The concept of using nerves as laparoscopic landmarks may help to standardize and master laparoscopic rectal cancer surgery.

Different approaches for complete mobilization of the splenic flexure during laparoscopic rectal cancer resection

PURPOSE

Laparoscopic resection of rectal cancer has already become the standard procedure in many hospitals. The splenic flexure mobilization (SFM) is an important preparational step. Several methods are used for laparoscopic SFM; however, studies comparing different approaches are lacking. In the present study, three different approaches for SFM have been compared to each other.

METHODS

Between January 1998 and December 2010, 415 patients with rectal adenocarcinoma underwent laparoscopic rectal resection at one center. Of these, 303 patients received complete splenic flexure mobilization. The SFM was performed using either a medial (SFM-M; n = 41), lateral (SFM-L; n = 214), or anterior (SFM-A; n = 48) approach.

RESULTS

There was a significantly higher rate of intraoperative complications in the SFM-L group as compared to the SFM-M or the SFM-A group (p = 0.038). Postoperative surgical complications occurred in 5 (10.6 %) patients of the SFM-A group compared to 38 patients (17.7 %) in the SFM-L group (p = 0.002) and 5 (12.1 %) patients in the SFM-M group (p = 0.037). SFM-L was also associated with a higher frequency of overall postoperative morbidity which was mainly due to wound infection rates (p = 0.001).

CONCLUSIONS

The anterior approach for SFM in laparoscopic surgery seems to be associated with lower frequency of intra- and postoperative morbidity.

From Archiv für Klinische Chirurgie to Langenbeck's Archives of Surgery: 1860-2010

INTRODUCTION

In February 1860, B. Langenbeck, Th. Billroth, and G. Gurlt certified in Berlin with the publisher A. Hirschwald the founding of Archiv für Klinische Chirurgie. The journal published extended reports about application of new and case-proven surgical procedures. Separate sections were dedicated to surgical casuistics and small surgical communications and report of surgical institutions from Germany, Austria, and Switzerland as well as annual statistical reports of hospitals. Beginning with the first issue, the Archive was an international journal with the focus on gastrointestinal, trauma, orthopedic, thyroid, and vascular surgery. A section Achievements and Progress in Surgery referred to published results in national and international medical and surgical journals.

GERMAN SOCIETY OF SURGERY

Surgeons from Germany contributed strongly to the rise of operative treatment concepts in the second half of the nineteenth century by new surgical procedures, many of them published in the Archiv für Klinische Chirurgie. Since 1923, the German Society of Surgery took Archiv für Klinische Chirurgie as the official journal of the society. Beginning 1950, Langenbeck's published in a separate supplement the proceedings of the annual congress of the German Society of Surgery. A second supplement published since 1972 focused exclusively on reporting of research work presented in the section of Surgical Forum for Experimental and Clinical Surgery.

AFTER THE WAR

After World War II, Langenbeck's Archiv für Chirurgie gained acceptance as the leading scientific surgical journal in Germany. Since 1998, the concept of Langenbeck's Archiv was completely changed to an English journal with the title Langenbeck's Archives of Surgery. In the last 12 years, Langenbeck's has turned to an international German-surgery-based electronic journal. Langenbeck's Archives of Surgery experienced an increasing international reputation; in 2001, only two non-American journals (British Journal of Surgery and Langenbeck's) belonged to the top ten journals in general and GI-tract surgery. The present impact factor (IF) of Langenbeck's Archives of Surgery is 1.829 (5-year IF). The decrease of subscriptions for the journal is compensated by an increase of electronic readers. The electronic supplementary material provided by the Springer Company is used to publish manuscripts in the section How-To-Do Surgery, combined with a video clip about surgical techniques. The focus of Langenbeck's is general, GI-tract, endocrine, and HBP surgery.

CONCLUSION

Langenbeck's has continuously been published for 150 years and is considered to be the worldwide oldest scientific surgical journal. The English-language-based journal contributes increasingly to an international communication of surgical research and clinical surgeons from Germany.