Laparoscopic rectal cancer surgery.

Barely a century after his publication on surgical technique for rectal cancer, Ernest Miles would have found it surprising that the most vociferous debate is not the pursuit of oncological perfection, but the size of incision. Miles was able to reduce his almost 100 per cent local recurrence rate to less than 50 per cent during his own lifetime through technical refinement1. More recently, and despite the increasing popularity of adjuvant therapies, it is the acceptance of a standardized surgical technique, total mesorectal excision (TME)2, that has been the single most important factor in improving survival and lowering recurrence rates further after rectal cancer surgery. Whether we have reached a plateau in terms of oncological success is contentious. If this is not the case, then a debate on laparoscopic versus open resection of rectal cancer is hardly appropriate but, for the sake of argument, let us suppose that we have achieved excellence in open surgery and turn our attention to laparoscopy. Laparoscopic resection seems a safe and feasible alternative to open surgery in colonic cancer3. The subtleties of pelvic surgery, however, may not make rectal cancer entirely ideal for laparoscopy or indeed immediately comparable. Anatomical, oncological and functional factors become even more important when planning surgery. The rectum is related to both neural and visceral structures in the pelvis far more intimately than the colon within the abdominal cavity. Minimal disturbance to these structures can have profound functional effects for the patient. The main opposition to laparoscopic rectal resection is fear of oncological inadequacy. Careful scrutiny of pathological specimens allows resections to be assessed qualitatively4. Current evidence suggests that local recurrence, lymph node harvest and oncological clearance are not compromised and may be equivalent to those of open surgery5. These ‘primary markers’ of outcome have, however, generally not been emphasized as much as lesser benefits such as shorter length of stay (LOS) and earlier return of bowel function. Sexual and urological dysfunction have been even less well documented. It seems that LOS has become a symbol of bravado for some surgeons – discharging patients before they have had a chance to settle into their hospital beds is now heralded as a sign of success. Day-case colectomies and anterior resections appear to be on the horizon. It is important that surgeons should not become overly obsessed with surrogate markers and short-term objectives. LOS, for example, may be an issue in socialized healthcare systems or in private hospitals, but this may not be a problem in many countries where cultural factors influence bed occupancy. Essentially, LOS has minimal effect on patient care and, ultimately, long-term outcome. Furthermore, it is debatable whether a reduction inLOSmay be attributed to technical aspects of the actual surgery, the motivations of the surgeon or more general approaches. For example, enhanced recovery programmes are frequently associated with laparoscopic surgery but many of their components would be equally suitable in open surgery, and may flatter LOS outcomes attributed directly to laparoscopy. Most reports, however, do show a decreased LOS for patients undergoing laparoscopic rectal cancer surgery compared with its open counterpart. Laparoscopy involves less handling, manipulation and forcible retraction of the bowel, with less likelihood of ileus. It seems reasonable to conclude that laparoscopic surgery does lead to a faster recovery and return to normal life. Early criticisms of laparoscopy largely ignored the effect of the steep learning curve on results. During the early trials, most surgeons had far greater experience in open surgery than laparoscopy. The principles of good open surgery are relevant to laparoscopy. Traction and countertraction allow precise dissection, but translating these elements along with other techniques to laparoscopy takes time. Learning curves affect not only technique but also the outcome of the operation, such as lymph node harvest, intraoperative complications and conversion rates6. One of the difficulties in laparoscopy that leads to conversion is indecision due to anatomical uncertainty. Laparoscopy provides an initially unfamiliar anatomical perspective requiring new pattern recognition that is eliminated only through experience. Appreciating when to convert to laparotomy seems important and there is evidence that late conversion leads to worse outcomes,